The objections to these methods are various: the more gentle are uncertain and inefficient; of the more severe, some involve mutilation, by the loss or removal of the t.e.s.t.i.c.l.e; others, as those of Langenbeck and Schmucker, are very dangerous and fatal, by the inflammation spreading to the peritoneal cavity (20 to 30 per cent. died); while all of these methods afford at best only temporary relief. And this is only what might have been expected, for the sac was only a _result_ of the protrusion, not a _cause_; and so long as the weakness and insufficiency of the parietes of the abdomen remain, so long will the extensible loosely-attached peritoneum continue to furnish new sacs for visceral protrusions.

3. We have now only the ca.n.a.l left to act upon; and the operations on the ca.n.a.l may be divided into two great cla.s.ses:--

(_a._) Those in which the operator attempts to plug up the dilated ca.n.a.l. (_b._) Those in which he tries to constrict it, by reuniting its separated sides.

(_a._) Attempts to plug the ca.n.a.l have, in most cases, been made by inv.a.g.i.n.ation of the skin of the s.c.r.o.t.u.m and its fascia. These have been very numerous and various in their adaptation of mechanical appliances, but have all been designed with the same object. Dzondi of Halle, and Jameson of Baltimore, incised lancet-shaped flaps of skin, and endeavoured to fix them by displacement over the ring. Gerdy inv.a.g.i.n.ated a portion of s.c.r.o.t.u.m and fascia into the enlarged ca.n.a.l, by the forefinger pushed it up, and secured it in its place by a thread pa.s.sed from the point of his finger first through the inv.a.g.i.n.ated skin, then through the abdominal walls, endeavouring to include the walls of the inguinal ca.n.a.l, causing the point of the needle to project some lines above the inguinal ring; the same process being effected with the other end of the thread on the other side of the finger, and the two ends which have been brought out near each other on the abdominal wall, being tied tightly over a cylinder of plaster. The ensheathed sac was then painted with caustic ammonia to excite inflammation, and a pad put on over all.

Signoroni modified this by fixing the inv.a.g.i.n.ated skin by a piece of female catheter, retained in its place by transfixion by three harelip needles, tied by twisted sutures.

Wutzer of Bonn, again, modified this, by subst.i.tuting a complicated instrument, consisting of a stout plug in the inguinal ca.n.a.l, held in position by needles which are pa.s.sed through the anterior wall of the ca.n.a.l in the groin. Compression between plug and compress, with the intention of causing adhesion between skin, fascia, and sac, is then managed by means of a screw. The plug is retained for about seven days.

Modifications of this method have been tried by Wells, Rothmund, and Redfern Davies, all aiming in the direction of simplicity; but by far the most simple and efficacious method on the Wutzer principle yet devised is that of Professor Syme, which he described in the pages of the _Edinburgh Medical Journal_ for May 1861, in which the inv.a.g.i.n.ation of integument is both simply and securely managed by strong threads, as in Gerdy's method, while a piece of bougie or gutta-percha, to which the threads are fixed, replaces Wutzer's expensive and complicated apparatus. Sir J. Fayrer of Calcutta has had a very large experience of Wutzer's method, and also of a plan of his own. Out of 102 cases by the latter method, 77 were cured, 9 relieved, 14 failed, and 2 died.[147]

Mr. Pritchard of Bristol has proposed an additional step in operations on the inv.a.g.i.n.ation principle, consisting in the stripping of a thin slip of skin from the orifice of the cutaneous ca.n.a.l, and then putting a pin through the parts to get them to unite, and thus close the aperture completely.

Now, what results follow these operations? At first they are almost invariably successful, but the complaint is that, in most cases, the rupture recurs. The principle is to plug up the pa.s.sage by the mechanical presence of the inv.a.g.i.n.ated skin, the plug being retained in position by adhesive inflammation between it and the edges of the dilated ring. But the ring is left dilated, or, indeed, generally its dilatation is increased; and as, on continued pressure from within, the new adhesions give way, or, as often happens, a new protrusion takes place in the circular _cul-de-sac_ necessarily left all round the apex of the inv.a.g.i.n.ation, the still lax ring and ca.n.a.l offer no resistance to the protrusion.

(_b._) The principle of constriction of the ca.n.a.l by reuniting its separated sides. This is the principle of the various methods introduced by Mr. Wood of King's College, and described by him in his most able and exhaustive work.[148]

He applies sutures through the sides of the dilated inguinal or crural ca.n.a.ls, or umbilical openings, in such a manner as to insure their complete closure.

