ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section Number :'iA;j.£L.f_. Fokm 113c, W. IX, S. G. O. bpo 3—10543 (Revised Juno 13, 1936) / AN EXPERIMENTAL AND CRITICAL INQUIRY INTO THE NATURE AND TREATMENT WOUNDS OF THE INTESTINES: ILLUSTRATED BY ENGRAVINGS. By SAMUEL D. GROSS, M. D. m PROFESSOR OF SURGERY IN THE LOUISVILLE MEDICAL INSTITUTE; SURGEON TO ""***"^L«!_ THE LOUISVILLE MARINE HOSPITAL; MEMBER OF THE PATHOLOGICAL SOCIETY OF PHILADELPHIA; &C. &C. "The honor of our art, and the moral character of its professors suffer, whenever we pay so blind a defer- ence to any one as prevents us from using our own judgments, and from declaring freely the results of our inquiries or experiments."—Poll. LOUISVILLE: PRENTICE AND WEISSINGER. 1843. PREFACE. A monograph on wounds of the intestines has long been an acknowledged desideratum in our surgical literature. The work of Mr. Travers, the only production of the kind in the English language, has been out of print upwards of a quarter of a century, and hence the only information accessible to practitioners, especi- ally to those of the United States, is such as is to be found in the various periodicals of the day, in the transactions of societies, or in our systematic treatises on surgery. The latter, unfortunately, contain little, if anything, that is worthy of reliance; they enter into no details, and some of them do not even allude to the sub- ject; a circumstance so much the more surprising when we reflect upon the importance of these injuries, and the attention which has been bestowed upon them by some of the most respectable members of the profession. In the following pages an attempt has been made to supply this deficiency, by exhibiting a connec- ted view of the subject, embracing an account of the results of my own researches, and of those who have preceded me in the same field of inquiry. The experiments which form the basis of the present treatise were commenced in the Spring of 1841, and continued, with va- rious intermissions, until a few months ago. The object was, in the first place, to inquire into the process employed by nature in repairing wounds of the intestinal tube; and secondly, and more particularly, to determine, if possible, the value of the more im- portant methods of treatment recommended by surgeons from the time of Ramdohr down to our own. The experiments, amount- VI PREFACE. ing altogether to upwards of seventy in number, were performed exclusively upon the dog, as the most eligible animal that could be procured for the purpose. The wound was generally made in the small bowel, not only because it is the more accessible por- tion of the alimentary tube, but because it is more liable, when thus injured, to become the seat of faecal effusion, and also, per- haps, of high inflammation. The results are stated, in every in- stance, with as much brevity as is consistent with a work of this description. In conducting my experiments, I was kindly assisted by my private pupils, Messrs. Wendell, Comstock, Baker, Shumard, Church, Grant, and Williams. Many of them were also witness- ed by Mr., now Dr. Hagan; by Dr. Colescott, one of the Edi- tors of the Western Journal of Medicine and Surgery; by Mr. Mullen, an enterprising and intelligent student; and by Dr. Rich- ard Ferguson, of this city. To the latter gentleman, who has kindly furnished some of the accompanying drawings, together with a number of others that have been unavoidably excluded from the work, I am desirous thus publicly to tender my ac- knowledgements. The figures illustrative of the methods of Jo- bert and Reybard have been copied from Bourgery. The wood cuts were executed by Mr. Lovejoy, a young artist of Cincinnati. It is proper to state that an abstract of this essay was read be- fore the Medical Convention of Ohio, at Cincinnati, in May, 1842. At that time I had not performed any experiments according to Lembert's process, which will account for the remarks which I made respecting it on that occasion, as well as for those which appeared a few months subsequently, in my edition of Mr. Liston's Elements of Surgery. Louisville Medical Institute. } July, 1843. J CONTENTS. Preface, -........ CHAPTER I.—Nature of Wounds of the Intestines, - - 1 Sect. 1. Structure of the Alimentary Canal, - - - - 3 — 2. Nature and Extent of the Peritoneal Cavity,- - 6 — 3. Symptoms, Diagnosis, and Prognosis, - - - 12 — 4. Mode of Reparation,.........23 CHAPTER II.'—Treatment of wounds of the Intestines, 33 Sect. 1. Wounds without protrusion of the bowel, - - — — 2. Wounds with protrusion of the bowel and omen- tum, .............36 — 3. Wounds with protrusion and injury of the bowel 42 — 4. Therapeutic means, - - '.......46 — 5. Treatment by different kinds of sutures, - - 50 1.—Continued Suture,.......- - 51 Transverse wounds, -------- 53 Longitudinal wounds, -------- 54 Oblique wounds, --------- 62 2.—Interrupted Suture, -------- 73 Transverse wounds, -------- — Longitudinal Avounds, -------- 77 Oblique wounds, - - - -.....80 Cases,..........- - - 82 3.—Method of Ramdohr,.....- - - 91 4.—Method of Le Dran,........99 5.—Method of Bertrandi, ...... 100 viii contents. 6.—Method oi" the Four Masters, - - , - - 1°2 7.—Method of Palfin, Bell, and Scarpa, - - 105 8.—Method of Jobert, -------- HI 9—Method of Lembert, ------- 120 Cases,........... - 122 Transverse wounds, ....... 131 Longitudinal wounds, ------- 137 Oblique wounds, ........ 143 10.—Method of Denans,....... 146 11.—Method of Reybard,....... 150 12.—Method of Amussat, Thompson, Choisy, and Beclard, ... -..... 152 CHAPTER III.—Partial and Complete Division of the Intestines, ......- 160 CHAPTER IV.—Artificial Anus,......- 174 ERRATA. Page 6, line 2, for or read and. " 150, line 27, for 1837 read 1827. INQUIRY INTO THE NATURE AND TREATMENT OF WOUNDS OP THE INTESTINES. CHAPTER I. Of the Nature of Wounds of the Intestines. The notions of the older writers respecting the nature and treatment of wounds of the intestines were, for the most part, exceedingly crude and erroneous. Neglecting to institute experiments for their successful elucidation, they contented themselves with such facts as they witnessed in the human subject; and as these were not only few, but generally imper- fectly noted, the conclusions which they deduced from them were far from throwing any real and substantial light upon this interesting branch of pathology. Indeed, until the pub- lication of the researches of Mr. Travers, of London, early in the present century, the management of wounds and injuries of the alimentary tube was altogether empirical, being regu* lated rather by accident than sound principles derived from the study of healthy and morbid action. His labors in this department, conducted as they were at an early period of his professional life, evinced no ordinary judgment and talent, and served as a happy presage of the reputation which hag 1 * WOUNDS OF THE INTESTINES. since awaited him. They are comprised in an octavo vol- ume of nearly four hundred pages, including a complete sum- mary of aU that was known on the subject at the time at which it appeared in 1812. It is entitled: "An Inquiry into the Process of Nature in Repairing Injuries of the Intes- tines; Illustrating the Treatment of Penetrating wounds and Strangulated Hernia;' and is one of the most able and phi- losophical productions that have enriched the science of sur- gery within the last fifty years, so prolific in discovery and improvement. In the investigations just referred to, Mr. Travers did not, like his predecessors, limit his inquiries to the human sub- ject, but extended them to the inferior animals, upon which, especially the dog, he performed a series of the most interesting experiments, equal in point of beauty and im- portance to those instituted by his countryman, Dr. Jones, to ascertain the process employed by nature in suppressing hemorrhage from divided arteries. The results of these researches are well-known to the profession, and any further notice of them, excepting in an incidental manner, will there- fore be unnecessary in a work of this kind, which is intend- ed more particularly as a record of my own observations and of the facts that have been disclosed within the last quarter of a century. It is but just to say that several years before Mr. Travers issued his work, Dr. Thomas Smith, of the Island of St. Croix, was engaged in making some researches on the same subject, an account of which was published in his Inaugural Dissertation, presented to the Trustees and Faculty of the University of Pennsylvania, in 1805. His object seems to have been rather to inquire into the pro- priety of using certain kinds of sutures, recommended by Le Dran, Ramdohr, John Bell, and other surgeons, than to as- certain the process employed by nature in effecting repara- tion. His experiments, twelve in number, were conducted with considerable care, though he has failed, in almost every instance, to notice with proper minuteness the results of his dissections; a circumstance so much the less surprising when STRUCTURE OF THE ALIMENTARY CANAL. 3 we reflect upon the low state of pathological science at the period at which he wrote. Limited as these researches are, and imperfectly as they have been detailed by their author, they nevertheless tended to establish some important practical pre- cepts, to which allusion will be made in another part of this inquiry. Before I proceed to detail the results of my own experi- ments, and the inferences which I have been led to deduce from them, it will not be amiss to make some remarks on the structure of the alimentary tube, the arrangement of the peri- toneal cavity, and the phenomena which characterize the pre- sence of wounds in the situation in question. Sect. I.—Structure of the Alimentary Canal. Into the consideration of the structure of the intestinal canal I do not deem it necessary to enter at any length, as it must be familiar to all who have any pretensions to correct ana- tomical knowledge. It will be sufficient for the object I have in view to make a few remarks respecting the different tunics, and the manner in which they are united to each other. The outer membrane of the intestinal tube belongs to the class of serous textures, and deserves to be mentioned here chiefly on account of the facility with which it takes on in- flammation, and the important part it plays in the reparation of traumatic lesions. It is intimately connected, except along the line of reflection of the mesentery and omentum, to the subjacent muscular tunic, by short, dense cellular sub- stance, and consists every where of a single lamella, the strength of which varies in proportion to the age of the indi- vidual. In young animals it is easily lacerated, and incapa- ble of withstanding much traction or pressure. Hence, if, in sewing up a wounded bowel, the ligature be carried merely through the serous investment, it will be almost certain to be torn out in the efforts which are necessary to replace the part within the abdomen. When inflamed, this tunic promptly pours out plastic lymph, which, under favorable circumstan- 4 WOUNDS OF THE INTESTINES. ces, becomes readily organized. If the morbid action runs high, the lymph is generally intermixed with serum, and some- times even with blood. Pus is a more common attendant on the chronic form of the disease; it is, however, occasionally observed in the acute stage, and that, too, within a very short time after the development of the disorder. The muscular tunic, interposed between the preceding and the cellulo-fibrous, to both of which it is intimately connect- ed, is composed of two planes of fibres, a superficial and deep-seated. The first, which is much the more delicate of the two, is made up of thin, pale fibres, which are arranged longitudinally, and which exhibit certain, but as far as the present inquiry is concerned, unimportant peculiarities in dif- ferent parts of the tube. The second layer consists of circu- lar fibres, much more distinctly marked than the preceding, which extend in parallel lines round the entire circumference of the bowel, their extremities being inserted as it were into each other. Lying beneath this muscular plane is the celebrated ner- vous tunic, as it was called by the ancient writers. Alter- nately admitted by some and rejected by others, this layer has / been recently described by Mons. Cruveilhier,* under the name of the fibrous lamella, in consideration of its structure, which closely assimilates itself to that class of tissues. It is in- timately connected, on the one hand, with the mucous mem- brane, and, on the other, with the muscular tunic, into the latter of which it sends a large number of processes, of a dense, firm character, which thus tend to strengthen the union between them. In its thickness and consistence it varies in different portions of the canal, being at its minimum in the ileum and colon, and at its maximum in the remainder of the small and large bowels. Strong and resisting, it is semi-transpar- ent, devoid of elasticity, and composed of condensed cellular tissue, in which it is impossible to distinguish any of that linear disposition so conspicuous in the fibrous membranes, *Anatomie Descriptive, T. ii, p. 470, STRUCTURE OF THE ALIMENTARY CANAL. 5 properly so called. The filaments of which it consists inter- lace with each other in every conceivable manner, forming thus a very close net-work, which it is difficult to unravel by insufflation and other artificial processes. In great obesity small particles of fat are occasionally to be seen in its meshes, which always disappear in emaciation, however induced. In chronic affections, especially in such as are of a malignant nature, this tunic is often remarkably altered in its structure, being rendered much thicker than in the normal state, at the same time that it assumes a dense and almost gristly hard- ness. - It readily re-unites when divided, as I have witnessed in numerous experiments, and deserves to be attentively stu- died, as it is the membrane through which the surgeon should always carry his needle in sewing up wounds of the intestines. This tunic—for so indeed it should be considered—is much more distinct in carnivorous animals than in herbivorous, or than in the human subject. In the small bowel of the Afri- can lion it is an exceedingly firm, dense, and elastic texture, of a white opake aspect, capable of great resistance, and nearly half a line in thickness. In the bear its characters are nearly similar. In the dog it is less strong, and also less dis tinctly fibrous, yet more so, considerably, than in the human subject. In the horse it forms a thick inelastic layer, of a dull greyish color, which frequently contains a good deal of adeps. In the ox its properties are very much of the same nature. The internal membrane, of a mucous character, varies in thickness and consistence, as well as in the mode of its arrange- ment, in different parts of the tube, and does not require any particular notice in relation to the subject under conside- ration. It is sufficient to observe that it is highly vascular and sensitive; that it re-unites with great difficulty, compara- tively,speaking, when divided; and that, although extremely prone to inflammation, it rarely, when thus affected, deposits plastic lymph, the constant and invariable product of perito- nitis. 