REPRINTED FROM 
UNIVERSITY 
Medical Magazine. 
EDITED UNDER THE AUSPICES OF.THE 'ALUMNI AND FACULTY OF MEDICINE 
EDITOr.IAL STAFF 
Editoriil CommittM: wiDtiwu 
ir^lTTtz 
::S 
CONTENTa 
. •:;; 5 • 
nucs. •sloo -<v tear rsr 
IVI A. Y, 1896 
CASES OF ARTIFICIAL ANUS AND FECAL FISTULE 
TREATED BY INTRAPERITONEAL OPERATION. 
BY JOHN B. ROBERTS, M.D., 
PHILADELPHIA. CASES OF ARTIFICIAL ANUS AND FECAL FISTULE 
TREATED BY INTRAPERITONEAL OPERATION.1 
John B. Roberts, M.D., 
Philadelphia. 
Intestinal Resection for Artificial Anus. 
A man, aged 67, was admitted to the Methodist Hospital on No- 
vember 21, 1895, with strangulated inguinal hernia of the right side. 
He had suffered from this hernia for about forty years, and it had 
previously been operated upon twice because of the occurrence of 
strangulation. 
Upon examination it was found that he had a small hernia on 
the left side and a large inguino-scrotal hernia of the right side which 
was strangulated. I promptly cut down upon the hernia, relieved 
the strangulation, and did an operation for the radical cure by the 
method of Bassini. The hernia consisted of the entire cecum, which 
showed a dimple-like depression at one point, evidently represent- 
ing the appendix, which was congenitally absent. Subsequent 
investigation from the surgeons, who had operated upon him pre- 
viously, proved that his appendix had never been removed, and that 
his case was therefore one of congenital absence of the organ. 
There were a good many old adhesions uniting the coils of intes- 
tine in the neighborhood of the cecum. 
The patient showed very little shock after the operation, and 
did well for one day, when his abdomen became somewhat tympanitic 
and painful. The next day the pain and tympany had increased, and 
vomiting occurred, when attempts were made to have his bowels 
moved by sodium phosphate. I determined to make an incision in 
the median line because it was evident that there was an obstruction 
in the intestinal canal. 
Active peritonitis was present and a portion of the small intes- 
tine just above the ileo-cecal valve was found to be dark in color, as 
if it had just been pulled from some encircling constriction. It was 
very evident that this portion of intestine, which was about two inches 
long, had been strangulated by being entangled in some of the 
twisted masses of adherent coils resulting from the previous at- 
tacks of inflammation. 
This bowel was so dark and the activity of the peritoneal inflam- 
mation so great that I made an incision into it and allowed a large 
Read before the Philadelphia County Medical j£96. 2 
John B. Roberts. 
quantity of feces and gas to be expelled. Being afraid to put this 
dark and gangrenous-looking bowel into the abdomen, I stitched the 
knuckle of intestine to the centre of the incision. The opening 
through which I had permitted the evacuation of feces was pinched 
shut with a hemostatic forceps, and the wound above and below the 
protruding bowel closed with sutures. Before doing this I also punc- 
tured the intestines within the abdomen in another place with the 
aspirating needle, to allow the escape of gas, and closed the opening 
with sutures. After the intestine had been stitched to the abdominal 
wall I found that it had regained its normal color. This showed that 
the gut would probably not have become gangrenous at this point, 
and could have been returned, though it is questionable whether 
such a proceeding would have been wise when the distention and 
violence of the peritoneal inflammation were so great. 
Inflammation of the belly wall around the protruding knuckle 
of bowel took place and an abscess formed in connection with 
some of the stitches. After the tympany and active signs of intra- 
abdominal inflammation had subsided I endeavored to close with 
sutures the opening which had been made in the protruding portion 
of bowel. Two attempts were made to do this, but both of them 
failed because gas and feces forced their way through the opening, 
notwithstanding the presence of the sutures. The final result, 
therefore, was the production of an artificial anus in the intestine 
left stitched in the incision. 
The anterior surface of the abdomen became the seat of a very 
painful and extensive eczema which caused the patient much pain, 
and gave us a great deal of annoyance. On January n, 1896,1 oper- 
ated for the cure of artificial anus, although I thought the operation 
was likely to be much complicated by the difficulty of preventing 
infection from the eczematous skin. 
Incision was made above and below the opening in the bowel; 
this was then detached from the abdominal wall and recent incisions 
of neighboring portions of intestine separated. During this stage 
of the operation my finger tore the bowel just above the artificial 
anus. Four inches of gut, which included this tear and the abnormal 
anus, were then resected and a circular suture of the intestine made 
with two rows of Lembert sutures of silk. No portion of the mes- 
entery was removed, but the portion corresponding to the removed 
bowel was folded. A drainage-tube was introduced because of the 
probability of infection and the wound closed. The subsequent his- 
tory of the case was unimportant, though there was some suppuration 
about the stitches, one or two of which were subjected to great ten- 
sion because of the retraction of the belly wall at the seat of the Artificial Anus and Fecal Fistitle. 
3 
artificial anus. The patient recovered without special symptoms 
worthy of record. 
Fecal Fistules resulting from Sloughing Hernia cured by 
Celiotomy and Intestinal Suture. 
A woman, over 60 years of age, had been operated upon several 
years previously for strangulated femoral hernia on the right side. 
