In cases where the tumour is of moderate size, Sir W. Fergusson found[109] it sufficient to divide the upper lip by a single incision exactly in the middle line, this incision to be continued into one or both nostrils, if required. The ala of the nose is so easily raised, and the tip so moveable as to give great facilities to the operator for clearing the bone even to the floor of the orbit.

In cases where the tumour is larger, or the bones more extensively affected, Sir W. Fergusson preferred an extension of the foregoing incision (Fig. XXVII. B) upwards along the edge of the nose almost to the angle of the eye, and thence at a right angle along the lower eyelid, as far as may be necessary, even to the zygoma. The advantages claimed for such procedures are that the deformity is less and the vessels are divided at their terminal extremities.

2. EXCISION OF THE LOWER JAW.—Removal of portions, greater or smaller, of the lower jaw, for tumours, simple or malignant, are now operations of very frequent occurrence, while in some few cases the whole bone has been removed at both its articulations.

The operative procedures vary much, according to the amount of bone requiring removal, and also the position of the portion to be excised.

(1.) Of a portion only of one side of the body of the bone.—This is perhaps the simplest form of operation, and is frequently required for tumours, specially for epulis.

Incision.—If the parts are tolerably lax and the tumour small, a single incision just at the lower edge of the bone, of a length rather greater than the piece of bone to be removed, will suffice; this will divide the facial artery, which must be tied or compressed,[110] while the surgeon, dissecting on the tumour, separates the flaps in front, cutting upwards into the mouth, and then detaches the mylohyoid below, and clears the bone freely from mucous membrane. He then, with a narrow saw, notches the bone beyond the tumour at each side, and, introducing strong bone-pliers into the notches, is enabled to separate the required portion. The wound is then stitched up, and a very rapid cure generally results with very little deformity, as the cicatrix is in shadow. If from the size of the tumour more room is needed, it can easily be got by an additional incision from the angle of the mouth joining the former.

To prevent deformity, which is apt to result from the centre of the chin crossing the middle line, it is often a wise precaution to have a silver plate prepared fitting the molar teeth of both jaws on the sound side, and thus acting as a splint. Such a precaution may be required in any operation in which the lower jaw is sawn through.

N.B.—There are certain cases in which the epulis is small and confined to the alveolar margin, in which an attempt may be made to retain the base of the jaw entire, and remove the tumour without any incision of the skin. The mucous membrane on both sides being carefully dissected from the affected part, the bone may be sawn as before, but only through the alveolar portion, the groves of the saw converging as they penetrate, then by a pair of strong curved bone-pliers, the affected alveolar portion is to be scooped out without injuring the base. This proceeding, which has been practised by Syme, Fergusson, Pollock, the author in many cases, and others, leaves no deformity, but, it must be owned, is much more liable to the risk of recurrence of the disease, and for this reason is strongly condemned by Gross.

Note.—In this, as in all other operations on the jaws, the very first thing to be done is to draw the teeth at the spots at which the saw is to be applied.

(2.) Excision of a portion involving the Symphysis.—Free access is of importance. The best incision is probably one which (Fig. XXVII. C) commences at the angle of the mouth opposite the healthy portion of jaw, extends down to the place at which the saw is to be applied and then along the base of the jaw past the middle line to the other point of section. The flap is to be thrown up and the bone cleared. The next point to be noticed is, that when, in clearing the bone behind, the muscles attached to the symphysis are divided, the tongue loses its support, and unless watched may tend to fall backwards, embarrassing respiration and even perhaps choking the patient. The tongue, being confided to a special assistant, must be drawn well forwards. Various plans have been devised for keeping it in position, as stitching it to the point of the patient's nose; putting a ligature into its apex, and fastening it to the cheek by a piece of strapping, and transfixing its roots with a harelip needle, used to stitch up a central incision in the chin. The tendency to retraction very soon ceases, new attachments are formed by the muscles, and after the first five or six days there is very little risk of the tongue giving rise to any untoward consequences by its displacement.

(3.) Disarticulation of one, or both Joints.—When the portion of bone implicated involves disarticulation for its complete removal, the difficulty of the operation is much increased. The remarkably strong attachments of the joint, especially the relation of the temporal muscle to the coronoid process, and the close proximity of large arteries and nerves, especially the internal maxillary artery and the lingual nerve, render this disarticulation very difficult.

The chief points to be attended to seem to be (1.) that the incision through the skin should extend quite up to the level of the articulation; (2.) that the bone should be sawn through at the other side of the tumour, and freely cleared from all its attachments, before any attempt be made at disarticulation, for by means of the tumour great leverage can be attained, so as to put the muscles on the stretch, and allow them to be safely divided; (3.) that the articulation should always be entered from the front, not from behind, and the inner side of the condyle should be very carefully cleaned, the surgeon cutting on the bone so as to avoid, if possible, the internal maxillary artery; (4.) free and early division of the attachment of the temporal muscle to the coronoid process.

Disarticulation of the entire bone has been very rarely performed.[111] If necessary, it can be performed without any incision into the mouth, by one semilunar sweep from one articulation to the other, passing along the lower margin of each side of the body, and just below the symphysis of the chin.

Disarticulation of the Ramus without opening into the cavity of the Mouth.—That this operation is possible, though it may not be often required, is shown by the following case by Mr. Syme. It was a tumour of the ramus, extending only as far forwards as the wisdom-tooth:—

"An incision was made from the zygomatic arch down along the posterior margin of the ramus, slightly curved with its convexity towards the ear, to a little way beyond the base of the jaw. The parotid gland and masseter muscle being dissected off the jaw, it was divided by cutting-pliers immediately behind the wisdom-tooth, after being notched with a saw. The ramus was then seized by a strong pair of tooth-forceps, and notwithstanding strong posterior attachments, was drawn outwards, its muscular connections divided and turned out entire. There was thus no wound of the mucous membrane of the mouth, the masseter and pterygoid muscles were not completely divided, and the facial artery was intact."[112]

Fergusson[113] holds that even the very largest tumours of the lower jaw may be successfully removed without opening into the orifice of the mouth at all by division of the lips. A large lunated incision below the lower margin of the bone, with its ends extending upwards to within half an inch of the lips, will give free access, and yet avoid both haemorrhage and deformity, as the labial artery and vein are not cut, and there is no trouble in readjusting the lips. Some tumours of lower jaw can be removed without any wound of skin.

FOOTNOTES:

[107] Diagram of operations on the jaws:—A, incision for removal of the whole upper jaw; B, incision for removal of alveolar portion and antrum; C, incision for removing the larger half of lower jaw; the opposite side is the one supposed to be operated on, and the incision is crossing the symphysis and turning up at a right angle.

[108] Operative Surgery, p. 265.

[109] Lancet, July 1, 1865.

