Since the above was written the operation of Litholapaxy has made great strides in the favour of surgeons, and many stones that would have been removed by lithotomy are now broken down by powerful instruments at a single sitting, and removed piecemeal by the suction apparatus.S. W. Gross has collected 312 cases, of which 17 died or 5.45 per cent., but of 180 done by experienced surgeons, Thompson, Bigelow, Van Buren, Weir, and Stevenson only five died, or 3.33 per cent., while of 1470 cases of lithotrity, as formerly practised, 159, or 10.81, per cent. died.[153]
Since the above was written the operation of Litholapaxy has made great strides in the favour of surgeons, and many stones that would have been removed by lithotomy are now broken down by powerful instruments at a single sitting, and removed piecemeal by the suction apparatus.
S. W. Gross has collected 312 cases, of which 17 died or 5.45 per cent., but of 180 done by experienced surgeons, Thompson, Bigelow, Van Buren, Weir, and Stevenson only five died, or 3.33 per cent., while of 1470 cases of lithotrity, as formerly practised, 159, or 10.81, per cent. died.[153]
Operations for Stricture of Urethra.—Under this head many manipulations and operations might be described; the very instruments devised being exceedingly numerous and complicated. Enough here to detail a few of the more simple and practical procedures under the different heads of—1.Dilatationgradual and forced. 2.Internal Division.3.External Division.
1.Dilatation.—Under this head we have—
a.Vital dilatation.—The passing of a succession of bougies, gradually increasing in diameter, at intervals ofthree or four days, for the purpose of exciting an amount of interstitial absorption in the new material constituting the stricture, sufficient to remove it. Passing a bougie, though certainly often very difficult, perhaps should hardly come into the category of surgical operations, yet to preserve a certain completeness in the account of stricture, a very brief description may be here inserted.
The recumbent posture is in most cases to be preferred. The patient should lie flat on his back, with the knees slightly bent and separated, and the head and shoulders slightly raised on a pillow. The operator standing on the patient's left side, raises the penis in his left hand, and with the right introduces the instrument, previously warmed and oiled, into the meatus. He then pushes it very gently onwards, at the same time stretching the penis with the left hand, just so far as to efface any wrinkles in the mucous membrane, till the point reaches the bulbous portion. The axis of the instrument, which at first for convenience was over the left groin, has now gradually been approaching the middle line. When this is reached, the instrument should be raised from the abdomen, and the handle cautiously carried in the arc of a circle first upwards and then downwards, till, when the instrument is fairly into the bladder, the handle is depressed between the patient's thighs. While this is being done the operator's left hand should be withdrawn from the penis, and the points of the fingers applied to the perineum.
In cases of difficulty certain points may be remembered:—
(1.) That the point of the instrument may in the first inch or two be occasionally entangled in a lacuna in the roof, especially when a small instrument is used; hence the beak should be at first maintained against the inferior wall of the canal.[154]
(2.) That the handle should not be depressed too soon; if it is, there is a risk of a false passage being made through the upper wall.
(3.) The opposite error may force the point out of the urethra between the membranous portion and the rectum, and onwards into the substance of the prostate gland.
And certain cautions may be given:—
(1.) In every exploration of an unknown urethra the surgeon should commence with an instrument of medium size, certainly not less than No. 7 or 8.
(2.) In cases of difficulty occurring in the urethra behind the scrotum, invariably use the forefinger of the left hand in the rectum as a guide.
(3.) Expression of pain on the part of the patient is no indication that a false passage is being made, nor its absence that the instrument is in the passage, for it is a remark of Mr. Syme, that passing an instrument through a stricture is generally more painful than making a false passage through the walls of the urethra.
An instrument may be passed, while the patient is erect, with the following precautions:—The patient should stand with his back against a wall, his arms supported on the back of a chair on each side, heels eight or ten inches apart, and four or five inches from the wall; his clothes thoroughly down, not merely opened. The bougie should then be held nearly horizontal, with its concavity over the left groin of the patient, the penis being raised in the surgeon's left hand. Introduced thus for four or five inches, the handle is gradually raised into the middle line of the abdomen, and to the perpendicular; it is then to be lightly depressed, and, as the point enters the bladder, brought down towards the operator until it sinks beneath the horizontal line.
An instrument may be passed, while the patient is erect, with the following precautions:—The patient should stand with his back against a wall, his arms supported on the back of a chair on each side, heels eight or ten inches apart, and four or five inches from the wall; his clothes thoroughly down, not merely opened. The bougie should then be held nearly horizontal, with its concavity over the left groin of the patient, the penis being raised in the surgeon's left hand. Introduced thus for four or five inches, the handle is gradually raised into the middle line of the abdomen, and to the perpendicular; it is then to be lightly depressed, and, as the point enters the bladder, brought down towards the operator until it sinks beneath the horizontal line.
b.Mechanical dilatationis of two kinds, both very rarely used:—(1.) When an instrument cannot be passed, it consists of passing down day after day the point of an instrument (sometimes armed with caustic, sometimes not), and pressing it against the stricturetill it is overcome.[155](2.) When an instrument is introduced through an intractable stricture, and is left there either for some hours, or for some days, to excite what is called "suppuration" of the stricture.[156]
c.Forced dilatation.—Under this head we might describe at great length mechanical contrivances to force or rupture a stricture. A word or two on a few of the most important:—
(1.) Conical bougies of steel or silver.