1. _For inguinal hernia._--To st.i.tch together the two sides of the ca.n.a.l with safety requires attention to several points--(1.) That it be done nearly, if not entirely, subcutaneously. (2.) That the protruding bowel should be kept out of the way, and not be transfixed by the needle. (3.) That the spermatic cord should be protected from injurious pressure.

These different indications are attained by Mr. Wood by a very ingenious mode of operating, which I can describe here only briefly, and for a full description of which I must refer to Mr. Wood's own monograph already alluded to.

For his first twenty cases Mr. Wood used strong hempen thread for the st.i.tches; of late, however, he has proved the greater advantage of strong wire.

When a large old hernia in an adult is the subject of operation, it is thus performed by Mr. Wood:--The p.u.b.es being shaved, and the patient put thoroughly under the influence of chloroform, the rupture is reduced, and the operator's forefinger forced up the ca.n.a.l so as to push every morsel of bowel fairly into the abdomen. An a.s.sistant then commands the internal ring by pressure, to prevent return of the rupture.

An incision is made in the s.c.r.o.t.u.m over the fundus of the sac, large enough to admit a forefinger and the large needle used in the operation; the edges of the skin are to be separated from the fascia below for about one inch all round. The forefinger is then to be pa.s.sed in at the aperture and pushed upwards, inv.a.g.i.n.ating the detached fascia before it, and it must be made to enter the inguinal ca.n.a.l far enough to define the lower border of the internal oblique muscle stretched over it. A large curved needle (unarmed) is then pa.s.sed on the finger as a guide, through the internal oblique tendon, the internal portion of the ring, and the skin of the abdomen; it is then threaded and withdrawn. Again, the needle (now with a thread) is guided by the finger and pushed through Poupart's ligament and the external pillar of the ring as before; while by a little manipulation its point is made to protrude through the same opening in the skin as before, a loop of thread is now left there, and the needle, still threaded, is again withdrawn. The next st.i.tch, still guided on the finger, takes up the tendinous layer of the triangular aponeurosis covering the outer border of the rectus tendon close to the pubic spine; the point of the needle is then turned obliquely, so as to protrude through the original puncture in the skin a third time, the needle is then freed from the thread and withdrawn, thus leaving two ends and one intermediate loop of thread all at the one opening. These are so arranged that when they are tightened they draw together the sides of the ca.n.a.l; they are then secured over a compress of lint. The compress is removed and the st.i.tches loosened, at dates varying from the third to the seventh day.

Mr. Wood now uses wire instead of thread. It has the advantage of greater firmness, excites less suppuration, and may be left much longer _in situ_, in consequence of which there is less risk of suppuration or pyaemia, and more chance of a good consolidation of the parts.

In congenital herniae, and small ruptures in children and young boys, Mr. Wood uses rectangular pins in the following manner:--The s.c.r.o.t.u.m being inv.a.g.i.n.ated (without any incision through the skin) as far as possible up the ca.n.a.l, a rectangular pin, with a slightly-curved spear-pointed head, is pa.s.sed through the skin of the groin to the operator's forefinger; guided by it, it is brought safely down the ca.n.a.l, and brought out through the skin of the s.c.r.o.t.u.m just over the fundus of the hernial sac. A second pin is pa.s.sed from the lower opening (still guided by the finger) in an upward direction, transfixing in its course the posterior surface of the outer pillar of the superficial ring, its point being brought out through, or at least close to, the first puncture made by the first pin. The pins are then locked in each other's loops--the punctures and skin protected by lint or adhesive plaster,--and the whole is retained by lint and a spica bandage.

The pins should generally be withdrawn about the tenth day.

The author has now in many cases st.i.tched with catgut the edges of the ring after the ordinary operation for hernia with the best effect.

2. _For Femoral Rupture._--Cases suitable for operation are very infrequent; but should such a one be met with, Mr. Wood proposes the following operation on the same plan as the preceding. The hernia being fully reduced and the parts relaxed by position, an incision about an inch long should be made over the fundus of the tumour, and its edges raised so as to admit the finger fairly into the crural opening. The vein is then to be pushed inwards, and the needle pa.s.sed through the pubic portion of the fascia lata of the thigh, and then through Poupart's ligament, appearing on the skin of the abdomen, a wire is then pa.s.sed through the eye of the needle and hooked down, appearing through the wound, it is then withdrawn, and the needle again pa.s.sed through the pubic portion of the fascia lata, but about three-quarters of an inch to the inside of the first puncture, then through Poupart's ligament again, and protruded through the same orifice in the skin; the other end of the wire is then hooked down as before, leaving a loop above, at the needle orifice, and two ends at the wound in the skin below. Both loops and ends must be managed as before.