[110] Temporary compression of the facial can be easily managed, in cases where it is of much importance to avoid loss of blood, by passing a needle from the outside through the skin above the vessel, then under the vessel, and out again through the skin below. A figure-of-eight suture can then be thrown round both ends of the needle, and the artery thus thoroughly compressed.

[111] Syme, Contributions to the Path. and Practice of Surgery, p. 21; Carnochan of New York, Cases in Surgery.

[112] Contributions to the Path. and Prac. of Surgery, pp. 23, 24.

[113] Lancet, July 1, 1865.



CHAPTER VIII.

OPERATIONS ON MOUTH AND THROAT.

SALIVARY FISTULA, Operation for.—After a wound or abscess of the cheek, in which the parotid duct is implicated, a salivary fistula is very apt to remain. The saliva thus discharges in the cheek, giving rise to considerable annoyance, as well as injury to the digestion. It is by no means easy to cure this. Perhaps the best operation is the one of which a rude diagram is given (Fig. XXVIII.). The duct (C) communicates with the fistula (D). One end of a thread, either silken or metallic, should be passed through the fistula, and then as far backwards as convenient through the cheek into the mouth; the needle should then be withdrawn, the thread being left in. The other end being threaded should then be re-inserted at the fistula, and carried forwards in a similar manner; the needle should be again unthreaded in the mouth and withdrawn; the two ends should then be tied pretty tightly inside, and allowed to make their way by ulceration into the cavity of the mouth. A passage will thus be obtained for the saliva into the mouth, and every possible precaution should be taken to enable the external wound to close.

]

EXCISION OF THE TONGUE, for malignant disease of the organ, may be either complete or partial. Complete excision affords a hope of permanent and complete relief from the disease, but it is an operation of extreme difficulty and danger. It may be performed in either of the following methods. The first is the only one in which absolute completeness of removal is insured.

1. Syme's method of excision.—The patient being seated on a chair, chloroform was not administered, so that the blood might escape forwards, and not pass into the pharynx. The operation is thus described:[115]—

"Having extracted one of the front incisors, I cut through the middle of the lip and continued the incision down to the os hyoides, then sawed through the jaw in the same line, and insinuating my finger under the tongue as a guide to the knife, divided the mucous lining of the mouth, together with the attachment of the genio-hyoglossi. While the two halves of the bone were held apart, I dissected backwards, and cut through the hyoglossi, along with the mucous membrane covering them, so as to allow the tongue to be pulled forward, and bring into view the situation of the lingual arteries, which were cut and tied, first on one side, and then on the other. The process might now have been at once completed, had I not feared that the epiglottis might be implicated in the disease, which extended beyond the reach of my finger, and thus suffer injury from the knife if used without a guide. I therefore cut away about two-thirds of the tongue, and then being able to reach the os hyoides with my finger, retained it there while the remaining attachments were divided by the knife in my other hand close to the bone. Some small arterial branches having been tied, the edges of the wound were brought together and retained by silver sutures, except at the lowest part, where the ligatures were allowed to maintain a drain for the discharge of fluids from the cavity." The patient was able to swallow from a drinking-cup with a spout on the day following the operation, and was able to travel upwards of 200 miles within four weeks of the operation.

2. By the Ecraseur.—Nunneley of Leeds has recorded cases in which he made a small incision through the skin, and mylohyoid and geniohyoid muscles, and through this passed a curved needle bearing the chain of the ecraseur completely round the base of the tongue. In one case the chain was unsatisfactory, but strong whipcord was introduced as it was withdrawn, and tied with all possible force. The organ eventually sloughed away, with a cure which lasted at least for some months.

Sir James Paget operates as follows:—

The patient is placed under the influence of chloroform, and the mouth held widely open. The tongue is then drawn forwards, the mucous membrane and soft parts of the floor of the mouth, including the attachment of the genio-hyoglossi to the symphysis being divided close to the bone. The steel wire of an ecraseur is then passed round its root as low down as possible, slowly tightened, and the tongue thus divided through its whole thickness in a very few minutes. The bleeding is slight, being almost entirely from the parts cut with the knife. Recovery has been rapid in the recorded cases.[116]

To Dr. George Buchanan of Glasgow the credit is due of the invention of the operation of removal of the half of the tongue in the median line. In at least one instance the cure after five years is still permanent.

Partial excisions of the tongue are as unsatisfactory in their results as they are unsound in principle, yet many cases present themselves, in which, while the patient urges some operative measure for his relief, the tumour is so limited as not to warrant the exceedingly dangerous operation of complete excision.

Portions may be removed in various ways:—

1. By the knife. If in the apex, by a V-shaped incision; if in the lateral regions, by a bold free incision with a probe-pointed bistoury round the tumour.

2. By ligature, drawn as tightly as possible, and, if the portion included be large, in successive portions.

3. By the ecraseur.

Mr. Furneaux Jordan has removed the whole tongue with success by means of two ecraseurs worked at the same time.[117]

4. By the galvano-caustic wire.

5. The author has in nine cases removed the affected half of the tongue by means of the thermo-cautery, first splitting it in the middle line and then cutting through the base with a curved platinum knife at a low red heat. In one only was there any trouble from haemorrhage, and all made good recoveries.

Mr. Barwell has recorded (Lancet, 1879, vol. i.) an easy, safe, and comparatively painless mode of removing the tongue by ecraseurs.

Mr. Walter Whitehead,[118] of Manchester, has had a very large experience of an operation devised by himself, in which, after pulling the tongue well forward by a string previously introduced near its apex, and the mouth being held open by a gag, he detaches the organ from jaw and fauces by successive short snips with scissors, and then in same manner divides the muscles, tying or twisting the vessels as they bleed. His success has been very great by this method, though others who have tried it have sometimes found bleeding troublesome.

It is comparatively seldom now necessary to split the jaw and perform Syme's operation, and in all operations on the tongue the thermocautory (Paquelin's) is of great use.

Regnoli's method[119] may deserve a brief notice. A semilunar incision along the base of the jaw, from one angle to the other, detaches the muscles and soft structures, and is thrown down; the tongue is then drawn through the opening, and can be freely dealt with either by knife or ligature. After removal the flap is replaced.

FISSURES IN THE PALATE.—The operations requisite for the cure of fissures in the soft and hard palates are so complicated in their details, that a small treatise would be required thoroughly to describe the various procedures.

Different cases vary so much in the nature and amount of their deformity, that at least five different sets of cases have been described. It is sufficient here merely to describe the absolutely essential principles of the operations for the cure of fissures of the hard and soft palate respectively.

In all operations on the palate, two conditions used to be considered requisite for success:—1. That the patient should have arrived at years of discretion, at twelve or fourteen years at least; that he be possessed of considerable firmness, and be extremely anxious for a cure, so as to give full and intelligent co-operation. 2. That for some days or weeks prior to the operation the mouth and palate should have been trained to open widely and to bear manipulation, without reflex action being excited. Professor Billroth of Vienna,[120] and Mr. Thomas Smith[121] of London, have had cases which prove the possibility of performing this operation in childhood, under chloroform, with the assistance, in the English cases, of a suitable gag, invented by Mr. Smith. The effect of the operation on the voice of the child has been very encouraging, as much more improvement takes place than in cases where the operation is performed late in life.