(2.) Mr. Wakley's method, on which many others have been founded. He passed a small bougie or wire into the bladder, over which were slipped straight tubes of varying size, with perfect certainty that they could not leave the urethra.
(3.) Mr. Holt's method.[157]—The principle of it is to rupture the stricture at once, so that a No. 12 catheter can immediately be passed into the bladder.
He attains this object by means of an instrument composed of two grooved blades, united about one inch from their apex, into a conical sound, which at its apex is about the size of a No. 2 bougie. This is passed into the bladder, and the grooved blades are separated to any extent that is desired by passing down between them a straight rod equal in size of a No. 8, 10, or 12, bougie. To guide this properly it is made hollow, and it is passed down over a central wire which lies between the grooved blades of the instrument and is welded to the apex. A great improvement is effected on Mr. Holt's later instruments by this wire being made hollow, and fitted with a stilette, for by this means we can with certainty ascertain whether or not the instrument has been passed into the bladder. This instrument, which is an improvement upon one inventedby Perrève nearly forty years ago, has been used on very many occasions by Mr. Holt and others with success. The risk to life, if the case be properly managed, is trifling, but, like every other means of treating stricture, it has the objection that the stricture is liable to recur, unless bougies be passed at intervals for months and years.
Sir Henry Thompson has introduced and described another very ingenious instrument for the same purpose, constructed on somewhat similar principles. His account of it, to which I must refer, will be found in Holmes'sSystem of Surgery, 1st ed. vol. iv. p. 399.
2.Internal Division of Strictureis a mode of treatment which by many surgeons is highly disapproved, yet of late years it has been more used than formerly, especially in resilient strictures. It may be done in two ways:—
(1.)From before backwards.—This method, to be at all admissible, requires a guide to be previously passed; a lancet-shaped blade may then be slipped down a groove in this guide till the stricture is divided. This is least objectionable in cases of stricture close to the meatus.
(2.)From behind forwards.—To make the incision thus, it is of course necessary that the stricture should be so far dilatable as to admit an instrument the point of which is large enough to contain the blade by which the stricture is to be divided. This will be found to be at least equal in size to a No. 3 or No. 4 catheter. In many instruments it is much larger.
Civiale'sinstrument for internal incision of the urethra from behind forwards has the very high recommendation of Sir H. Thompson.[158]It consists of a sound with a bulbous extremity (as large as a No. 5 bougie) which contains a small blade, which can be made to projectfor such a distance as the operator wishes. It is passed through the stricture with the blade concealed, till the bulb is carried about one-third of an inch or more beyond the stricture; the blade is then projected, and the incision made by drawing it slowly but firmly outwards towards the meatus, with the blade towards the floor of the urethra, till the stricture is divided in its whole extent. Sir H. Thompson recommends this to be used in caseswhere it is not that the stricture is of very small calibre, but that it is undilatable, that prevents the cure. Many modifications of above have been devised by Lund, Teevan, and other surgeons, on similar principles.
3.Mr. Syme's Operation of External Division.—Mr. Syme held that no stricture through which the water can escape should be calledimpermeable, for by patience and care the surgeon should always be able to pass a slender director through the stricture on which it may be divided with ease and certainty. The old operation of "perineal section" for so-called impermeable stricture is very different, being difficult, dangerous, and uncertain in its results.
Operation.—A director is passed into the stricture. Mr. Syme's directors are of different sizes, the smallest being in diameter less than an ordinary surgical probe. They are made of steel, are grooved on the convexity, and have this peculiarity, that while the lower half is small, the upper is of full size (No. 8 or 10), the difference in calibre occurring quite abruptly. The presence of this "shoulder" on the staff enables the operator to ascertain exactly the position of the stricture, and also to tell when it is fully divided without the necessity of withdrawing the instrument.
This being fairly in the stricture, the patient is put in the position for lithotomy, an assistant holds the staff in his right hand, drawing up the scrotum with his left.
The surgeon then makes an incision in the middleline over the stricture for the necessary distance, from above downwards, till he exposes the urethra, and feels exactly the shoulder of the staff. Care must be taken not to go past the urethra at either side. When he distinctly feels the outline of the staff, he takes it in his left hand, and a short sharp-pointed bistoury in his right. It should be held firmly in the palm of the hand, with the back of the blade resting on the forefinger, the pulp of which guides the point to the groove, and guards it when making the incision; the knife is to be placed on the groove beyond (on the bladder side) of the stricture, and brought forwards, slowly cutting throughthe wholestricture; till the shoulder of the staff is reached. It requires strength and precision to divide thoroughly the indurated stricture, which is apt to elude the knife.
