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Signoroni modified this by fixing the invaginated skin by a piece of female catheter, retained in its place by transfixion by three harelip needles, tied by twisted sutures.
Wützer of Bonn, again, modified this, by substituting a complicated instrument, consisting of a stout plug in the inguinal canal, held in position by needles which are passed through the anterior wall of the canal 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 Wützer 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 invagination 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 Wützer's expensive and complicated apparatus. Sir J. Fayrer of Calcutta has had a very large experience of Wützer'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.148
Mr. Pritchard of Bristol has proposed an additional step in operations on the invagination principle, consisting in the stripping of a thin slip of skin from the orifice of the cutaneous canal, 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 passage by the mechanical presence of the invaginated 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 invagination, the still lax ring and canal offer no resistance to the protrusion.
(b.) The principle of constriction of the canal 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.149
He applies sutures through the sides of the dilated inguinal or crural canals, or umbilical openings, in such a manner as to insure their complete closure.
1. For inguinal hernia.—To stitch together the two sides of the canal 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 stitches; 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 pubes being shaved, and the patient put thoroughly under the influence of chloroform, the rupture is reduced, and the operator's forefinger forced up the canal so as to push every morsel of bowel fairly into the abdomen. An assistant then commands the internal ring by pressure, to prevent return of the rupture.
An incision is made in the scrotum 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 passed in at the aperture and pushed upwards, invaginating the detached fascia before it, and it must be made to enter the inguinal canal far enough to define the lower border of the internal oblique muscle stretched over it. A large curved needle (unarmed) is then passed 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 stitch, 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 canal; they are then secured over a compress of lint. The compress is removed and the stitches 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 pyæmia, and more chance of a good consolidation of the parts.
In congenital herniæ, and small ruptures in children and young boys, Mr. Wood uses rectangular pins in the following manner:—The scrotum being invaginated (without any incision through the skin) as far as possible up the canal, a rectangular pin, with a slightly-curved spear-pointed head, is passed through the skin of the groin to the operator's forefinger; guided by it, it is brought safely down the canal, and brought out through the skin of the scrotum just over the fundus of the hernial sac. A second pin is passed 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 stitched 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 passed 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 passed through the eye of the needle and hooked down, appearing through the wound, it is then withdrawn, and the needle again passed 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, stitched up the neck of the sac, and also stitched 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 stitching the two edges of the tendinous aperture by wire; the needle is passed on a sort of small scoop or broad grooved director, which at once invaginates the skin and protects the bowel. Two stitches 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 Anus.—In children the condition known as imperforate anus 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 rectum, as well as the anus, 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 rectum and anus, 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 anus 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 anus and deficiency of rectum 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 spinæ 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 stitches, 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 fæces, which must be provided for, special care being taken lest any get into the cavity of the peritoneum.
Fig. xxxiii. 150
2. Colotomy in the left groin, for absence of anus and deficiency of rectum 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 passed 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 passed 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 Anus, 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 anus. If adhesions do form, and the patient recovers, it becomes a matter of great importance for his future comfort that the canal 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 fæcal contents passing into the distal portion of the bowel. This septum or éperon 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 éperon 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 passage 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.
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.
There are three different situations in which the bladder may be entered for the purpose of removing a calculus:—
