Part 7

In contrasting this operation with cholecystotomy, it may be said that the latter simply aims at removing the existing calculi, and makes no provision against the recurrence of the same. Where the “natural” method of Bernay is adopted, and the gall bladder dropped back into the abdominal cavity after suturing the incision made in its walls for the removal of its contents, in case of a recurrence of the disease, the entire operation must be repeated. In the “ideal” method of Spencer Wells, only an incision need be made, in such an emergency, at the site of the first operation. Troublesome fistulæ, however, are apt to remain.

In cholecystectomy, on the other hand, hæmorrhage from breaking down of adhesions between the gall bladder and the surface of the liver, it is claimed, is a frequent and troublesome complication. It is claimed by Thiriar, however (“De l’intervention chirurgicale dans certains cas de lithiase biliaire,” _Revue de chirurgie, 1886, No. 3_), that cholecystectomy is a less dangerous operation than simple cholecystotomy. Again, by Bardenheuer, that hæmorrhage from the liver can be readily arrested. The abstractor witnessed an operation in which the liver was accidentally wounded and the resulting hæmorrhage arrested by the thermo-cautery.

Hertin, a French naval surgeon, in 1767, after experiments made upon dogs, proposed, in wounds of the gall bladder, extirpation of the latter, after ligature of the cystic duct. In these experiments he demonstrated the feasibility of the operation of cholecystectomy upon the lower animals, at least.

Campaignac, in 1826, proposed ligature of the cystic duct, with partial resection of the gall bladder (Journ. hebdom. Bd. ii, 1829). K. Zagorski has recently attempted this latter procedure on dogs, with fatal results (Przegl. lekarski, 1887, No. 48). Nevertheless, to Zielewicz belongs the credit of being the first to demonstrate, by its successful performance, the feasibility of combining in man the two operations of ligature of the cystic duct and cholecystotomy with suture of the gall bladder to the abdominal wound. Upon further trial the operation may prove to be not only feasible, but to follow out a rational indication with relative safety.

SUPRA-PUBIC PROSTATECTOMY.

A. F. McGill, F.R.C.S. (_The Lancet_, February 4, 1888). The operation consists of two parts: (1) The opening and drainage of the bladder; and (2) The removal of the prostatic valve which prevents the egress of the urine. A full sized silver catheter, curved according to the nature of the case, is passed into the bladder, its contained urine withdrawn and its cavity washed out with a warm saturated solution of boracic acid till this is returned clean and unchanged. The usual rubber rectal bag is now introduced and filled with fourteen ounces of water. The bladder is now rendered prominent by injecting it with a sufficient amount of warm boracic acid solution. The catheter is retained in the bladder, and the fluid with which the latter has been distended, prevented from escaping. The usual median supra-pubic incision is now made, the bladder exposed and made to project into the abdominal wound by depressing the catheter. A large curved tenaculum is now passed transversely into the bladder, touching as it goes the point of the catheter. An incision is now made longitudinally through the bladder wall, the fluid being prevented from escaping by plugging the opening with the finger. The bladder is now seized with nibbed forceps, and applied on each side of the incision, the catheter is withdrawn from the urethra and the bag from the rectum, and the first part of the operation is complete. The interior of the bladder and its neck is now examined, in order to ascertain the exact nature of the prostate enlargement. A pedunculated middle lobe can be removed with the curved scissors, but in the case of a sessile middle lobe, this must be assisted with the finger and forceps. The “collar” enlargement is removed with greater difficulty. In order to insure the patency of the urethra, it is advised to pass the forefinger into the canal as far as the first joint. It is claimed that the hæmorrhage is not excessive. The operation completed, drainage is effected by passing a rubber tube out of the abdominal wound, the latter being partially closed by a point or two of suture. The tube is removed after forty-eight hours.

The author’s experience is limited to five cases, four of which have proved successful, while the fifth case is still under treatment. He claims that, in cases operated upon early, before diseased bladder or surgical kidney have developed, a radical cure may confidently be expected.