The shoulder of the staff can now be passed through the stricture if the operation is complete; if not, the incision must be extended, always in the middle line, and guided by the groove. When thoroughly divided, the staff is now to be withdrawn, and a full-sized catheter with a double curve passed into the bladder. This shouldnotbe furnished with a stop-cock or plug, lest the bladder should by inadvertence be allowed to be too full, and extravasation into the cellular tissue of the urethra take place along the side of the instrument.
The catheter should be tied in, and left for two, sometimes for three days, when it can generally be removed with safety, and a bougie should be passed at intervals of three or four, till the wound is healed. To prevent recurrence of the stricture, it is a wise precaution to pass an instrument at intervals for many months after the cure is apparently complete.
In certain cases, where the stricture is far back and the urinary symptoms severe, Mr. Syme found advantage from the introduction of a shorter double-curved catheter (only about nine inches long) through thewound into the bladder, where it should be left for three days. This seems to diminish the risk of rigors, and other symptoms of fever, which are apt to occur when the urine is allowed for the first time to pass over the wound.
Perineal Sectionis an operation both dangerous and difficult; as Sir Astley Cooper used to say, "the surgeon who performs it requires to have a long summer's day before him."
No director or guide can be passed. A full-sized catheter must be passed as far as possibleupto the stricture, and held firmly in the middle line. The patient must be tied up in lithotomy position on a table in the very best light that can be obtained. The perineum being shaved, an incision must be made in the middle line from over the point of the catheter to the verge of the anus, if the stricture extends far back.
The urethra should then be opened over the catheter, the edges of the mucous membrane held to each side by silk threads passed through them; and the surgeon must endeavour to pass a fine probe into the opening of the stricture; if this can be done, it is comparatively easy to slit the stricture up. If not, the surgeon must simply seek for the remains of the urethra by slow, cautious dissection in the middle line. If successful, a catheter must be secured in the bladder in the usual way.
A stricture near the orifice, or, as it is not uncommon, involving merely the meatus, can be treated with great ease in the above manner by division on a grooved probe. When quite close to the orifice, with a well-defined hardness, as of a ring round the urethra, it may be divided subcutaneously by a tenotomy knife or other narrow-bladed instrument. It is not necessary to keep a catheter in the bladder in cases where the stricture has been in front of the scrotum.
Puncture of the Bladder.—A patient and dexteroususe of the catheter prevents this operation from being often required; still, circumstances may arise in which it is found impossible to enter the bladderper vias naturales. In such a case the bladder may be punctured from the outside by a curved trocar and canula, in either of two situations.
1.From above the pubis.—This operation is a very simple one, and when the bladder is distended need not imply a wound of the peritoneum.
Operation.—A preliminary incision, varying in length according to the amount of fat, should be made above the pubis exactly in the middle line; the edges of the recti should be separated, the peritoneum pushed out of the way and upwards by the finger, and a curved trocar plunged into the distended bladder obliquely backwards. The canula should be retained for a day or two, and then a flexible catheter with a shield inserted instead. Such instruments have been worn for years. The aspirateur pneumatique of Dr. Dieulafoy will be found an exceedingly useful instrument for puncture of bladder and removal of urine. The author has now used it very frequently with the best results. Its advantage is that the urine is removed through an aperture so small as to allow of the withdrawal and reintroduction of the canula as often as is necessary.
Fig. xxxvi.Fig. xxxvi.[159]
2.From the Rectum.—Except in cases of enlargement of the prostate, it is at once easier and safer to puncture the bladder from the rectum. The well-known triangular space uncovered by peritoneum, with its apex in front close to the prostate, and bounded on either side by the vasa deferentia and vesiculæ seminales, can be easily reached by a curved trocar. This should be guided by one, or, still better, by two fingers, into the rectum, with its concavity upwards, and the point should be pushed upwards by depression of the handle, whenever it is fairly behind the prostate. The trocar may then be withdrawn, and the canula retained for at least forty-eight hours by a suitable bandage. Mr. Cock, of Guy's Hospital, had a special canula for the purpose, which expands at its extremity after its introduction, and thus is not apt to slip.[160]Some surgeons insist that the surgeon should be able to ascertain the existence of fluctuation between the finger in the rectum, and the other hand above the pubes. This is exceedingly difficult to elicit when the bladder is very much distended, and from the constrained position of the finger in the bowel.
Phymosis.—Elongation of the prepuce, with contraction of its orifice, in most cases congenital, sometimes so extreme as to cause difficulty in micturition, and frequently preventing the uncovering of the glans.