1 * 6 WOUNDS OF THE INTESTINES. Sect. II.—Nature and Extent of the Peritoneal Cavity. Is there any cavity, properly so called, in the peritoneal sac, and,, if so, what are its nature or capacity? Concerning this question various views have been expressed by anato- mists and surgeons, and it is important, therefore, that it should be carefully examined before we pass an opinion on it, either affirmatively or negatively, as our decision, whatever it may be, must be calculated to exert no inconsiderable influence upon the treatment of traumatic lesions of the alimentary canal. Mr. John Bell, in his Principles of Surgery,* affirms that, "there is not, truly, any cavity in the human body, but that all the hollow bowels are filled with their contents—all the cavities with their hollow bowels—and that the whole are equally and fairly pressed." That this is really so every one will admit; but when he declares, as he does almost in the same sentence, that all the viscera of the abdomen may be deeply wounded, and yet no blood or faeces can escape, he makes an assertion which is unsustained by facts, and which daily observations on the human subject, as well as experiments upon the inferior animals, wholly disprove. Examples of faecal effusion, either alone or in combination with blood, are mentioned by a great number of pathologists, by Hoyerus, Ravaton, and Morgagni, of the last century; by Cooper, Travers, and others, of the present. Indeed, there is literally no end to cases of this description—a vol- ume would scarcely suffice to record them all; for there is hardly a physician, at all extensively engaged in practice, who has not met with them. A few years ago I assisted my col- league, Professor Cobb, in examining the body of a stout, ath- letic man, who had been stabbed in the abdomen, apparently with a dirk, which had entered near the umbilicus, and per- forated the jejunum, laying open that tube in an oblique di- rection to the extent of nearly half an inch. Through this *Vol. i, p. 487. London, 1827. PERITONEAL CAVITY—NATURE AND EXTENT. 7 aperture a small quantity of stercoraceous matter had made its way into the peritoneal sac, where it induced violent inflammation, of which the patient died in less than two days. Moreover, certain pathological facts clearly show the fal- lacy of the above opinion. In ulceration of the bowels the morbid action occasionally extends to the serous investment, which it at length perforates, leading thus to a discharge of faecal matter. Of this not less than five or six well-marked cases have fallen under my own observation, and numerous others of a similar kind are narrated by authors. This occur- rence must, in fact, inevitably happen whenever nature fails to effect adhesion in the surrounding parts, however slight the opening. In several of my cases the aperture did not exceed two lines, or the sixth of an inch in diameter, and in some of those that have come under the notice of other observers, it was still smaller, scarcely equalling the size of a crow- quill. Additional facts have been furnished by Smith and Travers, in their experiments on dogs. My own researches have afforded the following results. Having opened the cavity of the abdomen of a small slut, a transverse wound, half an inch long, was made into the je- junum, and the part returned without suture. The animal be- came sick soon after the operation, and evinced a disinclina- tion to move about. In thirty-two hours she died. The aperture in the bowel was perfectly patulous, with the mu- cous coat everted, of an oval form, and without the slightest attempt at reparation or adhesion to the circumjacent struc- tures. About six ounces of a dirty yellowish looking fluid, evidently of a faeculent nature, were contained in the perito- neal sac; and there was extensive inflammation of the omen- tum, together with the serous coat of the bowels, several coils of which adhered with tolerable firmness to each other. In another experiment, the subject of which wTas a small dog, and in which the incision was of the same extent and direction, the results were of a similar character. The ani- mal became sick shortly after the operation, and continued 8 WOUNDS OF THE INTESTINES. in that condition for thirty-six hours, when he died. On dis- section, the edges of the wound were found to be in a gaping state, without any apparent effort at restoration; some hard- ened and fluid fasces had escaped into the abdominal cavity; the bowel was red and contracted for several inches above and below the affected part; and the neighboring knuckles of intestine were agglutinated by plastic lymph. In a third experiment, in which the wound was only four lines, or the third of an inch in length, and in which the bowel was replaced without suture, recovery occurred without any untoward symptoms, and without any apparent inconve- nience to the animal. Oblique wounds, six lines long, and treated without suture, were followed by the same result as transverse wounds of the same extent. Only two experiments were performed to elu- cidate this point. The particulars it is unnecessary to detail. It will suffice to say that, in one of the dogs, death took place in thirty-six, in the other, in forty-seven hours, from peritoneal inflammation, occasioned by the effusion of faeculent matter. The wounds in both were in a gaping, patulous state, with- out any evidence whatever of reparation by the adhesive pro- cess. To ascertain whether a longitudinal wound, six lines long, would be attended with the same degree of danger, was the ob- ject of the next experiment. For this purpose a healthy, full grown dog, of moderate size, was selected. Soon after the opera- tion he vomited, and appeared to be in great agony; in thirty-six hours he died. On opening the belly, a considerable quantity of gas, of a highly offensive odor, escaped with a loud noise. Both hardened and fluid faeces were contained in the peritoneal sac, the enteric portion of which, especially in the immediate vicinity of the wound, exhibited marks of violent inflammation. The edges of the wound were separated to the extent of at least two lines, and through the opening thus formed the mucous membrane projected beyond the level of the serous covering. No attempt had been made to re-es- PERITONEAL CAVITY--NATURE AND EXTENT. 9 tablish the continuity of the tube by adhesions of the gut to the surrounding parts. In a second experiment, in which the wound was only four lines long, speedy recovery followed. The dog was a good deal indisposed for the first forty-eight hours, after which he became well and lively, and continued thus until he was killed on the fifteenth day after the operation. A process of omentum occupied the outer wound, which was nearly healed, the small bowels were extensively matted together, and the reparation of the enteric breach had evidently been effected by the adhesion of its edges to the two neighboring coils of intestine. The bottom of the wound was nearly two lines in width at its middle, and imperfectly filled with lymph. A large dog, killed nine days after having been stabbed with the sword of a cane, two lines in diameter, presented the following appearances: two punctures, distant about five inches from each other, were found in the small bowel; the edges of each were in close contact, and their outer surface was completely covered with plastic lymph, which was quite firm, slightly ecchymosed, and vascular. The animal retained his original embonpoint, and did not appear to have suffered ma- terially from the injury which had been inflicted upon him. From the foregoing observations and experiments, the fol- lowing conclusions may be established: First—that, although there is not, in the true sense of the term, any peritoneal cavity, yet the arrangement existing be- tween it and the enclosed viscera is of such a nature as to admit, and that very frequently, too, with great readiness, the effusion of stercoraceous matter in wounds and ulcerative perforation of the bowels. Secondly—that wounds of the bowels to the extent of six lines, whether transverse, oblique, or longitudinal, are almost always, if not invariably, followed by the escape of faecal matter, and the consequent development of fatal peritonitis. Thirdly—that wounds not exceeding four lines in length, no matter what may be their direction, are not near so apt, if 10 WOUNDS OF THE INTESTINES. left to themselves, to be succeeded by the extravasation of the contents of the intestinal tube; and that, in the majority of cases, nature, properly aided by art, is fully competent to effect reparation. These deductions derive additional support from the follow- ing experiments, instituted with a view to ascertain the effects of wounds and punctures of different forms and dimensions: 1. A longitudinal incision, two lines and a half in length, immediately contracted to one line and three-quarters, with a sufficient amount of eversion of the mucous lining to close the resultant orifice. 2. A similar wound, four lines long, diminished in a few seconds to three lines, by one line and a half in width; it assumed an oval shape, and the internal membrane protruded on a level with the peritoneal covering, leaving no perceptible aperture. 3. An oblique cut, seven lines in length, contracted to five, by two and a half in width, with marked eversion of the mucous lining. 4. A transverse wound, two lines and a half long, was reduced almost in- stantaneously to two lines in diameter: it was of a rounded form, and the two outer tunics of the gut retracted so as to expose the mucous membrane. 5. In another experiment, in which the incision, likewise transverse, was half an inch in extent, the orifice assumed a rounded, oval shape, and was reduced to four lines, by two and a half in width, the internal coat exhibiting, as in the other cases, a pouting, or everted arrangement. These observations are interesting chiefly as showing the efforts which nature institutes to close a breach of this kind, the very moment almost it is inflicted. It is doubtless by a process of this description that the effusion of stercora- ceous matter into the peritoneal sac is so generally prevented in those cases in which the solution of continuity is of small extent, not exceeding, for example, a few lines in diameter, and where, consequently, it amounts rather to a puncture than a wound. The eversion of the lining membrane forms a striking and constant feature in injuries of this character, PERITONEAL CAVITY—NATURE AND EXTENT. 11 and may be. compared, in its effects, to the contraction and retraction observed in the extremities of a divided artery. It is a circumstance in the highest degree interesting, and worthy of notice, that the eversion of the lining membrane, which is so conspicuous in traumatic lesions of the alimen- tary tube, is never witnessed in the openings which result from ulcerative action. In the latter, the perforation proceeds in a slow and gradual manner, at the expense mainly of the mu- cous and fibrous lamellae, which are always destroyed to a much larger extent than either the muscular or peritoneal. Hence, by the time the ulcer reaches the surface, it is impos- sible for the lining membrane to protrude across it, as it does when the bowel is wounded by a sharp instrument, a blow, or a kick. Another circumstance which no doubt con- tributes to produce this result, is the indurated condition of the serous and muscular layers immediately around the^erfo- ration, caused by the deposition of lymph during the progress of the ulcerative action. There is thus a striking difference, as respects their imme- diate effects, between an opening of the bowel from ulcera- tion and one produced by an incised or lacerated wound. In the former, although it may not be two lines in diameter, extravasation would be almost certain; in the latter, it might be nearly double that size, and yet, for the reason just men- tioned, that event, so much to be dreaded, would be little likely to occur. It is much to be regretted that Mr. Travers, in the experi- ments which he instituted to illustrate this branch of the sub- ject, as well as in the cases which he has adduced from his own and the practice of others, has not specified the size of the lesion; a matter of such paramount importance that it is only surprising how it could have been overlooked. His chief object, however, appears to have been, not so much to deduce from them any practical precept in reference to the manage- ment of such accidents, as to show that the apprehension of intestinal effusion in penetrating wounds of the abdomen, is, 12 WOUNDS OF THE INTESTINES. in the majority of cases, without foundation. How far he has succeeded in accomplishing this end, I leave it to others to determine. Sect. III.—Symptoms, Diagnosis, and Prognosis. The next topic into which I proposed to inquire is the consideration of the symptoms of wounds of the intestines, A few remarks under this head will be sufficient for the ob- ject in view. The symptoms of a wounded bowel necessarily divide themselves into two classes, into those, namely, which are furnished by the system at large, and those which are pecu- liar to the part more directly and immediately implicated. In regard to the first, they are such, generally, as denote a severe shock of the nervous system, but as they are common to this and other injuries, they are of little consequence in enabling us to make out the diagnosis. In almost all instances there is nausea, either alone, or accompanied with vomiting; these symptoms often make their appearance within a few minutes after the infliction of the wound, and continue with great obstinacy for several successive days, or, in fatal cases, until death relieves the patient of his suffering, They are commonly more violent and distressing in lesions of the small than of the large bowel, owing to the more delicate organiza- tion of the former than of the latter, and to its more inti- mate connexion with the stomach and the sympathetic nerves. The prostration of the vital powers is not always in proper* tion to the extent of the wound, or the danger of the case. Some persons, it is well-known, suffer much more severely from a slight than others do from a violent injury, for rea- sons which cannot always be explained, but which may be supposed, generally, to be dependent upon some constitu- tional peculiarity. Reaction is often postponed for ten or fifteen hours after the occurrence of the accident, and until it is fairly established there is sometimes a constant tendency to syncope, with an alarmed and agitated state of the mind, LOCAL SYMPTOMS. 