PART II. PRACTICE OF SURGERY

SECTION IV. OPERATIVE SURGERY

Part 19. 3. Abdominal

Modern surgery has made its greatest advance and has achieved its most signal triumphs in connexion with operations performed in those cavities of the body which are lined by a synovial or serous membrane. The older surgeons did not dare to systematically attack the joints and the cranial, thoracic, and abdominal cavities ; but the surgeon of to-day performs the most daring operations hero with confidence, and is rewarded with a success which at first sight appears almost marvellous. The timid extraperitoneal manipula-tions of former days made use of in the treatment of hernia and kidney disease and in the formation of artificial anus, have now given way to systematic intraperitoneal modes of treatment, where-by we aim at the radical cure of hernia and bring disease affecting any of the abdominal viscera directly under our control. We have Peri- to consider the conditions under which wound treatment of the toneal peritoneum is placed, and in wdiat respect this portion of the human wound framework reacts upon injuries as compared with the general he-treat- haviour. It is generally acknowledged that rest in the surgical ment. sense, the factor necessary for healthy wound closure, is obtained by a condition of asepsis and fixation. Moreover, it is generally granted that tension as a condition of unrest is dangerous not so much in itself as in the character of the material that gives rise to tension ; hence the extravasated serum and blood in a case of simple fracture give rise to comparatively little disturbance. The presence of ascites need not lead to fever. But once let sepsis gain entrance and the fermenting exudate is resented by the organism ; violent attempts to throw it off are made ; and forms of blood-poisoning more or less severe and variable ensue. In a severe injury of the extremities, say a compound fracture, the effused serum and blood-clot are not readily removed by the damaged lymphatic system, and, when that does act, sepsis having already occurred, the ab-sorption of the putrid fluid does much harm. Fortunately the open character of the wound may allow the foetid discharge to escape. In any case, the surgeon ensures a good result when he makes use of splints, drainage, and antiseptics. He brings about local fixation, removes the excessive exudation, and so relieves the . lymphatics and prevents sepsis. In the case of a penetrating abdo-minal wound, where the healthy peritoneum is injured, we have somewhat different conditions, mainly varying in degree. It must ever be borne in mind that here we open into a huge lymph-sac. The peritoneum consists of a sheet of vascular and lymphatic network, covered with epithelium and provided with stomata. It is easily injured, and then rapid effusion ensues. Like most vascular struc-tures, however, it heals quickly with favourable surroundings, and, the source of irritation having been removed, it speedily returns to ihe normal. In comparison with the large absorbing surface the injured portion is but small, and the effusion thrown out at the seat of injury may readily enough be absorbed by the remainder of the healthy sac. So long as the rate of absorption equals that of effusion tension cannot exist. If, however, the nature of the fluid be of importance, it is evident that nowhere in the body is this more marked than in the case of the peritoneum, and here above all other parts must we preserve strict asepsis. This may be gained in vari-ous ways. (1) By drainage, in which case the surgeon carefully draws off from the pouch of llouglas any excess of fluid thrown out as the result of injury, until such time as the peritoneum itself has recovered its full absorbing power and the excessive secretion has ceased. (2) Where by careful sponging the operator so far relieves the peritoneum and then, closing the wound to prevent entrance of further sepsis, leaves the rest to nature. For, if we do permit a moderate septic inoculation, it is evident that the rapid change of fluid may prove inimical to the development of septic ferments and the contact of healthy tissue will finally render impossible the existence of organisms. The presence, however, of any accumula-tion of putrid effusion is at once resented by the peritoneum and an attempt by local peritonitis may shut off the collection, or even previous to any local reaction septic absorption may prove fatal, or again severe general peritonitis may kill the patient. (3) From the above we at one* see how applicable the antiseptic system must be to the abdomen, and the most signal success has crowned atten-tion to matters of detail in this respect. By means of antiseptics we can securely close the abdomen, resting assured that the peri-toneum is perfectly capable of carrying off effusions due to our interference. Where we dread that oozing may complicate matters, the drainage-tube can in addition be employed, but the necessity for its use becomes less marked as the operator acquires experience. Abdominal surgery requires from beginning to end the utmost care, and it is well that specialists reached a high standard of success before the adoption of the antiseptic system, since various points have been formulated, all of which, however, are of minor import-ance compared with the one great end in view,—that of asepsis from first to last. The utmost care should be taken to ascertain the general bodily condition of the patient, to see that the kidneys are healthy, and to select an anesthetic suitable to the requirements of the case. The temperature of the room, the clothing during operation, rapid dexterous manipulation, and preventives against hemorrhage require the utmost attention. The patient should be prepared by having had low diet and gentle purgatives for a few days prior to surgical interference, so that rest of the intestinal tract may readily be assured. As a material for ligature fine silk Chinese twist, of various sizes, may be employed. It must be care-fully disinfected by boiling, and is readily preserved pure in a five per cent, solution of carbolic acid. The ends should always be cut short. It possesses certain advantages over catgut.