Operation.—In all well-marked cases, the following is required:—The elongated prepuce should be pulled forwards by a pair of catch-forceps, and a circle of skin and mucous membrane removed by a single stroke of a bistoury, or by sharp scissors. Care should be taken lest the glans be included in the incision, as has happened inat leastone instance. The skin will then be found to retract very freely beyond the glans, but the mucous membrane is found still to cover the glans, andits orifice is still constricted. It must then be slit up (Fig.xxxvii.b b) on the dorsum of the glans, with probe-pointed scissors, as far as the corona, and the glans will then be thoroughly exposed. The edges of mucous membrane and skin should then be stitched to each other by at least five or six fine silk sutures, any bleeding points having been first carefully secured. The angles will in time round off, and a wonderfully seemly prepuce be obtained. This operation may be done as a method of cure for obstinate enuresis in cases in which the prepuce is very long and redundant, even when it is not too tight. The author has done this in more than twenty cases with excellent results.
Fig. xxxvii.Fig. xxxvii.[161]
Varieties.—When the prepuce is narrowed at its orifice without being redundant in length, a milder operation will prove sufficient. The principle is the same as in the former, but the amount of incision is less, and nothing is removed. Two methods are possible:—1.By scissors.—The blunt point of a pair of scissors is introduced through the preputial orifice, the other blade being outside, and the skin and mucous membrane are divided for about half an inch; the skin being then retracted, the mucous membrane is still further divided by one or two additional snips, and then the edges of skin and mucous membrane are stitched together by one or two points of suture.2.By knife.—A director being introduced within the prepuce, a narrow-bladed knife is guided along it, and pushed through the prepuce from within, and then made to divide skin and mucous membrane from within outwards. Stitches as before.N.B.—Be careful lest the director pass into the meatus urinarius, and the glans be split up.Again, some surgeons prefer two lateral incisions instead of one dorsal one. In this case skin and mucous membrane should be divided by scissors for about a quarter of an inch, and then a single stitch inserted in the angle of junction. This has been further modified by Cullerier, who proposed the division of the tight mucous membrane only, in three or four points. He used a pair of scissors with one sharp and one probe-pointed blade, the sharp one thrust in between skin and mucous membrane, the blunt one between the mucous membrane and the glans.
Varieties.—When the prepuce is narrowed at its orifice without being redundant in length, a milder operation will prove sufficient. The principle is the same as in the former, but the amount of incision is less, and nothing is removed. Two methods are possible:—
1.By scissors.—The blunt point of a pair of scissors is introduced through the preputial orifice, the other blade being outside, and the skin and mucous membrane are divided for about half an inch; the skin being then retracted, the mucous membrane is still further divided by one or two additional snips, and then the edges of skin and mucous membrane are stitched together by one or two points of suture.
2.By knife.—A director being introduced within the prepuce, a narrow-bladed knife is guided along it, and pushed through the prepuce from within, and then made to divide skin and mucous membrane from within outwards. Stitches as before.
N.B.—Be careful lest the director pass into the meatus urinarius, and the glans be split up.
Again, some surgeons prefer two lateral incisions instead of one dorsal one. In this case skin and mucous membrane should be divided by scissors for about a quarter of an inch, and then a single stitch inserted in the angle of junction. This has been further modified by Cullerier, who proposed the division of the tight mucous membrane only, in three or four points. He used a pair of scissors with one sharp and one probe-pointed blade, the sharp one thrust in between skin and mucous membrane, the blunt one between the mucous membrane and the glans.
Amputation of the Penis.—This exceedingly simple operation is performed by a single stroke of an amputating knife, drawn along from heel to point, while the penis is stretched in the operator's left hand. As there is more risk of redundancy than of deficiency of the skin, no attempt is made to save it. Numerous vessels in the corpora cavernosa require ligature. Amputation of the penis may be done bloodlessly by the thermo-cautery even close to its root. Transfix the root of corpora cavernosa by a needle; above this pass two or three turns of an elastic ligature; then slowly divide at a low red heat the skin and corpora cavernosa below the needles; split the urethra after dividing its mucous membrane with a knife. The author has done this several times with ease and rapid healing.
Fig. xxxviii.Fig. xxxviii.[162]
The chief risk is stricture of the orifice of the urethra. To prevent this, several modifications of the operation have been introduced.
1.Ricord's method.[163]—After the amputation the surgeon seizes with forceps the mucous membrane of the urethra, and with a pair of scissors makes four slits in it, so as to form four equal flaps, and with a silk ligature stitches each of these to the skin. Contraction of the cicatrixwill thus tend to open rather than close the urethral orifice.
2.Teale's method.[164]—He slits up, by a bistoury on a director, the urethra and skin over it for about two-thirds of an inch, and then stitches the one to the other, thus making it a long oval dependent orifice (Fig.xxxviii.).