13 which it is almost impossible to calm or subdue. The coun- tenance under such circumstances has a pale, anxious, and haggard expression; the pulse is small, frequent, and tremu- lous; the skin is bathed with clammy perspiration; the extrem- ities are cold; the patient tosses about in his bed; the thirst is urgent, as is also the desire for cool air; there are griping pains in the abdomen; and occasionally the discharges from the bowels are involuntary. Conjoined with these symptoms there is sometimes slight delirium with partial blindness or indistinctness of vision. The local symptoms of a wounded intestine are often as equivocal as those which are furnished by the constitution. This must, indeed, always be the case when there is no pro- trusion of the tube, or when the external opening is so small, or its direction and situation are such, as to prevent effectu- ally the escape of feces or other matters. It not unfrequently happens that an instrument enters the abdomen, and passes out at the opposite side, directly in the course of the bowels, without in any wise interfering with them. Many interesting and instructive cases of this kind are recorded by writers on military surgery, as well as by civil practitioners, and seve- ral will be quoted hereafter in illustration of this part of the subject. The most characteristic signs of this lesion are, unquestionably, the escape of faeces, bile, food or foetid air from the external wound, and the sudden development of tympanites. The latter symptom, which does not appear to have been sufficiently insisted upon by systematic writers, as very few, if any, mention it, is often present when the others are absent, and may therefore be regarded as in some degree pathognomonic. Jobert thinks it is the most valuable and positive sign of a wound of the intestine that we can have when there is no external opening, or only so small a one as not to permit the egress of stercoraceous or other substances. He relates several instances from his own practice and that of others, in which, by this phenomenon alone, the diagnosis was clearly established. The tympanites supervenes at vari- ous periods, from a few minutes to several hours, after the 2 14 WOUNDS OF THE INTESTINES. occurrence of the accident, and is always attended with a hollow, drumlike sound on percussion, with tenderness on pressure, and difficulty of respiration. The following cases will more fully explain the nature and importance of this symptom. A young man, eighteen years of age, of an excellent con- stitution, an apprentice in a drug-store, in a rencounter with a robber, in May, 1842, was stabbed with a knife in the right side of the abdomen, the instrument entering the anterior wall of the ascending portion of the colon in a transverse direction, and about two inches above the ileo-coecal valve. The outer wound was fifteen lines in length, and the inner was sufficiently large to allow the escape of a considera- ble quantity of faecal matter. A short time after the occurrence of the accident there was diffuse pain of the abdomen, with a discharge of blood from the anus, and at the end of twenty- four hours decided tympanites. The distention progressively augmented for four days, when it had attained an enormous height. From this period it slowly subsided, but did not entirely disappear under a month. Pressure on the abdomen during the first week occasioned the most exquisite pain. The patient finally recovered under the judicious management of Dr. E. S. Williams and Professor Mussey, of Cincinnati, where the case occurred, and where, through the politeness of those gentlemen, an opportunity was afforded me of see- ing it, during a visit which I made to that city last summer. A carriage-driver, sixty years of age, was kicked by a horse upon an old rupture in the left groin, for which he was carried to the St. Louis hospital of Paris. The following morning he had great pain in the belly, especially on pressure, and the swelling, which was very large and emitted a peculiar gurgling noise, was tympanitic. He died the next day under all the symptoms of gangrene or rupture of the intestine. The scro- tum, hernia, and belly, were all distended with gas, which could be readily forced from one to the other; the intestinal folds were agglutinated by plastic lymph; black matter was LOCAL SYMPTOMS. 15 effused into the pelvic and abdominal cavities; and the small bowel was entirely torn across.* A young man, twenty-one years of age, was thrown from his carriage, the wheel of which passed over his belly. When brought to the St. Louis hospital, immediately after the accident, the skin of the abdomen was found to be per- fectly natural, but he complained of great pain, and there was enormous tympanites, the parts on percussion sounding like a drum. His sufferings for eight days were very violent, after which they gradually subsided, and he was rapidly con- valescing from his injury, when, at the end of a month, an unexpected attack of pleuro-pneumonitis occurred, which quickly destroyed him. The jejunum adhered to the last false rib, and presented the remains of an opening, which had been completely closed by a sort of plug of the omentum.f A man affected with cancer of the rectum was admit- ted into the surgical ward of the St. Louis Hospital under the care of Mons. Richerand. The abdomen became sud- denly tympanitic, and this distinguished surgeon at once pronounced the case to be one of intestinal perforation. The autopsy justified the diagnosis. The bowel was found to have given way above the seat of the disease, and thus per- mitted the escape of the gas upon which the distention de- pended. J Examples of a similar character are recorded by Scarpa, Sevestre, Kapeler, Marjolin, and other writers. Tympanites, however, does not attend all traumatic injuries of the intestinal canal. When the opening is very small, amounting rather to a puncture than a wound, the escape of gas will either be entirely prevented, or occur only in a small de- gree, owing to the protrusion of the mucous membrane, which, as was seen in a previous part of this essay, is a constant phenomenon in lesions of this description. A sort of valve *Jobert, Maladies du Canal Intestinal, T. i, p. 61. flbid. T. i, p. 62. {Ibid. T. i, p. 63. 16 WOUNDS OF THE INTESTINES. is thus formed, which opposes an effectual barrier to the egress of faecal matter, intestinal secretions, and even air. A discharge of blood from the anus is another symptom which, in connexion with some of those already pointed out, is of considerable importance in the discrimination of the lesion before us. Still, as it may, and often does attend other inju- ries, it cannot be regarded as at all characteristic. The quan- tity of blood evacuated occasionally amounts to many oun- ces. In the case previously adverted to, which I saw along with Professer Mussey and Dr. Williams, at least two pints of fluid and grumous blood were discharged during the first three days. It began to pass off seven hours after the occur- rence of the injury, nearly unmixed with faeces, and com- paratively fresh in its appearance. What was subsequently evacuated was of a darker color, and more firmly coagulated, as if it had been retained for sometime in the bowel. Equally equivocal is hematemesis, or vomiting of blood which may be enumerated as another, though by no means constant symptom of traumatic lesion of the alimentary tube. The degree of pain accompanying wounds of the intestines varies remarkably in different individuals, being very slight in some, and exceedingly severe in others. In most instances it is of a colicky character, though occasionally it is dull and aching, and it is almost constantly increased by pressure, by coughing, and by a full inspiration, especially if some hours have elapsed since the infliction of the injury. The wound is occasionally complicated with hemorrhage into the peritoneal sac, caused by lesion of the epigastric or internal mammary artery, of some of the branches of the mesentery or omentum, of the aorta or vena cava or of some of their immediate offsets. Unless the abdominal wound be large, very little blood, if any, will appear externally, but it will flow into the serous cavity, where it will occupy the in- tervals between the intestinal convolutions, descend into the pelvis, or be extensively diffused among the viscera. The amount and rapidity of the effusion will vary in proportion to the size of the wound and the volume of the vessel con- SYMPTOMS—DIAGNOSIS. 17 cerned. When the vessel is very large and the opening con- siderable, the hemorrhage may be instantly fatal, or death may ensue in a few hours. In cases of an opposite char- acter the symptoms will be less urgent, and the patient prob- ably suffer no inconvenience, save what results from the tem- porary debility and faintness. The blood will soon coagulate, and by the pressure which it exerts upon the orifice of the bleeding vessel, a mechanical obstacle will be opposed to its further effusion. When the quantity of fluid poured out is considerable a tumor is sometimes formed, which may be easily detected by its prominence and hard feel. If the patient survive the im- mediate shock of* the accident, he may die from inflamma- tion, caused by the clotted blood acting as an extraneous sub- stance. At other times the coagula are absorbed, or they become encysted by an exudation of plastic lymph. In the diagnosis of a wounded bowel important informa- tion may frequently be obtained, in regard to the direction, extent, and depth of the lesion, by a careful consideration oi the shape and size of the vulnerating body. When the outer opening is so large as to admit the finger, it will generally be easy to determine whether the injury reaches the cavity of the abdomen: probing with instruments is quite inadmissible; it can do no good, and may occasion much harm. It need hardly be observed that it is highly proper, in every inquiry of this kind, to place the patient as nearly as possible into the posture in which he was at the moment of the accident. When the wounded bowel protrudes at the external opening, the diagnosis is at once obvious, as the nature and extent of the injury may be determined by simple inspection. The lesion, in the absence of pathognomonic symptoms, ought to be suspected when nausea and vomiting occur after penetra- ting wounds of the abdomen, accompanied with griping pains, great debility and faintness, jactitation, extreme anxie- ty, and cold sweats. The case is plain enough when there is a discharge of the contents of the alimentary tube, or a sud- den development of tympanites. 2* 18 WOUNDS OF THE INTESTINES. It not unfrequently happens that an instrument enters the abdomen, and passes out at the opposite side, without, in the slightest degree, interfering with the bowels or other viscera. Many interesting cases of the kind are related by writers. I select the following in illustration of the subject. A young soldier received, in a duel, a thrust from a sabre on the anterior part of the abdomen, a little above and to the right of the umbilicus. The walls of the belly were divided, and a considerable mass of omentum protruded through the opening. The patient was removed to the hospital, where every attempt was made to reduce the prolapsed parts, but without success. Blood was freely abstracted from the arm, leeches, cups, and fomentations were applied to the abdo- men, and perfect quietude was enjoined; in short, every thing was done to prevent peritoneal inflammation. Eight days after the reception of the injury the extruded omentum was cut off, after which the wound became covered with healthy granulations, and at the end of five weeks the man was nearly well.* The following case, mentioned by Sir Astley Cooper,f is strikingly illustrative of the manner in which the intestines glide away from the edge of the instrument. He was called to a female whom he found lying on the floor, weltering in her blood, from the infliction of four wounds upon her throat, in an attempt to commit suicide. Having closed these with sutures, his attention was directed, by some incoherent re- mark which she made, to her abdomen, where he found the bowels exposed by a wound reaching nearly from the pubes to the ensiform cartilage of the sternum. After cutting her throat with a razor, she had ripped up her belly with it, and let out her bowels, which were still distended with air, and had not sustained the slightest injury. Dr. Hennen statesj that he was witness to the recovery of *Medico-Chir. Review, vol.ix, p. 527. tlbid., vol. ix, p. 528. {Principles of Military Surgery, p. 319. Phila.. 1830. SYMPTOMS—DIAGNOSIS. 19 a soldier who was shot through the body with a ram- rod at the siege of Badajos, in 1812. The instrument enter- ed the front of the abdomen, and actually stuck in one of the transverse processes of the vertebrae, from which it could not be disengaged without force. An analogous case is related by Dupuytren.* A man in a fit of severe grief resolved to put an end to his existence, and for this purpose rushed with all his force against the point of a sword, which he had previously fas- tened in the wall of his apartment. So completely was the abdomen transfixed that the point of the weapon stuck out for eight or ten inches on the right side of the spine. When Dupuytren saw him, he seemed to suffer but little pain, and there was no symptom of any extravasation, or, indeed, of a wound of any of the abdominal viscera. It required conside- rable force to withdraw the sword. By repeated bleedings and the employment of a very rigid antiphlogistic regimen, the patient speedily recovered. Richard Wiseman mentions the case of a young man who was run through with a rapier, which entered at the right hypochondriac region, and passed out at the back. On the the following day his skin was hot, and the pulse some- what accelerated, but there was no tension of the abdomen, colic, vomiting, or any thing denoting injury of the in- testine, or any other viscus, and he recovered in a very short time. "Thus," says Wisemen, "it frequently happeneth that a sword passeth through the body without wounding any considerable part-t" Two similar cases are recorded, one by Lamotte,J and the other by Garangeot, in each of which a sword passed directly across the cavity of the abdo- men, without injuring a single fold of the intestinal tube. Numerous instances of penetrating gunshot wounds of the •Medico-Chir. Review, vol. xxi, p. 301. fChirurgical Treatises, p. 373., 4to. London, 1676; {Traite Complet de Chirurgie, T. ii. 20 WOUNDS OF THE INTESTINES. abdomen are recorded* in which the bowels appear to have completely escaped injury. A case, which was evidently of this nature, is mentioned by Dr. John W. Richardson, of Tennessee, in the fourth volume of the Western Journal of Medicine and Surgery.