On examination at the Woman’s Hospital I found a minute orifice in 
the right groin, from which a small amount of liquid feces escaped 
more or less continuously. The tissues around were irritated by the 
escaping fluid. The opening would only admit the end of a probe. 
I therefore concluded to attempt closure by making an elliptical inci- 
sion around it, dissecting out the tissue at the edges and suturing 
the wound left by this procedure. After making the elliptical incision, 
the skin and fascia were dissected up, the mucous membrane lining 
the small opening in the intestine turned inward and catgut sutures 
inserted in such a way as to close the intestinal orifice. The edges 
of the integument were brought together by interrupted sutures 
of silk, and an occlusive dressing of iodoform and collodion was then 
applied. 
The operation, however, was unsuccessful, and fecal matter soon 
began to ooze through the wound, which failed to unite. The patient 
became very much discouraged and had rather serious symptoms a 
couple of weeks after the operation from partial suppression of urine. 
This condition had no relation to the operation. 
After getting her kidneys to act more satisfactorily, on Novem- 
ber 15, 1895, which was four weeks after the operation just described, I 
made a four-inch incision in the median line of the abdomen between 
the pubes and the umbilicus, and elevated the pelvis so as to throw 
the intestines upward towards the diaphragm. A loop of small intes 
tine was found adherent to the edges of the internal femoral ring. 
The external opening through which feces had been escaping com- 
municated with the interior of this loop of bowel. A piece of gauze 
was carried beneath the adherent coil, and the rest of the intestines 
protected as much as possible by pads of gauze. I carefully sepa- 
rated the bowel from the abdominal wall around the margin of 
ring, and drew it out of the incision. A double row of Lembert’s 
sutures of silk was used to close the opening in the detached 
bowel. The line of suturing was made transverse to the long diam- 
eter of the gut in order to make as little constriction at that point 
as possible. 
The fistulous opening was then cut out by transfixing the abdom- 
inal wall, after thorough cleansing of the excoriated surface of skin 4 
John B. Roberts. 
around the site of the fistule. Catgut sutures were passed through 
the abdominal wall to close the opening, and the peritoneal sur- 
faces beneath were drawn together by catgut sutures introduced 
from within the abdomen. The abdominal incision was then closed 
in the ordinary way with silk sutures. The convalescence was unin- 
terrupted. The beneficial moral effect of the operation upon the 
patient was very marked. 
I had intended to operate by the intra-abdominal route when 
she first came under my care, but was led to do the less serious 
operation by the exceedingly small orifice through which the contents 
of the bowel escaped. 
A year and a half ago I operated upon a similar case in a feeble 
old woman of 64, who had had for about two years an artificial anus 
in the left groin due to a sloughing femoral hernia. An unsuccessful 
attempt to close this fistule was made, it was said, at the Presbyterian 
Hospital about fifteen months before I saw her at the Jewish Hos- 
pital. Fecal discharges occurred in small quantities almost constantly, 
and the woman seemed greatly depressed by this occurrence. Her 
age and feebleness made me hesitate for a long time to operate upon 
her. In October, 1894, however, I finally concluded that the risk 
was justifiable. The case was not one suitable for using the Dupuy- 
tren enterotome, as there seemed to be no special spur to be divided. 
A median incision was made and the patient put in the Trendelen- 
burg position. The attachment of the bowel to the abdominal wall 
was much more extensive in this case than in the other. The fecal 
fistule was really sufficiently large to be called an artificial anus, for 
nearly all the contents of the bowel escaped here. This was quite 
different from the condition of the other patient, in whom nearly all 
the alvine evacuations passed through the normal route. 
In both instances an effort was made to prevent contamination 
of the operative wound from the discharges coming from the fistule. 
In the present case I sewed the cutaneous margins of the fistule 
together over the orifice before making the median incision. 
The gut, where attached to the abdominal wall, was encircled 
by a ligature which was drawn sufficiently tight to prevent the escape 
of feces into the abdomen when I detached the intestine from the. 
neighborhood of the femoral ring. This was done because the open- 
ing was a large one and I feared fecal material would pour out into 
the peritoneal cavity. After the bowel was cut loose with the 
scissors, intestinal sutures were applied so as to close the opening 
in a transverse direction. The bowel was then dropped into the 
abdominal cavity. 
This step of the operation left an opening in the anterior abdom- Artificial Anus and Fecal Fistule. 
5 
inal wall at the site of the femoral canal lined with mucous membrane 
which had been left by cutting away the attached intestine on the 
inner side. The woman’s condition was rather bad, and I, therefore, 
did not dissect out all this tissue and bring the rawsufaces in contact 
as in the first case. Some of the mucous membrane, however, was 
dissected away. The rest was allowed to remain and the opening 
closed spontaneously by nature’s efforts. This portion of the oper- 
ation I considered unsatisfactory because of the prolongation of con- 
valescence. It would have been better if I had encircled the opening 
with an incision through the entire abdominal wall and brought the 
parts together so as to get primary union. This is easily done when 
the abdominal cavity is open, because the surgeon has access to both 
sides of the orifice. 
In the other case this method was used satisfactorily. With a 
sponge pushed up against the internal orifice I was able to prevent 
wounding of the intestine when the knife was entered from the external 
surface, and also avoided contaminating the peritoneal cavity by secre- 
tions from the inflamed skin around the old artificial anus. 
The intraperitoneal treatment of the conditions present in these 
three cases seems to me probably preferable, and much more effective 
than plastic operations done on the exterior of the abdomen or the 
use of the enterotome.