THE

DU]3LIN

JOURN_A_L

OF

MEDICAL

SCIENCE.

OCTOBER 1, 1889.

P A R T I. ORIGINAL

COMMUNICATIONS.

ART. X I . - - A Contribution to the Su~'gery of the Abdomen. By J. S. M'AROLE, F.R.C.S.I. ; Surgeon and :Lecturer on Surgery, St. Vincent's Hospital, Dublin. (Continued from page 111.)

BEFORE referring to cases in which laparotomy is justifiable, and, indeed, imperatively demanded, I desire to call attention to a strange condition, produced under certain circumstances, by inflation or injection. I allude to a state of collapse more or less profound and prolonged, followed by fever of varying intensity, and usually intermittent. In reference to this state, the following are the points which strike me as of most interest : - 1. Prostration sets in within two or three hours of the distension of the bowel. 2. Before a rise of temperature occurs, a clammy perspiration breaks out over the patient's head, face, and chest. 3. The fever usually reaches its height in from eight to ten

hours. 4. Then for from two to five days there is a gradual fall, the evening temperature being a degree or so higher than the morning. 5. When the attack is severe and prolonged, the face assumes a dusky appearance, and the eyes appear glassy, and the tongue becomes foul. The circumstances under which I have seen this febrile condition are--(a), when the bowel is inflamed; (b), if there be ulceration iu VOL. L X X X V I I I . - - N O .

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A Contribution to the Surgery of the Abdomen.

the distended p a r t ; (c), where there has been long-standing stricture, more or less complete. I have frequently compared this affection with the more marked varieties of catheter fever, and there is a great resemblance between them. M y notion of its causation is that hyperdistension of the bowel, when intermittent, causes expulsion of the contents of the terminal capillaries at the diseased area; thus, absorption of septic products from the neighbouring ulcers is allowed, and continued pressure drives colonies of micrococci along the lymphatics and venules of the part. Added to this is the danger of microscopic tears in bowel, allowing free invasion of the lymph spaces. Once in the vessels the production of fever is rapid, and prostration is prolonged. Believing that the foregoing is the correct explanation of the phenomena, I have invariably washed out the stomach and intestines with dilute carbolic or boric solution prior to inflation. This process, especially as regards the stomach, renders the observations more uniform in character, as it produces similar conditions of the bowel or stomach, as the case may be, at each examination, while it certainly lessens the chance of causing systemic infection. I shall now call attention to abdominal cases, intra- and extraperitoneal, which are of such a character as to be readily passed over as being beyond the reach of surgery, and yet are most speedily and completely relieved by operation : CASE L--Pelvic Perltonitis~ with Impaction of Small Intestines in Pelvis; Laparotomy ; Recovery.--E. H.~ aged twenty-six years, came under my care on September 16th, 1885. She had been treated for constipation for some weeks, and had opiate fomentations over lower abdomen for a sickening pain, felt chiefly at a point an inch or so below umbilicus. This pain was at first colicy, then intermittent, sharp~ always referred to the lower abdomen, in which she complained of a sense of weight and fulness. When I saw her for the first time the symptoms were not severe ; her pupils were contracted, and I found that she had been kept under the influence of opium for some days. There had been no motion from the bowels for six days~ and before that the discharges were scanty, the last containing mucus and blood. Her pulse was irregular, weak, and 110 per minute; temperature~ 102"6~ She passed water frequently in small amount--it was high-coloured, and she had, before being narcotised, experienced pain in passing it. The abdomen was tense, tender on pressure at its lower part, which was dull on percussion in the lower umbilical, inguinal, and suprapubic regions, as in Fig. 1. The stomach was dilated and resonant~ and both lumbar regions were comparatively resonant.

