A Manual of the Operations of Surgery

Various canulæ and tubes have been proposed. The ones recommended by the older surgeons had all one great fault; they were much too small, and were many of them straight, and thus liable to displacement. The smallness of their bore was their greatest objection, and Mr. Liston conferred a great benefit on surgery by his insisting upon the introduction of tubes with a larger bore, and with a proper curve, so as thoroughly to enter the trachea. The tube ought to be large enough to admit all the air required by the lungs, without hurrying the respiration in the least.

There is a mistake made in the construction of many of the tubes even of the present day; the outer opening is large and full, while for convenience of insertion the tube tapers down to an inner opening, admitting perhaps not one-half as much air as the outer one does.

It must be remembered that for some days there is great risk of the tube becoming occluded, by frothy blood or mucus, especially in cases of croup, and in children. To prevent this a double canula will be found of great service, providing only that it be remembered that the inner canula, not the outer merely, is to be made large enough to breathe through, and that the inner should project slightly beyond the outer one.

The inner one can thus be removed at intervals and cleansed, by the nurse, without any risk of exciting spasm or dyspnœa by its absence and reintroduction.

After-treatment.—The after-treatment of a case in which tracheotomy has been performed demands great care and many precautions. For the first day or two the constant presence of an experienced nurse or student is always necessary to insure the patency of the tube. The temperature of the room should be equable and high, and it seems of importance that the air should be kept moist as well as warm by the use of abundance of steam.

A piece of thin gauze, or other light protective material, should be placed over the mouth of the tube, to prevent the entrance of foreign bodies.

In cases where the operation has been performed for some temporary inflammatory closure of the air passage, retention of the tube for a few days may suffice. It may then be removed, but it must be remembered that the wound will generally close with great rapidity, so that it is as well to be quite sure of the patency of the natural passage before the artificial one is allowed to close by the removal of the tube.

In cases where from long-standing disease or severe accident the larynx is rendered totally unfit for work, and the tube has to be worn during the rest of the patient's life, care must be taken (1.) lest the tube do not fit accurately, in which case it may ulcerate in various directions, even into the great vessels;¹³⁴ (2.) lest the tube become worn, and lest the part within the windpipe fall into the trachea and suffocate the patient.¹³⁵

Laryngotomy.—As a temporary expedient in cases of great urgency, where proper instruments and assistants are not at hand, laryngotomy is occasionally useful, though from the want of space without encroaching on the cartilages of the larynx, and from its close proximity to the disease, laryngotomy is by no means a suitable or permanently successful operation.

In the adult, especially in males with long spare necks, the operation itself is exceedingly easy to perform. The crico-thyroid space (Fig. xxxi. a) is so distinctly shown by the prominence of the thyroid cartilage, and is so superficial that it is quite easy to open it in the middle line with a common penknife, there being merely the skin and the crico-thyroid membrane to be cut through, with very rarely any vessel of any size. The opening can then be kept patent by a quill or a small piece of flat wood. This simple operation has in many cases, where a foreign body has filled up the box of the larynx, succeeded in saving life, and even in cases of disease I have known it useful in giving time for the subsequent performance of tracheotomy.

Easy as it appears and really is, cases are on record in which the thyro-hyoid space has been opened instead of the crico-thyroid, such operations being of course perfectly useless.

The incision is best made transversely.

Laryngo-Tracheotomy.—This modification consists in opening the air passage by the division of the cricoid cartilage vertically in the middle line, along with one or two of the upper rings of the trachea.

It seems to combine all the dangers with none of the advantages of the other methods of operating. It is close to the disease, involves cutting a cartilage of the larynx, and almost certain wounding of the isthmus of the thyroid; and it is not easy to see what corresponding advantages it has over tracheotomy in the usual position.

Thyrotomy is an operation by which the larynx is opened in the middle line by a vertical incision, and its halves separated, while any morbid growths are excised from the cords or ventricles. The merits and dangers of this operation have been discussed at length by Mr. Durham¹³⁶ and Dr. Morell Mackenzie.¹³⁷

Laryngectomy or Excision of the Larynx, first performed by Dr. Heron Watson in 1866, has been lately frequently performed for carcinoma and sarcoma. Each case presents its own difficulties, which vary according to the amount and extent of the disease for which it is done.

