Camp before Sebastopol, August 8th, 1855.
LECTURE XXIX.
ABNORMAL OR ARTIFICIAL ANUS, ETC.
401. In some cases of wounds of the intestine the continuity of the bowel is not sufficiently re-established; the external wound remains open, and becomes indurated and fistulous, giving passage to the fecal matters, and rendering the sufferers very miserable. These cases are of rare occurrence among the hardy natives of Great Britain and Ireland, and comparatively little has been done or even recommended in this country for the relief of this misfortune.
When an intestine has lost a more or less considerable part of its substance at a particular spot, and an artificial anus is about to be formed, it adheres to the peritoneum around the inside of the external wound, although the adhesion is of little extent or width, and forms but a narrow barrier for the protection of the cavity of the abdomen. The upper end of the bowel is more open than the lower, the caliber of which is contracted in size, and is sometimes even difficult to find; while its opening is partially closed by a sort of septum extending across, or from where the two portions of a divided gut have come irregularly in contact with each other by their sides, without uniting in the first instance in their length; or from the falling in especially of the posterior part of the lower end, to which the upper has become united. The projection thus formed in the tube is called by the French eperon or promontoire, valve or spur, ridge or septum; it directs the fecal matter through the external wound, while it obstructs its passage into the lower part of the bowel. There is generally great difficulty in ascertaining the fact of the existence and exact situation of this valve during life; in distinguishing the upper from the lower end of the intestine, as well as the nature and extent of the adhesions by which the injured intestine is retained in its situation. If the absence of such a valve can be satisfactorily made out—and it is sometimes wanting—the external opening may be successfully closed by compression, or by operation. If the valve should exist, its removal by a preliminary operation is necessary; it has been attempted in France with various but somewhat doubtful success.
402. When a portion of small intestine has been lost by mortification or otherwise, and the patient has recovered with an unnaturally situated or artificial anus, the intestine, although at first in contact with the wall of the abdomen, is gradually, in many cases though not in all, retracted into the cavity—it has been supposed by the dragging of the mesentery upon it at the point of union of the divided extremities outside where the eperon or valve is formed; and it is said that this dragging has even led to the gradual disappearance of the valve, admitting thereby of the contents passing more readily from the upper part of the intestine into the lower, and consequently laying the foundation for a cure. This dragging of the intestine, or its movements under the different motions of the body, in some cases cause an elongation of the membrane formed under the adhesive process, by which the intestine is attached to the inside of the wall of the abdomen in the same manner as adhesions are elongated between the pleuræ, and a sac or pouch is thus formed between the cut ends of the intestine and the fistulous external opening which Scarpa was the first fully to demonstrate and explain, and which he called an entonnoir, infundibulum, or funnel. If, then, in an old case, a small portion of the wall of the abdomen be removed in the form of a V, the internal opening at the apex of the V, if small, would be made into a sort of funnel, while the outer incision would remove all the hardened fistulous parts—an operation which is sometimes required to be done when the external opening is not free, and fecal matters have insinuated themselves between the aponeurotic parts, giving rise to abscesses and other small fistulous openings in different directions. It is necessary to bear the formation of this pouch in mind as well as that of the valve, in order to understand the operations proposed for the relief or cure of this complaint.
If simple compression fail in the first instance to prevent the passage of the feces, which never can be thoroughly controlled from the want of a sphincter and the uncertainty of pressure, the method of Desault may be adopted. This consists in gradually dilating the external wound so as to enable the operator to discover the open ends of the bowel, when a tent is to be introduced into the lower end, and afterward into the upper, being fastened by a thread passed around its middle. A pyramidal-shaped pad is then to be placed over the opening, and compression made by bandage upon it so as to press the whole inward. The size of the tent is to be gradually enlarged until the contents of the gut begin to pass downward with ease, when a well adjusted pressure is to be made on the fistulous opening only, to prevent all oozing from it until the internal parts have had time to close.
403. Dupuytren invented a pair of forceps, consisting of a male and female branch, to be applied separately, one on each side of the valve or eperon, to the extent of an inch or an inch and a half at most, when they were to be closed by a screw until they had compressed the part between them sufficiently to destroy its life. The separation of the valve included within the forceps would take place by the usual processes of ulceration in its immediate proximity, and by adhesion of the parts external to the bowels to those surrounding them. The inflammation, however, did not always stop at the adhesive stage, and death has been the result as well as a successful cure.
404. Mr. Trant has invented an instrument he calls a propeller, for pressing back the eperon, an account of which is given in the Dublin Medical Press, May 14th, 1845. He used this in one case with complete success. The instrument by its formation admits of being passed through the artificial anus, and of being placed on the eperon at the bottom of the wound, where it can be retained for a considerable time without producing the slightest inconvenience. It does not, while in the intestines, offer any obstruction to the passage of the fecal matters flowing along the cavity of the tube. It acts as a forceps in retaining the anterior wall of the intestine in close contact with the posterior surface of the abdominal parietes, while the propeller is pressing back the eperon toward the spine; consequently the danger of separating the delicate adhesions in this situation is prevented, otherwise a fatal extravasation into the cavity of the abdomen might ensue. The instrument was made by Mr. Reed, of Dublin, and merits further trial, being apparently less dangerous than the other methods recommended in similar cases. Whatever may be the method employed for the cure of an artificial anus by operation, it cannot be doubted that the patient must be exposed to all the dangers which may result from inflammation, for which he must be prepared beforehand, and the symptoms of which must be met and subdued as they arise; or, if this cannot be accomplished, the mechanical means, if any be used that can be taken away, must be removed, and quiet, if possible, restored by their abstraction and by the treatment adopted. In successful cases, a small aperture will frequently remain, constituting a fecal fistula instead of an artificial anus. This will sometimes become irritable, inflame, ulcerate, or burst, discharging the solid contents of the bowel, although, on the subsidence of the irritation, the part under pressure usually returns to its former state.
405. Wounds and injuries of the liver, whether incised or penetrating, occurring from blows or from musket-balls, are very serious, although not necessarily fatal. Some few persons recover altogether, some few with more or less of permanent disability. The remainder die during the first or inflammatory stage, or in the secondary one, which follows from the twelfth or fourteenth day after the primary symptoms have in some measure subsided.