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On examining the rectum I found it difficult to pass the index finger beyond the second phalanx, owing to an elastic mass which filled the hollow of the sacrum, and pressed down to the tip of' the coccyx. The uterus was so pressed down that the os was within one inch of the vaginal orifice. Bimanual palpation showed that the mass felt in the rectum filled the entire pelvis, and by careful manipulation coils of intestine could be made out. I concluded that a pelvic peritonitis had glued the small intestines together, and fixed the entire mass to the pelvic viscera and walls. Operation.--After ineffectual efforts to dislodge the intestines by rectal distension, I made an incision in the linea alba one inch above the pubes (B, Fig. 1), and passed my finger deeply into the pelvis~ to find that the intestines adhere, and that the post-mesenteric sac is filled with a thin~ sour-smelling pus~ which escapes through the wound. W i t h a long glass tube, bulbous at the end, and having lateral openings, I washed out the pelvis with warm carbolic solution, half per cent., using at the same time the tube, and later on a sponge held by Wells' pedicle forceps (which I used to mop out the shreds of fibrin and pus) to separate the intestines. I inserted a fourinch celluloid drainage tube with a broad flange, and having a rubber tube attached. The wound was dusted with iodoform, masses of loose gauze were packed round the tube, and over this ordinary dressing perforated for passage of rubber tube, which was closed by a clamp, after exhausting the air by an aspirator. Twice daily the clamp was removed, all the dressings being conducted under the spray, and in the evening of each day 40 ounces of warm carbolic solution~ half per cent, containing 10

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A Contribution to tlte Surgery of tl~e Abdomen.

grains of quinine, were passed into the abdomen, and there retained for 15 minutes, when the fluid was allowed to drain away, which it did, carrying with it for the first few days pus and shreds of fibrin. When the solution returned clear--which it did on the ninth day--these flushings of the pelvis were discontinued, and soon after, the discharge ceasing, the tube was removed, and the wound--now reduced to the size of the t u b e - dressed with a peat moss pad. Recovery was rapid and complete. The temperature fell, on the evening of the operation, from 103"8 ~ to 100"5 ~, and from that it gradually came down to normal. CASE II.--]~erforation of ileum; Resection; Recovery.--P. R., aged sixteen years, came under my care in the following condition. He was pale and emaciated ; face drawn and anxious ; pupils dilated ; pulse, 120 ; temperature subnormal ; feet and hands cold and clammy; urine normal in amount and appearance ; no albumen ; tongue coated with white fur ; occasional vomiting of bile-stained fluid. He suffered from constipation, and complained of severe pain passing from right groin down thigh as far as knee. Right leg and thigh were greatly wasted. Above the middle of the iliae crest I found a fistula capable of admitting the point of the little finger, and leading into the right iliac fossa. Along this a probe passed readily as far as the edge of the true pelvis. A slight swelling appeared above the outer three-fourths of Poupart's ligament, and backwards to fistulous opening. I t was semi-elasti% dull on percussion, and extended towards umbilicus, as in Fig. 2.

The fistula discharged large amounts of curdy pus: containing all the

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solid particles of his food, and having a yellow colour and sour odour. He weighed on admission 6 st. 5 lbs. On March 10th, 1887, I cut down as represented in diagram, and found the ileum perforated some inches from the ileo-cmcal valve, l~emoving six inches of the thickened bowel, I sutured the ends after Czerny Leubert's method, and closed the abdominal wound. Some days after operation there was a slight faecal discharge through wound. On the 6th day the bowels moved, and from that forward the discharge ceased, and the patient made a rapid recovery. He is now a vigorous lad, weighing 9 st. 6 lbs. CASE III.--Abscess obstructing ascending colon, and causingperltonit~; Operatlon--Recovery.--Rev. Mr. D. came under my care on March 15th, 1887~ with the following history. Ten years ago had an attack of jaundice~ attended with intense pain in the right hypochondrium. Since then he has had frequent atlacks of biliousness and intestinal h~emorrhage. Some weeks ago felt pain in right side~ and suffered from gastric irritation, then passed blood from the bowels, and had some difficulty in keeping them regular, the evacuation being clay-coloured. In the end of February constipation became marked, vomiting set in, and I found him with a temperature of 103 ~ ; pulse~ 100 ; jaundice ; furred tongue ; urine scanty and deeply stained with bile. On examining the abdomen I discovered a tender area extending from the cartilages of the ninth, tenth~ and eleventh ribs, downwards to the crest of the ilium, and inwards to the umbilicus. In the area marked out on diagram, Fig 3, a swelling appeared, dull on percussion, and having a somewhat doughy feel, all over this area pain was constant, the abdomen was distended and tympanitic, his legs were drawn up, breathing shallow~ and he found it impossible to obtain rest in any position.

