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remain and produce pain; in fistula cases; in some cases of persistent jaundice due to obstruction of the common duct, although there may be a possibility of cancer existing; in phlegmonous cholecystitis and gangrene of the gall-bladder. Besides these conditions which may be produced by gallstones, Robson operates for wounds of the gall-bladder, rupture of the gall-bladder, infective and suppurative cholangitis, and for some conditions of chronic catarrh of the bileducts and gall-bladder.1

The common operation is cholecystotomy (or cholecystostomy), which consists in opening the gall-bladder, removing the stones, and closing the bladder again, or in making a fistula of the gall-bladder (page 697). If calculi exist in the common duct, it may be possible, after celiotomy, to manipulate them back into the bladder. In some cases cholecystotomy is performed, or a fistula is made, and the duct and bladder are frequently irrigated. In other cases the stone may be crushed by the fingers manipulating the duct and the concretion within it. The duct may be opened, and after the removal of the stone closed by sutures (choledochotomy). If the stone is impacted near the outlet of the duct, the duodenum is incised and the stone removed (choledocho-duodenotomy). A dilated bile-duct may be anastomosed to the bowel (choledocho-enterostomy) or to the surface (choledochostomy). The obstruction may be side-tracked by anastomosing the gall-bladder to the bowel (cholecystenterostomy) (page 697).

THE PANCREAS.

Hemorrhage.-Pancreatic hemorrhage is a recognized cause of sudden death. The symptoms arise without warning, and comprise severe pain, nausea, vomiting, abdominal tenderness, distention, great restlessness, constipation, and collapse. The blood may collect in the lesser peritoneal cavity, or about the spleen and left kidney (Prince and F. W. Draper).

Acute Pancreatitis.-Hemorrhagic pancreatitis occurs in people in middle life, and especially in tipplers. It begins suddenly: there are violent pain, nausea and vomiting, moderate fever, constipation, distention, and rapid collapse (Reginald Fitz, and Osler and Welch). Inflammation of the pancreas with pus-formation is, as a rule, more chronic. The 1 Robson's treatise, from which the above is taken, is a valuable exposition of the surgery of the gall-bladder and bile-ducts.

symptoms are similar at the beginning of the attack and a septic fever develops. In some cases the pancreas becomes gangrenous.

Treatment. In view of the difficulty of distinguishing acute pancreatitis from intestinal obstruction and perforated ulcer of the stomach, in any case where either of these conditions is suspected an exploratory laparotomy is indicated. Osler speaks of cases of hemorrhagic pancreatitis in which operation was followed by recovery.

Cysts of the pancreas occasionally follow injury. They are due, as a rule, to obstruction of the orifice of the common duct or of the pancreatic duct by calculi, tumorpressure, or cicatricial contraction. These cysts may grow rapidly or slowly. They usually produce considerable pain and gastro-intestinal disturbance. Examination of the abdomen maps out a mass which is usually median, is elastic, and is dull at some parts but resonant at others (where it is crossed by the colon). The fluid of the cyst is apt to contain urea, and will convert starch into sugar.

Treatment.-Tapping is contraindicated. It might do much damage. In Keen's case, if an aspirating-needle had been introduced it would have perforated both walls of the stomach. Confirm the diagnosis by an exploratory incision. It may be possible to extirpate, but it is better to incise the cyst, stitch its edges to the belly-wall, and drain.

THE SPLEEN.

Wounds and Rupture.-A wound of the spleen causes great hemorrhage, and if no surgical aid is offered will rapidly produce death. The treatment consists in celiotomy and splenectomy.

Rupture of the spleen produces the signs and symptoms of intra-abdominal hemorrhage. It can only be certainly recognized after exploratory celiotomy. If such a condition is suspected while intravenous saline transfusion is being employed, the surgeon opens the abdomen, and if the spleen is ruptured, removes it.

Abscess of the spleen is a rare condition which is metastatic in origin. Pain is felt, and enlargement is noted in the splenic region, and the symptoms of pyemia exist. The treatment consists in incision and drainage.

Wandering Spleen.-The spleen may wander into any part of the general peritoneal cavity. This condition is. almost never met with except in women. It is most com

mon in women who have borne children (J. Bland Sutton). A wandering spleen may undergo atrophy, engorgement, or axial rotation (J. Bland Sutton). The organ, when displaced, drags upon the stomach, producing dilated stomach; it may interfere with the bile-duct, causing jaundice; it may cause intestinal obstruction by forming adhesions, or may cause uterine retroflexion or prolapse by passing into the pelvis.

J. Bland Sutton says this condition may endanger life, as it may lead to rupture of the stomach, intestinal obstruction, splenic abscess, or splenic rupture.' A wandering spleen can be identified by the fact that it has a notch upon its edge, and can be pushed about the abdomen. When this condition exists the spleen may be missed from its normal situation. Always examine the blood in order to determine if leukemia or malaria exists.

Treatment.-Greiffenhagen advocates suturing the organ in place (splenopexy). Most surgeons prefer to perform splenectomy. Splenectomy should not be undertaken if leukemia exists. In such a case apply a support and employ medical treatment for the existing disease.