1. The perineum, where access is gained through the urethra, prostate, and neck of the bladder.
2. Above the pubes, where the portion of bladder not covered by peritoneum is opened from above.
3. From the rectum.
1. Lithotomy through the Perineum, by far the most frequent position for the operation.—Very various methods for its performance have been devised, differing in the nature and shape of the instruments employed, the direction and size of the incisions, the nature of the wound; but all resemble each other in certain very cardinal and important particulars. Thus all agree that it is absolutely necessary to enter the bladder at one spot—the neck of the bladder; and that to do this safely the urethra must be opened, and some instrument previously introduced by the urethra is to be used as a guide for the knife. But an instrument in the urethra and bladder is surrounded for at least an inch of its course by the prostate; and thus the knife, gorget, or finger, which, guided by the instrument in the urethra, is intended to cut or dilate the entrance to the bladder for the purpose of allowing the calculus to be removed, cannot do this without also cutting or dilating this prostate gland. Experience has proved that much of the success of the operation depends upon the position and amount of incision made in this prostate gland. But it might be asked, Why can we not enter the bladder by one side, avoiding altogether its neck and this prostate gland? For this, among other reasons, that the bladder normally contains, and so long as the patient lives must contain, a certain quantity of a very irritating fluid. It is surrounded by the loose areolar tissue of the pelvis, into which, if any of this fluid escapes, abcesses will form and death probably ensue; this result will almost certainly follow any opening made into the bladder except at one spot. This spot is the neck of the bladder. Why does urinary infiltration not occur there? Because the fascia of the pelvis (which when entire can resist infiltration) is prolonged forwards at the neck of the bladder, over the prostate (Fig. xxxiv. pf), for which it forms a very strong funnel-like sheath. So long as this sheath is not cut where it covers the sides of the prostate, urinary infiltration of the pelvis is impossible, the urine being carried forwards and fairly out of the pelvis in this urine-tight funnel.
Fig. xxxiv. 151
But it may now be said, If this be the case, we are very much limited in the size of the incision we may make into the bladder. We cannot remove a large stone, for the prostate ought not to be larger than a good-sized chestnut, and any cut we might make through a chestnut without cutting out of its side must be very small. Very true; but fortunately the sheath of the prostate, unlike the rind of the chestnut, is very freely dilatable, and will allow the passage of a very considerable stone.
Again, an inquirer might ask, If it is so dilatable, why should we run the risk of cutting the prostate at all? Why should we not introduce instruments gradually increasing in size into the membranous portion of the urethra, and thus dilate prostate and neck of bladder? For this reason, that the urethral canal passing through the prostate is itself lined immediately outside of the mucous membrane by a firm membranous sheath (Fig. xxxiv. rr), which resists dilatation to the utmost. Experience tells us that any attempts to dilate or even forcibly to tear this ring of fibrous texture are both ineffectual and dangerous, while a clean cut into it and through it into the substance of the prostate is at once effectual and comparatively safe.
In a word, we can describe the relation of the prostate to the operation of lithotomy somewhat in this manner:—Its fibrous sheath surrounding the urethra must be cut freely. The gland substance may be cut and freely dilated by the finger. Its fibrous envelope must, as far as possible, be preserved intact, but this interferes the less with the operation, as it is comparatively freely dilatable.
The firm lining of the urethra, which must be cut, is specially strong at its base, forming a tough resisting band just at the aperture of the bladder, which, unfortunately, is often so high up in the pelvis in tall patients, or in cases in which the prostate is much enlarged, as to be almost out of reach of the finger, and so far up the staff as perhaps to escape division. You will be warned of such an occurrence by the urine in the bladder failing to make its appearance; and if any attempt be made to dilate the opening and introduce the forceps without further incision of the base of the prostate, the result will very likely be fatal, generally from pyæmic symptoms depending on a suppurative inflammation of the prostatic plexus of veins (Fig. xxxiv.). In fact, upon a recognition of this fact is founded the aphorism, "that cases in which the forceps have been introduced before the bladder fairly begins to empty its contents are generally fatal."
Fig. xxxv. 152
We have thus traced the necessary guiding principles as to our incisions from the bladder outwards through the prostatic portion of the urethra. We have next to discover what sort of an opening is necessary in the membranous portion of the urethra consistent with the fulfilment of the same conditions, namely, freedom of escape for the urine, and room enough to remove the stone. Both of these are gained at once by a free incision of the membranous portion, dividing especially those anterior fibres of the great sphincter muscle of the pelvis, the levator ani, which embrace the membranous portion, under the special names of compressor (Fig. xxv.) and levator urethræ (Guthrie's and Wilson's muscles).
