A Contribution to the Surgery of the Abdomen.
105
cannot but regard myself as fortunate in having the opportunity of demonstrating the occurrence of what is regarded by many physicians as problematical. A~tT. V . - - A Contribution to the Surgery of the Abdomen. By J. S. M'ARDLE, F.R.C.S.I. ; Surgeon and Lecturer on Surgery, St. Vincent's Hospital, Dublin. N o w that early operative interference has become, and rightly so, the rule in abdominal lesions, it is worth considering the conditions in which such interference is not only justifiable, but imperatively demanded. The object of the present paper is to briefly review the more important diseases which are amenable to surgical treatment, and to bring under the notice of the profession an aid to diagnosis which will, I think, be found of great value, as it proved itself in many of the writer's cases, some of which are herein detailed. Until recently operations on the gastro-intestinal tract were postponed until all hope of the patient's recovery without surgical intervention had vanished, then, as a forlorn hope, laparotomy was tolerated. Mere toleration of a procedure is not very certain to procure for its advocates that hearty assistance, that vigorous and sympathetic co-operation and countenance so necessary in bringing to a successful issue cases of grave moment. Four causes have combined to retard our progress in this branch of surgery--lst, the dread of injury to the peritoneum ; 2nd, the want of accuracy in carrying out the details of our operations; 3rd, the difficulty in determining the exact seat of intra-abdominal lesions; and 4th, the unsatisfactory condition in which patients underwent operation. Thanks to Lister, the first barrier to our surgical advance no longer exists. The second has yielded, gradually but surely, owing to the vigorous efforts--experimental and otherwise--of Madeling, Billroth, Czerny, in Germany ; M. Bouilly, Chavasse, and Verneuil, in France; Parkes, Senn, Bernays, and others, in America; and at home the pioneers have been numerous and successful. The third obstacle is overcome at its worst by laparotomy, but still there are cases in which diagnosis is very difficult, and where laparotomy is unjustifiable or unwise until the diagnosis is certain. The cases detailed herein show how some difficulties of diagnosis may be overcome.
106
A Contribution to tl~e Surgery of the Abdomen.
In reference to the 4th, we must admit that fewer patients die now than heretofore from unrelieved obstruction, hernial or otherwise, chiefly because the conditions likely to prove fatal are discovered earlier, and the danger of delay is more widely recognised. The same may be said--wlth slight reservation--of intra-abdominal affections which heretofore engaged only the attention of the physician but are now happily embraced in the modern extensions of surgery. Before detailing my cases, I wish to call attention to the instrument here depicted, to explain its working and the conditions in which it is of value as a diagnostic aid. The instrument consists of a strong rubber balloon, A, a 3". tube with stop cock, D, for filling this, a stop cock, C, for regulating the amount of air or gas passing from the reservoir A ; then comes a manometer for determining the pressure used in distending the bowel, next a long connecting tube, H, for attaching to the stomach tube, of flexible rubber, K, or Lund's rectal tube N. Inflation of Stomach.--When the reservoir A is filled the stomach tube is introduced by getting the patient to swallow it, no force of any kind being necessary--indeed, any attempt at forcing the flexible tube only delays its introduction. Through this tube the stomach is washed out with dilute boracic solution; then the connecting tube H is attached to the gastric one and the gas is allowed to enter the stomach at a pressure of 88lb. to the square inch--a greater pressure causes spasm. Gradually the outline of the viscus becomes marked, and the pressure becomes better borne by the patient, and with a pressure of from 89to 1 lb. complete dilatation may be effected. A firm (esophageal tube is closely surrounded by that passage, so that, unless the patient allows it, no escape takes place until hyperdistension is brought about. In the normal condition a sulcus marks the position of the pylorus, and here, on pressing the stomach, can be heard an intermittent rush of the air or gas through the valve. I~ation of Intestines.--When only the large intestines are to be examined the process is rapid and simple. Lund's tube is inserted until the rubber ring M is close up-to the anus, then the connecting tube is attached, and a pressure of 89 to 1 lb. used in the dilatation. Often spasm of the colon occurs, and then a pressure of 2 lb. or so may be necessary to complete the inflation. If the stricture or perforation be in the small intestine a pressure of 289 or even 3 lbs. may be necessary to open the ileo-c~eeal valve.