The author after operating for the relief of strangulation in a case of very large femoral hernia in a girl aged 23, st.i.tched up the neck of the sac, and also st.i.tched it to Gimbernat's ligament.

The result for some months was admirable, though the hernia had been a very difficult one to replace from its size, and had been long in the habit of coming down. Eventually protrusion occurred to a very slight extent, but a truss keeps it completely up.

3. _For Umbilical Rupture._--The principle involved in Mr. Wood's operation for umbilical rupture is precisely the same as for inguinal and crural. It consists in st.i.tching the two edges of the tendinous aperture by wire; the needle is pa.s.sed on a sort of small scoop or broad grooved director, which at once inv.a.g.i.n.ates the skin and protects the bowel. Two st.i.tches are thus inserted on each side. For the ingenious method by which they are introduced subcutaneously, I must refer to the detailed description in Mr. Wood's monograph. The wires are thus twisted and tightened over a pad of lint or wood, drawing together the edges of the opening in the tendon.

OPERATIONS FOR ARTIFICIAL a.n.u.s.--In children the condition known as imperforate a.n.u.s may sometimes be remedied by exploratory operations in the perineum, guided by the protrusion caused by the distended intestine. There are other cases, however, in which the r.e.c.t.u.m, as well as the a.n.u.s, seems to be deficient, and in which, from the want of protrusion, there is no warrant for attempting an operation there; in these the only chance of life that remains is in an attempt to open the bowel higher up.

In adults, again, absolute closure of the r.e.c.t.u.m and a.n.u.s, and complete obstruction, may be the result of malignant disease, or even, very rarely, of simple organic stricture.

In such cases, where the patient is tolerably strong and yet evidently doomed from the complete obstruction, an attempt at the formation of an artificial a.n.u.s is warrantable, and in many cases afford great relief, and prolongs life for months.

Without going into all the various positions proposed for such operations, I select the two most warrantable, which have borne the test of experience. These are--1. Colotomy in the left loin. This is applicable in the case of adults with rectal obstruction. 2. Colotomy in the left groin applicable in cases of imperforate a.n.u.s and deficiency of r.e.c.t.u.m in infants.

1. _Colotomy in the left loin_, generally known by the name of _Amussat's operation_.--The patient is laid upon his face, a pillow placed under the abdomen, rendering the left flank prominent. A transverse incision should then be made at a level about two finger-breadths above the crest of the ilium, extending from the outer edge of the erector spinae muscle forward for four or five inches, according to the fatness of the patient; the muscles must then be carefully divided till the transversalis fascia is exposed. It is then to be pinched up and divided, as in the operation for strangulated hernia. The muscular wall of the colon uncovered by peritoneum is then in most cases very easily recognised from its immense distension. The bowel should then be hooked up by a curved needle, two or three points at least secured to the margins of the wounds by st.i.tches, and then the bowel should be opened by a longitudinal incision of at least an inch in length. When the distension has been great, there is generally a rush of fluid faeces, which must be provided for, special care being taken lest any get into the cavity of the peritoneum.

[Ill.u.s.tration: FIG. x.x.xIII.[149]]

2. _Colotomy in the left groin_, for absence of a.n.u.s and deficiency of r.e.c.t.u.m in newly born infants.--The dissections of Curling, Gosselin, and others have shown that in infants the operation of lumbar colotomy is very difficult, and its results uncertain, while it is comparatively easy to open the colon in the left groin. Huguier, again, has shown that in certain cases the colon is not to be found in the left groin, but is accessible in the right groin. This abnormality seems, as shown by Curling, to occur not oftener than once in every ten cases.

_Operation._--An oblique incision from an inch and a half to two inches in length should be made in the left iliac region above Poupart's ligament, extending a little above the anterior-superior spinous process of the ilium. The fibres of the abdominal muscles should be divided on a director pa.s.sed beneath them, and the peritoneum should next be cautiously opened to a sufficient extent. The colon will most likely protrude, but if small intestine appear the colon must be sought for higher up. A curved needle armed with a silk ligature should be pa.s.sed lengthways through the coats of the upper part of the colon, and another inserted in the same way below, and the bowel, being drawn forwards, should then be opened by a longitudinal incision. The colon must afterwards be attached to the skin forming the margin of the wound by four sutures at the points of entry and exit of the needles.