Fissure in the soft palate only appears as a triangular cleft, the apex of which is above, the base being a line between the points of the bifid uvula, which are widely separated. To cure this it is required—

1. That the edges of the fissure should be brought together without strain or tightness. In small fissures this can generally be done easily enough; but where the fissure is extensive, some means must be used to relieve tension. For this, Sir William Fergusson long ago proposed the division of the palatal muscles, the levator, tensor, and palato-pharyngeus muscle of each side. The incisions in the palate for this purpose certainly aid apposition, but many surgeons entertain doubts whether the division of the muscles has much to do with the good result, and believe that the simple incisions in the mucous membrane, in a proper direction, are all that is required (see Fig. XXIX.).

]

2. That the edges of the fissure be made raw, so as to afford surfaces which will readily unite. Complicated instruments, such as knives of various strange shapes, have been devised for this purpose; an ordinary cataract knife, very sharp, and set on a long handle is perhaps the best. It greatly facilitates the section if the parts are tense, so the point of the uvula should be seized by an ordinary pair of spring forceps, and drawn across the roof of the mouth, while the knife should enter in the middle line, a little above the apex of the fissure, and make the cut downwards as in harelip.

3. That sutures should be inserted to keep the edges in apposition, yet not so tightly as to cause ulceration. They may be either of metal, silver being preferable, or of fine silk well waxed. The metallic sutures are now generally preferred. Some dexterity is required in their introduction, and various instruments have been devised; the best seems to be a needle with a short curve fixed on a long handle, which should be entered on the (patient's) left side of the fissure in front, and brought out on the right side.

If silk sutures be used, the chief difficulty, that of passing the thread through the second side from behind forwards, can be avoided in the following manner.[123] A curved needle is passed through one side of the fissure, and then towards the middle line, till its point is seen through the cleft. One of the ends of the thread is then seized by a long pair of forceps, and drawn through the cleft; the needle is then withdrawn, leaving the thread through the palate, and both ends are brought outside at the angle of the mouth. Another needle is then passed through a corresponding point at the opposite side of the palate, till its point again appears at the cleft; this time a double loop of the thread is also brought out through the cleft by the forceps into the mouth. If then the single thread of the first ligature which is in the cleft be passed through the loop of the second one also in the cleft, it is easy, by withdrawing the loop through the palate, to finish the stitch (see Fig. XXIX.). All the stitches should be passed and their position approved before any one be tied, and it is most convenient to secure them from above downwards. To prevent confusion, each pair of threads after being inserted should be left very long, and brought up to a coronet fixed on the brow, which is fitted with several pairs of hooks numbered for easy reference. This will prevent twisting of the threads or any mistake in tying.

FISSURE OF THE HARD PALATE.—This may vary in extent from a very slight cleft in the middle line behind, up to a complete separation of the two halves of the jaw, including even the alveolar process in front, and sometimes complicated with harelip.

To close such fissures by operation is difficult, as the breadth of the cleft is so great as to prevent the apposition of the edges when prepared, without such extreme tension as quite prevents any hope of union. Through the researches of Avery, Warren, Langenbeck, and others, a method has been discovered of closing such fissures by operation, which, though certainly not easy, is, when properly performed, generally successful.

Operation.—In addition to the usual paring of the edges of the cleft, an incision is made on each side of the palate, extending "from the canine tooth in front to the last molar behind,"[124] along the alveolar ridge (Fig. XXX.). The whole flap between the cleft and this incision on each side is then to be raised from the bone by a blunt rounded instrument slightly curved. With this the whole mucous membrane and as much of the periosteum as possible should be completely raised from the bone, attachments for nourishment of the flap being left in front and behind where the vessels enter.

]

The flaps thus raised will be found to come together in the middle line, sometimes even to overlap, and, when united by suture, form a new palate at a lower level than the fissure, experience having shown that in cases of fissure the arch of the palate is always much higher than usual. The flaps do not slough, being well supplied with blood, unless they have been injured in their separation.

The edges must be carefully united by various points of metallic suture, and the fissure of the soft palate closed at the same sitting, unless the patient has lost much blood, or is very much exhausted with the pain. The stitches may be left in for a week, or even ten days, unless they are exciting much irritation. The patient must exercise great self-control and caution in the character of his food and his manner of eating for ten days or a fortnight after the operation.

EXCISION OF TONSILS.—To remove the whole tonsil is of course impossible in the living body, the operation to which the name of excision is given being only the shaving off of a redundant and projecting portion. When properly performed it is a very safe, and in adults a very easy operation, but in children it is sometimes rendered exceedingly difficult by their struggles, combined with the movements of the tongue and the insufficient access through the small mouth. Many instruments have been devised for the purpose of at once transfixing and excising the projecting portion; some of them are very ingenious and complicated. By far the best and safest method of removing the redundant portion is to seize it with a volsellum, and then cut it off by a single stroke of a probe-pointed curved bistoury; cutting from above downwards, and being careful to cut parallel with the great vessels.

The ordinary volsellum is much improved for this purpose by the addition of a third hook in each tonsil placed between the others, with a shorter curve, and slightly shorter; this ensures the safe holding of the fragment removed, and prevents the risk of its falling down the throat of the patient.

If both tonsils are enlarged they should both be operated on at the same sitting, and the pain is so slight that even children frequently make little objection to the second operation. Bleeding is rarely troublesome if the portion be at once fairly removed, but if in the patient's struggles the hook should slip before the cut is complete, the partially detached portion will irritate the fauces, cause coughing and attempts to vomit, and sometimes a troublesome haemorrhage.

The plentiful use of cold water will generally be sufficient to stop the bleeding, though cases are on record in which the use of styptics, or even the temporary closure of a bleeding point by pressure, has been necessary.

M. Guersant has operated on more than one thousand children, with only three cases of any trouble from haemorrhage, while four or five out of fifteen adults required either the actual cautery or the sesqui-chloride of iron.[126]

FOOTNOTES:

[114] Rough diagram of operation for salivary fistula:—A, section of cheek close to buccal orifice; B, section of zygoma, muscles, etc.; C, the duct of the parotid; D, the fistulous opening of the cheek; E E, the thread knotted inside the mouth; F, the palate.

[115] Lancet, Feb. 4, 1865.

[116] Med. Times and Gazette for Feb. 10, 1866.

[117] Lancet, April 20, 1872.

[118] Transactions International Medical Congress, 1881, vol. ii. p. 460.

[119] Gross's Surgery, vol. ii. p. 472.

[120] Langenbeck, Archiv, ii. p. 657.