3.Miller's proposed method.[165]—"A narrow-bladed knife is first used to transfix the penis between the spongy and cavernous bodies close to the root; the knife having been carried forwards for an inch and a half, its edge is turned perpendicularly downwards, and the urethra and skin flap are divided, the cavernous bodies and dorsal integument being then cut perpendicularly upwards where the knife was originally entered for transfixion. A button-hole is afterwards made in the lower flap, though which the corpus spongiosum and urethra protrude, while the flap itself is turned upwards, and attached dorsally and laterally, so as to cover in the exposed cavernous structure."
Hydrocele.—The very simple operation necessary for hydrocele is thus performed:—The surgeon supports the tumour in his left hand so as to project it forwards, and make the scrotum as tense as possible in front. Having carefully ascertained the exact position of the testicle, which can generally be easily enough done by a finger accustomed to discriminate the difference between a soft solid, and a bag tensely filled with fluid, aided by the peculiar sensation of the testicle when squeezed, the surgeon enters a trocar and canula about an eighth of an inch in diameter into the distended cavity of the tunica vaginalis, near the fundus of the swelling. When it is evident the instrument is fairly entered, and not till then, the trocar is withdrawn, and the fluid allowed completely to drain off. When itceases to flow the surgeon places his forefinger over the end of the canula to prevent the entrance of air, till he fits into its orifice a suitable syringe containing two drachms of the tincture of iodine, made according to the Edinburgh Pharmacopœia: the tincture of the British Pharmacopœia is not sufficiently strong. Having injected this cautiously into the cavity, the canula is withdrawn, and the surgeon, seizing the now flaccid scrotum in his right hand, gives it a thorough shake, so as to spread the iodine over as much as possible of the inner wall. When properly performed this very simple procedure very rarely fails to produce a radical cure; though less thorough operations, such as mere evacuation of the fluid, less stimulating injections, unguents introduced on probes, and the like, often fail of success, and thus give encouragement to absurdities, such as wire-setons, or to more severe operations, such as laying open the sac.
Hæmatocele.—When the contents of the sac of the tunica vaginalis are found to be grumous instead of simply serous, or when, as often happens, only pure blood escapes when the fluid is nearly evacuated, it is found that simple evacuation and injection are very rarely sufficient to effect a cure.
After they have been fairly tried, the sac of the hæmatocele should be laid open in its full extent; any large vessels which bleed should be tied, and the cavity then stuffed with lint. When the lint can be removed, which will be after two or three days, the edges of the wound should be brought closely together, and the cavity will then rapidly heal up from the bottom, and be obliterated by secondary union of granulations.
In cases where the walls of the cavity are enormously thickened, or even, as sometimes happens, almost bony in consistence, an elliptical portion may be removed with advantage.
Excision of Testicle.—This operation is rarely required except for tumours of the testicle. Hence the size of the incision necessary must vary much with the size of the tumour; and the amount of skin to be removed (if any) on the amount of adhesions it has formed to the tumour.
One or two points must be attended to in every case of extirpation of a testicle:—
1. The incision should commence over the cord just outside of the external ring, and be continued fairly over the tumour to its base.
2. As to removal of skin, some surgeons advise that none should be taken away, others that a considerable quantity can be spared. There is certainly less risk of secondary hæmorrhage if a portion be removed, than when a flaccid empty bag is left. The author invariably removes a very large quantity of skin if the tumour is large, as there is much more rapid healing, and the resulting scrotum is much more comfortable for the patient.
3. The cord should be exposed at the beginning of the operation, raised from its bed and given to an assistant, who should compress it gently, not from any fear of its escape into the abdomen, but to prevent hæmorrhage. If the tumour has been very large and heavy, the cord will have been much stretched, and if divided too high up, may really give trouble by its elasticity, unless the above precaution is taken. The cord then having been divided close to the tumour, the latter is removed, care being taken not to include the sound testicle in the removal. All the vessels are then to be tied or twisted, and the spermatic artery is to be secured alone, not, as used to be the case, included in a common ligature with the other constituents of the cord. Secondary hæmorrhage is very apt to occur from small scrotal branches which may have escaped notice during the operation.
Operations on the Anus and its Neighbourhood.—Fistula in Ano.—While much might be written on the pathology of fistula, and a good deal even on its diagnosis, a very few words will suffice to describe the simple and effectual operation for its relief.
Dismissing at once all so-called palliatives, drugs, unguents, pressure, and injections, as mere waste of time, and holding that the only method of cure consists in laying the fistula fairly open, the question narrows itself into this: What is the best method of laying it open? Prior to the discovery by Ribes of the great principle that the internal orifice of the sinus is always within an inch or an inch and a half of the orifice of the anus, the operations for fistula were most unnecessarily severe; the gut used to be divided as far up as the sinuses extended; and large portions of the anus used to be excised bodily along with the sinuses. It is now a much simpler and more satisfactory operation.