B y MR. J . S. M'ARDLE.
107
W h e n this event takes place the inrush of gas can be distinctly heard, and the umbilical and suprapubic regions become prominent. The instrument above described can be made use of in determining-1 The position of strictures of the bowel. 2. The presence, and often the position, of perforation, ulcerative or traumatic. 3. The position of tumours, and their relation to the gut. 4. The condition as to dilatation, &c., of the stomach or intestines. I have briefly described the method of using the insuffiator. I shall now detail a few of the cases in which I have found it of great value : CASE I . u M r . T. IT., aged forty years, came under my eare on January 17th, 1889, with the following symptoms. He has had colicky pain in lower abdomen, constipation with recurrent attacks of diarrhoea and copious h~emorrhage, severe pain in left lumbar region~ where there is a firm tumour extending from end of tenth rib to erest of ilium. There is tenderness on pressure over this swelling, which has gradually developed within the past fourteen months. He is greatly emaciated, has quick weak pulse r foul tongue, and the evacuations are very offensive, the urine being high-eoloured and loaded with lithates. The question arose (owing to the h~emorrhage, the long-standing and persistent pain, the wasting and the scarcely changed temperature)--Is this a malignant turnout of the bowel, or is it an extra mural obstruction of inflammatory nature, causing constipation by pressure, and leading to hypera~mia of the bowel at the point compressed. The bowel was distended by hydrogen, at a pressure of half a pound to the square inch, and on watching the gradual distension of the abdomen one could see the sigmoid flexure of the colon bulge prominently forward, then the descending colon became distinctly marked, and in a few minutes the entire colon and ,meum were distinctly seen distended. The dulness in the left lumbar region receded backwards, the rounded colon could be distinctly felt, but efforts at moving it caused pain shooting through the back~ but there was no superficial tenderness ; there was no constriction at the level of the tumour, and so I decided that-1st. The bowel was free from any marked infiltration, as no constriction appeared at the site of the tumour. 2nd. The tumour was behind the bowel, as the dulness had disappeared. 3rd. The peritoneum was not engaged, as distension of bowel removed the pain produced by pressure. Operation.--Oblique incision as for left lumbar colotomy ; free incision of peri-nephritic tissue ; pushing forward the colon I came upon a fluctuating
108
A Contribution to the Surgery of ts Abdomen.
spot below the left kidney ; on laying this open an ounce and a half of dark and very fa~tid pus was discharged. The cavity was washed out with a 1 in 40 solution of carbolic acid ; a large and firm drainage tube laid in the lower angle of the wound and extending into the bottom of the abscess cavity; all other parts of the wound and cavity were plugged with iodoform gauze; the whole side was now covered with a gauze dressing and the patient removed to bed. F o r some days the discharges from the bowel were stained with blood, and the urine remained dark and high coloured; the temperature reached 101"6 ~ on the evening of the fourth day after operation ; on the fifth the dressings were changed, and from this date recovery was uninterrupted. The patient has already gained twenty pounds in weight, and is in perfect health.