Two objections to this method occur to us: (1) Whoever has performed or witnessed supra-pubic cystotomy, either for the purposes of removal of a calculus or a neoplasm from the interior of the bladder, must have been struck by the difficulties in the way of a thorough appreciation of the condition of its posterior wall low down, or of the cystic neck. Unless specially devised instruments are available for each particular form of prostatic enlargement, it would seem to be a matter of great uncertainty as to just how much of the growth is removed. (2) Until satisfactory granulation of the wound surfaces has been accomplished, drainage, to be efficient, must be facilitated by placing the patient upon one or the other side, a position difficult to maintain, particularly in old people.

RESEARCHES UPON THE VAGINAL PROCESS OF THE PERITONEUM AS A PREDISPOSING CAUSE OF TENDENCY TO EXTERNAL INGUINAL HERNIA.

H. Sachs (Archiv. f. Klinisch. Chirurgie, Band xxxv., p. 321–372) advocates quite decidedly the view, basing his opinions upon preparations of the spermatic cord examined and upon microscopic examinations of cross sections of the latter, particularly as to the relations of the vas deferens and the vessels to the vaginal process of the peritoneum, that the latter is formed before the beginning of the descent of the testicle rather than as a portion of the abdominal wall formed or dragged into position by the testicle in its descent. In proof, he alleges that he has always found, in cases of incomplete descent of the testicle, that organ upon the posterior wall of the vaginal process, and not on the floor of the same. In females, the formation of the canal of Nuck cannot be said to be due to any dragging.

The entrance to the opening of the vaginal process is found covered by a valve arrangement, and the same is particularly noticeable in the canal of Nuck. The opening of the vaginal process can be caused to gape through a spreading out of the mesentery attached to the ilium or that of the sigmoid flexure. The diameter of the opening is, in general, greater on the right side than on the left in boys, while in girls this difference is not observed. Further, the different forms of the incompletely obliterated opening of the vaginal process agrees with the most frequently occurring forms of the hernial sac in inguinal hernia. The relations of the vaginal process to the elementary parts of the spermatic cord are not constant. On the contrary, the relations which the smooth muscular structures of the cord bear to the vaginal process, in so far as their arrangement into bundles, and their positive relation to the posterior and lateral walls of the same are concerned, are quite constant, and almost form an integral part of the same. The obliteration of the vaginal process depends upon a granulating process, which begins in the middle third of the funnicular portion, and from thence proceeds more rapidly in a downward than in an upward direction. This granulation formation takes place essentially during the first ten to twenty days after birth; after this time it takes place more slowly. The canal of Nuck, on the contrary, is found to have almost entirely disappeared at the time of birth. They are both found to be more frequently open upon the right side.

From these observations it would appear that it is not essential to the production of inguinal hernia that a broad and short inguinal canal should be present. The only essential predisposing cause, in children at least, depends upon the condition of the vaginal process of the peritoneum itself.

The question of the legal responsibility of employers is an interesting one, in connection with this question. Hernia cannot be considered as an accident, in the surgical sense, according to Socin (Korrespondenzblatt f. Schweizer Aertze, 1887, No. 18), but is really a slowly occurring disease, to which certain well-defined anatomical peculiarities act as predisposing causes.

ACID SUBLIMATE SOLUTION IN SURGERY.

E. Laplace (Deutsche Med. Wochenschrift, No. 40, 1887), after repeated and careful examinations and experiments, became convinced that dressing materials consisting of wood-wool, made with sublimate in the usual manner, were far from being germless themselves, much less efficient as antiseptic applications. Gauze, however, showed much better results, but were far from realizing an idealistic asepsis. He likewise found that ordinary sublimate, in the presence of albuminous material, is quickly precipitated and becomes at once ineffective. L. experimented at first with hydrochloric acid as a means of preventing changes in the sublimate from occurring in the presence of organic matter, and particularly albuminous material. But, as hydrochloric acid itself was far from possessing the stability needful for the purpose of preparing dressings, he substituted for it, with the most gratifying results, tartaric acid. The proportions are as follows: sublimate, 1 part; tartaric acid, 5 parts; distilled water, 1,000 parts.