The trachea must be divided and tamponed by a Trendelenburg canula, after which the larynx must be carefully dissected out. The immediate mortality, i.e. in first ten days, is fifty per cent., and Dr. Gross holds that life has not been prolonged by the operation.¹³⁸

Œsophagotomy.—This operation is very rarely required, and has as yet been performed only for the removal of foreign bodies impacted in the œsophagus, and interfering with respiration and deglutition. To cut upon the flaccid empty œsophagus in the living body would be an extremely difficult and dangerous operation, from the manner in which it lies concealed behind the larynx, and in close contact with the great vessels. When it is distended by a foreign body, and specially if the foreign body has well-marked angles, the operation is not nearly so difficult. It has now been performed in forty-three cases at least, of which eight or nine have proved fatal. Seven, along with another in which he himself performed it with success, were recorded by Mr. Cock of Guy's Hospital.¹³⁹ Three others were performed by Mr. Syme, with a successful result. Of the seven cases collected by Mr. Cock only two died, one of pneumonia, the other of gangrene of the pharynx.

Operation.—Unless there is a very decided projection of the foreign body on the right, the left side of the neck should be chosen, as the œsophagus normally lies rather on the left of the middle line. An incision similar to that required for ligature of the carotid above the omohyoid should be made over the inner edge of the sterno-mastoid muscle; with it as a guide, the omohyoid may be sought and drawn downwards and inwards, the sheath of the vessels exposed and drawn outwards, the larynx slightly pushed across to the right, the thyroid gland drawn out of the way by a blunt hook, the superior thyroid either avoided or tied. The œsophagus is then exposed, and if the foreign body is large, it is easily recognised; if the foreign body be small, a large probang with a globular ivory head should then be passed from the fauces down to the obstruction; this will distend the walls of the œsophagus, and make it a much more easy and safe business to divide them to the required extent. The wound in the œsophagus should be longitudinal, and at first not larger than is required to admit the finger, on which as a guide the forceps may be introduced to remove the foreign body, or, if necessary, a probe-pointed bistoury still further to dilate the wound.

For some days or even weeks the patient must be fed through an elastic catheter introduced through the nose and retained, or by an ordinary stomach-tube through the mouth. In introducing the latter there is always a risk of opening the wound. No special sutures for the wound in the œsophagus are required, nor is it advisable too closely to sew up the external wound.

CHAPTER X.
OPERATIONS ON THORAX

Excision of Mamma.—When the whole breast is to be removed, two incisions, inclosing an elliptical portion of skin along with the nipple, must be made in the direction of the fibres of the pectoralis muscle. The distance between the incisions at their broadest must depend upon the nature of the disease for which the operation is performed, and the extent to which the skin is involved; in every case the whole nipple should be removed. The incisions should, if possible, be parallel with the fibres of the pectoralis major, and extend across the full diameter of the breast. During the operation the arm should be extended so as to stretch both skin and muscle. The lower flap should be first raised and dissected downwards, with care that the cuts are made in the subcutaneous fat, and wide of the disease; the upper flap is then thrown open, and the edge of the gland raised, so that the fibres of the pectoralis are exposed below it. These should be cleanly dissected, so as to insure removal of the whole gland.

Any bleeding during the operation can easily be checked by the fingers of an assistant, and if the arteries entering the gland from the axilla be divided last, they can be at once secured. If there are many bleeding points, the application of cold for a few hours before the wound is finally closed is a wise precaution.

The requisite stitches may be inserted while the patient is under chloroform, but not tightened. The arm should then be brought down to the side, and a folded towel laid over the wound after it is finally closed. Great benefit results from the free use of drainage-tubes in most cases; for this purpose a dependent opening in the lower flap is often made.