CASE I I . - - J . C., aged fifty-six years, came under m y care on the 5th of February, 1889, with well-marked evidence of chronic intestinal obstruction. He was pale a n d emaciated; had a cachectic look, and appeared very feeble. He complained of pain in the left lumbar region, and shooting inward to umbilicus. F o r two years he had suffered from constipation, followed by severe attacks of diarrhoea, with now and then hmmorrhage from the bowel. On examining the abdomen I found the walls very lax, the skin hanging in folds, as if rapid wasting had occurred ; the region of the colon was marked by a rounded prominence, resonant and elastic ; at the junction of the descending colon and sigmoid flexure an indistinct mass could be felt, firm~ dull on percussion, and somewhat painful on pressure. I t was difficult to ascertain the actual relation of this swelling to the bowel, its extent, and its attachments; to determine these rectal insufflation was carried out with the following result. W i t h a pressure of half a pound to the square inch, the sigmoid flexure became distended gradually in a few minutes, and without causing the l e n t pain or inconvenience; at the site of the swelling a well-marked depression now appeared, and at the bottom of this the dull mass remained fixed to the posterior abdominal wall; continuing the pressure a whistling noise was heard at this spot, and the colon became distended and distinctly mapped out, leaving a sulcus at the point which we now knew to be strictured, and bound down to the posterior wall of the abdomen. Two inches of the colon was so fixed, and from his age and appearance I considered it a case of cancerous stricture infiltrating the tissues behind the colon. As the obstruction was not threatening life, we decided to postpone ooerative treatment (which could only take the shape of a colotomy), until such procedure became absolutely necessary. C.~s~ ]IL--Tumour of Descending Colon.--P. M., aged fifty-three years~ consulted me about a pain he had had for some years in the left
B y N[a. J . S. M ' A R O L E .
109
lumbar and inguinal regions. He had suffered much from constipation, and purgatives caused so much pain that he avoided their use as long as possible. The result was that swelling and uneasiness in the abdomen frequently occurred~ and often feverish attacks were superadded, rendering him very miserable. On examining the abdomen I found the colon distended, the ascending and transverse portions being resonant, the region of the descending colon and sigmoid flexure being dull on percussion. Two inches internal to the anterior superior spine was a rounded and somewhat nodular tumour, movable from side to side, but apparently not so from above downwards. To decide the exact situation of this tumour, which I believed to be the cause of the obstruction, I inflated the bowel with hydrogen at a pressure of half a pound to the square inch, and found that, after the sigmoid flexure bulged forwards above Poupart's ligament, the tumour ascended to a level with the highest part of the iliac crest, became still more marked and less painful on pressure. After a time, the gas could be heard rushing through beneath the tumour, which now became somewhat resonant. JDiagnosis.--Sacculated cancerous tumour of colon. Operation.--In order to place the patient in the most favourable position for a resection of the descending colon and its splenic flexure, I performed a right lumbar colotomy, which has reduced the size of the abdomen very considerably, removed the febrile condition, and allowed the patient to gain strength. CAs~ IV.--Pyloric Obstruction due to Adhesive Peritonitisfixing Pylorus to Abdominal Wall.--A. C., aged thirty-nine years, came under my care with supposed cancer of pylorus. F o r two years he had suffered from severe pain over an area of 2{ inches, reaching from the ninth costal cartilage towards the umbilicus. Here there was dulness on percussion~ while to the left of this point and extending down to the umbilicus there was an extensive area of resonance corresponding to a dilated stomach. F o r many months vomiting occurred in from one to three hours after every meal, and nothing would in any way relieve this symptom. He had not a cachectic appearance, although he was greatly emaciated. Believing that he had stricture, which was spasmodic and depending on some ulceration near the pylorus, I dilated his stomach, using a pressure of { lb. to the square inch, with the following result : - - W h e n the stomach became outlined on the abdominal wall, every inspiration of the patient caused a creaking under the hand laid over the pylorie region, and from this until complete distension occurred the patient complained of somewhat severe pain in the dull area. The dulness became more marked until under a pressure of 1 lb. to the square inch, the stomach became very tense, and something seemed to give way, and the patient experienced a sharp pain in the part. The gas now escaped into the duo-
110
A Contribution to the Surgery of the Abdomen.
denum, wlth~ at first, a gurgling, then a rushing sound, which was dlstinctly audible, ttyperdistension was soon removed, and the stomach could still be distinctly defined by its prominence; but the dulness had almost entirely left the area above-mentioned, nor could we detect any abnormal dulness elsewhere over the abdomen. The conclusion I came to was that adhesive peritonitis had fixed the pylorus to the anterior wall of the abdomen. Under pressure the adhesion yielded, and tho stomach soon resumed its function, so that in three weeks he gained 16 lbs. in weight, and left for England, feeling well. I have since heard from him, and learn that he has gained $8 l b s , and is in vigorous health.