In reviewing the field of abdominal surgery we must study shortly the methods and results gained by ovariotomy, removal of the uterine appendages (ovaries, Battey; tubes, Tait), hysterectomy, myotomy, removal of fibroid tumours of the uterus, intraperi-toneal operations on the kidney, liver, spleen, intestinal tract, including stomach, pylorus, duodenum, small and large intestine. Finally, attention should be given to the extraperitoneal operations for sarcoma and disease of the kidney and intestine.

From 1701, the date when Houston of Carluke, Lanarkshire, Ovario-carried out his successful partial extirpation, progress was arrested tomy. for some time, although the Hunters (1780) indicated the practica-bility of the operation. In 1809'Ephraim M'Dowell of Kentucky, inspired by the lectures of John Bell, his teacher in Edinburgh, per-formed ovariotomy, and continuing to operate with success estab-lished the possibility of surgical interference, and was followed in the United States by many others. The cases brought forward by Lizars of Edinburgh were not sufficiently encouraging; the operation met with great opposition; and it was not until Clay, Spencer Wells, Baker Brown, and Keith began work that the pro-cedure was placed on a firm basis and regarded as justifiable. Im-proved methods were introduced, and surgeons vied with one another in obtaining good results, until by the introduction of the antiseptic system of treating wounds this operation, formerly regarded as one of the most grave and anxious in the domain of surgery, has come to be attended with a lower mortality than any other of a major character. We may now briefly outline the mode employed in operating. The room should be well heated, be free from draughts, have a good light, and above all a pure atmosphere. The patient is secured to a firm table and well protected with blankets. An-esthesia having been obtained, the state of the bladder being known, and the urine drawn off if thought necessary, the surgeon purifies the integument with carbolic acid five per cent, solution, attending specially to the region of the umbilicus and pubes, which latter should be shaved. A large perforated waterproof sheet may be spread over and secured to the body, through which the more pro-minent part of the tumid abdomen protruding presents a localized field for manipulation ; this also protects adjoining parts and ob-viates unnecessary exposure. An incision 2 or 3 inches in length in the linea alba and midway between the umbilicus and the sym-physis pubis carries the surgeon down to the interval between the I recti; bleeding points are seized with pressure forceps ; and by a further use of the knife the subperitoneal fat is exposed, the peritoneum divided, and its free edges seized with forceps. The operator next introduces his finger and with the scissors enlarges the wound downwards or upwards on the left side of the umbilicus if neces- sary. The entire hand is then introduced between the parietal peritoneum and the tumour and swept around so as to ascertain the condition of affairs, and even to separate gently slight adhesions. A few sponges are next packed round the exposed tumour surface, which serve to keep the intestines and omentum out of the way and to retain any tumour content which may escape during tapping. With a large trocar, aided perhaps by an exhausting jar, the con- tents are drawn off, and, as the tumour collapses, its folds may be caught by forceps and the whole sac gradually pulled outside the abdomen. The pedicle is clamped by strong forceps; the tumour is cut off; the stump of the pedicle is carefully ligatured, the clamping forceps removed, the peritoneum carefully sponged out, more especially the pouch of Douglas, the ligature cut short, and the pedicle dropped into the cavity of the abdomen. At this stage the forceps and sponges are counted, a definite number being always employed, and, their tale being perfect, the surgeon pro- ceeds to close the wound. For this purpose his needle traverses the entire thickness of the pariotes from peritoneum to skin ; the stitches should be about one-third of an inch apart, and closer apposition is gained by secondary sutures, which go through the integument alone. A dressing is now applied, and for the next few days the patient gets little else than occasional spoonfuls of hot water and milk, unless brandy be necessary, until she passes wind, after which time the usual diet is gradually resumed. It is necessary that the most precise precautions he taken against septic infection. The sponges are steeped in a five per cent, solution of carbolic acid, then dipped in boiling water, and squeezed dry immediately before use. Should the contents of the cyst he too viscid to run through the trocar, the contents of the sac must be pulled out with the hand. Adhesions to various organs must be dealt with by careful separation and ligature. Rents in the peri- toneum should be stitched up with fine catgut, and some operators also stitch over the stump of the pedicle, or bury it in a bared portion of the adjacent broad ligament, so that it may not contract adhesions. While the great majority of surgeons are at one as regards the use of antiseptic precautions, they do not agree as to the use of the spray. Many dispense with it altogether. Some employ it in the room prior to the operation. A few surgeons also, without availing themselves of the antiseptic system, appear to obtain as good, if not better, results than their fellows. It may also be noted that the antiseptic in use by different operators varies, and that, while the pedicle is usually ligatured, Keith attaches great importance to the clamp and cautery introduced by Baker Brown. The drainage-tube is not now so frequently employed as formerly. The statistical results show an increasing success in the case of every surgeon. Spencer Wells tells us that in his first five years one patient in throe died, in his second and third five years one in four, in his fourth five years one in five, in 1876-77 one in ten, since the introduction of antiseptics (complete Listerism), 1878-84, 10'9 per cent,—the last series showing a marked absence of septic fatality. Keith in 1884 reported a mortality of 9T1 ; for- merly, when using the spray, he once had a successful consecutive series of 80. Koeberle up to 1878 had performed 800 operations, of which 281 had a favourable result. Of 300 patients operated on by Schroeder up to 1882 258 recovered ; in the last hundred cases there were only 7 deaths. Other figures are—Knowsly Thornton, 423 cases, 40 deaths ; Tait, 405 cases, 33 deaths, and in 1885 (in- cluding parovarian cysts) 139 cases, no deaths ; Olshausen (1885), 293 cases, 27 deaths (in the last hundred only 4 deaths).