Operation.—A common silver probe bent to the required shape is passed into the external opening, or, if there are more than one, into the largest and oldest one. The forefinger of the left hand being introduced into the rectum, the probe is passed through the internal orifice, and its point brought out by the anus. The portion of tissue raised by the probe can then be easily divided with the certainty that the fistula is laid fully open. Anal fistulæ have been divided by the elastic ligature, but it seems slower in action and more painful, with no counterbalancing advantages.
The author has for last few years operated almost exclusively by a long knife which is continued into a steel probe. The probe is passed up the fistula, then into the bowel, and is hooked out at the anus, and in being simply pushed on the knife cuts the fistula—tuto, cito, et jucunde, the patient rarely knowing that more has been done than an exploration.In cases where, from the hardness and density of the parts it is impossible to pass the probe and bring it out at the anus, a strong probe-pointed bistoury may be passed in by the externalorifice till its probe-point can be felt by the finger in the bowel at the internal opening. Supported by the finger it can then be made to cut outwards till the whole septum is divided.
The author has for last few years operated almost exclusively by a long knife which is continued into a steel probe. The probe is passed up the fistula, then into the bowel, and is hooked out at the anus, and in being simply pushed on the knife cuts the fistula—tuto, cito, et jucunde, the patient rarely knowing that more has been done than an exploration.
In cases where, from the hardness and density of the parts it is impossible to pass the probe and bring it out at the anus, a strong probe-pointed bistoury may be passed in by the externalorifice till its probe-point can be felt by the finger in the bowel at the internal opening. Supported by the finger it can then be made to cut outwards till the whole septum is divided.
Fissure of the Anus, Ulcer of the Anus, resemble each other alike in the exceeding annoyance which they give to the sufferer, and in the simplicity of the treatment needed.
Operation.—Once the presence of either is determined by the finger in the anus, a sharp-pointed curved bistoury should be introduced, transfixing the base of the fissure or ulcer, and then guided on the finger, completely dividing it, so as to change the ragged ulceration into a simple wound which will rapidly heal.
Prolapsus Ani,Operation for.—Complete prolapsus in which the whole gut is involved, as seen in the very young and the very aged, is suited for palliative rather than radical treatment.
Cases of prolapsus of the mucous membrane only, as is not uncommon in connection with or as a result of hæmorrhoids in adults, give opportunity for operative interference.
We may act on either the skin or mucous membrane, or both at once.
1.The skinis often found loose, and arranged in radiating folds round the anus. In such cases, as recommended first by Dupuytren, some of these projecting folds may be removed. Again it may be prolapsed in a great loose ring or circular fold round the margin, forming an exaggerated external pile; in such a case the loose fold may be fairly excised with curved scissors, as recommended by Hey of Leeds.
The first of these methods is apt to be insufficient, the second again has the risk of removing too much.
2. If the protrusion is chiefly mucous membrane exposedin folds, or a ring, which is generally outside, one of two methods of treatment may be tried:—
a.By ligature, as recommended by Mr. Copeland. Raising a longitudinal fold of the mucous membrane, he passed a ligature round it as if it were a pile. There is less chance of the ligature slipping if a double thread be used and its base thus transfixed. Three, four, or even more folds may be thus treated.
b.When the mucous membrane has been so long exposed as to have lost many of its characters, and to resemble leather in its toughness, excision will be found less painful and much more rapid than ligature.
A longitudinal fold at each side of the anus should be pinched up and excised by a pair of probe-pointed curved scissors. There is always a certain amount of risk of hæmorrhage following such an operation. The risk is lessened and the result improved by stitching up the wound in the mucous membrane before the protruded portion of bowel is returned.
Polypi of the Rectum.—Pedunculated growths varying in consistence, shape, and size, but resembling each other in having a distinct stalk, and in frequently being protruded at stool.
Operation.—Invariably by ligature, which may be single round the stalk, if the tumour be globular and with a distinct narrow stalk, or by transfixion, if (as sometimes happens) the tumour be of uniform thickness throughout, like a worm.
Hæmorrhoids Or Piles.—In the treatment of piles it is the differential diagnosis that is troublesome and occasionally difficult; the operative interference required is generally very simple, if the nature of the case be rightly determined.
External piles.—Operation.—The apex of the soft flabby excrescence should be seized by a pair of catch-forceps,and it should be cut off close to its base with a knife, or, what is better, a pair of curved scissors. Any little vessel which jets may then be secured. If, instead of numerous individual tumours, a ring of skin round the anus be involved, the whole of it should be shaved off, but not very close to its base, lest too great contraction of the anal orifice should ensue.
If the surgeon, after excising a pile or piles, will take the trouble to stitch up the wound with catgut, he will find the cure much more rapid and less painful than when this is omitted.
If the surgeon, after excising a pile or piles, will take the trouble to stitch up the wound with catgut, he will find the cure much more rapid and less painful than when this is omitted.