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A Contribution to the Surgery of t]~e Abdomen.

For some days I tried the effect of opium and grey powder, using at the same time hot fomentations, but as the symptoms became alarming, and there was an evident spread of peritoneal mischief, I made an incision as in Fig. 3, Ct dissected carefully inward to the posterior part of ascending colon, and gave exit to some ounces of pus, dark and fcetid, which lay high up in front of the kidney. I laid in a large drainage tube t and applied antiseptic dressings. On the twelfth day after this the patient was able to leave his room, and in one month recovery was complete. There was no further pain t only from the bowel t and the constipation yielded to mild laxatives, while ttle jaundice rapidly disappeared, the evacuations being deeply stained with bile. T h e diagnosis made in this ease was t h a t an abscess had f o r m e d in f r o n t of t h e r i g h t kidney, and t h a t the pressure exercised by t h e surrounding effusion compressed the descending duodenum, thus causing the vomiting and obstructing the common bile duct, t h e r e b y producing jaundice. T h e h~emorrhage was evidently the result of pressure on the colon, causing a hypermmic condition of the mucous membrane. CAs~ IV.--Pelvi~ p6ritonitls from perforation of ileum ; Operation ; Recovery withfwcalfistula.--J. C., aged twenty-one years t came under my care on June 9th, 1889, with the following history. For some months he had been unwell, suffering much from repeated attacks of diarrhoea and cramps in lower abdomen t but had been able to go about until ten days before he came under observation t when t after severe pain in the right inguinal region, and down the right thigh, he became faint and was obliged to go to bed ; since that time he suffered from severe pain over the area marked B, Fig. 4, occasional fits of vomiting, and great thirst; diarrhoea stopped and urine became thick and high-coloured, depositing urates in large quantities. On examining his abdomen I found the area marked A t Fig. 4, quite dull, and all over it marked fluctuation, while extending to B there was distinct but not complete dulness. All over the abdomen was tender, the legs were drawn up, and he complained of sharp pain down the right thigh. I made an incision one inch to the inner side of the anterior superior spine of the ilium (C, Fig. 4), and after a careful dissection, laid open an abscess which filled the right side of ~he false, and the greater part of the true, pelvis. I had discovered that the recto-vesieal region was filled with fluid, bimanual examination producing a distinct wave from the supra-pubic region to the finger in the rectum. The patient made a slow recovery t but he i s n o w in good health. He still has a fistula discharging bile-stained, sour-smelling material, evidently from the small intestine, and more than likely from the last coil of the ileum~ where it turns over the pelvic brim to join the creeum.

By MR. J. S. M'A~DLE.

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I have seen the ileum perforated on many occasions without extravasation into the peritoneal cavity occurring--(1) where the lower part was not provided with a mesentery; (2)where it ran along the colon for a couple of inches ; (3) where adhesive peritonitis had glued the intestines together round the point being perforated.

CASEV.-- Veslco.ccecal abscess causing peritonitls ; Operation; Recovery.-M. C., aged thirty-nine years, came under my care with retention of urine~ for which I was obliged to perform perineal section.

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A Contribution to the Surgery of the Abdomen.