Removal Removal of the uterine appendages, the ovaries and Fallopian ofuterine tubes, is performed for three distinct conditions—(1) for disease, appen- when the tubes are the seat of inflammatory changes and dis- dages. tended, or when the ovaries are the seat of cystic and cirrhotic changes ; (2) for fibroid tumours, in which case by operating we hasten the menopause and bring about involution ; (3) in cases where dysmenorrhcea is wearing out and rendering useless the life of the patient, and where less severe treatment is ineffectual. Oophorectomy, by which we mean removal of the ovaries only, was introduced by Battey of Georgia in 1872. It is now replaced by the more extensive procedure of Lawson Tait, sapingo-oophor- v eetonry. The operation is sometimes followed by loss of sexual feeling and has been said to unsex the patient, hence strong objections have been urged against it. The patient and friends should clearly understand the object and results likely to be gained. According to Angus Macdonald, "as soon as we are certain that the ovaries or tubes are distinctly diseased and are not likely to yield to our ordinary methods of treatment . . . we are hound to at least inform our patient of the possibility of relieving her by opera-tion. The operation presents greater difficulties and is associated with a higher mortality than ovariotomy." The greatest care must be taken in making the initial incision for fear of wounding the boweL The organs are not uncommonly deeply placed and have contracted adhesions. Every trace of ovarian tissue should be removed along with the tubes and the ligatures must be carried close up to the uterus. The stitches should be placed closer, since the tendency to hernia is greater.