* The ball, which weighed two drachms and a half, entered the abdomen on the right of the median line, and issued midway between the last rib and the sacro-iliac symphysis, immediately on the right side of the spine. There was no escape of gas or faeculent matter from the wound; some bloody urine was discharged soon after the infliction of the injury, and for the first eight or ten days there was considerable tension with soreness and swelling of the abdomen. The whole treatment was very simple, and the patient recovered in less than a month. When the ball does not pass entirely through the body, it may be retained in the peritoneal cavity, or, if it wound the bowel, it may at once fall into the latter, and be dis- charged by stool. In the former case the foreign body excites adhesive inflammation, by which it becomes encysted; after it has remained in this condition, however, for a while it usually induces suppurative action, which gradually extends to the coats of the intestine, and finally produces perforation., whereby an outlet is established for its evacuation. When the extraneous substance is very small, as, for example, a shot, or even a small bullet, it occasionally continues encysted for many years, or even during the remainder of life, without occasioning any ill effects. An instance in which a number of encysted shot were found in the peritoneum recently occurred in the Louisville Marine Hospital, in an old man who had been wounded by a musket ten or twelve years previously. He soon recovered from the injury, to which he never referred any of his subsequent ailments. I shall conclude this citation of authorities with the follow- ing extraordinary case recorded by Dr. Hennen, in his work * This case is reported as having involved the colon and small intes- tines, without any evidence whatever that this was the fact. SYMPTOMS--PROGNOSIS. 21 on Military Surgery. A soldier of the Brunswick corps was wounded on the 16th of June, 1815, by a grape shot, which struck the right arm near the elbow, the articulation of which was destroyed. An English surgeon amputated the limb some hours after. The patient remained that night at Genappes. Next morning he observed blood flowing through the bandages, and requested Dr. Spangenberg, physician-in- chief to the Hanoverian army, to examine the arm. He found the humerus split as far as the joint, and with the con- sent of the patient immediately extracted it. After having dressed the parts, the man complained of pain in the abdo- men, which was ascertained to proceed from a wound caused by a grape shot, which had passed through the exterior part of the belly, leaving two openings, one in front and the other behind, through each of which a portion of intestine protru- ded, not injured or inflamed, but in the natural state. The bowel, smeared with oil, was carefully reduced, and the two apertures were covered with adhesive plaster. The patient was brought to the hospital at Laecken, on the 10th of June, with moderate fever, and very little pain in the abdomen, or in the wound of the arm. The functions of the intestinal tube were not disturbed. He took little or no medicine; in four weeks the sores in the arm were cicatrized, and those of the abdomen, which were slightly affected with gangrene, in about three months. The prognosis of wounds of the intestines must necessarily be influenced by a great variety of circumstances, such, par- ticularly, as the extent of the mischief, the nature of the vul- nerating body, and the state of the patient's health at the time of the accident. A small and simple lesion will be much more likely to turn out favorably than one involving a large surface, or one complicated with injury of some other organ, or the perforation of a large vessel. It is also less serious in an incised than in a contused or lacerated wound, and in a superficial than a deep one. Persons occasionally perish from the most trivial accidents of this kind, from the mere shock probably of the nervous system; they lie in a pale and ex- 22 WOUNDS OF THE INTESTINES. hausted condition, and death takes place unpreceded by reac- tion. On the other hand, recovery sometimes occurs under circumstances apparently the most desperate and unpromising. No certain rule can, therefore, be laid down in respect to the prognosis of wounds of this description; which, however, must always be considered as severe accidents, likely to be followed by the worst consequences. Wounds of the large bowel were regarded by the ancient surgeons as less serious than those of the small; a view in which most modern au- thors seem to concur. The reason of this difference is, first, the more fixed condition of the lower portion of the tube; secondly, its more capacious calibre; and thirdly, the more solid nature of its contents. These circumstances may all be supposed to be favorable to the prevention of the effusion of faecal matter. Extravasation will also be less apt to occur when the bowel is empty than when distended. When the contents of the bowel are effused over the peri- toneum, death is sure to take place from the effects of inflam- mation. Occasionally, as was before intimated, life seems to be destroyed by the shock sustained by the nervous system within a few hours after the accident, and before the constitu- tion has had time to rally. The faecal extravasation, when slight, is sometimes limited by the deposition of plastic lymph, and the discharge of it is ultimately promoted by the forma- tion of an abscess; or chronic action is established in the serous membrane, and the patient, after weeks or months of suffering, sinks under the exhausting influence of the malady. In the great majority of instances, however, death is induced by acute peritoneal inflammation. The symptoms presented are violent burning pain of the abdomen with great tenderness on pressure; intense thirst; a sharp, frequent, and contracted state of the pulse; constipation of the bowels; coldness of the extremities; constant wakefulness; great anxiety and restless- ness. In the latter stages there is generally some degree of nausea with occasional vomiting; the pulse is weak and flut- tering; the surface is bathed with a cold clammy sweat; the features are collapsed; the breathing is oppressed and labori- MODE OF REPARATION. 23 ous; the belly extremely tense and tumid; the patient is ha- rassed with cough, his strength rapidly forsakes him, and he dies under all the symptoms of one sinking from the effects of mortification. The attack rarely continues beyond forty-eight hours, and often terminates fatally in a much shorter period. The appearances after death are always well-marked when the disease has been protracted. The peritoneal surface is highly inflamed, the bowels are covered with lymph, and the abdominal cavity usually contains a small quantity of turbid serum. The intestinal coils are fre- quently united to each other and to the neighboring parts, and on penetrating the belly there is almost always an escape of foetid gas. Sect. IV.—Mode of Reparation. 1 come, in the next place, to consider the process employed by nature in repairing wounds of the intestinal tube, and the mode in which she disposes of the ligature used in securing their edges. If a small circular ligature be drawn firmly round the bowel of a dog, or other animal, the resulting effects will be very similar to those which attend the ligation of an artery. The opposite surfaces will not only be forced into close contact with each other, but it will produce at the same time a complete division of the mucous coat. If the cord be pulled very tightly, there will be in addition, especially in young subjects,a partial separation of the cellulo-fibrous lamella and of the muscular fibres. These effects I have repeatedly witnessed in my experiments on dogs, and they may be readily produced in the human body after death. If a flat ligature be used, even when 24 WOUNDS OF THE INTESTINES. it is drawn with considerable firmness, the opposite surfaces of the tube are merely brought into contact, without any rupture of the substance of any of the tunics. The only exception to this is where the animal is very young and the parietes of the bowel are unusually tender; in which case there will be occasionally a slight division of the lining membrane, but not of the muscular fibres. When a narrow ligature is used, the parts above and be- low it are so closely approxi- mated that they touch in the greater portion of their cir- cumference: a circumstance which must necessarily exert a most favorable influence over the reparative process and the re-establishment of the continuity of the canal. Soon after an operation of this kind, in which a narrow circular ligature is used, inflammation is set up, plastic lymph is deposited upon and around the constricted parts, ulcerative absorption is established, and the cord at length works its way into the intestinal tube, where it is discharged along with the faeces. The period required for the detachment of the ligature may be supposed to be influenced by various cir- cumstances, the principal of which are referable to the form and size of the foreign substance, together with the force with which it is applied, the thickness of the different tunics of the bowel, the age of the subject, and the state of the general health at the time of the operation, as well as immediately after it. In a small but full grown dog, killed at the end of the third day after the experiment, the ligature, which was round and narrow, had found its way through more than one- MODE OF REPARATION. 25 half of the circumference of the tube, and in another animal of the same kind, which died from the effects of the operation thirteen hours later, the progress of the foreign body was still greater. In the latter, indeed, the cord had entirely dis- appeared, having lost its hold, and escaped into the bowel, in which, after a minute examination, it was discovered at the distance of several feet from the seat of the injury, surround- ed by faecal matter. In both cases the continuity of the parts was thoroughly re-established by an abundant deposition of lymph, which, notwithstanding the brief period that had elapsed, exhibited already well-marked traces of organization. The bowel, however, presented in each instance a constricted appearance; and in one of the animals, that, namely, which was killed at the end of the third day, the opposed mu- cous surfaces were still in close contact, no attempt having apparently been made to restore that portion of the tube. In the other the parts were not only perfectly continuous with each other, as has just been intimated, but the cavity was par- tially re-established. In a third experiment, performed on a middle-sized dog, not more than eighteen months old, the ligature was found lying at the seat of the constriction, where it was retained by a layer of plastic lymph, which had sealed up, as it were, the surface of the fissure in the mucous tunic. The canal of the bowel was completely restored, and the bond of connexion between the divided parts firm and organized. The animal was killed on the eleventh day. (PL fig. 1, 2.) The following experiment was performed by Mr. Travers, and is recorded in his work on wounds of the intestines. A ligature of thin pack thread was firmly tied around the duo- denum of a dog, so as completely to obstruct it. The ends of the string were cut off, and the part returned. On the fif- teenth day, his cure being established, he was killed. A por- tion of omentum connected to the duodenum was lying within the wound, and the folds contiguous to the strictured intestine adhered to it at several points. A slight circumfer- ential depression was observed in the duodenum, and the mu- cous surface was more vascular, as well as of a deeper color, than 3 26 WOUNDS OF THE INTESTINES. usual. A transverse fissure marked the seat of the ligature. The edges of the sections were distinctly everted, and the appearance corresponded with that of the union by suture. The lymph which is effused upon the external surface of the bowel, consequent upon the operation, gives the part at first a rough uneven appearance; but after a few weeks, sooner or later, according to circumstances, it undergoes a sort of modelling process, and hence, if the animal survive several months, it is generally no easy matter to determine the seat of the injury. In a dog which was killed four months after the experiment was performed, the reparation was so perfect that, had it not been for the attachment of a small process of omentum, it would have been impossible, by mere external inspection, to discover the place where the cord was originally applied, such were its smoothness and polish. Nor was this confined solely to the outer surface of the tube. Internally the cicatrization was almost as complete, the continuity of the mucous membrane having been every where re-established. There was scarcely even a seam at the original seat of the constriction. (PI. fig. 3, 4.) It will thus be perceived that, from the rapid manner in which the ligature is detached, there is no danger that the animal will suffer much inconvenience from the want of a passage. Indeed, when the ligation is made in the small bowel, or high up in the large, the alvine discharge may go an with the same facility as before, making allowance of course for the pain which must necessarily attend an opera- tion of such severity. Effects similar to the above are produced when a ligature is applied round the edges of a small wound, that is to say, from two to three lines in diameter, provided it be drawn with sufficient firmness not to slip off. The cord gradually cuts through the different coats of the bowel, and the continuity of the canal is re-established by the effusion of plastic lymph upon the constricted part. The process of reparation, how- ever, is not so speedily completed, owing to the breach being much wider than when a ligature is simply cast round the MODE OF REPARATION. 