Hæmatocele.—When the contents of the sac of the tunica vaginalis are found to be grumous instead of simply serous, or when, as often happens, only pure blood escapes when the fluid is nearly evacuated, it is found that simple evacuation and injection are very rarely sufficient to effect a cure.

After they have been fairly tried, the sac of the hæmatocele should be laid open in its full extent; any large vessels which bleed should be tied, and the cavity then stuffed with lint. When the lint can be removed, which will be after two or three days, the edges of the wound should be brought closely together, and the cavity will then rapidly heal up from the bottom, and be obliterated by secondary union of granulations.

In cases where the walls of the cavity are enormously thickened, or even, as sometimes happens, almost bony in consistence, an elliptical portion may be removed with advantage.

Excision of Testicle.—This operation is rarely required except for tumours of the testicle. Hence the size of the incision necessary must vary much with the size of the tumour; and the amount of skin to be removed (if any) on the amount of adhesions it has formed to the tumour.

One or two points must be attended to in every case of extirpation of a testicle:—

1. The incision should commence over the cord just outside of the external ring, and be continued fairly over the tumour to its base.

2. As to removal of skin, some surgeons advise that none should be taken away, others that a considerable quantity can be spared. There is certainly less risk of secondary hæmorrhage if a portion be removed, than when a flaccid empty bag is left. The author invariably removes a very large quantity of skin if the tumour is large, as there is much more rapid healing, and the resulting scrotum is much more comfortable for the patient.

3. The cord should be exposed at the beginning of the operation, raised from its bed and given to an assistant, who should compress it gently, not from any fear of its escape into the abdomen, but to prevent hæmorrhage. If the tumour has been very large and heavy, the cord will have been much stretched, and if divided too high up, may really give trouble by its elasticity, unless the above precaution is taken. The cord then having been divided close to the tumour, the latter is removed, care being taken not to include the sound testicle in the removal. All the vessels are then to be tied or twisted, and the spermatic artery is to be secured alone, not, as used to be the case, included in a common ligature with the other constituents of the cord. Secondary hæmorrhage is very apt to occur from small scrotal branches which may have escaped notice during the operation.

Operations on the Anus and its Neighbourhood.—Fistula in Ano.—While much might be written on the pathology of fistula, and a good deal even on its diagnosis, a very few words will suffice to describe the simple and effectual operation for its relief.

Dismissing at once all so-called palliatives, drugs, unguents, pressure, and injections, as mere waste of time, and holding that the only method of cure consists in laying the fistula fairly open, the question narrows itself into this: What is the best method of laying it open? Prior to the discovery by Ribes of the great principle that the internal orifice of the sinus is always within an inch or an inch and a half of the orifice of the anus, the operations for fistula were most unnecessarily severe; the gut used to be divided as far up as the sinuses extended; and large portions of the anus used to be excised bodily along with the sinuses. It is now a much simpler and more satisfactory operation.

Operation.—A common silver probe bent to the required shape is passed into the external opening, or, if there are more than one, into the largest and oldest one. The forefinger of the left hand being introduced into the rectum, the probe is passed through the internal orifice, and its point brought out by the anus. The portion of tissue raised by the probe can then be easily divided with the certainty that the fistula is laid fully open. Anal fistulæ have been divided by the elastic ligature, but it seems slower in action and more painful, with no counterbalancing advantages.

The author has for last few years operated almost exclusively by a long knife which is continued into a steel probe. The probe is passed up the fistula, then into the bowel, and is hooked out at the anus, and in being simply pushed on the knife cuts the fistula—tuto, cito, et jucunde, the patient rarely knowing that more has been done than an exploration.

In cases where, from the hardness and density of the parts it is impossible to pass the probe and bring it out at the anus, a strong probe-pointed bistoury may be passed in by the external orifice till its probe-point can be felt by the finger in the bowel at the internal opening. Supported by the finger it can then be made to cut outwards till the whole septum is divided.

Fissure of the Anus, Ulcer of the Anus, resemble each other alike in the exceeding annoyance which they give to the sufferer, and in the simplicity of the treatment needed.

Operation.—Once the presence of either is determined by the finger in the anus, a sharp-pointed curved bistoury should be introduced, transfixing the base of the fissure or ulcer, and then guided on the finger, completely dividing it, so as to change the ragged ulceration into a simple wound which will rapidly heal.

Prolapsus Ani, Operation for.—Complete prolapsus in which the whole gut is involved, as seen in the very young and the very aged, is suited for palliative rather than radical treatment.

Cases of prolapsus of the mucous membrane only, as is not uncommon in connection with or as a result of hæmorrhoids in adults, give opportunity for operative interference.

We may act on either the skin or mucous membrane, or both at once.

1. The skin is often found loose, and arranged in radiating folds round the anus. In such cases, as recommended first by Dupuytren, some of these projecting folds may be removed. Again it may be prolapsed in a great loose ring or circular fold round the margin, forming an exaggerated external pile; in such a case the loose fold may be fairly excised with curved scissors, as recommended by Hey of Leeds.

The first of these methods is apt to be insufficient, the second again has the risk of removing too much.

2. If the protrusion is chiefly mucous membrane exposed in folds, or a ring, which is generally outside, one of two methods of treatment may be tried:—

a. By ligature, as recommended by Mr. Copeland. Raising a longitudinal fold of the mucous membrane, he passed a ligature round it as if it were a pile. There is less chance of the ligature slipping if a double thread be used and its base thus transfixed. Three, four, or even more folds may be thus treated.

Страница 77 из 83

Назад 1…76 77 78…83 Далее