The principles which guide the position and size of the preliminary incisions which enable the urethra to be opened are very simple:—(1.) The wound in the perineum should be large enough to give free access to the urethra, and easy egress to the stone; (2.) It should be conical, with its base outwards, so as to favour escape of urine and prevent infiltration; (3.) It should not wound any important organ or vessel; that is, it must avoid the rectum, the corpus spongiosum, especially the bulb, if possible, the artery of the bulb, and in every case should leave the pudic artery intact.
So far for broad general principles, which must guide all methods of successful lithotomy.
The Lateral Operation.—Operation of Cheselden.—(1.) Instruments required.—A staff with a broad substantial handle, and a longer curve than the ordinary catheter requires, furnished with a very deep and wide groove, which occupies the space midway between its convexity and its left side. The one used should invariably be large enough to dilate fully the urethra.
A knife, with its blade three or four inches in length, but sharp only for an inch and a half from its point, its back straight up to within a sixth of an inch of its point, and there deflected at an angle to the point, which again curves to the edge. The angle from the back to the point permits the knife to run more freely along the groove in the staff.
A probe-pointed straight knife with a narrow blade may occasionally be useful in enlarging the incision in the prostate, when this is required by the size of the stone.
Forceps of various sizes and shapes, some with the blades curved at an angle to reach stones lying behind an enlarged prostate, all with broad blades as thin as is consistent with perfect inflexibility, the blades hollowed and roughened in the inside, but without the projecting teeth sometimes recommended, which are dangerous from being apt to break the stone.
A scoop to remove fragments or small stones, sometimes useful with the aid of the forefinger in lifting out a large one.
A flexible tube of at least half an inch calibre, and about six inches long, rounded off and fenestrated above, fitted at its outer end with a ring and two eyelet-holes for the tapes, with which it is tied into the bladder.
Prior to the operation the patient's health should be attended to, the stomach and bowels regulated, and any disorder of the kidneys or bladder as far as possible alleviated. If his health has been good and habits active, three or four days' confinement to his room on low diet, with a full purge the evening before the operation, is all the preparatory treatment that is necessary.
It is of the utmost importance for the safety of the operation and the patient's comfort after it, that the rectum be completely unloaded before the operation, and the bowels so far emptied as to permit three or four days after the operation to elapse without any movement of the bowels being necessary. If there is any doubt as to the effect of the laxative, a large stimulant enema should be administered on the morning of the operation.
Position.—Much depends on the proper tying up of the patient. He should be placed with his breech projecting over the edge of a narrow table, with head slightly raised on a pillow, but the shoulders low. The hands are then to be secured each to its corresponding foot, by a strong bandage passing round wrist and instep, or by suitable leather anklets, the knees should be wide apart, and on exactly the same level, so that the pelvis may be quite straight. An assistant should be placed to take charge of each leg.
The staff is next introduced and the stone felt; if there is little water in the bladder a few ounces may be injected, but this is rarely necessary, for the patient should be ordered to retain as much water as possible, and when he cannot retain it, injection of water may do harm, and will probably not be retained, but at once come away along the groove in the staff. The staff is then committed to a special assistant, who must be thoroughly up to his duty, and attend to the staff alone.
Some surgeons direct the assistant to make the convexity of the staff bulge in the perineum, to enable the groove to be struck more easily. It will be, however, safer both for the rectum and the bulb, if the staff be hooked firmly up against the symphysis pubis, as advised by Liston. The same assistant can also keep the scrotum up out of the way.
If the perineum has not been previously shaved, this is now done.