CAsE V.mPfloric Cancer.--J. C., aged fifty-seven years, consulted me on April 9th, 1889, in reference to epigastric pain and tenderness. He had all the evidence of pylorlc obstruction, and one inch above and to the right of the umbilicus a nodular mass could be felt. I t was the size of a hen-egg, and apparently free. When I first examined the patient I believed the case one for explgratory laparotomy, but before recommending the procedure I examined the stomach by means of the insufllator~ to find that the tumour was fixed to a mass which could be traced up to the liver and down to the transverse colon. This left no doubt on my mind that the mesenteric and portal vessels were obstructed by infiltration of the cancerous material, and that, consequently, operation was out of the question, as, no matter how permeable the intestinal canal might be made, absorption could not take place with sufficient rapidity to ensure repair of the wound or to nourish the patient should he survive. The patient hag since died. Rapid emaciation occurred. CAsE VI.--Omental Cancer.--Rev. Mr. T., aged fifty years. Dilatation of stomach at pressure of ~ lb. to square inch. Before insuffiation~ a rounded nodule could be felt half way between umbilicus and ensiform coat, and to right of umbilicus 1] inches a patch of dulness could be detected and a hardness felt, which extended downwards and inwards to below the umbilicus. After insufflation stomach became distinctly defined, lower border reaching down to umbilicus; pylorie effd passed to right side to line with the costal cartilage. The dull area was pushed downwards and to the right. The nodule on the anterior wall of the stomach was turned upwards under the ensiform cartilage. W e thus became aware that---lst, the marked and movable tumour was not pyloric; 2nd, the thickening at pylori~s extended along the greater curvature in the omentum, and was pushed down by the distended stomach. W e now pressed gently on the distended viscus, and the air rushed through the pylorus, showing that close stricture was out of the question.
Cl~e,nistry of Sele~ic Acid and other Selenium Compounds. 111 I wish to remark here that when infiltration of the pylorus occurs to such an extent as to offer resistance to the passage of semi-solid food, gas usually escapes readily through the opening, as the annular muscular valve becomes incapable of totally occluding the opening ; 2nd, when ulceration exists near the pyloric orifice spasm frequently prevents the passage of gas as well as food, although there may be not the least trace of organic narrowing ; and, 3rd~ the healthy pylorus resists the passage of gas until tired out by continuous pressure. Bearing these points in mind, one will not rush to the conclusion that the pylorus is narrowed whenever gas or air does not freely pass through. What, then, may be asked, does inflation of the stomach show ? It determiaes--lst, the amount of distension, if any; 2nd, the position of the pylorus; 3rd, whether or not it is infiltrated; and 4th, the fixity or mobility of any tumour of the stomach. (To be concluded in the next Number.)
A~tT. IV.--Researcltes in the Chemistry of Selenic Acid and other Selenium Compounds. By SIR C~tARLES A. CAMERON, M.D., F.R.C.S.I., V.P.I.C. ; Professor of Chemistry and Hygiene, R.C.S.I. ; and JOaN MACALLAN, F.I.C.; Demonstrator of Chemistry, R.C.S.I. ALTrmuort selenic acid was prepared by Mitscherlich so far back as the year 1827, few chemists appear to have studied its properties. This want of interest in selenic acid is rather surprising, seeing that it possesses so close a relationship to sulphuric acid, which is so important a compound. Finding the chemistry of selenic acid so meagre we resolved to make an investigation of this body, with the view of bringing, so far as we could, its chemistlTr abreast with that of sulphuric acid, and also in the hope that its study would yield results which might throw additional light on the relations of the latter acid. The following pages contain the results at which we have arrived. PREPARATION
OF ANHYDROUS SELENIC ACID, H2SeO 4.
Selenic acid has hitherto been known only in a dilute form. When heated to upwards of 260 ~ C. it commences to decompose into selenium dioxide, oxygen, and water, which prevents any further concentration. Berzelius describes it as containing, when of