Surgeons now operate even when the axillary glands are diseased, and by a very free dissection and removal, even in hopeless-looking cases, life may be prolonged. To insure the removal of the lymphatic vessels as well as the glands, it is best not to separate the breast at its axillary margin, but keep it attached by the tail of lymphatics surrounded by fat, which will lead up to the glands. Section of the great pectoral muscle will aid the dissection.

When the tumour is very large, and the skin has been much stretched and undermined, more complicated incisions may be necessary; these must be governed a good deal by the presence and positions of adhesions or ulcerations of the skin. The best direction, when the surgeon has his choice, that these incisions can take, is that of radii from the nipple, bisecting the flaps made by the original elliptical incision.

N.B.—In operating for malignant disease, the one paramount consideration is that all the disease be excised, however curious, inconvenient, or awkward, even insufficient, the flaps may look. Partial excisions are worse than useless.

Paracentesis Thoracis, for the relief of pleurisy, acute and chronic, and empyema, is an operation of extreme simplicity.

The proper selection of cases, the settling of the suitable position for the tapping, and the choosing of the suitable time for it, are more difficult, and not within the scope of the present work. On these subjects much information may be obtained from the papers of Dr. Bowditch of Boston, of Dr. Hughes and Mr. Cock,¹⁴⁰ and an exceedingly interesting and valuable paper by Dr. Warburton Begbie.¹⁴¹

Where is it to be performed? Not above the sixth rib, else the opening is not sufficiently dependent; very rarely below the eighth on the right side, and the ninth on the left. The intercostal space generally bulges outwards if fluid is present, and this bulging acts as an aid to diagnosis. As the intercostal artery lies under the lower edge of the upper rib in each space, the trocar should be entered not higher than the middle of the space; and because the artery is largest near the spine, and also the space is there deeply covered with muscle, the tapping should never be behind the angle of the rib. In most of the manuals we are told to select a spot midway between the sternum and spine for the puncture; but Bowditch, Cock, and Begbie, who have had large experience, prefer, and I believe rightly, a position considerably behind this, an inch or two below the angle of the scapula, between the seventh and eighth, or between the eighth and ninth ribs.

The operation may be performed with a simple trocar and canula, round, about an eighth of an inch in diameter, and at least two inches in length. The point must be sharp, and it must be pushed in with considerable quickness, so as to penetrate, not merely push forwards, the pleura, which may be tough, and thicker than usual. Once the skin is pierced, the instrument must be directed obliquely upwards, so as to make the opening and position of the trocar dependent. When the trocar is withdrawn the fluid may be allowed to flow so long as it keeps in a full equable stream; whenever it becomes jerky and spasmodic, the canula should be removed before the sucking noise of air entering the chest is heard.

In more chronic cases, where the quantity of fluid is large, and especially if it is thick and curdy, the exhausting syringe of Mr. Bowditch is an improvement on the simple trocar and canula.

It consists of a powerful syringe, which fits accurately to the trocar with which the puncture is made. There is a stop-cock between the trocar and syringe, and another at right angles to the syringe. The trocar being introduced, it is held firmly in position by an assistant, by means of a strong cross handle; the first stop-cock is then opened, and the syringe worked slowly till it is filled with fluid through the trocar, the other delivery stop-cock being closed. The first is then closed, and the second opened; the syringe is then emptied through the second into a basin. By a repetition of this process, the fluid can be removed at pleasure, without any risk of the entrance of air.

Dieulafoy's aspirateur, which the author has now used in a very large number of cases, will be found the best method yet devised of safely removing the fluid in cases of serous effusion. But in severe cases of empyema the pus is sure to be reproduced in the great majority, and then a free incision, with strict antiseptic precautions, will be needed, and subsequent free drainage.

The author has used with great benefit silver tubes, like long narrow trachea-tubes, with broad shields, to insure free drain.

CHAPTER XI.
OPERATIONS ON ABDOMEN

Paracentesis Abdominis.—To withdraw fluid from the abdominal cavity is an exceedingly simple operation in itself, though certain precautions are necessary to render it safe.

