A Manual of the Operations of Surgery.

by Joseph Bell.

PREFACE TO THE FIRST EDITION.

Having been asked, year after year, by the members of my Cla.s.s for Operative Surgery, to recommend to them some Manual of Surgical Operations which might at once guide them in their choice of operations, and give minute details as to the mode of performance, I have been gradually led to undertake the production of this little work.

My aim has been to describe as simply as possible those operations which are most likely to prove useful, and especially those which, from their nature, admit of being practised on the dead body.

In accordance with this plan, neither historical completeness of detail, nor much variety in the methods of performing any given operation, is to be expected. Hence, also, many omissions which would be unpardonable in the briefest system of Surgery are unavoidable. For example, excision of tumours and operations for necrosis are hardly mentioned, because for these no special instructions can well be given; for, while general principles may guide us to _what_ should be done, the special circ.u.mstances of each case must dictate _how_ it is to be done.

In such a work as this, to attempt originality would be undesirable and intrusive; a judicious selection, a faithful compilation, are all that can be expected.

That the selection of operations may sometimes show "Northern Proclivities" is possible; and this is perhaps not unnatural to a scholar and teacher in the Edinburgh School.

An earnest endeavour has been used to make the references correct and copious: for any mistakes or omissions the author would crave indulgence.

The four plates which precede the letterpress were drawn on wood (from original photographs) by Mr. D.W. Williamson, Melbourne Place, and the lines of incision for the various operations were added by the author.

The rough woodcuts scattered through the work were drawn on wood by the author, and for their roughness he, not his engraver, is responsible. He also hopes that the references in the letterpress will be accepted as sufficient acknowledgment of the true ownership, in those few instances in which the idea of the diagram has been borrowed.

It has been thought unnecessary to introduce woodcuts of surgical instruments, as the ill.u.s.trated catalogues lately published by Weiss, Maw, and others, are sufficiently accurate.

In excuse of the frequent baldness and brevity of the style, the author must point to the size and price of the work. Its composition would have been easier had its dimensions been greater.

Though intended chiefly to guide the studies, on the dead subject, of students and junior pract.i.tioners, the author ventures to hope that the Manual may be useful to those who, in the public services, in the colonies, or in lonely country districts, find themselves constrained to attempt the performance of operations which, in the towns, usually fall to the lot of a few Hospital Surgeons.

JOSEPH BELL.

5 CASTLE TERRACE, EDINBURGH, _July 1866._

CHAPTER I.

LIGATURE OF ARTERIES.

LIGATURE OF ARTERIES.--In a work of this nature there is no room for any discussion of the principles which should guide us in the selection of cases, or of the pathology of aneurism, or the local effects of the ligature on the vessels. One or two fundamental axioms may be given in a few words:--

1. In selecting the spot for the application of the ligature, avoid as far as possible bifurcations, or the neighbourhood of large collateral branches.

2. A free incision should be made through the skin and subjacent textures, till the sheath of the artery is reached and fairly exposed.

3. The sheath must be opened and the artery cleaned with a sharp knife till the white external coat is clearly seen. The portion cleaned should, however, be as small as possible, consistent with thorough exposure, so that the ligature may be pa.s.sed round the vessel without force.

4. As the artery should never be raised from its bed, it is generally advisable to pa.s.s the needle only so far as just to permit the eye to be seen past the vessel. The ligature should then be seized by a pair of forceps and gently pulled through, the needle being cautiously withdrawn. When catgut is used, it is better to pa.s.s the unarmed needle till the eye is visible, then thread and withdraw it, thus pulling the catgut through.

5. As a rule, the needle should be pa.s.sed from the side of the vessel at which the chief dangers exist. This will generally be in the side at which the vein is.

6. The ligature should be single, and consist of strong well-waxed silk, and should always be drawn as tight as possible, so as to divide the internal and middle coats of the vessel. In cases where the wound is to be treated with antiseptic precautions and an attempt at immediate union made, the ligature may be of strong catgut properly prepared, and both ends of it may be cut off.

7. Before the ligature is tightened, it is well to feel that pressure between the ligature and the finger arrests the pulsation of the tumour.

LIGATURE OF THE AORTA.--It has been found necessary in a few rare cases to place a ligature on the abdominal aorta; no case has as yet survived the operation beyond a very few days, but they have in their progress sufficiently proved that the circulation can be carried on, and gangrene does not necessarily result even after such a decided interference with vascular supply.

_Operation._--The ligature may be applied in one of two ways, the choice being influenced by the nature of the disease for which it is done.

1. A straight incision (Plate I. fig. 1) in the linea alba, just avoiding the umbilicus by a curve, and dividing the peritoneum, allows the intestines to be pushed aside, and the aorta exposed still covered by the peritoneum, as it lies in front of the lumbar vertebrae. The peritoneum must again be divided very cautiously at the point selected, and the aortic plexus of nerves carefully dissected off, in order that they may not be interfered with by the ligature. The ligature should then be pa.s.sed round, tied, cut short, and the wound accurately sewed up.