[121] Med. Chir. Trans. for 1867-8.

[122] Diagram of staphyloraphy, chiefly to illustrate the passing of the threads:—a, the first thread; b, the second. The dotted line at edge of fissure shows amount to be removed; the other dotted lines showing size and position of the incision through the mucous membrane above.

[123] Holmes's Surgery, vol. ii. pp. 504-513.

[124] Edinburgh Medical Journal for Jan. 1865, Mr. Annandale's instructive paper on "Cleft Palate."

[125] Diagram of fissure of hard palate:—a, anterior palatine foramina; b, posterior palatine foramina with groove for artery; c, incisions requisite to free the soft structures.

[126] Holmes's Diseases of Children, p. 555.



CHAPTER IX.

OPERATIONS ON AIR PASSAGES.

OPERATIONS ON THE LARYNX AND TRACHEA.—The great air passage may be opened at three different situations, and to the operations at these different places the following names have been given:—

Laryngotomy, when the opening is made in the interval between the cricoid and thyroid cartilages, through the crico-thyroid membrane.

Laryngo-tracheotomy, when the cricoid cartilage and the upper ring of the trachea are divided.

Tracheotomy, when the trachea itself is opened by the division of two, three, or more rings.

Of these the last, tracheotomy, is by far the most frequent, important, difficult, and dangerous, and requires a very detailed description. Chassaignac[127] says "the only really rational operation for the opening of the air passages by the surgeon is tracheotomy."

TRACHEOTOMY.—Anatomy.—Between the cricoid cartilage and the level of the upper border of the sternum, the middle line of the neck is occupied by the upper portion of the trachea. Its depth from the surface varies, gradually increasing as the trachea descends, and varying very much according to the fatness, muscularity, and length of the neck. It is, however, almost subcutaneous at the commencement below the cricoid, and on the level of the sternum it is in most cases at least an inch from the surface, in many much deeper. Again, its length varies, even in the adult, from two and a half to three, or even four inches. This is important, as affecting the simplicity of the operation, which, as a rule, is easier the longer the neck is.

The trachea has most important and complicated anatomical relations—some constant, others irregular.

1. The carotid arteries and jugular veins lie at either side, but, where these are regular in their distribution, do not practically interfere in a well-conducted operation.

2. The thyroid gland lies in close relation to the trachea, one lobe being at each side (Fig. XXXI. B B), and the isthmus of the thyroid crosses the trachea just over the second and third cartilaginous rings. In fat vascular necks, or where the thyroid is enlarged it may occupy a much larger portion of the trachea. The position of the isthmus practically divides the trachea into two portions in which it is possible to perform tracheotomy. Both have their advocates, but the balance of authority tends to support the operation below the thyroid. A separate notice of each will be required immediately.

]

3. The muscles in relation to the trachea are the sterno-hyoid and sterno-thyroid of each side. The latter are the broadest, are in close contact across the trachea by the inner edges below, but gradually diverge as they ascend the neck. In thick-set, muscular necks, however, they are in close contact for a considerable distance, and require to be separated to give access to the trachea.

The arteries are in most cases unimportant; no named branch of any size ought to be divided in the operation. However, occasionally very free bleeding may result from the division of an abnormal thyroidea ima running up the trachea to the thyroid body from the innominate, or even from the aorta itself.

The veins are very numerous and irregularly distributed. There is generally a large transverse communicating branch between the superior thyroid veins just above the isthmus. The isthmus itself has a large venous plexus over it. Below the isthmus the veins converge into one trunk (or sometimes two parallel ones) lying right in front of the trachea.

4. The last anatomical point which may give trouble in normal necks is the thymus, which is present in children below the age of two, and covers the lower end of the trachea just above the level of the sternum. Where this is not only not diminished, but enlarged, as it sometimes is in unhealthy children, it may give a very great deal of trouble, rolling out at the wound and greatly embarrassing proceedings.

Abnormalities are very various and sometimes very dangerous: vessels crossing the trachea, as the innominate did in Macilwain's case,[129] or where two brachiocephalic trunks are present, as recorded by Chassaignac.[130] One of the most frequent dangers to be guarded against is a possible dilatation of the aorta or aneurism of the arch. This may very possibly, as happened in one case to the author, give rise to suffocative paroxysms from its pressure on the recurrent laryngeal nerves. Tracheotomy may be deemed necessary, and there is a great risk, unless proper precautions be taken, of wounding the aorta, where it passes upwards in the jugular fossa. In the author's case the vessel had actually to be pushed downwards by the pulp of the forefinger while the trachea was opened, the knife being guided on the back of the nail of the same finger.

THE OPERATION.—In a work of this kind it would be utterly impossible to go at all into the subject of what diseases, injuries, etc., warrant or require the operation. It is enough to describe the various methods of operating, their dangers and difficulties.

1. The operation above the isthmus of the thyroid.—A spot about a quarter or half of an inch in vertical diameter between the cricoid cartilage (Fig. XXXI.) and thyroid isthmus.

Advantages.—It is near the surface, the vessels are few and comparatively small. It is most suitable in cases of aneurism.

Professor Spence[131] gives his sanction to the high operation in adults with thick short necks when the operation is performed for ulceration or papilloma of larynx or for spasm from aneurism, the low operation being still best in cases of croup or diphtheria.

Disadvantages.—The space is too small, requires very considerable disturbance of the thyroid isthmus, or actual division of it. It is too near the point where the disease is; so much so, that in most cases of croup or diphtheria it would be perfectly useless. However, if required, or if the operation lower down be contra-indicated, this may be performed easily enough. A straight incision being made in the middle line about one inch and a half in length, expose the upper ring by careful dissection, if possible draw aside the veins, and depress the thyroid isthmus, divide the rings thus exposed, and introduce the tube.

The operation below the isthmus.—This, though more difficult in its performance, is a much more scientific and satisfactory operation. Considerable coolness and a thorough knowledge of the anatomy of the part are absolutely required.

The patient being in the recumbent posture, the shoulders should be well raised, and the head held back so as to extend the windpipe, and thus bring it as near as possible to the surface. A pillow, or the arm of an assistant, behind the neck will be of service.

N.B.—Be careful lest too great extension by an anxious assistant, accompanied by closure of the mouth, should choke the patient (whose breathing is of course already much embarrassed) before the operation be begun.