Trocar.—The usual instrument used to be a simple round canula with a trocar, the point of which should be very sharp, and in the shape of a three-sided pyramid. It should be about three inches in length, and a quarter of an inch in diameter. It may for convenience have an india-rubber tube fixed to its side or end, for the purpose of conveying the fluid to the pail or basin, but any other additions or alterations have not been improvements. Lately surgeons have been diminishing the size of the tube so as to withdraw the fluid more slowly, and taking many precautions to insure the wound being kept aseptic.

Where to tap.—In the linea alba, midway between the umbilicus and pubes, or rather nearer the umbilicus. Here, there are no muscles nor vessels, the opening is a dependent one, and the bladder is quite out of the way of injury.

N.B.—It is a wise precaution, in every case where there is a possibility of doubt as to the state of the bladder, to pass a catheter. I have myself known at least one case in which a surgeon was asked to tap an over-distended bladder, as a case of ascites.

The Operation.—As there is great risk of syncope coming on during the operation, from the sudden relief to the pressure on the organs, a broad flannel bandage should be applied to the belly, the ends of which are split into three at each side, and crossed and interlaced behind. An assistant should stand at each side to make gradual pressure by pulling on the ends of the bandage, thus assisting the flow, and maintaining the pressure. A hole should be cut in the bandage at the spot where the puncture is to be made, and the trocar inserted by one firm push, without any preliminary incision, unless the patient is inordinately fat. As the trocar is withdrawn, the canula should be pushed still further in. The surgeon should be ready at once to close the canula with his thumb, if the flow begins to cease, lest air should be admitted. If the flow ceases from any cause before all the fluid seems to be evacuated, the trocar should not be re-introduced, lest the intestines be wounded, but a blunt-headed perforated instrument fitting the canula should be inserted.

When all the fluid that can be easily obtained is evacuated, the canula may be withdrawn, and a pad of lint secured over the wound by strapping.

Gastrotomy.—Cutting into the stomach for the extraction of a foreign body has now been performed at least ten times, and all but one recovered. A typical example is that by Dr. Bell of Davenport, who removed a bar of lead one pound in weight and ten inches in length, by an incision four inches in length from the umbilicus to the false ribs. The opening into the stomach was as small as possible, and required no sutures.

Gastrostomy has within the last few years been practised very frequently. Gross has collected 79 cases, 57 of which were for carcinoma of œsophagus, all of which died within a few weeks, except eight who survived for periods varying from three to seven months. The results in cases of cicatricial and syphilitic strictures are more favourable.—Howse's method seems the best, consisting of two stages.

1. A curved incision is made through the parietes parallel with, and a finger-breadth below, the lower margin of chest wall on left side, the peritoneum should be opened at the linea semilunaris, the stomach sought for, and then attached to the abdominal wall by an outer ring of sutures and to the edge of the wound by an inner ring. It should then be dressed with carbolised lint and supported by a bandage.

2. A small opening should be made four or five days after the first stage and the patient should be fed through this opening.

For full details, see Mr. Durham's paper in vol. i. of Holmes's Surgery, edition of 1883, pp. 801-4.

Gastrectomy.—Excision of whole or part of the stomach is one of the latest developments of operative daring, first done as a regular operation by Pean in 1879, it has now been repeated sixteen times; four cases have survived the operation for more than ten days. The chief points to be attended to are prevention of death from shock and hæmorrhage, and very careful stitching up of the wound. Considering the difficulty of the diagnosis, the danger of the operation, and the almost certain recurrence of the disease, the propriety of such operation seems very doubtful.

Ovariotomy.—For the pathology of ovarian disease we must refer to Sir Spencer Wells's work on the subject, and to the smaller Monograph on Ovarian Pathology, by the late lamented Dr. Charles Ritchie, junior.

Even the modifications in the method of operating which have been devised are so various and numerous, that if collected from the medical journals of the last ten years they would fill a large volume. Besides this, the operation of ovariotomy is one attended by so many complications, that individual cases vary from each other as much as do individual cases of hernia and tracheotomy; and as the specialities of each case require to be met by specialities of treatment, there is hardly any operation in surgery which requires greater readiness of invention, or more individual sagacity in the operator.