2. Without wounding the peritoneum.

A curved incision (Plate I. fig. 2), with its convexity backwards, from the projecting end of the tenth rib to a point a little in front of the anterior superior spinous process of the ilium. At first through the skin and fascia only, this incision must be continued through the muscles of the abdominal wall, one by one, till the transversalis fascia is exposed, which must then be sc.r.a.ped through very cautiously, so as not to injure the peritoneum, which is to be detached from the fascia covering the psoas and iliacus muscles, and must be held inwards and out of the way by bent copper spatulae. The common iliac will then be felt pulsating, and on it the finger may easily be guided up until the aorta is reached.

The really difficult part of the operation now begins: to isolate the vessel from the spine behind, the inferior cava on the right side, and the plexus of nerves in the cellular tissue all round. The cleaning of the vessel must be done in great measure by the finger-nail, and much dexterity will be required to pa.s.s the ligature without unnecessarily raising the vessel from its bed, especially as the vessel itself may very possibly be diseased, and the aneurism of the iliac trunk for which the operation is required will displace and confuse the parts, and may have set up adhesive inflammation.

_Results._--Operation has been performed at least ten times. By the first method by Sir Astley Cooper and Mr. James; by the second by Drs.

Murray and Monteiro, M'Guire, Heron Watson, and Stokes, and Mr. South, and Czerny of Heidelberg. All the cases proved fatal; Dr. Monteiro's survived for ten days, and eventually perished from haemorrhage; the rest all died at shorter intervals.

LIGATURE OF COMMON ILIAC.--_Anatomical Note._--This short thick trunk varies slightly in its relations on the two sides of the body. As the aorta bifurcates on the left side of the body of the fourth lumbar vertebra, the common iliac of the right side would have a longer course to pursue than that on the left, if both ended at corresponding points.

However, this is not always the case, as has been pointed out by Mr.

Adams of Dublin, as the right common iliac often bifurcates sooner than the left does. With this slight difference, the position of the two vessels is precisely similar, each extending along the brim of the pelvis from the bifurcation of the aorta towards the sacro-iliac synchondrosis for about two inches. Sometimes the division takes place a little higher, even at the junction of the last lumbar vertebra and the sacrum. This variation depends chiefly on the length of the artery, which, as Quain has shown, varies from one inch and a half to more than three inches.

The anterior surface of both arteries is covered by the peritoneum, and each is crossed by the ureter just as it bifurcates into its branches.

The artery of the right side is in close contact behind with its corresponding vein, which at its upper part projects to the outside, and below to the inner side. The artery of the left side is less involved with its vein, which lies below it, and to the inside. The right is in contact with a coil of ileum, the left with the colon. The inferior mesenteric artery crosses the left one, while to the outside of both, and behind them, lie the sympathetic and obdurator nerves.

There are no named branches from the common iliac.

_Operation._--The chief difficulties to be encountered are--1. The close proximity of the peritoneum, and specially the risk there is that it has become adherent to the sac of the aneurism; 2. The depth of the parts, and tendency of the intestines to roll into the wound; 3. Specially on the right side, the proximity of the great veins. With these exceptions the pa.s.sing of the ligature is not so difficult as in some situations, the lax cellular tissue in which the vessel lies generally yielding much more easily than the tough sheath which elsewhere, as in the femoral, requires accurate dissection.

_Incision._--(Plate I. fig. 3.)--From a point about half an inch above the centre of Poupart's ligament, a crescentic incision should be made, at first extending upwards and outwards, so as to pa.s.s about one inch inside of the anterior superior spine of the ilium, and then prolonged upwards and inwards, as far as may be rendered necessary by the size of the aneurism or the depth of parts. It must extend through skin and superficial fascia, exposing the tendon of the external oblique, which must then be slit up to the full extent visible. The spermatic cord may then be easily exposed under the edge of the internal oblique, and the forefinger of the left hand inserted on the cord, and thus beneath the internal oblique and transversalis muscles, the peritoneum being quite safe below.

On the finger these muscles may be safely divided to the full extent of the external incision. The deep circ.u.mflex iliac artery if possible should not be divided, but may bleed smartly and require a ligature.

The peritoneum must then be very cautiously raised from the tumour, and supported, along with the intestines, by copper spatulae. The surgeon will rarely succeed in obtaining anything like a satisfactory view of the vessel, but can expose it for the ligature by the aid of his finger-nail. An ordinary aneurism-needle will generally suffice for the conveyance of the ligature.

The difficulties may occasionally be much increased by special circ.u.mstances, such as great stoutness of the patient, and consequent thickness of the abdominal wall; or large size of the aneurism, which may cause alterations in the relation of parts and adhesion of the peritoneum. The ureter generally gives no trouble, as in pressing back the peritoneum it is adherent to it, and is removed along with it towards the middle line.

_Results._--Are not by any means satisfactory.

Out of twenty-two cases in which the common iliac has been tied for aneurism, eight recovered and fourteen died; while out of thirteen cases where it required ligature for haemorrhage after amputation, rupture of aneurism, etc., only one recovered.