Chloroform may occasionally be given, and, if well borne, renders the operation very much easier than it would otherwise be. An incision must then be made exactly in the median line of the neck, from a little below the cricoid cartilage, almost to the upper edge of the sternum; at first it should be through skin only, then the veins will be seen, probably turgid with dark blood; the larger ones should be drawn aside, if necessary divided, the bleeding stopped by gentle pressure. The deep fascia must then be cautiously divided, great care being taken to keep exactly in the middle line, and the contiguous edges of sterno-thyroid muscles separated from each other by the handle of the knife. A quantity of loose connective tissue, containing numerous small veins, must now be pushed aside, the thyroid isthmus pressed upwards, still with the handle of the knife. The forefinger must then be used to distinguish the rings of the trachea. If there is much convulsive movement of the larynx and trachea, they should be fixed by the insertion of a small sharp hook with a short curve, just below the cricoid cartilage, and this should be confided to an assistant. The surgeon should then, with the forefinger of his left hand, fix the trachea, and open it by a straight sharp-pointed scalpel, boldly thrusting it through the rings with a jerk or stab, the back of the knife being below, and divide two or three of the rings from below upwards. Any attempt to enter the trachea slowly with a blunt knife or trocar will probably be unsuccessful, as the rings, especially in children, give way before the knife, which merely approximates the sides of the trachea without opening it.

Question of Haemorrhage.—It is often a question of some importance, and one which sometimes it is not easy to settle, how far attempts should be made completely to arrest the venous haemorrhage before opening the trachea.

On the one hand, if not arrested, besides the risk of weakening the patient, we have to dread the much more serious complication of the admission of blood into the wound. And this is very serious in a patient whose respiration has already been much impeded, whose lungs are probably engorged, and who has certainly, by the mere existence of a wound in his trachea, lost the power of coughing properly; it must never be forgotten that a quantity of blood so trifling as to be at once ejected by a single cough in the case of a healthy chest, may be a fatal obstacle to respiration in one already weakened by disease. Thus any well-marked arterial haemorrhage from cut branches, or from the isthmus of the thyroid, must certainly be arrested prior to opening the trachea. Besides this, blood once having entered the bronchi is apt to extend into their smaller ramifications and prove a cause of death, by acting as a local irritation, and setting up intra-lobular suppurative pneumonia. The author has found this to be the case both after tracheotomy and still more frequently in suicide by cut throat.

But, on the other hand, it is equally true that there is almost always a considerable amount of oozing from small venous radicles divided during the operation, which depends simply on the great venous engorgement resulting from the obstruction to the respiration, so that while to attempt to tie every point would be simply endless, we may be almost certain that the oozing will cease whenever the trachea is opened, and respiration fairly improved. Slight pressure on the wound is generally sufficient to stop the bleeding till the venous engorgement has disappeared.

Of late years many tracheotomies have been done bloodlessly by use of the thermo-cautery, for division of the soft parts, but the subsequent sloughing of the wound is a great objection to this method.

In cases of extreme urgency, all such minor considerations as suppression of venous oozing must be ignored, and the trachea simply opened as rapidly as possible. I had once to perform the operation after respiration had entirely ceased, and no pulse could be felt at the wrist, with no assistance except that of a female attendant. Merely feeling that no large arterial branch was in the way, I cut straight through all the tissues, opened the trachea, and commenced artificial respiration. The patient eventually recovered.

Question of Tubes, etc.—Once the trachea is opened, the next question is, How is the opening to be kept pervious? For the moment the handle of the scalpel is to be inserted in the wound, so as to stretch it transversely; this will probably suffice to allow of the escape of any foreign body. But where, to admit air, the wound is to be kept open, how is this to be done? It used to be advised that an elliptical portion of the wall of the trachea be removed; this, though succeeding well enough for a time, was unscientific, as the wound always tended to cicatrise, and ended of course in permanent narrowing of the canal of the trachea. It may be necessary thus to excise a portion of the trachea, in cases where it is very intolerant of the presence of a tube. Such a case is recorded by Sir J. Fayrer of Calcutta.[132] Not much better is the proposal to insert a silk ligature in each side of the wound, and by pulling these apart thus mechanically to open the wound. This also is evidently a merely temporary expedient.

Various canulae 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 dyspnoea 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;[133] (2.) lest the tube become worn, and lest the part within the windpipe fall into the trachea and suffocate the patient.[134]

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. Durham[135] and Dr. Morell Mackenzie.[136]

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.[137]

OESOPHAGOTOMY.—This operation is very rarely required, and has as yet been performed only for the removal of foreign bodies impacted in the oesophagus, and interfering with respiration and deglutition. To cut upon the flaccid empty oesophagus 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.[138] 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 oesophagus 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 oesophagus 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 oesophagus, and make it a much more easy and safe business to divide them to the required extent. The wound in the oesophagus 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 oesophagus are required, nor is it advisable too closely to sew up the external wound.

FOOTNOTES:

[127] Lecons sur la Tracheotomie, p. 10.

[128] Rough diagram of larynx and trachea:—A, crico-thyroid space, laryngotomy; B B, dotted outline of thyroid isthmus and lobes, defines the upper and lower positions for tracheotomy; C, thyroid—D, cricoid cartilages; E, dotted outline of thymus gland in child of two years; F F, outline of clavicles and jugular fossa.

[129] Surgical Observations, p. 335. See also Harrison On the Arteries, vol. i. p. 16.

[130] Lecons sur la Tracheotomie, p. 9.

[131] Lectures on Surgery, 3d ed., vol. ii. p. 900.

[132] Clinical Surgery in India (1866), p. 143.

[133] Mr. John Wood, Path. Soc. Trans., vol. xi. p. 20.

[134] South's Chelius, vol. ii. p. 400; and case recorded by Spence, in Ed. Med. Journal, for August 1862.

[135] Med. Chir. Transactions of London, 1872.

[136] British Med. Journal (Nos. 643, 644), 1873.

[137] Gross's Surgery, 6th ed., vol. ii. p. 342.

[138] Guy's Hospital Reports for 1858.



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,[139] and an exceedingly interesting and valuable paper by Dr. Warburton Begbie.[140]

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.

FOOTNOTES:

[139] Both in Guy's Hospital Reports, second series, vol. ii.

[140] Edinburgh Medical Journal for June 1866.



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 oesophagus, 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 haemorrhage, 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 haemorrhage 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,[141] 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.

Or again, it is sometimes possible, after applying one clamp firmly as near the tumour as possible, to apply another above it when the greater part of the tumour has been cut away; when the second is firmly fixed it may then be safe to remove the first, and thus an artificially elongated pedicle is obtained.

When still shorter, two plans remain for selection—(1.) to transfix the pedicle in one or more points, then, securing it in two, three, or more portions, cut it off above the ligatures and return it, leaving the ligatures at the lower end of the wound. This gives a free drain for pus, but theoretically the sloughing pedicle might be expected to set up peritonitis; (2.) to transfix and tie the pedicle with one or more loops of stout string, cut the ends off short, and return the whole affair, closing the external wound at once. Theoretically there are grave objections to this plan, but it has proved very successful, especially in the hands of Dr. Tyler Smith.

Another ingenious modification, sometimes useful in a short narrow pedicle, is to tie it as close to the cyst as possible, bring the ligature out at the wound, and then with a strong harelip needle transfix the pedicle, along with both sides of the wound, just below the ligature.