The retention was of long standing, and he complained of severe pain in the right side of the abdomen and down the right thigh. This did not subside after evacuating the bladder, and, on examining the suprapubie region, I discovered to the right of the middle line a tender area (A, Fig. 5), dull on percussion~ and very painful on deep pressure. Round this was an area of comparative dulness, and also tender. I tried opiates and grey powder, but without effect. His temperature was subnormal ; he had cold clammy perspirations~ and his breath was fcetid. Rectal examination detected a fluctuating mass projecting from the right pelvic wall inwards between the rectum and bladder. The examination caused great pain. Seeing that palliative treatment was useless I cut down in the direction indicated in the woodcut at C, and gave exit to about an ounce of very feetid pus. The improvement was rapid and permanent. In a few days fcetor disappeared, a healthy discharge took place r and soon recovery was complete. It is now four years since the operation, and there has been no retention or other trouble since.

CASE VI. Suppurative Peritonitis following tIerniotomy; Re-opening of the Wound; Flushing out Abdomen; Recovery.--Mr. B., aged fifty-eight years, was operated on for the radical cure of hernia, on the 12th of l~Iay, 1889. On the 19th I saw him for the first time, in the following condition : - - H i s pulse was so quick that it could not be counted ; temperature in the axilla 97~ body covered with cold clammy perspiration, from which there was a sickening sweetish odour. He was quite unconscious, and had been so for thirty-six hours. The wound seemed healed in its entire length, but, on carefully percussing over the

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inguinal and supra-pubic regions, I discovered a circumscribed area of dulness, well represented in Fig. 6, complete in the part shaded, and extending to the line B, where it was only comparative. I opened up the wound afresh, at A, Fig. 6, passed my finger along the inguinal canal and into the abdomen, and, turning it downwards and inwards to the true pelvis, I gave exit to a large quantity of fcetid, creamy pus. On withdrawing my finger some coils of intestine presented at the wound~ and on them some shreds of lymph appeared. These I removed, and, on examining the neighbourhood of the internal ring, which I dilated with my fingers, I found the inverted sac of the hernia lying on the edge of the true pelvis. Slight traction served to remove this, which turned out to be gangTenous. I now washed out the lower abdomen with warm carbolic solution, 1 per cent, lald in a large rubber drainage tube, and applied masses of loose gauze over the wound. This was at 8 p.m. on the 19th. At 3 a.m. on the 20th he became conscious, and from that out gradually improved. In the end of June he had quite recovered from the operation. Fig. 7.

Cxs~ VII.--Retro-peritoneal Abscess, causing Obstruction of Transverse Duodenum and Localised Peritonitis ; Opera$ion ; Recove~T.--Miss S.9 aged twenty years, came under my care in August, 1885. She gave the following history :--Some months ago she complained of darting pains in the region of the ensiform cartilage, great difficulty and pain in swallowing. Later she had difficulty of breathing, which lasted some weeks, and then vomiting set in, each attack being attended with much pain and precordial distress. The patient now commenced to waste, and at the same time wondered that her corset seemed too tight.

290

A Contribution to tlte Surgery of the Abdomen.

For some weeks before I saw her she had had attacks of very severe epigastric pain, followed in some hours after subsidence by a discharge of pus from the bowels. My reading of this case was that an abscess descending along the spine had perforated the duodenum, giving rise in its development to infiltration round the solar plexus, and all the disturbance arising therefrom. There was an indistinct dulness over the area marked B, Fig. 7, and here, also pain and tenderness were felt. I n this case I made an incision from the last rib to the crest of ilium (C, Fig. 8), cut through the tissues along the outer border of the quadratus lumborum~ and~ pressing my fingers inwards in front of left kidney, I came upon a fluctuating mass close along the spine. Into this I passed a director, giving exit to a large quantity of creamy but sour-smelling pus. I washed out the cavity with 1-2,000 corrosive sublimate solution, and laid in a large drainage tube. The dressings were frequently renewed~ and the cavity washed out with carbolic solution, and in five weeks from the date of operation the wound was soundly healed. I n three days after operation the patient was able to take nourishment freely, and no vomiting occurred from that dater nor did pus pass from the bowels.