Internal piles.—Incision is extremely dangerous, from the vascularity of the parts, and their being so inaccessible from their position within the sphincter ani. Hence ligature is safer and equally effectual. The patient should be directed to sit over hot water, and strain till the whole of his piles are fairly protruded. The surgeon should then transfix the base of each separately with a curved needle bearing a strong double thread. The needle being cut off, the threads should be very firmly tied, each isolating its own half of the pile. The tying should be exceedingly tight, so as to cause instant and complete strangulation and death of the tumours. All the piles should be tied at the same sitting. If the piles are very small they may be secured without transfixion in a single noose after being seized by a hook or forceps. There is greater risk of the noose slipping than when the base has been transfixed.
The strangulated masses must then be returned into the bowel, and the patient kept in bed or on a sofa till the ligatures separate, which is generally not till the fourth or fifth day. A certain amount of urinary irritation, showing itself sometimes in strangury, sometimes in complete retention, occasionally follows this operation.
Mr. Smith of King's College, and many other surgeons, treat internal piles by means of an ivory clamp to holdthem tight, while they are burned off by the actual cautery or the thermo-cautery at a low red heat. They claim that pyæmia more rarely follows this mode.
There are certain cases in which the lower inch or two of the rectum are found red and congested, and in which every stool is followed by the loss of a certain quantity of florid arterial blood, and yet no distinct hæmorrhoidal tumour is to be seen. In such cases the ligature is not applicable, and relief is obtained by the application of pure nitric acid, or other potential caustics to the bleeding surface, as recommended by Houston, Lee, Smith, Ashton, and others. These cases are comparatively rare, and whenever they can be applied, the ligature is much simpler, safer, and more certain.
There are certain cases in which the lower inch or two of the rectum are found red and congested, and in which every stool is followed by the loss of a certain quantity of florid arterial blood, and yet no distinct hæmorrhoidal tumour is to be seen. In such cases the ligature is not applicable, and relief is obtained by the application of pure nitric acid, or other potential caustics to the bleeding surface, as recommended by Houston, Lee, Smith, Ashton, and others. These cases are comparatively rare, and whenever they can be applied, the ligature is much simpler, safer, and more certain.
Venous piles.—When a sudden effusion of blood has occurred into one of the varicose veins or sinuses of a congested anus, an oval or rounded tumour is felt, very tense, shining, and painful. To slit it freely up with an abscess lancet, and evert the clot inside, at once relieves all the symptoms.
For convenience' sake I group under this one head certain operations used for the relief of distortion, in which muscles or tendons are divided subcutaneously. Since the discovery of the principle by Delpech, and the application of it by Stromeyer, Dieffenbach, Little, and countless successors, it has been used for very many cases for which it is totally inapplicable,e.g.for the division of the muscles of the back in spinal curvature. Still there remain several deformities for the relief of which subcutaneous tenotomy is a most important remedy; chief among these are Wry Neck and Club-foot.
Operation for Wry Neck.—Subcutaneous section of the sterno-mastoid.—In what cases of wry neck is this operation suitable? In those only in which the muscles are the starting-point of the mischief. These are sometimes congenital, more frequently they commence in childhood. In cases where the distortion depends on disease of the cervical vertebræ, or is secondary to curvature of the spine, division of the muscle is worse than useless.
Operation.—A tenotomy knife, which should be sharp-pointed, narrow in the blade, with a blunt back, should be introduced through the skin a little to one side of the sternal portion of the affected muscle, passed alongwith its flat edge between the skin and the tendon, till it has fairly crossed the tendon; the blade should then be turned so that by a gradual sawing motion the edge may be made to divide the tendon about an inch above the sternum. A distinct snap will then be felt or heard, and the position of the head will be at once much improved. Exercise, warm bathing, and rubbing, will generally suffice to complete the cure, without it being necessary to call in the aid of the instrument-maker with his expensive apparatus.[166]
Operations for Club-Foot.—The following are the tendons whichmayrequire division in the cure of club-foot, and the operations for their division.
1.The tendo Achillis.—There are very few cases of true club-foot which can be successfully treated without division of the tendo Achillis. While in talipes equinis it is generally the only disturbing agent, in talipes varus and valgus it invariably increases and maintains the deformity, which the tibiales or peronei seem to originate.
Operation.—The foot being held at about a right angle with the leg, the operator should pinch up the skin over the tendon, introduce the knife flatwise, a little to one side of the tendon, till its point is nearly projecting at the other, then turn the edge on the tendon and cut inwards with a sawing motion till the tendon gives way with a distinct snap, and the foot can be completely flexed with ease.
Dr. Little[167]recommends that the tendon should be divided from before backwards. There is more risk by this method of wounding the skin, and thus losing the subcutaneous character of the operation.Professor Pancoast[168]divides the inferior portion of the soleus muscle instead of the tendo Achillis.
Dr. Little[167]recommends that the tendon should be divided from before backwards. There is more risk by this method of wounding the skin, and thus losing the subcutaneous character of the operation.