When the pedicle is excessively broad and stout, it should be transfixed by strong needles and double threads in various places, and thus tied in several portions. Absence of the pedicle greatly adds to the danger in any given case. Various plans have been tried, as cutting the attachment through slowly by the ecraseur, ligature of each vessel separately, so many as twelve being sometimes required, and cauterising the stump. The latter, as used by Mr. Baker Brown, has met with a large measure of success, and is much used now.[142]

Dr. Keith for a time operated with antiseptic precautions, but has now (1883) entirely given up the use of the spray, which he believes has especial dangers in abdominal surgery.

OPERATION FOR STRANGULATED INGUINAL HERNIA.—The great rule to be remembered with regard to this, as well as all other operations for hernia, is, that the earlier it is performed the better chance the patient has. Once a fair trial has been given to the taxis, aided by proper position of the patient, the warm bath, and specially chloroform, the operation should be performed.

The patient should be placed on his back with his shoulders elevated, and the knee of the affected side slightly bent. The groin should then be shaved, and the shape and size of the tumour, with the position of the inguinal canal, carefully studied. The surgeon should then lift up a fold of skin and cellular tissue, in a direction at right angles to the long axis of the tumour, and holding one side of this raised fold in his own left hand, commit the other to an assistant. He then transfixes this fold with a sharp straight bistoury, with its back towards the sac, and cuts outwards, thus at once making an incision along the axis of the hernia without any risk of wounding the sac or bowel. Any vessel that bleeds may now be tied. This incision will be found sufficiently large for most cases; if not, however, it can easily be prolonged either upwards or downwards. The surgeon must now devote his attention to exposing the neck of the sac, and in so doing, defining the external inguinal ring. The safest method of doing so is carefully to pinch up, with dissecting forceps, layer after layer of connective tissue, dividing each separately by the knife held with its flat side, not its edge, on the sac, and then by means of the finger or forceps raising each layer in succession and dividing it to the full extent of the external incision. It is not always an easy matter to recognise the sac, especially as the number of layers above it, which are described in the anatomical text-books, are often not at all distinct.

The thickness of the connective tissue of the part varies immensely; sometimes six layers or even more can be separately dissected, while, again, one only may be found before the sac is exposed.

If small and recent, the sac may be recognised by its bluish colour, and by the fact that it is possible to pinch up a portion of it between the finger and thumb, and thus to rub its opposed surfaces against each other.

If large and of old standing, it is sometimes so thin as not to be recognisable, or again so enormously thickened, and so adherent, as to be defined with great difficulty.

If it is small, i.e. when the whole tumour is under the size of an egg, it ought to be thoroughly isolated, and its boundaries everywhere defined. If large, and specially if adherent, the neck alone should be cleared.

The sac thus being reached, the external abdominal ring should be clearly defined, and the finger passed into it so as if possible to determine the presence or absence of any constriction in it. If it feels tight, the internal pillar of the ring should then be cautiously divided on the finger by a probe-pointed narrow bistoury, in a direction parallel to the linea alba.

At this stage the question comes to be considered as to whether the sac should or should not be opened. Much has been said and written on both sides.

Not to open the sac avoids the risk of peritonitis, and of injury to the bowel; but, on the other hand, exposes the patient to the danger of the hernia being returned unreduced; for in many cases the stricture is to be found in the sac itself, and adhesions very rapidly form between coils of intestine in the sac and the inner wall. Again, not to open the sac prevents us from discovering the condition in which the bowl is; it may possibly be gangrenous, in which case such a return en masse would be almost necessarily fatal.

A general rule or two may be given here:—

1. The sac should be opened in every case where there is any reason for doubt about the condition of the bowel, where there has been long-continued vomiting, or much tenderness on pressure.

2. Even in cases in which there is every reason to believe the bowel is perfectly sound, the sac should be opened, unless the whole contents can be easily and completely reduced out of the sac into the belly, as in cases where this cannot be done there probably exist either a stricture in the neck of the sac itself, or adhesions of the bowel to the sac. We should endeavour to avoid opening the sac in cases of old scrotal hernia of large size, where the symptoms have not been urgent, especially in large unhealthy hospitals, as the risk of peritonitis is so great. Antiseptic precautions seem considerably to diminish the risk of opening the sac.

If the sac then is not to be opened, the rest of the operation is very simple. Endeavour to reduce the bowel out of the sac, and then return the sac itself, unless the hernia is of old standing, and adhesions prevent its reduction. A few silver stitches to close the wound and a carefully adjusted pad are now all that is requisite.

If the sac is to be opened, how can it be done with least danger to the bowel?

If the hernia is small, and it is possible to define it all, the sac should be opened at its lower end, as there a small quantity of serous fluid which intervenes between the sac and the bowel will be found. Where this is present, there is no danger of wounding the bowel, as the sac can be easily pinched up; but this is by no means invariably the case, so great care should always be taken. A small portion of the wall being thus pinched up should be divided in the same manner as the layers of cellular tissue were divided in exposing the sac. A few drops of serum will then escape, and the glistening surface of the bowel be exposed; the finger should then be introduced at the opening, and the incision enlarged by a probe-pointed bistoury. If the hernia is small the sac should be slit up to its full extent; if large, only a sufficient portion of the neck should be opened. As soon as the opening in the sac is large enough to admit the point of the operator's forefinger, it should be inserted so as to protect the intestines, and the remainder of the sac slit up on it as a guide.

The sac thus opened, the next step is to divide the constriction, wherever it be. It is most likely to be found at the neck of the sac, just where it protrudes through the internal ring in an oblique hernia, or through the tendons of the transversalis and internal oblique, where the hernia is direct. Now, this constriction might be divided in any direction were it not for the risk of wounding the epigastric artery, and also of injuring the spermatic cord, which is in close relation to the neck of the sac of an oblique hernia.

Wound of the epigastric artery is the chief danger, for in all cases it is close to the neck of the sac. Were its position in relation to the neck of the sac constant, it might be easily avoided by an incision in the opposite direction; but as this relation varies according to the nature of the hernia, an element of danger is introduced. Thus, in oblique inguinal ruptures, where the sac passes out through the internal ring (Fig. XXXII. IR), the artery will always be found to the inside of the neck of the sac; while in direct herniae, where the bowel has made its escape through the triangle of Hesselbach (Fig. XXXII. +), and passed through the conjoint tendon straight to the external ring, the epigastric artery will be found on the outside of the neck of the sac. In recent herniae the differential diagnosis is comparatively easy, but in those of old standing and large size, in which the obliquity of the canal has been much diminished, it is almost impossible to tell of what kind the hernia originally was, and consequently to determine in which direction it is safe to incise the neck of the sac.

Such being the case, the best rule is to incise the neck of the sac directly upwards, i.e. in a line parallel with the linea alba, and also to cut it very cautiously bit by bit, in every case, if possible, with the finger inserted as a guide to the position of a vessel and a protection to the gut.