27 tube. In this case the mucous membrane is reproduced only after a long time, and the amount of lymph required is pro- portionally much greater. The ligature is detached at a pe- riod varying from five to ten days. Wounds and punctures of the bowel, unaccompanied by the effusion of faecal matter, heal, when left to themselves, either by the adhesion of their edges to the surrounding parts, or by the deposition of lymph upon their surface and the gradual approxi- mation of their lips. In the majority of cases the reparation is probably effected by the former method; since there is always a great tendency in the wounded structures to attach themselves to those in their immediate vicinity. Even wounds of large size are occasionally repaired in this manner. In some in- stances, again, the breach is closed by a piece of omentum, which projects into it, and fills it up like a tampon. When this happens the serous membrane is firmly fixed to the edges of the opening, and the part which corresponds with the in- terior of the canal and assists in maintaining its continuity, is eventually absorbed; an occurrence which leads to the grad- ual approximation of the lips of the wound and their ultimate re-union. Jobert thinks that this mode of reparation is not uncommon, an opinion in which my observations do not in- duce me to concur. That it takes place occasionally is cer- tain, for I have several times witnessed it in my experiments. He refers to a case, reported by Dr. Qurcial of Toulouse, of perforation of the jejunum, in which the epiploon project- ed into the opening, and thus effected a cure.* All the older surgeons, down to La Faye, Palfin,f and even Sabatier,J believed that wounds of the intestines never united, except through the intervention of the peritoneum, the omentum, or some of the neighboring viscera. In mortification of the bowels, especially when occurring * Traite des Maladies du Canal Intestinal, T. i, p. 66. f Anatomie Chirurgicale, T. ii, p. 66. J Medecine Operatoire, T.i, p. 33. 28 WOUNDS OF THE INTESTINES. in small patches, the mode of reparation appears to be simi- lar to that which takes place when a wound or puncture is left to itself. By the time the eschar is detached the edges of the breach will have formed adhesions to the circumjacent parts, by which the effusion of faecal matter will be effectually guarded against. Where this is prevented the patient dies from peritoneal inflammation, or an artificial anus is estab- lished. The subject of gunshot wounds of the intestines appears to have been more profoundly investigated by Baron Larrey than by any other surgeon. He divides the cuwtrwe process into four stages. In the first, the bruised and'-Uacerated tis- sues are deprived of their vitality, to an extent varying according to the amount of the injury they have sustained. In this respect a gunshot wound of the alimentary canal does not differ from that of any other part of the body. In the second stage, the eschar is detached, and the opening gives vent to feculent and purulent matter, which continues to escape for several weeks or even months. During the third stage, the discharge gradually diminishes, and at last ceases altogether to appear externally. The union of the wound constitutes the fourth stage. The corresponding textures gradually approach each other, and, cicatrizing from within outwards, the whole chasm is at length completely filled up: the primitive adhesions become absorbed, and there only remains a slight contraction of the intestinal tube at the wounded part.* When sutures are employed the mode of reparation is essen- tially alike, whatever may be their form. The inflammation which is lighted up induces an effusion of lymph, which is speedily followed by adhesion of the injured coil to the neigh- boring structures, among which it is sometimes completely burried. At other times no such adhesion occurs, but the affected part throughout the entire line of suture is coated * Medico-Chirurg. Review, vol. xvi, p. 58. MODE OF REPARATION. 29 with a layer of plastic matter, by which the continuity of the serous surface is finally re-established, and the threads used in sewing up the wound are concealed from view. In almost all cases—certainly in eight out of ten—there is an attach- ment of the omentum to the surface and edges of the wound, which thus assists, in an eminent degree, in the process of restoration. (PI. fig. 5.) I speak now of course only of what I have noticed in dogs; whether the same thing takes place so readily, and to the same extent, in the human subject, my in- formation does not enable me to determine. Probably it does not, as the epiploon is generally much smaller in man than in some of the inferior animals, especially in the canine races. The attachment of this membrane to the surface and edges of the wound is a very different matter, it will be observed, from the projection of it into the breach, in the manner pointed out and so strenuously insisted upon by Jobert. We have already seen that the latter is comparatively rare, while the other, on the contrary, is exceedingly frequent. This extraordinary tendency to adhesion in the external surface and edges of the wound to the parts around it, is no- thing more than what might be expected when we reflect upon the nature of the peritoneum, and its invariable dispo- sition, when inflamed, to pour out lymph. But it is oth- erwise with the mucous membrane. Here the process of re-union is not only much slower but much less perfect; lymph is furnished very sparingly, or in quantities barely sufficient to fill the chasm between the margins of the wound; and, owing to the heterogeneous and irritating nature of the contents of the tube, a long time must necessarily elapse be- fore it can become an organized or living intermedium. The little narrow band thus formed adheres firmly to the bottom of the wound, but very slightly, if at all, for some days, to its edges. Gradually, however, it becomes mo»;e and more dense; vessels extend into it from the circumjacent parts; its margins are flattened down; and, after a period varying from a few weeks to as many months, the adhesion is finally com. pleted. Subsequently, or, indeed, while the changes just 3 * 30 WOUNDS OF THE INTESTINES. adverted to are still in progress, the new matter is nearly all absorbed, the wound greatly diminishes in width, and when the cicatrizing process is perfected merely a small depression or seam remains, to indicate the original seat of the injury. The whole process may be compared to that which nature employs in the reparation of ulcers of the mucous lining of the small and large bowel. (PI. fig. 6, 7.) This, however, is only one mode in which the restoration of the mucous surface is effected. Another, though by no means a frequent one, is by granulation. It has been already stated that, owing to the irritating and heterogeneous charac- ter of the contents of the bowel, the lymph which is depos- ited upon the wound is very tardy in becoming organized, and it may now be added that this process is occasionally entirely prevented, the substance in question being either destroyed or removed by the faecal matter as it passes over the affected part. When this happens, nature, faithful to her duty, makes an effort to repair the breach by the formation of granulations, as in similar injuries of other textures. The process under these circumstances is generally much more tardy than in the previous case, the cicatrization is also less complete, and the tube is much more apt to be puckered im- mediately around the seat of the injury. Mr. Travers seems to doubt that the fissure in the mucous lining is ever filled by granulation. "I had been led to expect," says he, "that the interstice of the villous coat would be filled by granulation, and that the substanee of the cylinder would in this way be restored at the place of division. But finding the eversion of the villous edges uniform and permanent, it seemed doubtful if such a process could be set up, as perfect surfaces were opposed to each other. It is also not inconsistent with the indisposition of mucous surface to the adhesive inflammation to infer that it does not readily admit of the granulating pro- cess, which is only an advanced stage of that inflammation.'** * Op. cit., p. 131. MODE OF REPARATION. 31 I quote the language of this distinguished author, in order that his meaning may be fully understood. I am not aware that a similar opinion has been expressed by any other writer, and how so accurate an observer should have arrived at so erroneous a conclusion cannot be easily conceived. That granulations are formed on mucous surfaces is a matter of daily observation, and my researches have abundantly satisfied me that they are occasionally concerned in the restoration of the villous portion of a wounded bowel. The process of course is difficult; it must be so from the very nature of the mucous tissue, indisposed as it is to pour out plastic lymph; but this does not prove that it may not take place. This writer has made another remark, not less erroneous, in relation to this subject, when he asserts that the adhesion which takes place between the mucous surfaces within a few hours after their connexion by suture is in no instance per- manent, but that it is destroyed by the retraction of the divided parts when the ligatures drop off. Such an occur- rence does undoubtedly sometimes take place, but I have re- peatedly observed the reverse, and there is reason to believe, judging from the results of my own researches, that this hap- pens much more frequently than is commonly supposed. Several days, often as many as eight or ten, must of necessity elapse before the sutures are detached; a period which is more than sufficient, in the plurality of cases, for the agglutination of the villous lips of the wound by plastic lymph. The appo- sition of the parts, moreover, is eminently favored by the crip- pled and paralysed condition of the muscular fibres at the seat of the injury, and by the tendency of the mucous mem- brane to eversion at the moment of the accident. From the foregoing observations it is evident that the pro- cess of re-union is the same, whether the bowel be encircled partially or wholly by a ligature, whether we employ the suture, or, lastly, whether the wound, provided it be not too ample, be entirely intrusted to the resources of nature. In each case the restoration is effected through the medium of plastic lymph, poured out as a consequence of inflammation, 32 WOUNDS OF THE INTESTINES. and undergoing, sooner or later, a certain degree of organiza- tion. The manner in which the ligatures are detached varies, as might be expected, according to the mode in which they are applied. Both in the interrupted and continued sutures, with their different modifications, the threads, provided their ex- tremities are cut off close to the surface of the wound, inva- riably fall into the alimentary canal, along with the contents of which they are afterwards evacuated. This, indeed, may be laid down as an axiom, to which I saw no exceptions in any of my experiments, and which fully confirm, in this par- ticular, as well as in many others, the researches of Smith, Thomson, Travers, and Cooper. The fact that the foreign body employed in making the suture is thus disposed of appears to have been first noticed, at all events hinted at, by Mr. Benjamin Bell in his System of Surgery; but it remained for two of the gentlemen whose names have just been cited, namely, Mr. Thomson and Mr. Travers, to settle the question by a direct appeal to experiments on the inferior animals. The same circumstance, as was previously intimated, occurs when a ligature is cast around a loop of intestine, or when it is employed to encircle the margins of a small aperture, whether caused by injury or mortification. If, on the other hand, the extremities are permitted to hang out at the exter- nal wound, they will be discharged outwardly instead of in- wardly, as in the former case. When the threads, through accident or negligence, slip beyond the reach of the operator, and escape into the peritoneal cavity, they will either induce fatal inflammation, or lymph will be poured out and they will thus become encysted, or they will excite ulcerative action in the coats of the bowel and find their way into it, or they will be evacuated through the opening in the wall of the abdo- men. TREATMENT. 33 CHAPTER II. Of the Treatment of Wounds of the Intestines. Having, in the preceding chapter, described the nature of wounds of the intestines, we come, in the next place, to speak of their treatment; a topic which necessarily involves the consideration of the suture in all its modifications and vari- eties. To exhibit this important subject in its true light, I shall treat it under the following heads: First, Penetrating wounds of the abdomen unattended with protrusion of the bowels. Secondly, Penetrating wounds with protrusion, but no lesion of the bowels and omentum. Thirdly, Penetrating wounds with protrusion and injury of the bowels. Fourthly, The therapeutic, or common local and constitu- tional means. Fifthly, The treatment of wounds of the bowels by dif- ferent kinds of sutures. Sect. 1.—Penetrating Wounds of the Abdomen unattended with protrusion of the Intestines. In entering upon this subject, the first question that pre- sents itself is, are there any circumstances in which the sur- geon should feel himself justified in returning into the abdo- men a wounded bowel without sewing it up? This is a point, it must be conceded, of paramount importance, since it closely concerns not only the reputation of the practitioner, but, what is of much greater moment, the fate of the sufferer. Penetrating wounds of the abdomen are not necessarily attended with protrusion of the bowels. Far from it. It is well-known that serious mischief is frequently inflicted, and yet, owing to the small size of the external opening, to the position of the body at the time of the accident, or to some 34 WOUNDS OF THE INTESTINES. other cause, there is not the slightest prolapse. In a case of this kind it does not matter, as a general proposition, what may be the extent or direction of the wound; whether, in other words, it be small or large, oblique, transverse, or longi- tudinal, since the treatment is to be conducted solely upon general principles, like that of any other internal or penetra- ting wound whatever. No probing is to be done, no dilata- tion practised, no suture employed. All that is required is to keep the patient quiet, and to resort to such means as are calculated to prevent inflammation, or, if this should arise, to limit its action. This is all that sound surgery demands, all that common sense indicates. Still, as there are no rules in grammar without exception, so there are very few, if any, in the healing art that do not admit of some deviation from established usages. This I believe to be eminently true in regard to the present subject. While, therefore, I would con- demn as much as any one, and in language as emphatic as it is possible to express it, an indiscriminate recourse to the means just referred to, or avoid dilating the external wound and searching for the injured bowel, with the view of sewing it up, simply because the patient has been hurt, I believe that circumstances may occasionally occur in which such a practice would not only be proper, but highly necessary to the safety of the individual. Let us, for the sake of being more fully understood, suppose a case: A man, after having indulged in a hearty repast, receives a penetrating wound in the abdomen from the thrust of a dirk or knife; the bowel is pierced, or, it may be, nearly divided, and there is a copious discharge of faecal matter, both externally and into the peri- toneal cavity, as is evinced, in the latter event, by the excru- ciating pain, the gastric oppression, and the collapsed condi- tion of the sufferer. Here the most prompt and decisive measures must be resorted to, or the person will perish from peritoneal inflammation with as much certainty as if his skull had been fractured and a portion of his brain let out. It will not do for the surgeon to fold his arms, and look upon the scene as an idle and uninterested spectator. Far otherwise TREATMENT--ABDOMINAL WOUND. 