OPERATIVE TREATMENT OF PYOTHORAX.

E. Rochelt (Wiener med. Presse, No. 32 and 38, 1887). The expansion of the lung is greatly impeded after the usual operation for empyema by incision, by the free entrance of air in the pleural cavity. Mader, Subbolik and Immerman devised means for preventing this. R. operates by first resecting a rib, leaving the periosteum intact, and subsequently opening the pleural cavity by means of a trocar and canula. A drainage tube accurately filling the latter is now introduced, through which a disinfecting fluid is injected and its outer opening closed by means of a spring clamp. The tube is connected to an aspirating bottle, into which the pus is discharged. The tube is again clamped, and the bottle into which the pus has been aspirated removed, being replaced by another containing a sublimate solution, 1 to 500. Removal of the clamp and raising and lowering the bottle thoroughly irrigates the pleural cavity. This being accomplished, the patient holding his breath in expiration, and the clamp again applied, the irrigating bottle is removed, and a short hard rubber tube connected to the outer end of the drainage tube. This hard rubber tube has a soft rubber diaphragm which acts as a check valve, effectually preventing the ingress of air during inspiration, but in no wise interfering with the egress of fluid from the pleural cavity during expiration, fits of coughing, etc. For purposes of further irrigation the short rubber tube containing the valve may be removed after guarding against the entrance of air by clamping the drainage tube beyond, and the washing bottle reapplied. During the intervals of irrigation, absorbent antiseptic dressing are kept applied.

The abstractor would suggest the application of this method, particularly in recent cases and in children, without the previous resection of a rib. The increased support afforded the canula by the greater thickness of the thoracic walls would be a still greater safeguard against the entrance of air into the pleural cavity. A certain proportion of acute cases will recover without resection of a rib.

WOUND-HEALING UNDER THE DRY ASEPTIC SCAB.

Prof. Kuester (Centralblatt f. Chirurgue, March 17, 1888,) in reply to remarks made by Dr. Sonnenberg before the Association of Berlin Surgeons, January 9, who characterized K’s method of treating the wound after the operation for the radical cure of hernia as an “open method,” objects to this designation of his method, and takes occasion to more fully describe his method as follows: After the reduction of the contents of the sac, the latter is sutured and excised, and the ring is also closed by suturing. The wound cavity itself is now closed by several rows of buried sutures, so arranged as to bring together the edges of the several layers, tissue to like tissue. In congenital cases he does not loosen the sac, but sutures its opposing surfaces down to the point where the testicle lies free. The wound of the skin is now closed by a continuous silk suture, and an iodoform and collodion mixture brushed over the line of suturing until it is perfectly covered in and blood no longer oozes through. No drain is used, and no further dressing is deemed necessary. If, after two or three days, a split occurs in the scab or crust formed by the drying of the iodoform and collodion, the gap is quickly filled by a slight oozing from the deeper portions of the wound, which, upon drying, becomes a bar against infection.

There can be no doubt, if thorough asepsis is observed and obtained during the operation, the method of completely obliterating every space in which blood clot or serum could accumulate would do away with the necessity for drainage. This granted, it follows, as a natural sequence, that absorbent dressings are superfluous, simple protection of the line of suturing from atmospheric influences, infection, etc., being alone indicated. The iodoform and collodion compound would seem to fulfil this admirably. The method could scarcely find application in large or deep wounds, particularly if the latter invaded planes of dense connective tissue, fasciæ, etc. Here it would be manifestly best to provide drainage, etc.

In marked contrast to K’s method is that of McBurney, who, providing against infiltration by suturing the entire thickness of each edge of the wound together in such a manner as to render it practically but one layer, packs the wound cavity, and thus obliterates the inguinal canal, the latter filling up by granulation, a firm cicatricial plug taking its place.

THE TREATMENT OF CAROTID HÆMORRHAGE.