The spermatic vessels lie sometimes behind, sometimes on either side of the sac, and in very old herniae may be separated from each other so as really to surround the sac. The cut directly upwards is also the safest for them.

All constrictions being overcome, it is not sufficient merely to push back the gut into the belly. Its condition must be carefully examined, and it must be decided whether the constriction has caused gangrene or not. To examine this properly, it is generally best to pull down an inch or two more of the gut, so as thoroughly to bring into view the constricted portion, as it is most likely to be fatally nipped.

It is not always easy to decide as to the condition of the bowel. Certain points must be observed:—

(1.) Colour.—There may be very great alteration in the colour of the bowel from congestion, and yet no gangrene. It may be dark red, claret, purple, or even have a brownish tint, and yet recover; where it is black, or a deep brown, the prognosis is unfavourable.

(2.) Glistening.—So long as the proper glistening appearance of the bowel remains, there is hope for it, even when the colour is bad; if it has lost it, and especially if, instead of being tense and shining, it is dull and flaccid and in wrinkles, the bowel is almost certainly gangrenous.

(3.) Thickness.—If much thickened, and especially if rough on the surface, the bowel has probably been forming adhesions to the sac, or to contiguous coils, and the prognosis is less favourable.

(4.) Smell.—The peculiar gangrenous odour on opening the sac is very characteristic. In cases where ulceration and perforation have occurred, the odour is faecal.

1. If, then, the bowel is tolerably healthy-looking, though discoloured, it should be returned gradually, not en masse, into the abdomen, the wound sewed up, and a pad of lint put on, with a bandage.

2. If there are adhesions of bowel to sac or to a neighbouring coil, or of omentum to sac, the stricture should be freely divided, the protruding coils of intestine should be emptied of their contents, but no rash attempt made to force their return. Especially is this rule to be observed with protruded, swollen, or adherent omentum, for considerable risks attend any attempt at excision of the protruded portion—risks of haemorrhage, peritonitis, and ulceration of the contiguous bowel.

If the bowel be returned, or even the continuity of the canal restored by the cutting of the stricture, though the bowel be not returned, no great risks accrue from the retention of a piece of omentum in the sac, in a position which it may possibly have already occupied for years.

3. If the bowel is absolutely gangrenous, even in a very small portion of its length, no reduction should be attempted, but the gangrenous portion should be kept outside, with the hope that adhesive inflammation may be set up, so as to glue the bowel to the abdominal wall, prevent faecal extravasation, and form a temporary artificial anus. If the gangrenous portion be very full of faeces or flatus, incisions may be made into it. This should be avoided in cases where the patient is already much prostrated, as I have seen cases in which the opening of the bowel seemed to inflict a fatal shock.

Enterectomy or excision of the gangrenous portion has recently been recommended and performed by some surgeons. The very high authority of the late Professor Spence is against such procedure.[143]

Cases of gangrene of even large portions of bowel are by no means necessarily fatal. They may recover with an artificial anus, the remedy of which by surgical means we must notice in its proper place.

OPERATION FOR STRANGULATED FEMORAL HERNIA.—While the general principles guiding treatment and ruling the conduct of the operation are the same as in inguinal, there are some differences in points of detail which render a brief separate description necessary.

A single word on the anatomy. Tracing a femoral rupture from within outwards, we find that its first stage is to push its way through the weak point of the arch formed by Poupart's ligament, that is, the spot called the crural arch, bounded on its outer side by the sheath of fascia which surrounds the femoral vein; above by Poupart's ligament; on its inner side by the curved fibres of Poupart's ligament, which, curving backwards, are inserted into the ilio-pectineal line, have a sharp falciform edge, and have been dignified by the special name of Gimbernat's ligament (Fig. XXXII. G); and below by the os pubis itself. This arch or ring thus bounded is, in the normal state of parts, filled by a layer of fibrous texture, a little fat, and occasionally a small gland. These parts are pushed forwards in the descent of the hernia, and in a small recent one may be said to form a sort of inner covering; in a larger and older one they are split by the hernia, and, while forming a constriction round its neck, leave the fundus of the sac, so far as they are concerned, quite uncovered.

A femoral hernia may stop there, satisfied with merely coming through the ring, and, if sudden and recent in a healthy, well-knit subject, such a rupture is exceedingly dangerous, the constriction being very severe, and the consequent gangrene of the bowel very rapid if unrelieved. In most cases, however, it makes its way still further out, and the next covering it gains is from the cribriform fascia. This is the layer of fibres, pierced (as its name implies) with orifices for the passage of veins and lymphatics, which stretches between the two curved edges of the saphenous opening. It varies much in strength; when the rupture has been slow and gradual, it will certainly add a covering of greater or less thickness, but where the hernia is large and old we must not expect to find many traces of the cribriform fascia, at least over the fundus of the tumour.

The ordinary superficial fascia of the part, with its fat, nerves, veins, and lymphatics, and the thin skin of the groin, are the only remaining coverings. It is very remarkable how exceedingly thin all the so-called coats become in large femoral herniae of long standing, especially in thin old people.

Operation.—Various incisions are recommended. The one which gives freest access and exposes the sac best, is shaped like a T, the horizontal limb of which is oblique, the direction of the obliquity varying on the two sides. The horizontal incision should be made just over Poupart's ligament, and parallel to it, the centre of the incision corresponding to the neck of the sac, and its length varying according to the size of the tumour and the depth of the parts; the other should extend downwards from the centre of the former, as far as is necessary to display the whole sac. The first should be made by pinching up and transfixing the skin, the second by ordinary incision, to the same depth as the first. The small flaps thus made must now be thrown back; any vessels that have been divided are to be tied. Now, with great care and caution the surgeon is to pinch up and divide any layers of condensed cellular tissue which may still cover the sac, till it is thoroughly exposed to its full extent, and remove any glands which may intervene.

The neck of the sac being exposed, it may be possible in some very exceptional cases to give the patient the benefit of the minor operation, which consists in leaving the sac unopened. In such a case (to be described immediately), the surgeon passes his finger along the neck of the sac as far as possible into the ring, and then with a probe-pointed bistoury very cautiously nicks the upper edge of Gimbernat's ligament, in one or more places, being careful to feel for any pulsation before dividing a single fibre. He may then be able to empty the sac of its contents, and return the bowel and omentum, still retaining the sac outside.