To lay open the abdominal cavity from the sternum to the pubes, and rapidly dissect out of this cavity an enormous tumour with a narrow neck, the operator's only embarrassment being the peristaltic movements of the bowels, and his only care being to tie the neck of the tumour firmly with strong string, sew up the wound, and trust to nature, was an operation very easy to perform, and requiring free cutting rather than dexterity, and rashness more than true surgical insight.

Such were the ovariotomies prior to 1857.

An ovariotomy in 1883 is a very different business, varying in certain important particulars.

(1.) Instead of the incision extending from sternum to pubes, it is now made as short as possible.

(2.) Instead of being removed entire, the cyst is now emptied with the greatest possible care (prior to its removal), and none of the contents allowed to enter the peritoneal cavity.

(3.) The pedicle is brought to the surface, and in every case where it is possible is secured outside the wound.

Besides these three important and cardinal points, there are other minor matters almost equally essential; these are—(1.) The proper management of the adhesions and the thorough prevention of all hæmorrhage from them; (2.) the stitching up of the external wound, including the peritoneum; (3.) the treatment of the patient during the first few days of convalescence.

Operation in a typical case, after the method of Sir Spencer Wells and Dr. Thomas Keith.—The patient having had her bowels gently opened on the previous day, and being as far as possible in her usual state of health, should be warmly clad in flannel, both in body and limb, and laid on an operating table of convenient height, in or near the room she is to occupy. No carrying from ward to operating theatre and back again is admissible. It will be found both cleanly and convenient to have a large india-rubber cloth over the whole abdomen, cut out in the centre so as to expose so much of the tumour as is necessary, but gummed on or otherwise secured to the sides of the abdomen, and thus protecting the clothes, and hanging down over the edge of the table; this will prevent all wetting of the clothes and unnecessary exposure of the patient's person, and can be easily removed after the operation. Chloroform being administered, the bladder is evacuated by means of a catheter, and the patient's head and shoulders are elevated on pillows. An incision is then made in the linea alba, between the umbilicus and pubes, for about four inches in length at first, so as to be large enough to admit the hand, through all the tissues down to and through the peritoneum. Care is necessary in dividing the peritoneum, on the one hand, not to divide too much, in which case the cyst-wall will be penetrated, and the contents effused into the peritoneal cavity; or, on the other hand, too little, in which case the peritoneum may be mistaken for the cyst, and separated from the transversalis fascia under the idea that adhesions exist. Once the peritoneal cavity is opened, the incision through the peritoneum must be extended to the full length of the external wound by a probe-pointed bistoury.

The operator's hand must now be passed into the abdomen, and the tumour isolated from its connections as far as possible. When no adhesions exist it is extremely easy to pass the hand quite round the tumour, ascertain its relations to the uterus and Fallopian tubes, and the length and thickness of its pedicle. The presence of adhesions adds very seriously to the danger and duration of the operation. We will suppose at present that none exist in this typical case, and that the pedicle is found of a satisfactory size and shape. The surgeon now protrudes the anterior portion of the cyst-wall through the wound, and pierces it with a large trocar,¹⁴² to which is attached an india-rubber tube, by means of which the effused fluid can be easily got rid of in any direction. During the escape of the fluid from the cyst a special assistant keeps up the tension by careful pressure on the abdomen. In cases where the cyst is multilocular, and thus only a portion of the contents of the tumour is at first evaluated, the operator should, by partially withdrawing the trocar, without removing it entirely from the cyst, endeavour to pierce and evacuate the other cysts, still through the original opening in the first one.

While doing this, great care must be taken lest he pierce the external wall of the tumour, and let any of the contents escape into the abdominal cavity; to guard against this, the punctures should be made by the right hand, while the left, re-inserted into the abdomen, supports the cyst-wall.