CASE u of Verm~rm Appendix; Abscess; Peritonitis; Operation ; Recovery.--P. M., aged sixteen years, came under my care on July 18th~ 1889. He had been kicked repeatedly in the lower abdomen some week or ten days before, and from that time there had been no action of the bowels until the morning I saw him~ when he complained of very severe pain in the right side of the abdomen, in the part marked A in Fig. 9; here also was there dulness on percussion and tenderness. He also complained of an intermittent twisting pain at umbilicus and some tenesmus ; temp. 103"6~ pulse 120. On examining the rectum I discovered a fluctuating mass bulging into the right side thereof, and I could detect a wave by percussing the abdomen with the left hand. I laid open the abscess in the line C~ Fig. 9 near the anterior superior

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iliac spin% giving exit to a large quantity of rather thin fmculent matter, and found therein an olivary calculus, which~ on secdon~ proved to be of slow growth, there being numerous concentric layers of firm material in it. Irrigation with one per cent. of carbolic solution was carried out in this case, and in twelve days after operation discharge had practically ceased~ and in one month the lad was in fair health. Fig. 9.

CxSE IX.~Abscess obstructing Descending Colon and causlng Perlto. nltis ; Evacuation; Recovery.--L. M.~ aged twenty-one years~ came under my care on April 2nd~ 1887. He had suffered from frequent micturitlon at first, then constipation, with occasional attacks of hmmorrhage from the bowels. On examination I discovered a deep-seated swelling in the left side; there was tenderness and pain all over the region marked in Fig. 10, while in the shaded part shown in the figure there was marked dulness in percussion. He cmnplalned of a pain shooting up to the left scapula and down the front of the left thigh. He was greatly emaciated~ and of late the constipation was very persistent. His temperature never went below 102~ and he had shiverings very often. I incised the abdominal wall~ as marked in Fig. 10~ and~ pushing the bowel forward~ I reached~ close to the left side of the lumbar spin% a fluctuating mass~ which I freely opened~ giving exit to about four.ounces of fcetid pus. I dusted the parts well with iodoform~ and laid in a large drainage tub% dressing the wound with peat moss pads~ saturated with corrosive sublimate~ the wound round the drainage tube being plugged with iodoform gauze. For ten days the case went on very satisfactorily~ but it was noticed that the discharge was more copious than ordinary at

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A Contribution to the Surgery of the Abdomen.

this time, notwithstanding frequent washings of the abscess cavity with corrosive sublimate solution ; and when I came to examine the case for the first time since operation I discovered at the bottom of the abscess cavity a rounded mass of iodoform gauze saturated with pus. The removal of this, and a continuation of irrigation, resulted in rapid recovery, which, I am glad to say, has been permanent. I saw the patient some days since in perfect health.

The foregoing are cases which, if allowed to take their own course, would, I have no doubt, end fatally, although in some of them, as Cases I I I . and I X . , such a result might be delayed indefinitely, the interval being one of misery to the patient owing to the pain and discomfort attendant on discharge of f~ecal or purulent material. W h a t these cases teach is, that, with accurate and early diagnosis, diseases which usually run a long and hopeless course may be brought to a happy and hasty ending. In all of them I have made the opening free, and no matter at what trouble I have always removed all solid or semi-solid material which could in any way delay granulation or retard free drainage. There is nothing in my mind so fatal to surgical progress as the tendency I have noticed to proceed by over-cautious steps in the emptying of such collections of pus as those I have noted. The passage of fine drainage tubes, puncture with trocar, aspiration, &c., are very well in their way, but they are not the methods suggested by modern surgical science, nor can they be defended, in the face of their tediousness and very frequent failure, i read