OPERATIONS UPON THE Abdomen,

Abdominal Section (Celiotomy; Laparotomy). - In opening the abdominal cavity for exploratory purposes or to gain access to some area of abdominal or pelvic disease, the patient is carefully prepared as for any other operation. The instruments required depend upon the nature of the case. As a rule, there are required scalpels, scissors, a dry dissector, two pairs of dissecting-forceps, hemostatic forceps, pedicle-forceps, Hagedorn needles, calyx-eyed intestinal needles, a needle-holder, drainage-tubes, gauze pads, sponges, silk, catgut, silkworm-gut, the Paquelin cautery, an electric light, also a bag, a tube, and a saline solution for hypodermoclysis or transfusion. Always count the instruments, sponges, and pads, and write down the number, and count them again after operation. This rule is adopted so that no instrument, sponge, or pad will be left in the abdomen. The abdominal pads and sponges are not used when dry. Dry sponges injure the peritoneum and favor the subsequent development of adhesions (Sänger). The pads and sponges should be wrung out in normal salt solution before using.

1 British Med. Journ., Jan. 16, 1897.

FIG. 201.-The Trendelenburg position.

Operation. In some cases the patient is placed recumbent, in others is put in the position of Trendelenburg (Fig. 201). The patient is to be carefully protected from cold, the extremities and the chest are covered with blankets, and sterilized sheets are placed well around the field of operation. The surgeon steadies the skin of the belly with the fingers of his left hand, and, holding the knife in the right hand, makes an incision about two inches long. This incision is often made in the middle line midway between the pubes and umbilicus, but may be in the semilunar line, in the epigastric region, or in some other situation. The first cut goes to the aponeurosis. Clamp the vessels. Do not hunt for the linea alba below the umbilicus, but go right through or between the recti muscles. Above the umbilicus the linea alba is very distinct and the surgeon often cuts through it. Divide the transversalis fascia, beneath which is a little fat, and expose the peritoneum. The latter structure is recognized by its glistening appearance, by the ease with which it can be pinched up between the finger and thumb, and by the readiness with which its opposed surfaces may be made to glide over each other. On identifying the peritoneum, catch it at each side of the incision with forceps, raise a fold, nick it with a knife, and open it with scissors to the length of the external wound. To prevent stripping of the peritoneum a good plan is to anchor it to the belly-wall with a stitch on each side of the incision. Through the wound thus made the abdomen and its contents are explored, the trouble located, and determination made as to whether or not further operation is advisable, and, if it is advisable, what form it shall take. It may be necessary to enlarge the wound. This is done by placing the index and middle fingers of the left hand in the belly, with their pulps against the peritoneum, in the line where the surgeon will cut, to serve as supports to the scissors and as guards to intraperitoneal structures. The scissors are introduced and the wound is enlarged upward around the umbilicus if necessary. As soon as the incision is complete it is a good plan to push a large pad into Douglas's pouch and leave it there until the operation is completed. Slender adhesions are broken off with the finger or are pushed off with gauze; firm adhesions are tied and cut.

The toilet of the peritoneum is important after the opera

[graphic]

tion is completed. Following a clean laparotomy, when but little blood has flowed into the cavity, flushing out is not required; if much blood has flowed or if any septic matter has passed into the peritoneal cavity, after removing the sponge from Douglas's pouch flush out the belly thoroughly with hot normal salt solution, empty out most of the fluid, but let a pint or more remain in the abdomen. The retention of saline fluid in the belly minimizes shock. If there is widespread infection, eviscerate, wipe out the peritoneum with pads soaked in hot normal salt solution, and wipe the intestines carefully, slowly returning them as they are wiped. Extravasated septic matter is apt to collect between the liver and diaphragm, and this area must be carefully wiped or irrigated. In some cases it is desirable. to drain through a lumbar incision. Rutherford Morrison has pointed out that on the right side a lumbar opening will drain a pouch which holds over a pint of fluid, and which, with the patient recumbent, is the most dependent portion of the peritoneal cavity. In some cases a drainage-opening is made on each side of the belly or above the pubis. In septic cases it may be advisable to pack with iodoform gauze instead of inserting tubes. Before closing the wound stop hemorrhage and count the instruments and sponges. In most instances drainage is not needed, but it must be used in septic cases and when hemorrhage has been severe. We may drain by a rubber tube, strands of gauze, or a glass tube. If a glass tube is used, it is introduced at the lower angle of the wound and reaches the bottom of the pouch of Douglas. This tube is repeatedly emptied during the progress of the case by means of a syringe. In closing the wound some surgeons close the peritoneum with a continuous catgut suture and close the belly-wall with interrupted sutures of silkworm-gut; some operators close with interrupted silkworm-gut sutures, including peritoneum, muscles, and skin in each stitch. In badly infected cases the wound is often kept open. Dress with aseptic gauze and woodwool, and apply a flannel binder.

For non-suppurative appendicitis the incision is two inches internal to the anterior superior iliac spine and perpendicular to a line drawn from the spine to the umbilicus. (Fig. 202). The incision is usually one and a half to two inches in length, but if there are many adhesions it may be necessary to make it longer. After opening the peritoneum find the appendix by the following method: follow the parietal peritoneum outward with the finger, then back

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