Elements of Surgery

by Robert Liston

in the crural ring, whilst a larger portion, which bore marks of having been protruded, was thus entangled, and confined to the spot. The bowel, though not completely obstructed, was narrowed by the confinement of part of its parietes.

Abscess often occurs externally to a small swelling of this nature, and on the giving way of the integument, matter, flatus, and thin feces are discharged. A fecal fistula remains for some time; but, by the aid of lymph and granulations, the breach in the parietes of the bowel is repaired gradually, the feces resume their natural course, and the external opening heals.

When the whole calibre has sloughed, and even when a large extent of bowel has come away, and there is still a chance of the patient recovering from the artificial anus by natural means, after the lapse of many months. As already remarked, the intestinal orifices retract, and come more into a straight line. A mucous discharge occurs from the lower bowels along with the passage of flatus, and at last part of the feces is voided by the rectum. The discharge from the external opening diminishes, and ultimately ceases, perhaps only a minute fistula remaining, through which a few drops of fluid, sometimes feculent, sometimes limpid, may occasionally escape. The funnel-shaped cavity previously contracts into a narrow fistula. This desirable result may be assisted and hastened by gentle pressure; and, after the feculent discharge has nearly ceased from the fistulous opening, the healing of this may be accelerated by the cautery lightly applied. It has been proposed to destroy the projecting septum between the two portions of bowel, either by ligature or by the pressure of forceps; but this should not be attempted unless nature seems unable to effect a cure. The former method consists in including a considerable part of the septum in ligature, so as to induce condensation of the parts by effusion of lymph, and destruction of the projecting portion. This has not been found very successful. The application of forceps presents a more rational expectation of cure. The external opening is dilated, and the situation of the septum ascertained. One blade of metallic forceps, with blunt serrated edges,—Dupuytren’s,—is passed into the one intestinal orifice, and the other into the opposite; the handles of the instrument are then approximated, locked, and fastened with a screw, and by means of the last-mentioned part of the apparatus the degree of pressure is regulated. Pain of the abdomen, furred tongue, loss of appetite, sickness, vomiting, and constitutional irritation, generally follow this proceeding, but gradually subside on the employment of enemata and fomentations, and on lessening the pressure of the forceps. The septum cannot long withstand the continued compression, and by its destruction the chance of cure is greatly augmented. The proceeding is, besides, not so dangerous as might at first be supposed; for effusion of lymph takes place to a considerable extent above the part grasped by the forceps, gluing the portions of bowel firmly to each other, and forming a new barrier against any of the feculent matter escaping inwardly. Attempts may be made to repair the loss of substance in the skin by paring the edges of the opening, and affixing a flap taken from the neighbourhood.[45]

There is a greater chance of recovery from the inconvenience of artificial anus after hernia than after wounds. If the opening in the bowel be near the stomach, the patient will die from inanition. When it is lower in the intestinal tube, nutrition is more perfect, and the patient can be further supported by nutritive enemata. When no natural cure is likely to take place, the inconvenience will be palliated by a truss with a soil pad being worn, so as to retain the feces till a favourable opportunity occurs for evacuation; or a soft plug of lint may be inserted into the aperture, and retained by a compress and roller. Prolapsus of the mucous membrane of the gut sometimes takes place through the artificial anus, and is reduced with difficulty. The use of a truss or tent, already mentioned, will tend to prevent the occurrence. Great attention to cleanliness is required when the opening cannot be closed.

Operations for other kinds of hernia, if discovered during life, are to be conducted on similar principles with those for inguinal and crural. The surgeon must be guided by his anatomical knowledge. No positive rules can be given.