The tumour having been as far as possible emptied of its fluid contents, must now be dragged out of the wound, care being still taken lest any of its fluid contents escape into the peritoneal cavity. In favourable cases the pedicle is now brought easily into view. This may vary very much in length and thickness. It is sometimes entirely absent, the tumour being sessile on the broad ligament of the uterus; sometimes it is thick and strong, sometimes long and slender. The manner in which it is to be managed depends on its length and thickness. Varieties in treatment will be noticed immediately. We will suppose that it is four inches in length and one or two fingers in breadth. This is quite a suitable case for the use of the clamp, the principle involved in the use of which is, that the pedicle should be brought quite out of the abdomen through the wound and secured on the surface. The best form seems to be one made like a carpenter's callipers, with long but removable handles, and a very powerful fixing-screw.

The blades of this clamp being protected by pads of lint should be made to embrace the pedicle close to the cyst, in a direction at right angles to the abdominal wound, and lying across it, the handles should then be removed, and pads of lint placed below the clamp to protect the skin. The cyst may now be cut away at some little distance above the clamp, enough being left to prevent all danger of its slipping. Further to avoid this danger, the pedicle may be transfixed by one or two needles above the clamp.

The wound is now to be sewed up by several points of interrupted suture, some inserted very deeply through all the tissues, including even the peritoneum, others in the intervals of the first, including little more than the skin. They may be either of iron, silver, platinum, telegraph-wire (Mr. Clover's copper, coated with gutta-percha), or silk. It seems of very little consequence which is used. Sir Spencer Wells, after many trials, uses silk, as being removed with least pain to the patient, and really causing no more suppuration than the metallic ones do, if only removed early enough, viz., about the second or third day, by which time the union of the wound should be firm.

The after-treatment should be very simple. Except under special circumstances, stimulants are rarely necessary, and indeed, to avoid vomiting, as little as possible should be given by the mouth during the first twenty-four hours. The patient should be allowed to suck a little ice to allay thirst, and opiate and nutritive enemata will be found quite sufficient to keep up the strength in ordinary cases. The urine should be drawn off by the catheter every six hours. The room should be kept quiet, and the temperature equable, so long as there is no interference with a plentiful supply of fresh air.

Some of the specialities and abnormalities involving special risks may now be briefly noticed:—

1. Adhesions.—These vary much in amount, in position, in organisation, and danger.

a. In amount.—In certain cases no adhesions exist, while in others, omentum, intestines, tumour, uterus, and abdominal wall may be all matted together in one common mass.

b. In organisation.—Occasionally they are so soft and friable as to break down under the finger with ease, and so slightly organised as not to bleed at all in the process, while again they may be so firm and close as to require a careful and prolonged dissection, and so vascular as to require many points of ligature to be applied to large active vessels.

c. There are special dangers connected with the presence of these adhesions, and varying much in different cases. Thus adhesions to the intestines can generally be separated with comparative ease, and seem, as a rule, to require the application of fewer ligatures than those which unite the tumour to the abdominal wall. Adhesions to the wall are sometimes so firm as to be quite inseparable, and thus to necessitate some of the cyst-wall being left adherent. In Sir Spencer Wells's cases, adhesions to the liver and gall-bladder occasionally occurred, requiring careful dissection to separate them, and yet the patients all survived, while pelvic adhesions, especially to the bladder and uterus, on more than one occasion prevented the completion of the operation.

Vascular adhesions to the wall which require many ligatures certainly add to the dangers of the case, while adhesions to the anterior wall of the abdomen render the operation, especially its first stages, much more difficult, preventing the cyst from being recognised.

2. The condition of the pedicle is of great importance. If it is too short, it prevents the use of the clamp, as if applied it is apt either to pull the uterus up, or, pulling the clamp down, to make undue traction on the wound, and rupture any adhesions. This is especially the case where much flatus is generated, or where the patient is naturally stout.

Treatment.—Where the pedicle is just long enough to allow the clamp to be applied, and yet too short to leave room for any distension of the abdomen without undue tension, the best plan is to transfix it with a stout double thread just below the clamp, tie it in two halves, and bring the threads out past the clamp, so that, if tension does occur, the clamp may be removed, the part beyond it cut off, and the rest allowed to slip back into the pelvis, the ligatures being kept out at the mouth of the wound.