Elements of Surgery

by Robert Liston

[45] [In a case of artificial anus which came under the notice of the late Dr. Physick, in 1808, relief was afforded by the following procedure. A crooked needle, armed with a ligature, was passed from one portion of the intestine to the other through the contiguous sides, about one inch within their orifices. The ends of the ligature were then tied with moderate firmness at the external aperture, where they were left protruding. In this situation it gradually made its way through the parts which it embraced by ulcerative action, at the same time that it produced strong adhesion between the two folds of the bowel. After several weeks had elapsed, Dr. Physick divided with a bistoury all the parts which now remained included within the noose of the ligature, thus establishing a direct communication between the upper and lower extremities of the gut.

Dr. Lotz, of Pennsylvania, succeeded a few years ago in curing a case of a similar kind, by means of an instrument which possesses some advantages over that of Dupuytren, and an account of which is published in the eighteenth volume of the American Journal of the Medical Sciences. It is composed of two blades, each six inches long, which are worked by two screws, and which terminate in front in two fenestrated branches, twelve lines in length by three in width. One blade being inserted into each extremity of the gut, they are carefully adjusted by tightening the screws, and are thus made to compress the intervening membranes. The pressure may be increased or diminished at pleasure. In the case treated by Dr. Lotz, the portion of the bowel corresponding with the fenestræ was excised with a gum-lancet on the fourth day from the application of the instrument, and in this manner a direct passage was created between the two ends of the tube.—ED.]

[46] [When the wounded bowel protrudes, the aperture, unless it be very small, should be closed either with the continued or the interrupted suture, and then returned within the abdomen. This procedure is far preferable to the mechanical contrivances recommended by Reybart, Denans, and other surgeons; or even to the more ingenious but almost impracticable method of stitching the intestine, proposed by Mons. Lembert of Paris. From some experiments, upwards of forty in number, which I performed upon dogs last summer with a view of more fully elucidating the subject under consideration, I am led to infer that it does not matter what kind of suture be employed, provided we use the precaution of closing the opening so completely as to prevent the escape of fecal substance. This is undoubtedly the grand principle which should regulate the conduct of the surgeon in the treatment of injuries of this nature. Let him guard against fecal effusion, and the patient will be comparatively safe, or free from the danger of peritoneal inflammation. To attain this object the continued, or glover’s suture as it is termed, is unquestionably preferable to any other, especially when made, as I would suggest it should be, with a small sewing-needle, armed with fine silk, and passed between the muscular and mucous coats, or, what is the same thing, through the substance of the cellulo-fibrous lamella. After the suture has been applied, the protruded part of the mucous lining, if there be any, should be pared off with a sharp knife, to facilitate the process of reparation, the surface of the bowel should be cleansed with tepid water, and the whole carefully returned into the abdomen. If the interrupted suture be used, the intervals between each two respective threads must not exceed two lines, or the sixth of an inch, otherwise there will be danger of fecal extravasation, and the ends, instead of being brought out at the external aperture, should be cut off close to the knots. The reason why I prefer the continued suture, made in the manner above mentioned, is simply because we can thereby more effectually close the wound, at the same time that the parts are placed in the best possible condition for speedy reunion, from the want of protrusion of the lining membrane, and consequently the more perfect contact of the serous surfaces.

The ligatures which are employed in sewing up a wounded intestine are detached at a period varying from ten days to three or four weeks, according to the nature of the suture. When the extremities are cut off close to the knots, they invariably fall into the cavity of the bowel, and are finally discharged along with the feces; if, on the other hand, they are brought out at the external opening, they pass off in that direction instead of the one just mentioned.

When the opening in the gut is small, not exceeding three or four lines in extent, the margins may sometimes be advantageously encircled with a ligature, with the ends cut off close to the peritoneal surface. Sir Astley Cooper tied up an aperture in this manner in the human subject, in a case of strangulated hernia, and the patient recovered without a bad symptom. Professor Gibson, of the University of Pennsylvania, states that he has performed a similar operation with similar results. My experiments on dogs convince me that the plan is a good one. The ligature should be drawn pretty firmly, to prevent it from slipping, and the ends must be cut off close to the knot. It generally makes its way into the bowel in from eight to ten days.