In Ascites, or accumulation of fluid in the peritoneal cavity, the surgeon is not unfrequently called upon to relieve the patient, when the abdominal parietes are much distended, and the functions of the viscera of the abdomen and thorax interrupted. He must, however, exercise his own judgment in regard to the case, and convince himself of the propriety of operating. He must examine into the symptoms, and ascertain that the tumour is really caused by accumulation of fluid in the bag of the peritoneum. In ascites, the abdomen has swelled slowly and uniformly, and distinct fluctuation is felt when the hand is placed on one side of the swelling, and gentle tapping made at the other. There is considerable difficulty of breathing, uneasiness in the abdomen, usually increased by pressure, thirst, and scanty secretion of urine. It ought to be remembered that other affections have been confounded with ascites, and lamentable operative mistakes committed in consequence. Trocars have been thrust into the belly for tympanitis, either of the bowels or of the peritoneum—for solid tumours of the viscera—for enlargement of the ovaria.

As already hinted, the operation of tapping the abdomen is to be undertaken only when the distention is very great, when the functions of the thoracic and abdominal viscera are interfered with, and when diuretics, and other means of getting rid of the fluid, have failed to diminish the accumulation. The trocar employed is either flat, with a spring steel canula, or round; when the latter is used, and the abdominal parietes are not very tense, a small incision is first made with a lancet or bistoury; a large trocar with blunted edges and point can then be readily and safely introduced; the flat one enters easily, and requires no previous wound, but does not permit so rapid and free a flow. The point usually chosen for the puncture is either in the linea alba, a little below the umbilicus, the bladder being previously emptied,—a precaution which should always be attended to, though in general there is little danger of wounding this organ—or midway betwixt the superior anterior spinous process of the ilium and the umbilicus, with the view of penetrating the parietes in the linea semilunaris. The latter situation, however, can seldom be obtained with accuracy, for the parietes yield irregularly. Little bleeding follows the puncture at either point; but the risk of hemorrhage is greater at the latter, for branches of the circumflex artery may be wounded. More serious bleeding is liable to occur, from the veins ramifying on the abdominal viscera giving way, on removal of their support, as the serum flows off. Fainting, also, may take place from accumulation in the branches of the vena portarum, unless the fluid is withdrawn slowly, and the precaution adopted of supporting the parietes with a broad band both during and after evacuation. Bandages are made for this purpose, with tapes and straps attached, and are well fitted for it. Three or four yards of flannel, however, with each end split, are equally effectual, and can always be readily obtained—a consideration of consequence in the choice of all apparatus. After the band has been applied, a person is placed on each side to tighten it gradually by steady pulling at the ends, which are carefully crossed behind. An opening is made in the cloth, opposite to where it is proposed to puncture, and the operation is then proceeded in. Sometimes the flow is impeded by the omentum or a fold of bowel falling forward on the canula, and closing or diminishing the opening; this is remedied by passing a tube along the canula, closed at the extremity, but perforated at the sides near it, and about half an inch longer than the canula. After the cavity has been emptied, the patient is placed recumbent, and a long broad flannel bandage applied over the whole abdomen, and retained, so as to prevent shifting, by straps passed over the shoulders and under the perineum.

Collections occur in the ovaria. The fluid is generally glairy, sometimes thick and gelatinous, often turbid and dark coloured. Not unfrequently the main cyst is subdivided, either by membranous septa, or by an aggregation of smaller cysts of the nature of hydatids. The swelling is at first on one side, and gradually rises out of the pelvis; often it remains long moveable; it increases, becomes more fixed, and ultimately fills the abdomen, displacing the viscera, and giving rise to feelings of much uneasiness, deformity, and loss of health. The cyst is generally thick; sometimes it is thin at one or more points, and this may give way, causing effusion of the contents into the peritoneal sac. Fluctuation is perceptible in many cases; in others it is obscured by the thickness of the cyst and viscidity of its contents. Many such swellings may be punctured both with advantage and with safety, but generally the tapping requires frequent repetition. Some patients require tapping, merely as a mean of improving the figure and relieving uneasy feelings, once, twice, or thrice a year; their existence is not much embittered or abridged by the disease. A large round trocar is necessary for the purpose; and the puncture is made at the softest and most prominent point of the tumour, a small incision through the integument being premised.