Professor Pancoast[168]divides the inferior portion of the soleus muscle instead of the tendo Achillis.
2.Tibialis posticus.—Next in frequency and importance to that of the tendo Achillis, division of this tendon is much more difficult to perform. It may be performed either above or below the ankle.
(a.)Above the ankle.—The blade of a tenotomy knife should be entered perpendicularly at the posterior margin of the tibia, half an inch or an inch above the internal malleolus, so as to pass between the bone and the tendon of the tibialis posticus, the blade directed towards the latter; the assistant should now evert the foot, the operator pressing the blade against the tendon.[169]
(b.)Below the ankle, close to the attachment to the scaphoid.This is the better position of the two when the position of the tendon can be made out, which is not always the case, especially in cases of old standing.
Raising the skin just over the astragalo-scaphoid joint, the knife should be entered with its blade downwards, and across the tendon, and should be made to cut on the bone, while an assistant everts the foot till the tendon gives way with a distinct snap.
3.Tibialis anticusmay in like manner be divided either just above the ankle, or at its insertion. When it requires division it can generally be made so prominent as to render its division comparatively easy.
4.Peronei.—These do not often require division, cases of talipes valgus being usually paralytic in character. If necessary they can be cut as they cross the fibula.
5.The plantar fascia, may require division; when this is the case, it is so prominent as to render the operation very easy, if conducted on the principles mentioned above.
Nerve-stretching.—Surgical literature in last ten years is full of cases in which nerves have been stretched for all manner of diseases with varying success: an example of the operative procedure may suffice:—
1. Stretching of the great sciatic either for sciatica, sclerosis, or locomotor ataxia.
Operation.—A line drawn from the centre of the space between the tuberosity of the ischium or the great trochanter to a corresponding point between the condyles of the femur will give the direction. A free incision in this line three or four inches in length—the nerve lies just below the the femoral aponeurosis, beneath the edge of gluteal fold, requiring no muscular fibres to be divided. It must be raised from its bed and boldly stretched or elongated into a loop. Symington's experiments have shown that in the average adult 130 lb. are required to break the nerve.
2. The facial has been stretched for spasm. The trunk is easily reached by an incision extending from near the external auditory meatus to the angle of the jaw, which enables the parotid to be pushed forward and the edge of the sterno-mastoid pulled backwards.
Neurotomy and Neurectomy.—Chiefly performed for neuralgia of the fifth nerve.
a.This is a very easy operation if directed at the terminal branches only of the nerve, where they make their exit from the frontal, supraorbital, and mental foramina. The author has done it in very numerous cases, and with great relief, if care be taken to destroy the nerve in the foramen to some extent—a sharp-pointed thermo-cautery does this easily and safely.
b.The more severe and radical operation of cutting out a portion of the trunk of the fifth nerve just after it has left the skull, and destroying Meckel's ganglion, has been done pretty frequently, chiefly by American surgeons—in various ways.
1.Carnochan's Operation.—Exposing the whole front wall of antrum, its cavity is opened into from the front by a large trephine. The lower wall of the infra-orbital canal is cut away by a chisel, the posterior wall of the antrum by a smaller trephine, the nerve thus isolated is traced up to and past Meckel's ganglion, which is removed close to the foramen rotundum by cutting the nerve by curved blunt-pointed scissors.
2.Pancoast's Operation.—Expose the coronoid process by a free incision, divide it at its root and throw it up, then expose and tie internal maxillary artery, after which the upper portion of the external pterygoid is to be detached from the sphenoid, thus exposing the nerve leaving foramen ovale; the second portion is deeper and not so easily got at.
3. The spinal accessory occasionally may be divided before it enters the sterno-mastoid in cases of spasmodic wry neck, with great advantage. This operation is an easy one; the sterno-mastoid edge being once fairly exposed, the nerve is easily seen, and a piece should be cut out at least half an inch in length.
Nerve Sutureis occasionally practised with great advantage in cases where nerves have been dividedeither by accident or in operation. Catgut seems to be the best medium, and cases are on record in which, even after months of separation and subsequent paralysis, improvement has followed an operation for refreshing and joining the divided ends.
Dr. Solis Cohenhas recently (in a paper read before the Philadelphia College of Physicians, April 4, 1883) collected the notes of sixty-five cases of excision of the entire larynx. Fifty-six of these were done for cancer, and the remainder for sarcomata, papillomata, etc. Of the fifty-six done for cancer, forty are reported as having died, either shortly after the operation from shock or pneumonia, or a few months later from recurrence of the disease. In two instances the disease had recurred, but death had not been reported when the paper was read. Fourteen remain in which neither death nor recurrence had been reported. Dr. Cohen's conclusion is that laryngectomy does not tend to the prolongation of life, and thinks that the greatest good to the greater number appears better secured by dependence on the palliative operation of tracheotomy.