In cases of fibroid tumour—myoma—the surgeon must be largely Hyster-guided by the condition of the patient and the new growth as to eetomy. whether removal of the uterine appendages is sufficient. If it is not and the patient is in such danger that the next period threatens life, he had better proceed to hysterectomy or entire removal of the uterus and appendages. When we consider the circumstances under which this operation is performed, the weakly anaemic state of the patient, the size of the tumour, and the rapidity with which procedure should be conducted, we must regard hysterectomy as one of the gravest in the domain of surgery. There is, moreover, a special danger which does not obtain in ovariotomy, —the risk of septic poisoning. Since we cut into the canal of the uterus, it is obvious that we open into a septic cavity, and it is impossible merely to ligature and drop the pedicle, since by doing so we should court failure. The surgeon, having made a way into the peritoneum, seizes and ligatures adhesions, projects the tumour through the wound, clamps the pedicle (cervix uteri), removes the tumour and uterus, and closes the wound, leaving the clamped pedicle protrud-ing. It is advisable to scoop out the septic central canal of the pedicle and carefully to pare away surplus tissue, and as dressing to have a plentiful supply of some potent non-irritating antiseptic in contact with the stump. If we take care that the septic focus is removed without coming in contact with its surroundings, if we keep the stump aseptic and dry, there will be little fear of septic fluid trickling down the side of the pedicle and causing septus, peritonitis, or blood-poisoning. Attempts have been made, by care-ful disinfection of the stump, paring its centre, careful ligature, and stitching its raw surfaces together, to treat the pedicle by dropping it into the abdomen as in ovariotomy, but as yet with no marked success. The results of hysterectomy in the hands of Keith (33 cases, 3 deaths, in 1885) stand unrivalled. Similar principles guide the performance of cesarean section and Porro's operation.

Affections of the liver and gall-bladder have also been treated Removal by laparotomy. In the latter case an incision is made over the of gall-swelling, and the gall-bladder, having been exposed, may be removed bladder; or explored, gall-stones cleared out, the walls stitched to the sides of the abdominal wound, and a drainage-tube inserted as occasion requires. The spleen has also been attacked. In removal of the spleen; entire organ special care must be taken that none of the larger veins give way during manipulation. Most careful ligation and sub-division of the pedicle is requisite. In recent years the surgery of the kidney has made gigantic strides. There* are three modes of kidney; reaching the organ, each of proportionate value according to the nature of the case. (1) From the lumbar region. In this way we may open abscesses, remove calculi, and even extirpate if the kidney be not enlarged. Increased room may be obtained by re-moving the twelfth rib. By this method we gain sufficient and dependent drainage and we need not open the peritoneum. (2) As in ordinary laparotomy, making an incision in the middle line. This admits of our examining both organs and to a large extent determining the condition of each. We get free access and can more readily treat the pedicle of vessels and the ureter. We open into the peritoneal cavity and again divide the peritoneum ; but our incisions are readily closed and we no longer dread interfering with this huge lymph-sac. For tumours of the kidney this method is clearly indicated. (3) Langenbuch has proposed making an incision along the outer border of the rectus, which is said to present advantages in certain cases.

Since the advance of ovariotomy the possibility of removal of portions portions of the intestinal tract with a subsequent suture of the of intes-divided ends has been repeatedly demonstrated, and thus resections tinal for disease of the pylorus and bowel have been successfully performed, tract. In cases of gunshot wound, laparotomy, arrest of haemorrhage, careful cleansing of the peritoneum, and suture of the wounded gut is now the established practice. Bull of New York reports a recovery in a case where seven wounds in the gut were sutured. All laparo-tomies are founded on the type of ovariotomy ; success depends on the fact that two opposed serous surfaces rapidly unite, and this fact must ever be borne in mind when we tear or injure the bowel and its coverings, or unite them. Sepsis is the main disaster likely to attend our interference, but with the means at our disposal, washing out the peritoneum if necessary, we should be able to obviate this.
In regard to operations on the abdominal organs in which we do not interfere with the peritoneum it is sufficient to note that from the lumbar region we can reach the colon, where it is uncovered by serous membrane, the kidney, and retroperitoneal tumours. (F. M. C.)


Footnote

691-1 The literature of abdominal surgery is very extensive. The most complete lists will ba found in Olshausen's " Die Krankheiten der Ovarien," in Die deutsche Chirurgie, 1880, and in Hart and Barbour's Manual of Gynaecology.





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