35 He has a duty to perform, and that duty consists in dilating the external wound, if it be not already sufficiently large, in hooking up the injured bowel, and in closing the solution of continuity with the requisite number of stitches, at the same- time that the effused matter is carefully removed with tepid water and ,a soft sponge. All wiping must, of course, be avoided, as this would add much to the risk of peritonitis. By the above procedure, which, under the circumstances pointed out, I should never hesitate to pursue, the patient is not placed in a worse condition than a female who has under- gone the Caesarian section, or a person whose abdomen has been ripped up in the first instance; recovery from both of which is not, as is well-known, of unfrequent occurrence. A case in which a most extensive wound of the belly, with complete division of the ileum, and serious lesion of the thoracic cavity, was successfully treated by Mr. Calton, of Scotland, is reported in the twelfth volume of the Edinburgh Medical and Surgical Journal, and another, in which still more frightful mischief was inflicted by a cannon-ball, and yet the man got well, is, mentioned in Hennen's Military Surgery, and will be found in another part of this essay. A number of similar examples are scattered through the records of the pro- fession, and could the experience of practitioners generally be ascertained in regard to this point it would be found, I doubt not, to afford a vast amount of additional evidence illustrative of this important subject. The truth is, the fatality of penetrating wounds of the abdomen has been greatly exaggerated. Inju- ries of this kind have been a sort of bugbear with surgeons and physicians, not so much from what they themselves have witnessed as from what they have heard from others; and hence a prejudice has arisen against the infliction of wounds and even punctures upon the peritoneum which has "grown with our growth and strengthened with our strength" until it has become almost impossible to eradicate it. In making these remarks respecting the dilatation of the outer wound, for the purpose of enabling us to search for the injured bowel, let it be understood that I would recommend 36 WOUNDS OF THE INTESTINES the practice only under particular circumstances. These cir- cumstances have been already pointed out, and it is not neces- sary, therefore, to dwell upon them in this place. When there is reason to suspect, from the nature of the vulnerating body, that the opening in the intestine is com- paratively small, not exceeding, perhaps, the third or fourth of an inch in diameter, it would be extremely improper, if not absolutely unjustifiable, to search for the bowel with the view of sewing it up. Such a step, indeed, could not be too strongly reprobated, as it would seriously complicate an injury which, if left to itself, might easily heal. The above remarks, with the reasoning founded on them, are fully borne out, if I mistake not, by some of the facts cited in a previous part of this inquiry, in relation to the escape of faecal matter from the alimentary canal, when laid open to the extent of from four to six lines, whether longitudinally, transversely, or obliquely. In all cases of this kind, with scarcely a solitary exception, death is produced in from thirty- six to forty-eight hours by peritoneal inflammation. Mr. Travers, with many other respectable surgeons, is, I am aware, strongly opposed to the practice of dilating the abdominal wound and searching for the injured bowel, on the ground that the intestinal aperture retains its apposition with the pa- rietal orifice; but he has adduced no experiments, or facts of any sort, in support of his conclusion, which is, besides, at variance with the existing stale of our knowledge in relation to the subject. My own researches, at all events, have led me to a different result, and I can therefore see no just rea- son why the suggestion which I have ventured to throw out should not be adopted under the restrictions indicated. Sect. II.—Penetrating Wounds of the Abdomen with protru- sion simply of the Intestines and Omentum. The next topic into which I shall inquire is the conduct which the practitioner should observe when he is called to a penetrating wound of the abdomen, attended with protrusion, TREATMENT—PROTRUSION OF THE BOWELS. 37 but no particular injury, of a portion of the alimentary canal. Cases of this description are by no means unfrequent, and they occasionally happen when the external opening is so small as to render it seemingly impossible for any prolapsion to take place. By the older surgeons such injuries were often treated in the most barbarous manner, and it is not im- probable that serious harm is sometimes done by the ignorant and timid in our own day. Instead of reducing at once the extruded intestine, a procedure sanctioned both by theory and experience, a great deal of time used to be wasted in fomenting the part, in the vain hope that this would promote recovery; and when at length, by the delay thus occasioned, the gut became too painful to be replaced, instead of dilating the outer wound, they did not hesitate to leave it in its exposed situation; a practice which, as might have been supposed, was speedily followed by the death of the patient, or, what is scarcely less pitiable, an artificial anus. It is perfectly plain that in such a case the part should be at once restored, without the loss of a moment. It is cer- tain that no good can be done by delay, while it is equally cl€ar that it may be productive of much harm. Before the surgeon proceeds to the operation, the patient should be placed in the best possible position for relaxing the abdominal muscles. For this purpose he should lie on his back, the head being supported by a pillow, the pelvis elevated higher than the shoulders, and the lower extremities bent at the hips and knees. If the bladder be much distended, it should be previ- ously emptied, and the patient should refrain from coughing, holding his breath, or any similar efforts calculated to impede the reduction. In a word, he should conduct himself pre- cisely as if he were about to undergo an operation for stran gulated hernia. When these arrangements are effected, the surgeon, stand- ing at the side of the patient that may be most convenient to him, takes the bowel into the left hand, while with the right he gently pushes it back, taking care to begin with the part which was protruded last, or which is nearest the wound. 4 38 WOUNDS OF THE INTESTINES. These efforts are to be continued until the whole slips into the abdominal cavity, when the external opening is to be closed in the manner to be pointed out presently, and the case treated upon general principles. Proceeding slowly and cautiously in this wise, the largest protrusions may gene- rally be replaced without much difficulty, without inflicting any undue violence upon the patient, or without endangering the result by peritoneal inflammation. Nevertheless, it is sometimes almost impossible to effect the reduction, even when the prolapsion is inconsiderable, owing to the smallness of the external orifice, to the distended condition of the bowel, or to the spasmodic action of the muscular fibres, or to all these causes combined. Be this as it may, the best method, under these circumstances, is to enlarge the wound to the re- quisite extent by means of a probe-pointed bistoury, cau- tiously insinuated between the gut and the resisting parts. Some of the older surgeons, as Pare, Low, and Garangeot» were in the habit, when the difficulty depended upon infla- tion, or gaseous distention, of making punctures in the bowel to evacuate the contained air; a practice which was after- wards embraced by Gooch, Sharp, Sabatier, Chopart and L'e. sault. The plan, as originally suggested, consisted in making the punctures with a small needle, which was replaced by a large round one in the hands of Chopart and Desault, who have described the operation with much minuteness. The pro- cedure, however, was pointedly condemned by Blancard and La Faye, on the very sufficient ground of its inefficacy, as well as danger, and is now scarcely ever thought of, except as a matter of scientific curiosity. Others have recommended the substitution of a small trocar, but the same objections lie against it as against the use of the needle. In our attempts to restore the bowel to the abdomen, it is all important to know that it has actually slipped into its natural situation. The route which the wound follows is occasionally very devious, or it may happen that there is a slight detachment of the peritoneum round the edges of the inner orifice, produced either in the first instance, or by TREATMENT--PROTRUSION OF THE OMENTUM. 39 the finger of the surgeon in his efforts at reduction. In either case, a most serious error may be committed by supposing that the protruded parts have been returned, when in reality they are retained on the outside of the serous cavity, where they may become strangulated, or affected with undue, if not fatal, inflammation. The operator should therefore never rest satisfied that the restoration has been accomplished unless he is convinced that the finger has been fairly within the abdomen, or in contact with the convoluted surface of the bowel. Penetrating wounds of the abdomen are rarely unattended with some protrusion of the omentum. From the situation of this serous lamella, and from the manner in which it is spread over the surface of the bowel, it is indeed usually forced out first, and not unfrequently it is the only part prolapsed. However this may be, it should always be carefully returned, otherwise the greatest mischief is to be apprehended. A dis- tinguished surgeon, Baron Larrey, has, it is true, advised us to let it alone, that is, neither to return it, nor to remove it by the knife or ligature; a practice recommended by some very eminent authorities. Soon after the accident, he observes, the extruded membrane swells, becomes thick and red, and assumes a rough, granulated aspect. These symptoms increase until the third day, after which they re- main stationary for nearly a fortnight, when the part begins to shrivel, and is ultimately reduced without any operation.* Very few practitioners will, I presume, be disposed to follow this advice, which is, to say the least of it, singularly at vari- ance with that of the best writers on penetrating wounds of the abdomen and the management of ruptures. That prac- tice is undoubtedly the safest which most readily promotes the recovery of the patient, and that this desirable end is more promptly and perfectly attained by returning the whole of * Medico-Chir. Review, vol. ii, p. 261. 1821. 40 WOUNDS OF THE INTESTINES. the prolapsed omentum at once into the abdomen, than by allowing it to remain in the situation pointed out by the Baron, no one can doubt. Both experience and common sense are in favor of the course of treatment so long pursued by the ablest surgeons, and I can therefore see no necessity for adopting a new one, especially when that method is of an equivocal character. It is a good maxim in surgery, as it is in morals, to let well enough alone. It need hardly be remarked that, when the protruded parts are covered with dirt, faeces and blood, or other extraneous matter, they should be carefully cleansed before any attempt be made to restore them to their natural situation. The im- portance of this practice is too obvious to require any com- ment. The best article for this purpose is tepid water, either alone or mixed with milk, applied by means of a sponge held some distance off. The stream thus produced is well calcula- ted to detach the foreign substances, whatever they may be, without inducing any additional irritation. In no case should the parts be sponged or wiped, for reasons which it is unne- cessary to specify. If the extraneous matter adhere with much firmness, it may be picked off with a pair of forceps, or some other instrument, and on no account should the bowel be replaced until it has been thoroughly cleansed. Fomenting the extruded parts with infusion of chamo- mile flowers, oil, hops, or wine and water, as recommended and practised by the late Baron Larrey, can do no good, and ought to be avoided. The advice of the French surgeon, in- deed, is decidedly objectionable, if not reprehensible. The abdominal organs are the best fomentors, and the sooner the protruded parts are brought into contact with them the better. The omentum, when prolapsed along with the bowel, should always be reduced last, and care taken to spread it out as much as possible over the parts which it naturally covers. This can generally be easily done by means of the index-finger of the right hand introduced into the peritoneal cavity, and is calculated to prevent its subsequent protrusion TREATMENT--EXTERNAL WOUND. 41 between the edges of the wound; a circumstance which almost constantly happens when this precaution is neglected. In regard to the management of the external wound, it is obvious that it must be conducted upon the same general principles as that of a solution of continuity in any other situation. Sutures should never be employed, except where they are imperiously indicated. It should be remem- bered that they are foreign bodies, which can never be resorted to without an increase of pain, or without endan- gering the development of too much morbid action. It is well-known, too, that when introduced into tendinous struc- tures they are apt to excite a bad form of inflammation, and that, if inserted into muscular parts, spasm and even convul- sions may be the consequence. Nevertheless, cases often do occur in which we cannot dispense with them. The wound may be unusually large, or the patient so restless and unman- ageable as to render it impossible to prevent a recurrence of the protrusion unless the parts be sewed up. Under circum- stances such as these we would not only be warranted in employing the suture, but we should be justly culpable if we neglected it. Dogs bear this treatment with perfect impu- nity, and many cases are recorded in which it was advan- tageously employed in the human subject. In making a suture in this situation the needle should be carried through the lips of the wound within a line and a half or two lines of the peritoneum, and the requisite number of threads placed before any of them are tied, in order to avoid injury to the omen- tum. The ends are then cut off, and the approximation perfected by means of adhesive strips, the whole being secured by a compress and broad bandage carried two or three times round the abdomen. At the expiration of thirty- six or forty-eight hours the ligatures should be cut away, as the parts will have sufficiently united to render them unne- cessary. When the wound is very extensive some sur- geons prefer the quilled suture, as it is termed, but for this 4 * 42 WOUNDS OF THE INTESTINES. there can seldom be any necessity, when the case is managed in the manner just mentioned. Sect. III.