When the bowel is completely severed, or mortified in its entire calibre, the edges, after being properly prepared, should be brought in contact, and retained by the continued or the interrupted suture. Cases of this kind, although apparently desperate, are not always of so hopeless a character as might at first sight be supposed. This is shown, not only by experiments on the inferior animals, but by what occurs in the human subject, in sphacelated hernia, and in intussusception. In the former, the greater part, or even the whole, of the circumference of the tube may be destroyed, and yet the patient ultimately recover, with perhaps the temporary inconvenience merely of an artificial anus; and in the latter, large pieces are not unfrequently detached without any serious suffering, save what is experienced during the antecedent and concomitant inflammation. In my morbid collection is a preparation of this kind, evidently a portion of the colon, nearly a foot long, which was discharged by a child six years old, who, notwithstanding, made a speedy and perfect recovery. Thirty-five cases of a similar character, collected from the writings of different pathologists, have been reported by Dr. Thompson of Europe.[47] In a dog, from which I removed two inches and a half of the ileum, and treated the edges of the wound with six interrupted sutures, complete recovery took place, unattended with a single bad symptom. The threads were introduced at equal distances from each other, with a small sewing-needle, and the ends cut off close to the knots. Four months after the operation, being in good health, and the outer wound entirely healed, he was killed. Externally the bowel was perfectly smooth and natural, as if no injury had ever been inflicted upon it: the mucous membrane was of the same appearance as elsewhere, with the exception of a small depression corresponding with the edges of the wound.—ED.]

[47] See the Editor’s Elements of Path. Anatomy, vol. ii., p. 260.

[48] [From my own observations and dissections I have long been convinced that there are two distinct and well marked varieties of hemorrhoidal tumours; one of which essentially consists in an enlargement of the capillary vessels of the mucous and submucous cellular tissue, the other in the formation of a small sac filled with fluid, coagulated, or organised blood. The latter, situated at the verge of the anus, or immediately within it, are composed partly of skin, partly of mucous membrane; they vary in size, from a pea to that of a small marble, are of a red florid complexion, hard and tender to the touch, and exquisitely painful when inflamed. The blood which they contain is at first fluid, but soon coagulates, and ultimately, if allowed to remain, becomes organised. Hence, in cases of long standing, the tumour is generally of a hard, gristly consistence, pale, and free from pain, producing no other than mechanical inconvenience.

In the other variety, the tumour is situated within the bowel, from six lines to two inches above the external orifice. Consisting, as was before intimated, in a varicose condition of the capillary vessels, especially the venous: it is soft and compressible, of a deep purple colour, extremely liable to bleed, and of various sizes, from a small bean to that of an almond or upwards. It rarely occurs as an isolated swelling, but in groups or clusters, as many as six or eight being sometimes situated upon a surface not more than an inch and a half or two inches in diameter.—ED.]

[49] [Until recently it was the opinion of surgeons, almost universally, that the fistula opened into the bowel at the distance of from two to three inches from the anal outlet; an error which often led to severe and hazardous operations, by which the unfortunate patient was sometimes rendered miserable for life. Mons. Ribes of Paris, who was the first to investigate the subject in a careful and extended manner, ascertained that the internal orifice is generally situated immediately above the place where the lining membrane of the rectum unites with the skin, sometimes a little higher, but never more than five or six lines. In eighty subjects affected with this malady it did not exceed this elevation, and in a considerable number it was not higher than a third or fourth of an inch. In my own operations and dissections I have rarely found the internal aperture more than a line or two above the internal sphincter muscle. The observations of the late Professor Bushe, of New-York, tend to a similar conclusion.—ED.]