Mr. Frederick Treves (_The Lancet_, January 21, 1888). In the neck, pressure upon the carotid artery, in hæmorrhages from the branches of that vessel, cannot be applied in the ordinary way with success, nor could it be maintained for a sufficient length of time, if the pressure succeeded in arresting the hæmorrhage, to be of service. Treves proposes, however, to occlude the vessel temporarily by throwing a broad piece of catgut around it, tying it in a loose loop, and then making traction upon the same. The circulation through the vessel is at once arrested, but can be at once restored upon relaxing the tension upon the loop. He relates four cases in which the method proved successful, so far as the arrest of the bleeding was concerned. One of the patients succumbed to the great loss of blood sustained prior to the application of the ligature, although the other carotid had been previously tied. In the first case the loop remained _in situ_ for four days. The second case was the fatal one. In the third and fourth cases the loop was removed on the seventh day.

The method is based upon the fact that temporary arrest of the circulation in certain cases of hæmorrhage from the limbs, where ordinary means may be employed to exercise pressure, are quite sufficient, not only for the purposes of a temporary expedient, but also seems as a curative measure. This temporary modification of the blood current may be all that is required in many instances. Just how long the blood current may need to be checked, must be carefully studied in each individual case. The thought occurs to us, however, that some risk may be run of setting up an ulcerative action in the vessel walls by the prolonged application of a loose ligature, upon which must be exercised an intermittent pressure, by the pulsation of the vessel itself.

ARTIFICIAL AID IN THE FORMATION OF CALLUS.

Prof. Helferich (Archiv. f. Klinische Chirurgie, Band 36, 4. Heft, 1888). In cases of delayed union, and even in normal cases, to hasten the natural process of repair, H. advises the application of an elastic rubber bandage in such a manner as to retard the return flow of venous blood, by this means favoring an increased amount of pabulum to the field of repair, thus indirectly augmenting the formation of callus. The patient must be taught to regulate the pressure, attention being directed to the condition of the nails, in order that the bandage may be adjusted to suit the varying condition of congestion present. Œdema may be controlled by the application of a flannel bandage to that portion of the limb below the site of fracture. It is claimed that by this method the cure, in normal cases even, is considerably shortened. The process of repair is hastened by keeping the limb in a dependent position. The presence of small erosions at the site of fracture is not a contra-indication to the use of the elastic band. The time of application is of some importance, a too early application leading to too active hyperæmia; while, on the other hand, if too long delayed, the period of time in which the action will take place has passed. In wired compound fractures and in resections, pressure may be applied in from five to fourteen days after the operation, providing inflammatory symptoms are absent.

Thomas, of Liverpool, has recommended a procedure, which is known as the percussion method, to hasten the repair in delayed bony union, in cases of imperfect union, and in ununited fractures. This consists of percussing, once in a day or two, the site of the injury with a small copper hammer for five minutes or more, and subsequently bandaging the parts firmly.

It is suggested that the formation of varicose veins may be an objection to the method of Helferich. Further, it is quite clear that the method is not to be thought of in tuberculous subjects, as well as in cases of large open wounds at the site of fracture, or where a gap is left by resection of bone, removal of tumors, etc. The question of its applicability to atrophic members is an open one.

COMMUNICATION OF TUBERCULOSIS BY RITUAL CIRCUMCISION.

F. S. Eve (_The Lancet_, January 28th, 1888), relates the case of a Jewish child, in whom, six weeks following the usual rite, a small swelling appeared in each groin. They were found to be filled with caseous material, which, upon being inoculated beneath the skin of guinea pigs, gave rise to tuberculosis in the latter. The “Mohl,” or person performing the rite, had ejected some wine from his mouth over the cut surfaces of the prepuce. It was subsequently learned that this person had died of pulmonary consumption shortly afterwards. Another child in the same house, operated upon by the same person, suffered from the same infection. Both children finally recovered.