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and hear that aspiration allows a patient's strength to improve, so that later a more vigorous method may be adopted with safety. I say, detect the disease before prostration occurs, and your patient will be in a better position to bear an operation than after he has run the gauntlet of inflammatory fever, often diffuse suppuration, and frequently hectic fever. Then, again, it is said in circumscribed peritoneal collections aspirate to allow the abscess wall to develop. Now this is sheer nonsense. The wall of such circumscribed abscesses is not a simple mass of dense tissue shutting off the pus from the general peritoneal cavity. Whoever examines this wall will find it teeming with micro-organisms of the most virulent character, and we are told, forsooth, that these colonies must be allowed to develop and extend so as to shut off the pus from the peritoneal cavity. I say, why not remove the pus at once, so that no such extension can occur, and at the same time expose the germs to the influence of some antiseptic, so thatw(1) no re-formation of pus can take place; ('2) proliferation may be checked, and (3) general infection may be prevented. Passing now from the consideration of these cases in their general aspect, let me direct attention more particularly to Cases IV. and VI. In them I find, by a reference to the charts, that before the onset of .septic absorption the temperature was usually high, while then a fall occurred, and from this time no appreciable rise ever took place. Now this is a point which I desire to emphasise most forcibly, for the simple reason that I have over and over again seen the descent of temperature pointed out as evidence of improvement. How sadly have the hopes thus raised been dashed, many a family can testify. Another point deserving of consideration is the absence of rigors in a large percentage of these cases, even when suppuration is very extensive, the smallest collection of pus in the cellular tissue will often give rise to more marked rigors than many ounces of the same material in the peritoneum, indeed [ have frequently seen pus in large quantity in the peritoneal cavity without the temperature being materially influenced by its presence. I believe that the aspect of the pahent, the peculiar, sickly, sweet odour of the breath, and the intermittent clammy perspiration, with occasional attacks of syncope, alternating with hurried breathing, must be taken as our guides in the prognosis of abdominal lesions. Many a time have I regretted delay in opening the abdomen when influenced by a descent of temperature, I have hoped for

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Unusual Case of Thyroid Turnout.

recovery, while I have never yet had reason to regard a laparotomy of mine, for the washing out of the peritoneum, as anything but the nmst beneficial of procedures. A serious operation, reclu~ring prolonged anaesthesia, is never necessary. An opening large enough to admit one finger and a long celluloid tube are all that is demanded, and when we confine ourselves to this it is hardly necessary to produce complete anaesthesia at all, as there is little or no pain experienced once the skin-wound is made, and when the patient is in the semi-unconscious state which precedes septic intoxication, the laparotomy wound only acts as a stimulant, as does also the flushing out of the abdomen with warm solutions. I t is marvellous what a change takes place immediately after the removal of septic fluids from the peritoneum; the aspect, skin, and tongue first show the change, then the temperature, which is often subnormal, goes up, consciousness returns, and if the dose already absorbed be not too great, or the patient's strength be not too far gone, recovery takes place with wonderful rapidity.

ART. X I I . - - Unusual Case of Thyroid Turnout-- Operation-Recovery.~ By A~THO~Y H. CORLEY, M.D. THE case which I submit to the notice of the Royal Academy of Medicine is one which, with respect to history, diagnosis, treatment, and result, presents features worthy of discussion. On the 16th of February last Dr. Byrne, of Derry, wrote to obtain my opinion on a case of tumour of the neck, which he had been attending, in consultation with Dr. M'Langhlin, of that city. The patient was sixty-two years of age ; and the lump had been growing for nearly thirty years. For the last two years its rate of increase had been unusually rapid, and it had begun to interfere with his respiration and his voice. Dr. Byrne had, in view of these threatened dangers, recommended puncture and aspiration, for exploration as well as for relief. This procedure was adopted early in February, 1888, and about eight ounces of fluid were drawn off. The size of the tumour was reduced, but in a few days it was as large as before. The fluid evacuated was sherry-coloured, and separated, on standing, into a floating jelly-like clot and a subjacent serum. The circumference of the neck before aspiration Read before the Section of Surgery in the Royal Academy of l~edicine in Ireland, on Friday, March 29, 1889.