—Penetrating Wounds of the Abdomen with protru- sion and injury of the Intestines. Penetrating wounds of the abdomen, attended with lesion of the intestinal tube, constitute a class of injuries of a much more serious character than such as are accompanied merely by prolapse. The symptoms are generally more severe, there is more danger of peritoneal inflammation, and the treatment, especially when the opening is extensive, is alto- gether different; or, to speak more intelligibly, two wounds, involving different structures, exist, and consequently require different modes of management. When the inner wound is large the treatment to be em- ployed is sufficiently obvious, for no well educated surgeon would hesitate to resort at once to the suture, or to some other expedient calculated to prevent faecal effusion. It is only where the opening is small that doubts seem to be entertained respecting the proper course to be pursued. Heister, who was confessedly one of the ablest anato- mists and surgeons of his day, expressly states that all wounds of the intestines not exceeding the diameter of a goose-quill should be returned without stitching, which he asserts to be generally productive of severe pain, inflamma- tion, and other bad symptoms.* Dionis says if the opening is very small, as, for example, when it is made by a bodkin or pen-knife, it is not necessary to sew it up; nature, seconded by a rigid diet, being fully competent to effect a cure.f To the same import very much is the testimony of Palfin,J and of Sabatier. The former of these authors observes that ♦Travers, op, cit., p. 172. f A Course of Operations, p. 53. English Edition, London, 1733. J Anatomie Chirurg., T. ii, p. 76. TREATMENT—LESION OF THE BOWELS. 43 whenever the opening is diminutive it is not necessary to sew it up, but simply to return the part, and to restrict the patient to the smallest possible allowance of food, barely sufficient to prevent starvation. "If the wound,'' says Sabatier, "is very slight, as when only a few muscular fibres are involved, it is needless to resort to the suture, since a cure may be ac- complished without it." Sharp, in his Operations of Surgery,* uses very nearly the same language. The opinion of Jobert, whose writings have been already several times quoted, is, that the wounded intestine may be safely returned, provided the opening does not exceed three lines. Where it is more extensive, as, for instance, half an inch, although reparation might possibly take place through the intervention of the epiploon, still there would be great danger of faecal effusion, and hence he very justly concludes that it would be much better to sew it up.f Richerand, also a modern writer, recommends a very differ- ent practice when the wound is very small, or does not exceed two or three lines.$ His plan is to pass a loop of waxed thread through the mesentery, and to keep the inner wound as nearly as possible in apposition with the outer. The object is to afford a ready outlet to the faecal matter, by the artificial anus which is thus established. This method, to which I shall hereafter recur, is not new with Richerand, but origina- ted long ago with La Peyronie, an old French surgeon. Boyer remarks§^that when the wound is more than four lines in extent enteroraphy becomes indispensable. In a preceding part of this essay—page 8—several expe- riments are related which have a direct bearing on this sub- ject. The particulars, however, it is not necessary to repro. duce in this place. It will be sufficient to say that in the * P. 9. London, 1784. f Maladies du Canal Intestinal, T. i, p. 72. \ Nosographie et Therapeutique Chirurg., T. iii, p. 319. Paris, 1821. J Traitc des Maladies Chirurgicales, T. vii, p. 377. Paris, 1831. 44 WOUNDS OF THE INTESTINES. three experiments in which the wound did not exceed four lines, or the third of an inch, the animals promptly recovered, while in the remainder, five in number, and in which the opening was of greater extent, they all died of faecal effusion. So far, then as these researches go, they tend to confirm the opinion of Heister, Sharp, Garangeot, and oth- ers, that a protruded bowel, in which there is only a very small wound, may be safely returned into the abdomen, without any apprehension of the escape of alvine matter. But would the surgeon be really justified in pursuing such a practice? I unhesitatingly aver that he would not, for the reason that, although this course may, in the gene- rality of cases, be attended with success, yet it is liable to occasional failure, and should therefore be discountenanc- ed. The introduction of a suture, which is all that can be needed in a small wound, will assuredly add little either to the present suffering of the patient or to the danger of peritoneal inflammation; the operation is neither painful nor tedious, and, what is of far more consequence, always, when well performed, protects the individual from faecal effusion. In several of my experiments death was produced, not from any undue injury inflicted upon the bowel from stitching or any rough manipulation, but from the interval between the sutures being so great as to prevent the perfect closure of the wound; a fact which should never be lost sight of in the management of a lesion of this kind. When- ever the contact is incomplete, the mucous membrane be- comes everted, and interferes with the adhesive process. The more accurately this is obviated the less risk will there be of the escape of feculent and other matter, calculated to induce fatal peritonitis. I do not care, therefore, how small the wound may be, if it is only a line and a half, or two lines in extent, it should by all means be sewed up. In this prac- tice alone can there be perfect security for the patient. The villous membrane may, it is true, effect a temporary closure of the wound, but there is always danger that before adhesion TREATMENT--LESION OF THE BOWELS. 45 can take place, the part will become so much relaxed as to lead to mischief. In closing this branch of the present inquiry I cannot omit quoting the sentiments of an old and distinguished surgeon, whose works, highly popular in their day, have been too much neglected by modern practitioners. I allude to Mr. Benja- min Bell.* "However small," says he, "a wound of the intestine may be, it ought always to be secured with a liga- ture; for although it is alleged by some that we should rather trust to nature for the cure of a small opening than to insert a ligature, to me it appears that the opinion is by no means well-founded; insomuch that I would not leave even the smallest opening that could admit either faeces or chyle to pass, without stitching it up. Much danger may ensue from omitting it; and the hazard of the patient cannot be increased by the practice being adopted.'' Co-incident with this opinion of Mr. Bell is that of Mr. Lawrence, of London, whose views upon the subject are entitled to great weight, from the unusual opportunities which he has enjoyed for treating strangulated hernia. Adverting to the practice recommended by Jobert, and referred to in a pre- vious paragraph, of replacing the bowel without suture, when the. wound does not exceed three lines, he affirms that such a procedure would not only be hazardous, but unwarrantable in the present state of the science. "In case of such an opening in the intestine," says he, "I should employ suture; not considering it safe to return the bowel into the abdomen without this precaution."t * A System of Surgery, vol. v, p. 281. f Treatise on Ruptures, p 301. London, 1838. 46 WOUNDS OF THE INTESTINES. Sect. IV.— Therapeutic Means. It might be supposed that, in a treatise professedly devoted to the subject, considerable space would be alloted to the therapeutic treatment of wounds of the intestinal canal. Such a course would undoubtedly be highly proper, if not, indeed, indispensable, if these lesions involved any thing peculiar in this respect; but when it is remembered that they are to be managed upon the same principles as wounds in other parts of the body, much discussion of this kind would, to say the least of it, be irrelevant. After the bowel has been restored to its natural situation, whether enteroraphy has been employed or not, the first and most important object is to guard against the occurrence of peritoneal inflammation, as it is upon this that the safety of the case mainly depends. Perfect quietude in the recumbent posture, the early and copious abstraction of blood, especially if the patient be plethoric, or the wound extensive, and the most rigid observance of the antiphlogistic regimen, are the means upon which our reliance is to be placed in the first instance. If the bowels be not evacuated spontaneously in six or eight hours after the parts have been returned, a stimu- lating enema should be thrown into the rectum, but under no circumstances should the alimentary canal be disturbed by the administration of purgative medicines by the mouth, as these, however mild, will be likely to cause griping pains and to interfere with the reparative process. This plan is to be persisted in for at least three or four days, when a dose of castor oil may be given, or, which would be better, an ounce of sulphate of magnesia or soda. The more fluid the alvine matters can be rendered the less likely will they be to be arrested at the affected part, to derange the sutures, or to disturb the healing process. All drastic articles must be sedu- lously avoided, on account of their tendency to create gastric irritation, and to excite undue peristaltic action of the bow- TREATMENT—THERAPEUTIC MEANS. 47 els; two circumstances concerning which we cannot be two much on our guard. The pulse should be attentively watched, and as soon as re-action is fully established, blood must be taken from the arm by a large orifice, and while the patient is in the semi-erect posture. The amount to be abstracted must vary according to the indications of the case, particularly the age and constitution of the individual, the return, continu- ance, or increase of the local pain, the force and frequency of the pulse, and the extent of the injury. The first bleeding ought, in general, to be tolerably copious, but after this eight or ten ounces at each repetition will be sufficient. In this way we prevent inflammatory action, or moderate it, where it has already taken place, without inducing too much prostration. It should be recollected that the pulse in peritonitis is hard, wiry, and contracted, and that the practitioner, if he be not fully aware of this, will be apt to fall into the error of omitting the abstraction of blood at a period when it is loudly called for, and when it can alone be of any avail in arresting the progress of the malady. General bleeding, however, is not always admissi- ble. The shock which the system has received may be unusually severe; the reaction may be tardy and imperfect; and the patient may perhaps be for several days in a do- sing state, with a weak and tremulous pulse, cold extremi- ties, and great pallor of the countenance. In such a case, instead of taking blood from the arm, the practitioner must content himself with fomentations to the abdomen, consisting simply of warm water, or of water in which hops, opium, or poppy-heads have been infused, and frequently renewed. Even leeches are scarcely to be thought of. Where the stomach is irritable, mustard poultices are to be applied to the epigastric region; and if the patient is unable, as he occasionally is, to void his urine, it must be drawn off with the catheter. If cough be present, it is to be combated by the usual means, and not allowed to progress, as the concussion thus induced 48 WOUNDS OF THE INTESTINES. might prove highly detrimental. When the patient is haras* sed with colicky pains, relief may be attempted by laudanum or the salts of morphia, but as the effect of these and similar articles is to create constipation, they should be employed as sparingly as possible. The tenesmus which is sometimes present is to be allayed by anodyne injections or supposito* ries; and where there is much discharge of blood from the bow- els, the acetate of lead may be administered in large and repeated doses. When there is much tumefaction of the abdomen with gas- tric irritability, and tenderness on -pressure, Baron Larrey* advises cupping, aided by camphorated and oily embroca- tions, emollient cataplasms, and anodyne enemeta. In a case, apparently of the most hopeless character, in which this practice was put in force, the disease yielded in a very short time, not, however, without vesication of the whole surface of the abdomen. With cupping I have no experience in the treatment of peritoneal inflammation, traumatic, or otherwise, but it seems to me that it would be attended with so much suffering to the patient as to preclude its employment in most, if not all cases of the kind. Leeching would certainly be preferable. The diet must be of the most simple nature. For the first fortnight or three weeks, it should consist chiefly of amylace- ous articles, as arrow root, tapioca or sago; afterwards it may be more nutritious, but must still be fluid. Solid, stimu- lating, or flatulent food is not to be used for several months after the accident. Two or three cases will hereafter be men- tioned, where, from disregard of this precaution, the patient fell a victim to his imprudence, when he was apparently out of all danger. As a constant drink, nothing can be better than cold water, flax-seed tea, slippery-elm water, or a solu- • Surgical Essays, translated by Dr. Revere, p, 235. TREATMENT--THERAPEUTIC MEANS. 