NOTES OF A CASE OF GASTROSTOMY

GeorgeA. Hawkins-Ambler
1886 The Lancet  
Oct. llth: Has passed a fairly good night. Swelling of scrotum much diminished; no urine passing by incisions. Chloroform administered, the boy placed in the lithotomy position, and the perineum incised in the median line until the bulb of the urethra was exposed and the cavity of the perineum fully opened. The urethra was then seen to be completely torn across just behind the bulb; the posterior part was retracted and separated for about two inches, lying deeply in the perineal cavity. A
more » ... eal cavity. A catheter was easily passed through this into the bladder, and some urine withdrawn. A lithotomy staff was next passed along the whole extent of the urethra into the bladder, and the separated parts brought together and stitched with three silver wire sutures. The sutures were passed completely through the wall of the urethra and each tied outside in a reef knot, the ends being cut short. With the staff still in the bladder, the membranous part of the urethra was opened by an incision such as is made in lithotomy to allow of the escape of the urine by the perineum, and, by keeping the stitched urethra free from contact with that nuid, to give a better chance of union. A tube was passed through the incision into the bladder, the boy placed in bed, and irrigation continued.-12th : Patient looks comfortable; has passed a good night; temperature normal. A black clot fills each incision in the scrotum; urine passes freely by the tube. A warm water enema was administered, by which the bowels were freely moved.-13th: Continues improving; tube had partly slipped out and was completely withdrawn, as the urine escapes freely without it.-16th : As there appeared to be rather an ammoniacal odour about the wound, a flexible indiarubber catheter was passed into the bladder from the perineum. The urine withdrawn was clear, pale straw colour, and free from any ammoniacal odour. The same catheter, a No. 7, was passed down the urethra into the bladder quite easily. This was the only time an instrument was passed along the urethra from the time of the operation. For the next few days the boy steadily improved, and on the 26th it was noted that all the urine passed by the urethra, and that the perineal wound was rapidly closing. -Nov. 13th: A careful observation was made of the size of the stream passed during micturition; it was estimated to be as large as a No. 8 catheter, and was attended by no straining or pain. -23rd : Perineal wound quite healed; boy to get up. -I have seen this patient about every month since, and he continues in every respect well. The size of the stream of urine during micturition is larger than when he left the hospital; no induration or pain is experienced at the site of the sutures. It will be observed that these were not removed; they became so quickly buried in the wound, and excited so little irritation, that it was unnecessary to disturb them. Hitherto they have given no trouble, and the boy would not be conscious of their presence if he had not been told. 1 believe there are several cases on record in which suture of a ruptured urethra has been practised; but as yet it scarcely seems to be a recognised proceeding, as our surgical text-books say so little about it. My friend, Mr. Hawkins, had a somewhat similar case to the above, with an excellent result; and Mr. Mayo Robson has, I believe, excised a stricture and successfully united the two parts of the urethra. Mr. Birkett's case is also well known. But every additional case is worth recording, as showing that in such injuries to the perineum from falls or sudden impact, attended with retention of urine, we ought at once to dissect down to the urethra, ascertain the amount of damage, and endeavour to repair it. Such a course of proceeding, more frequently followed, would do away with the surgical difficulties in the relief of the miseries of traumatic stricture by preventing its occurrence. PRESENTATION TO SIR DYCE DUCKWORTH.--On Saturday last the matron, many of the sisters, and nurses of St. Bartholomew's Hospital assembled in John ward to present a testimonial to Sir Dyce Duckworth on the occasion of his resigning the medical lectureship in the nursing school of the hospital. The testimonial consisted of a Doulton ware salad-bowl, mounted in silver, and suitably inscribed, together with a large photographic album and an address. Sir Dyce Duckworth expressed his thanks for the very handsome gift, and regretted that he was compelled to give up teaching in the nursery school, which he had always been much interested in since he began the lectures nine years ago. -—, master dyer, aged sixty-one years, came under my observation on November 14th, 1885, when I was called to him in consequence of a severe attack of haemorrhage, which came on suddenly whilst he was standing at his office desk early in the morning. He " felt something cut or break" in the throat, and blood came up in mouthfuls to the extent of about two pints. Complete rest in bed, the hypodermic injection of three grains of ergotin, and the exhibition of half-drachm doses of oil of turpentine in egg albumen every three hours was followed by entire stoppage of the bleeding. These circumstances-the patient's age, haemorrhage easily controlled, with the following symptoms-led me to diagnose cancer of the gullet. Family history good; no history of syphilis. With the exception of repeated attacks of quinsy he has always enjoyed good health. For two years past he has felt a slowly increasing difficulty in swallowing, and in July last consulted a surgeon who, by dilating the oesophagus with bougies, enabled him to swallow with more ease for some months. The last time the bougie was passed the instrument was stained with blood, and he grew alarmed and never went again. From July to November he underwent no further treatment, but lived on thick soups with such solids as Yorkshire pudding, which he could swallow with difficulty, and milk foods. A loss of some two stones in weight, however, indicated the progress of the disease and insufficiency of food; but he carried on his business regularly uptoNov.14th. The recent haemorrhage precluded the passing of a bougie; but I learnt from his former attendant that the constriction was opposite the manubrium sterni. The haemorrhage relieved the constriction somewhat, so that for a fortnight later he could swallow dry oatmeal porridge. I asked for the opinion of Dr. T. Kilner Clarke of Huddersfield, which confirmed my diagnosis of cancer, and suggested a gastrostomy as the only thing to be done. 1 may add there were no physical signs whatever to help the diagnosis. As the patient could not be adequately fed, and the weakness increased rapidly, especially after a second attack of hoemorrhage, the operation was done, as soon as patient gave his consent, Dec. 17th, by Dr. Clarke. Half a pint of Benger's food was given by the mouth at 6.30 A.M. and a Slinger's nutrient suppository at 7.30. The operation commenced at 9 o'clock A.M. Ether was administered, but was soon changed for chloroform, as the action of the abdominal muscles was tumultuous. The margins of the stomach being ascertained by percussion, an incision four inches long, commencing three-quarters of an inch above the edge of the ribs, was made in the line of the fibres of the rectus abdominis, an inch and a half internal to the left nipple-line-viz., half an inch to the inner-side of the linea alba. After the integument and fascia had been divided, the fibres of the rectus came into view, and were separated by the handle of the scalpel, and held apart by retractors till the peritoneum was reached. This was divided on a director, and the qtomach readily found and recognised by its thick substantial coats and arrangement of vessels, and drawn well forwards. Two silk loops were inserted into the stomach at an interval of onethird of an inch apart at its most presenting part, and four silk sutures on either side, each traversing half an inch of the serous and muscular coats of the stomach, brought its wall into close contact with the margins of the wound, leaving exposed at the bottom of the wound a piece of stomach the size of a sixpence. The peritoneum was united with carbolised catgut sutures, and the margins of the wound carefully approximated above and below the loops in the stomach. A small piece of drainage tubing was placed on the lower part of the wound, and the whole covered in with salicylic silk and bandages. Antiseptic precautions were used throughout. The patient was fed every two hours with Slinger's suppositories, which proved of great value, and injections of peptonised milk and other foods alternately, all of which were retained. The rectum was washed out with warm water prior to each nutrient injection, which gave the patient great ease and comfort, and the bowels were relieved daily. The temperature kept at and below normal for a week after the operation, and there was no bad symptom throughout. The wound was dressed under the spray every second day; the drainage-tube was removed at
doi:10.1016/s0140-6736(02)26450-8 fatcat:2nu6qbl2mngkpeubbsk5zecatq