The operator sits down on a low stool in front of the patient's breech, his instruments being ready to his hand, and then steadying the skin of the perineum with the fingers of his left hand, enters the point of the knife in the raphe of the perineum, midway between the anus and scrotum (one inch in front of anus—Cheselden, Crichton; one and a quarter—Gross, Skey, and Brodie; one and three-quarters—Fergusson; one inch behind the scrotum—Liston), and carries the incision obliquely downwards and outwards, in a line midway between the anus and tuberosity of the ischium. The length of the incision must vary with the size of the perineum, and the supposed size of the stone, but there is less risk in its being too large, so long as the rectum is safe, than in its being too small. Its depth should be greatest at its upper angle, where it has to divide the parts to the depth of the transverse muscle of the perineum, and least at its lower angle, where a deep incision is not required, and would be almost sure to wound the rectum.
The forefinger of the left hand is now to be deeply inserted into the wound, and any remaining fibres of the levator ani in front are to be divided, the edge of the knife being directed from above downwards. The left forefinger being still used to push its way through the cellular tissue, the groove in the staff is now felt in the membranous portion of the urethra covered by the deep fascia of the perineum. Now comes the deeper part of the incision. Guided by the finger-nail of the left hand, the surgeon introduces the point of the knife into the groove of the staff. He then takes hold of the staff for a moment to feel that it is held up properly against the pubis, and in the middle line, and also that the knife is fairly in the groove. Giving the staff back again to the assistant, and keeping the rectum well out of the way by the left hand, he now steadily directs the knife along the groove of the staff till the bladder is fairly entered, and the ring at the base of the prostate completely divided. When this is the case a gush of urine takes place, following the withdrawal of the knife.
When making the deep incision, and in the groove of the staff, the blade of the knife should lie neither vertical nor horizontal, but midway between the two, so as to make the section of the left lobe of the prostate in its longest diameter, that is, in a direction downwards and backwards (Fig. xxxiv. L).
The knife is now withdrawn, and the left forefinger inserted. In most cases it will be long enough to reach the bladder and touch the stone, and may then be freely used by gradual pressure to dilate the wound; this may be done very freely when necessary for a large stone, if only the ring of fibrous tissue surrounding the urethra be first cut and the bladder fairly entered. Whenever the stone is felt by the finger, the assistant may withdraw the staff.
When the operator has thus felt the stone and sufficiently dilated the wound, the next step is to introduce the forceps; this should be done under the guidance of the finger, and with the blades closed. When the stone is felt the blades should be opened very widely, slightly withdrawn, and then pushed in again, the lower one, if possible, being insinuated under the stone. The blades must be made fairly to grasp and contain the stone in their hollow, for if they only nibble at the end of an oval stone, extraction is impossible. Extraction should then be performed slowly, with alternate wrigglings of the forceps from side to side, so as gradually to dilate, not to tear, the prostate, and the operator must remember to pull in the axis of the pelvis, not against the os pubis or the promontory of the sacrum.
If there is much resistance, it may possibly be caused by the stone having been caught in its longer axis, and this may be remedied by careful manipulation by means of the finger and forceps. If the stone is still too large to be extracted without greater force than is warrantable, there are still various expedients (see infra, pp. 265, 270).
In most cases, however, the stone is removed rapidly enough by the single incision. The finger, or a sound, must then be introduced to feel if any more stones are present. The closed forceps make a very effectual instrument for this purpose. Much information may be gained from the appearance of the first stone, the presence or absence of facets. Its smoothness or roughness enables us to form a pretty certain opinion; yet the bladder should always be carefully searched; and if the stone has been friable or broken in extraction, should be washed out by a current of water. Where the calculi are very numerous, or where many fragments have separated, the scoop will be found useful, both for detecting and removing them. All the stones being extracted, there is in most cases little or no bleeding (see infra, Hæmorrhage). The tube already described may now be inserted and tied into the bladder. It may be retained for forty-eight or seventy-two hours, according to circumstances. Care must be taken lest it be closed up by coagula during the first hour or two after the operation. In children the tube is not necessary, and from their restlessness might possibly do harm, but in adults (though neglected by some surgeons) experience shows it is a valuable adjunct in the after-treatment.