OPERATION FOR THE REMOVAL OF AN ARTIFICIAL a.n.u.s, in cases where the bowel is patent below.--After the operation for hernia in a case where the bowel is gangrenous, the only hope of the patient's recovery consists in the formation of adhesions between the bowel and the external wound, and the presence, for a time at least, of an artificial a.n.u.s. If adhesions do form, and the patient recovers, it becomes a matter of great importance for his future comfort that the ca.n.a.l of the intestine should be re-established, and the fistulous opening allowed to close. This, however, is by no means easy, as even when the portion of intestine destroyed has been very small, a septum or valve remains which directs the contents of the bowel outwards, and so long as it exists is an effectual obstacle to any of the faecal contents pa.s.sing into the distal portion of the bowel. This septum or eperon is formed by the mesenteric side of the two ends of the bowel. To destroy this without causing peritonitis is the aim of the surgeon, and it is not an easy matter to accomplish. To cut it away would at once open the peritoneal cavity, so the mode of treatment now adopted in the rare cases where it is necessary is that recommended by Dupuytren. The principle of it is to destroy the eperon by pressure so gradual as to cause adhesive inflammation between the two surfaces, and thus seal up the cavity of the peritoneum, before the continuance of the same pressure shall have caused sloughing of the septum. This is managed by the gradual approximation by a screw of the blades of a pair of forceps, to which Dupuytren gave the name Enterotome. The process, which extends over days and weeks, must be carefully watched lest the inflammation go too far.

Plastic operations are occasionally required to close the opening after the pa.s.sage is restored. For a good example of such an operation see _Edin. Med. Journal_ for August 1873, in which Mr. John Duncan describes a case.

FOOTNOTES:

[141] _Description of Sir Spencer Wells's Trocar._--"It consists of a hollow cylinder six inches long, and half an inch in diameter, within which another cylinder fitting it tightly plays. The inner one is cut off at its extremity, somewhat in the form of a pen, and is sharp. The sharp end is kept retracted within the outer cylinder by a spiral spring in the handle at the other end, but can be protruded by pressing on this handle when required for use. When thus protruded it is plunged into the cyst up to its middle; the pressure on the handle is taken off, and the cutting edge is retracted within its sheath. The fluid rushes into the tube, and escapes by an aperture in the side, to which an india-rubber tube is attached, the end of which drops into a bucket under the table.

The instrument is furnished at its middle with two semicircular bars, carrying each four or five long curved teeth like a vulsellum. These teeth lie in contact with the outer surface of the cylinder, but can be raised from it by pressing two handles. When the cyst begins to be flaccid by the escape of the fluid, these side vulsellums are raised, and the adjoining part of the cyst is drawn up under the teeth, where it is firmly caught and compressed against the side of the tube."

[142] For further details on the operations described above, reference may be made to Sir Spencer Wells's work on ovarian disease, and to the very valuable papers contributed by Dr. Thomas Keith to the _Edinburgh Medical Journal_. To the latter especially the author is indebted for much oral instruction, and for the opportunity of seeing his careful and dexterous mode of operating.

[143] _Lect. on Surgery_, 3d ed., vol. ii. p. 998.

[144] _Operative Surgery_, p. 462.

[145] Rough diagram of abnormal course of obturator and its relation to the neck of a hernia. Parts seen from the inside: H, femoral hernia; A, femoral artery; V, femoral vein; E, epigastric artery; O, obturator from epigastric (dangerous); S O, obturator from epigastric (safe); N O, normal course of obturator; I R, internal inguinal ring; Sp C, spermatic chord and its vessels; G, Gimbernat's ligament; +, in triangle of Hesselbach.

[146] Holmes's _Surgery_, 3d ed., 1883, vol. ii. p. 837.

[147] _Clinical and Pathological Observations in India_, pp. 44, 325.

[148] Wood _On Rupture_, 1863.

[149] Diagram of an artificial a.n.u.s, showing small sutures which unite the edges of the gut and the skin, and the large ones st.i.tching up the wound beyond.

CHAPTER XII.

OPERATIONS ON PELVIS.

LITHOTOMY.--However interesting and even instructive it might be, any history of the various operations for the removal of calculi from the bladder would be quite out of place in a manual such as this. It will be sufficient here to describe the operations recommended and practised in the present day.