On the other hand, where it is determined to open the sac, the pinching up of the sac must be managed with great care, to avoid injury of the bowel. There is generally a little fluid to be found at the fundus, which will protect the bowel. In one case in which Liston operated, he tells us, "there was no possibility of pinching up the sac, either with the fingers or forceps; it contained no fluid, and was impacted most firmly with bowel; very luckily the membrane was thin; and, observing a pelleton of fat underneath, I scratched very cautiously with the point of the knife in the unsupported hand, until a trifling puncture was made, sufficient to admit the blunt point of a narrow bistoury."[144] If the sac contains bowel and omentum, it is safer to open it over the omentum than over the bowel. When a small opening is made, an escape of the contained fluid takes place, and then the sac should be slit up as far as its neck by a probe-pointed bistoury, guided by the finger, introduced to protect the bowel, whenever the opening is sufficiently large. The forefinger must now be cautiously insinuated into the neck of the sac, the nail being directed to the bowel, the pulp to the crescentic margin of Gimbernat's ligament, and any constriction very cautiously divided. The bowel should then be drawn down a little, the constricted point carefully examined, and then returned or not, according to its condition.

Two points require a brief separate notice:—

1. In what direction is the crural arch to be divided? Not outwards certainly, on account of the vein, nor downwards, as the bone prevents that direction. Is it to be upwards or inwards? Not upwards, for such an incision would endanger the spermatic cord or round ligament, besides greatly weakening the abdominal wall by the division, partial or complete, of Poupart's ligament. Inwards then it must be; and little more need be said about it, were it not for the occasional existence of an abnormal course and distribution of the obturator artery.

]

The usual origin of this vessel is from the internal iliac, in which case (Fig. XXXII. N O) it never comes near the sac at all. In certain cases (1 in 3-1/2) it rises from the epigastric, and in a very few (1 in 72) from the external iliac. If rising from either of the two last, it most commonly passes downwards at the outer side of the hernia, in which case (Fig. XXXII. S O) no harm can possibly result; but in a few rare cases, perhaps 1 in every 60 of those operated on, the vessel winds round the hernia (Fig. XXXII. O), crossing at its inner side, and thus may be (and has actually been) divided by a rash incision. With due care, however, and by cutting a very little at a time, even this danger may be avoided.

2. Under what circumstances is it possible or justifiable to reduce a femoral hernia, without previously opening the sac? Only in certain very select cases, where the hernia is recent, the constricting parts lax, the general symptoms very mild, and where there is reason to believe the bowel has completely escaped injury by compression or the taxis. There are both difficulties and dangers in this so-called minor operation:—1. Difficulties, For it is not easy to divide the constriction without the assistance of the finger in the sac, and it is not easy to reduce the contents with the sac unopened, except through a much freer opening than is necessary when the bowel has been fairly exposed. 2. Dangers, Of reducing sac and viscera, together with the strangulation still kept up by tightness in the neck of the sac; or of supposing the sac is emptied while a knuckle of bowel still remains in it, and is strangulated; or, lastly, of reducing the intestine which has already become gangrenous. It is very remarkable how very soon gangrene may come on, in a case of a small recent femoral hernia, in which the fibrous tissues constricting the neck of the sac are tense and undilatable. A protrusion for eight hours has been sufficient to destroy the life of a knuckle of bowel.

A note here on a certain condition very frequent in femoral herniae, which may occasionally give a good deal of trouble. Symptoms of strangulation have been well marked, yet when the sac is opened nothing is to be seen except a mass of omentum, perhaps tolerably healthy-looking. To reduce this en masse would be very unsafe; it is necessary carefully to unravel it, and disengage the knuckle of bowel which is almost certainly included in it, and which has given rise to the symptoms of strangulation.

OPERATION FOR STRANGULATED UMBILICAL HERNIA.—The operation is practically the same, whether the hernia is a true umbilical one, or one which with more strict accuracy might be called ventral. True umbilical hernia is a disease of infancy and childhood, being almost always congenital, and the viscera protrude through the umbilical aperture. This rarely requires operation, as it may generally be returned with ease, and even cured by a proper bandage and compress. Ventral hernia, commonly called umbilical, is generally a protrusion of viscera through a new preternatural aperture in the fibrous tissues close to the navel, may often attain a large size, is liable to strangulation, and is not easily palliated or cured.

In either case the operation requires a very brief description. If the hernia is small, under the size of a hen's egg, a crucial incision through the thin skin which covers it will thoroughly expose the sac when the flaps are dissected back. The forefinger should then be inserted in the round opening, and the edges cautiously incised in several directions, each incision however being very small.

If the rupture is large, a single linear, or a T-shaped incision, exposing the base of the tumour, will be sufficient to allow the requisite dilatation of the opening to be made. It is not at all necessary in every case to open the sac of the peritoneum. If required, it must be done with great caution, as the sac is generally very thin. In cases where the hernia is chiefly omental, the sac should be opened, lest a knuckle of bowel be inclosed and strangulated in the omentum.

OBTURATOR HERNIA is an extremely rare lesion, and a large proportion of the recorded cases were discovered only after death. When diagnosed during life and strangulated, some have been reduced by taxis, and only a very few cases have been operated on, some with success. It is not likely that a diagnosis could be made, except in very emaciated patients, in whom pain at the obturator foramen was a prominent symptom, and in whom it could be ascertained positively that the crural ring was empty. An incision over the tumour, sufficient to allow the pectineus muscle to be exposed and divided, is necessary. The hernia may then be reduced without opening the sac, if recent; if of long standing, the sac must be opened. One case is recorded by Dr. Lorinzer, in which, after strangulation for eleven days, he opened the sac and found the bowel gangrenous. The patient had a faecal fistula; but survived the operation for eleven months. Nuttel, Obre, and Bransby Cooper have each diagnosed and treated such cases.[146]

Other forms of hernia are so rare, and the treatment of each case must necessarily vary so much in its circumstances, as not to require or admit of any detailed account of the operations requisite for their relief.

OPERATIONS FOR THE RADICAL CURE OF HERNIA.—The inconveniences and discomfort caused by even the best-adjusted trusses or bandages, the unsatisfactory support they afford, and the risk of their slipping and allowing the hernia to escape, have given rise to many attempts to cure hernia by operation.

Even to enumerate these would be quite beyond the limits of the present volume; suffice it to classify a few of the most important of them according to the principle involved in each, and then give a very brief account of the method of operating which seems to be at once the most scientific, least dangerous, and most permanently useful.

The question at issue is briefly this. We have, in a hernia, the following condition:—The walls of a great cavity are at one or more points specially weak, the contained viscera have protruded, either by extension and stretching of a natural opening, or by the formation of a new breach in the walls, and, in protruding, they have brought with them as a covering a serous membrane, extremely extensible, highly sensitive to injury, and, when injured, certain to resent it by severe, spreading, and dangerous inflammation.

Do we desire to remedy this protrusion, we may act—

1. On the intestines themselves; but for all surgical purposes, they are out of our reach. We cannot do more than, by diminishing their contents, diminish their volume, and by position and rest reduce to the utmost their tendency to protrude. This includes the medical and prophylactic treatment of hernia, or rather of the tendency to hernia.

2. We may try what can be done with the sac which the intestines have pushed down before them. Can it be obliterated? If it can, perhaps the intestines may be retained in their cavity. Very many plans of dealing with the sac have been tried.