The principles and practice of modern surgery

by Roswell Park

Here, as elsewhere, operation should not be too long delayed. To wait for a chronic obstruction to merge into one of the acute forms, and then to wait until the patient is moribund, is to have deliberately deprived him of that which otherwise might have prolonged his life.

For chronic obstruction whose cause is not easily revealed the hypothesis of cancer affords the most common explanation. This may be intrinsic or extrinsic, so far as the bowel itself is concerned, the results however not differing. It matters but little whether cancer is producing an annular stricture or involving a considerable extent of bowel, something should be done. When health has gradually failed, and obstructive symptoms have come on slowly, and when distinct cachexia is present the presence of cancer within the abdomen may be suspected. When a distinct tumor is palpable or when the abdomen gradually fills with fluid there is little doubt. When to these signs is added pigmentation of the abdominal wall the diagnosis may be considered certain. Even now exploratory section is justified, in the hope that some operative measure may offer comfort and at least temporary relief.

On the other hand, when obstructive symptoms appear and increase without the accompaniment of other serious indications, it may be hoped that the condition is benign rather than malignant. Obstruction with ascites may possibly be due to tuberculous lesions, which are not uncommon, especially in children. The recognition of enlarged mesenteric nodes would corroborate this diagnosis. A history of typhoid fever or of injuries or foreign bodies might confirm the theory of cicatricial stenosis. The possibility of enteroptosis of the colon and impaction of hardened fecal matters should not be disregarded and that of enteroliths, especially gallstones, not forgotten.

FECAL FISTULA; ARTIFICIAL ANUS.

A fecal fistula implies any communication between the intestinal tract and the exterior of the body or one of its other cavities. Thus it is possible to have a rectovaginal fistula as well as a vesicovaginal. In rare instances we may meet also with intestinal communication with the bladder, the other viscera, or even the pleura or lungs.

Fecal fistulas are always abnormal productions, and result either from congenital causes, previous injury, or disease. Among the traumatic causes may be mentioned penetrations or ruptures of the intestines, injuries to the bowel occurring in the course of abdominal operations (for instance, the inclusion of some part of the bowel wall within a ligature or suture), while the pathological causes include the possibilities of perforation of any form of ulcerative lesion, cancer, actinomycosis, or the secondary sloughing which may follow appendicitis, or even the pressure of a drainage tube. Fistulas result also from escape of foreign bodes (for instance enteroliths or bone fragments), which may work their way into some other viscus, or out through the abdominal wall to the body surface. Old pelvic and abdominal abscesses also occasionally cause perforation and fecal fistulas. These fistulous tracts may be long or short, and direct or indirect. They may also permit the escape of a large amount of fecal matter or the smallest appreciable amount. The majority of them tend to close spontaneously in the course of time, but this time is sometimes so prolonged that a surgical operation is preferable to waiting for natural processes. The communications may be high in the intestinal canal. In such a case matter that escapes will be but partially digested and will have the character of chyme rather than of feces; and patients suffer in consequence, as products of digestion are not complete and opportunities for absorption have been too limited, and they are deprived of all that should normally happen further along in the bowel. In such a case there is temptation to operate much earlier than is advisable. Another form of fistula results from certain cases of strangulated hernia, in consequence of necrosis of the strangulated loop of bowel. In fact this is true of any of the mechanical causes of acute obstruction, where this expedient may be resorted to under compulsion and we produce a fistula as an emergency measure.

The difference between intestinal or fecal fistula and artificial anus is that the former is an undesirable and untoward event, whereas the latter is deliberately produced by operation practised for the purpose. Artificial anus is in the main limited to cases of cancerous or other hopeless or inoperable obstruction of the lower bowel, and in such case is purely a palliative measure. It is made occasionally at the upper end of the colon in order to give a diseased colon physiological rest and permit of more perfect irrigation of that tube, the intent being to later close the opening. It is an inevitable emergency measure in certain cases of acute obstruction, where the patient is in no condition to bear anything more extensive or prolonged.

The operation for making an artificial anus, usually referred to as enterostomy or colostomy, will be described below.

Fecal fistulas should be treated largely according to their causes; when they are the product of actinomycotic or cancerous disease little can be done, and perhaps nothing should be. On the other hand, when resulting from traumatism, from sloughing of some portion of the bowel, or from strangulation, much can be accomplished.

A small, fistulous tract should be kept clean and stimulated occasionally with silver nitrate or something of the kind, and perhaps by introducing into it every day a small piece of gauze, which provokes the granulation process as well as fills the opening. It is bad practice, however, to simply close the outer end and let the lower portion distend with feces. Much will depend upon whether it now connects with the bowel. This may be determined by injecting into the fistula some methyl blue and then noting the subsequent stools. When communication with the bowel is evidently free the surgeon may feel like making a deeper operation, perhaps with intestinal suture or even intestinal resection, whereas if there be little or no actual fecal leakage it may be sufficient to enlarge the outer end of the fistula, to thoroughly scrape it with the sharp spoon, and then, lightly packing it, see it close with granulations. A passage-way which is exceedingly short may be treated by simple superficial plastic operation, including freshening of the entire margin of the opening and the passage around it, and a purse-string suture, with or without a circular incision of the skin. By drawing this suture tight the external opening may be closed. This is a neat way in which to dispose of a small fistulous opening resulting from a previous enterostomy or appendicitis operation.