Similar experiences have been recorded by Eisenberg (Berlin Med. Woch., No. 35, 1886), and Meyer (Centralblatt f. Chirurgie, No. 46, 1887). Of greater importance, because of a probably greater frequency, is the transmission of syphilis in this manner. A group of cases of this kind were recently collected and made the subject of study at the London Hospital.

TRANSPLANTATION OF THE SKIN.

Baratoux and Dubonsquet (Progres. Med., No. 15, 1887). D. treated two extensive wounds caused by burning, in which no attempt at cicatrization seems to have been made, although granulation was progressing well, by transplantation. Simultaneous auto-transplantation, and pieces of skin from a frog’s back the size of a thumb-nail, was practiced. Most of the latter lost their pigmented aspect after ten days, and adhered well, taking on the natural color of the human skin. The wound where the frog’s-skin transplantation had been performed healed more rapidly than the other where human skin was used, the cicatrix being softer as well. B. treated cases of ulceration of the nose, and also perforations of the membrana tympani, successfully by transplantation of frog’s skin, healing taking place in from one to two weeks.

In three old cases of perforation of the drum membrane, the margins were freshened by touching them with nitrate of silver, and a piece of frog’s skin attached. In three days a cicatrix had formed, with considerable improvement in the hearing. Transplantation must be practiced with a healthy granulating wound, hæmorrhage being avoided. According to the authors, the wound should be irrigated with a strong solution of carbolic acid, and dried; the pieces of skin should also be washed in a weak solution of carbolic acid.

It suggests itself to the abstractor that still better results would be obtained by substituting a sterilized solution of chloride of sodium, say of the strength of 6 to 1,000, for the strong carbolic solution recommended, to be used just prior to the operation. The changes produced in the vessels and their contained blood by the use of strong disinfecting solutions are calculated to prevent early adhesion of the new skin. At least such is the general experience of recent observers. Reliable disinfection of the ulcerated surface may be obtained by keeping the parts covered with gauze wrung out of a 1 to 12,000 solution of potassio-mercuric iodide for a day or two previously.

OBSTETRICS.

BY CHARLES JEWETT, A.M., M.D.,

Professor of Obstetrics and Diseases of Children, and Visiting Obstetrician, Long Island College Hospital; Physician-in-Chief to the Department of the Diseases of Children, St. Mary’s Hospital, Brooklyn.

THE IMPROVED CÆSAREAN SECTION.

Garrigues (Am. J. M. S., May, 1888,) describes in detail a successful case of Cæsarean section with observations on the _technique_ of the improved operation. He prefers a long abdominal incision, and eventration of the uterus before opening it, the advantage claimed being the easier application of the rubber constrictor. The constrictor is more manageable if held in the hand of the assistant instead of the clamp, since it can be loosened and tightened as required. To prevent prolapse of intestines he sutures the upper end of the abdominal incision before turning out the uterus, tying the sutures before that organ is opened. Extraction of the fœtus by the head is much easier than by the feet. When a long uterine incision is required, it is better to go an inch into the fundus than to extend the wound into the lower segment, which may cause troublesome hæmorrhage.

Removal of the ovaries for the prevention of subsequent pregnancies he thinks not justified. The omentum he pushes up above the uterus to prevent adhesions to the suture line and the consequent danger of subsequent intestinal obstruction.

Dr. Garrigues believes Cæsarean section safer than _difficult_ extraction through the natural passages.

Eleven Cæsarean sections were done in this country between December 16, 1886, and February 24, 1888, (Dr. R. P. Harris) all by the improved method but one. Six women and eight children were saved. Six of the operations were performed in hospitals, saving five women; five in private practice, saving only one. All the five hospital cases operated by the improved technique were successful. The bad results in private practice Dr. G. ascribes to imperfect antisepsis. He alludes to the tardy adoption by our own countrymen of the antiseptic methods in general obstetric practice which have met with almost universal acceptance elsewhere—in Germany midwives being even compelled by law to use antiseptic precautions in every case of confinement.

Including the above-mentioned case, one hundred and sixty-three Cæsarean sections had thus far been done in the United States (Harris). One hundred and seventy to date of this writing.—ED.