49 tion of gum-arabic, simple or acidulated. In a word, the patient should be half-starved, and as much depleted as is consistent with the restorative process. Our treatment must be prompt and energetic. No time is to be lost, or the case will slip out of our hands. The great error with most prac- titioners is that they do not abstract blood sufficiently early, or before peritoneal inflammation is thoroughly established, or has made such inroads upon the system as to render it impossible to arrest its progress. When blood is extravasated in considerable quantity into the peritoneal sac, as is evinced by the soft and tremulous state of the pulse, the pallor of the countenance, the coldness of the extremities, and the constant disposition to swooning, the patient must be immediately placed in the recumbent posture, and made to take large and frequently repeated doses of the acetate of lead in union with opium. Mustard poultices should be applied to the hands and feet, and cloths, wrung out of cold water, to the abdomen, which is to be encir- cled at the same time with a broad bandage, to afford equa- ble support to the viscera, and thereby promote the coagula- tion of the effused fluid. When there is reason to suspect that a large artery has been opened, the most effectual prac- tice will be to cut down upon the parts, and secure it with a ligature. This procedure, however, has few advocates, and should only be employed as a dernier resort, not as a matter of choice. It would certainly be better to make an effort to save the patient by an operation, even of a desperate character, than to allow him to perish from the loss of blood, when the wounded vessel is within our reach. The dressings must be light, simple, and unirritating. If there be a discharge of feculent matter, as there may be when the internal wound has not been properly sewed up, or even where there has been no protrusion in the first instance, it should be disturbed as little as possible, until there is reason to be- lieve that the bowel has contracted firm adhesions to the surrounding parts. By disregarding this precaution fatal effects might ensue from the extravasation of the matter into 5 50 WOUNDS OF THE INTESTINES. the peritoneal cavity. During the whole treatment the utmost attention should be paid to cleanliness. As the external opening diminishes, means are to be employed to prevent the escape of faeces, by which the patient will be rendered more comfortable, and the healing process expedited. When the patient is well enough to sit up or walk about, the weakened parts should be supported by a compress and broad bandage, or, what is better, a good truss, which should be worn day and night, to prevent the separation of the edges of the sore, and the protrusion of the contents of the abdomen. This caution, as has been justly observed by Mr. Benjamin Bell, ought to be persisted in for a considerable time after the cure has been completed. By a want of attention to this point, very troublesome cases of hernia have occurred, which might otherwise have been obviated. Patients, who have recovered from wounds of this kind must pay particular attention to their bowels, which should be kept in a soluble condition, and on no account be allowed to be costive, even for a single day. They should also be extremely temperate in their diet, and carefully masticate their food before it is swallowed. All rough exercise, as riding on horse-back, jumping, running, and even rapid walk- ing, must be avoided. Sect. V.—Treatment of Wounds of the Intestines by Different Kinds of Sutures. Having in the preceding pages discussed the nature, symp- toms, mode of reparation, and therapeutic treatment of wounds of the intestines, I shall now proceed to speak of the different kinds of sutures. In studying this branch of the subject, the reader will be struck with the numerous and diversified expedients that have been devised for the management of this class of injuries. TREATMENT--CONTINUED SUTURE. 51 § I.—Continued Suture. The earliest suture employed for sewing up wounds of the intestines was the glover's, or, as it is generally term- ed by the French surgeons, the "suture du pelletier." It has also the name of the continued suture, and appears to have been extensively resorted to by the older sur- geons in the management of common wounds. It was, how- ever, long ago rejected in the treatment of injuries of this kind, and was for many years entirely abandoned even in cases of enteroraphy of the alimentary canal. Mr. Samuel Cooper, in speaking of this suture, observes that it may, in every point of view, be now considered as totally disused in every case of surgery which can possibly present itself. "When we remember," says he, "in making this suture, how many stitches are unavoidable; how unevenly, and in what a puckered state, the suture drags the edges of the skin together; and what irritation it must produce: we can no longer be surprised at its now being never practised on the living subject. It is commonly employed for sewing up dead bodies; a purpose for which it is well-fitted; but for the honor of surgery, and the sake of mankind, it is to be hoped that it will never again be adopted in practice."* How far this sweeping denunciation is entitled to consideration, we shall endeavor to show in another part of this inquiry; it is suffi- cient, at present, to say that the glover's suture has, in my judgment, been unfortunately too long neglected, and that, when judiciously employed, it is capable of affording the most happy results in the treatment of intestinal wounds, no matter what may be their situation, direction, or extent. The glover's suture is usually executed with a straight, round needle, armed with a single waxed thread, which is carried from within outwards obliquely from one lip of the * Dictionary of Surgery, vol. ii, p. 331. New York, 1836. 52 WOUNDS OF THE INTESTINES. wound to the other, until the whole track of it is sewed up. The instrument should be introduced throughout at the same distance from the edge of the breach, and the intervals be- tween each two respective stitches must not be too great for fear of fecal effusion. The thread, moreover, must not be drawn too tightly, otherwise the lips of the wound will over- lap each other and have a puckered arrangement; an occur- rence which, as it is calculated to interfere with the ad- hesive process, should be scrupulously avoided. In perform- ing enteroraphy, the older surgeons were in the habit of leaving at each angle of the wound a length of thread equal to about five inches, which was brought out at the external open- ing, where it was secured by a strip of adhesive plaster, or by a small compress and bandage. In about six days the ligature was generally sufficiently loose to be withdrawn, or, if it was still pretty tight, the attendant cut it at the middle, and removed it by pulling gently at the ends. During this manoeuvre great care was taken to give proper support to the external wound. As executed at the present day, the extremities of the suture are fastened either by a knot, or by passing them under an adjoining loop, after which they are cut off close to the surface of the bowel, into the interior of which the thread employed in the operation ulti- mately finds its way. The experiments which I have performed to illustrate the use of the continued suture embrace the subject of transverse, TREATMENT—CONTINUED SUTURE. 53 longitudinal, and oblique wounds, and amount altogether to seventeen in number. I shall detail them in the order in which they are here enumerated. a.—Transverse Wounds. Experiment I.—Transverse wound of the arch of the colon two inches in ex- tent—continued suture—recovery. After considerable difficulty I succeeded in drawing out of the abdomen a portion of the arch of the colon, into which I made a transverse incision two inches in length, and sewed it up with the continued or glover's suture. The dog was large, old, and made much resistance during the operation, which was attended with tolerably copious hemorrhage from the intestinal wound. The stitches were drawn very tight, to insure the more accurate apposition of the divided parts, and considerable violence was done to the omentum and surrounding structures, owing to the unusual restlessness of the animal. Notwithstanding this, he speedily recovered from the shock of the operation, was in excellent spirits the next morning, and had altogether a most rapid convalescence. On the eleventh day after the experiment he escaped from the room in which he was confined, as well, apparently, as if he had not been hurt. Experiment II.—Transverse section of the ileum—continued suture introduced between the muscular and mucous coats—the animal killed on the twelfth day. A tarrier was submitted to the same experiment as the pre- ceding, with this difference, that the incision was made into the small bowel, and extended through the entire cylin- der. The needle, moreover, was carefully conveyed between the mucous and muscular tunics, instead of through the whole of them, as was the case in the former operation. The wound was fourteen inches from the ccecum. The animal was permitted to live until the end of the twelfth day, when, the cure being considered sufficiently established, he was 5* 54 WOUNDS OF THE INTESTINES. killed. The small bowel and omentum were extensively glued together by plastic lymph, in a state of organization: the omentum projected into the outer, and adhered to the surface of the inner wound: the suture still retained its hold, though not every where in the same degree, and the villous edges were united by adhesive matter. b.—Longitudinal Wounds. Experiment I.—Longitudinal wouud one inch long—continued suture—the ani- mal killed at the end of two months and a half. The subject of this experiment was a large dog several years old; he had fasted for twenty-four hours, and was per- fectly well. The wound, one inch in length, was made along the convex surface of the ileum, a short distance from the ccecum, and sewed up with the continued suture with such firmness that nothing could escape through the interstices of the stitches. The day after the operation the animal was well, and continued so, eating and .drinking with his accus- tomed avidity, until he was killed two months and a half after. The outer opening was perfectly healed with a por- tion of omentum in it. No adhesions existed between the bowels, or between these and the wall of the abdomen. Al tached to the outer surface of the intestinal wound was a process of epiploon, which thus served to mark its situation, which it would otherwise have been difficult to detect, so complete was the reparation. The mucous part of the breach was beautifully cicatrized, a slight depression being the only thing out of the way, and the tube retained its normal dimen- sions throughout. Numerous tape-worms were seen in the small bowel. The various tissues and organs were loaded with fat. Experiment II.—Longitudinal wound six inches in length—continued suture— the animal killed on the twentieth day. The dog, as in the last experiment, was large and old. The TREATMENT—CONTINUED SUTURE. 55 lower part of the ileum being withdrawn, I made an incision, six inches in length, along its convex surface, sewing up the whole of it with the continued suture. Considerable blood was lost during the operation, which was painful and protracted. The next day the animal was thirsty, looked stupid, and had occasional vomiting. Some blood, which had evidently pro- ceeded from his wounds, was found on the floor of the room. On the third day he was quite cheerful, took some meat that was offered him, and from this time on he rapidly recovered. He was permitted to live until the twentieth day. The outer wound was perfectly healed, with a small pro- cess of omentum intervening between its inner edges. The bowels were free from adhesions, except at the seat of the injury, where two folds were connected to each other and to a piece of the mesentery. On laying open the tube, a verti- cal fissure, three inches long by three lines in width at the middle, was discovered as the remains of the original wound. The bottom of the chasm was formed by a process of the mesentery, which was firmly attached to the exterior of the bowel, and exhibited a smooth, transparent appearance. The mucous lining was puckered, or thrown into numerous hori- zontal rugae, like those of a ruffle, and along the edges of the fissure it was rounded off, elevated, and somewhat irregular. The caliber of the intestine was nearly a quarter of an inch wider than above and below the wound. All the other vis- cera were healthy, and the animal was in good condition. Every trace of suture had. disappeared. Experiment III.—Wound two inches long—continued suture—the everted mu- cous membrane pared off—the animal killed at the end of the third month. The dog, the subject of this experiment, had fasted for twenty-four hours; he was small and several years old. The wound, situated five feet and a half from the ileo-ccecal valve, was two inches long, and united with the continued suture, the stitches being so near each other as to leave no chance for the escape of any thing through their interstices. The 56 WOUNDS OF THE INTESTINES. everted mucous membrane was carefully pared away, and the whole returned in the usual manner. The recovery was rapid, and three months after the operation the dog was killed. The suture, indeed every trace of it, had disappeared, the breach being thoroughly repaired, and the continuity of the villous membrane re-established. A small process of the omentum adhered to the surface of the affected intestine, and another projected into the outer opening, but was in progress of absorption. The caliber of the tube was in no wise dimin- ished. No adhesions existed between the different convolu- tions. Experiment IV.—Longitudinal wound two inches in length—continued suture— the everted mucous membrane pared off—-the animal killed at the end of a month. The dog was small and about eighteen months old; the wound, situated within a short distance of the ileo-ccecal valve, and two inches in length, was closed in the same manner as in the preceding experiment, and the everted mucous membrane pared off on a level with the serous surface. The animal had been fed a few hours previously, and vomited several times immediately after he was removed from the. table. The next day he appeared comfortable, and quarrelled with his com- rades for his part of the rations. On the 21st of September, precisely one month after the operation, being rather lean, but in good health, he was killed. The omentum, as in the preceding case, adhered to the small bowels, and a process of it was prolonged into the outer wound, which was perfectly healed. There was no appearance of recent peritonitis; a part of the ligature employed in making the suture was still retained, but the wound was beautifully cicatrized, and the cure completely established. The caliber of the tube was natural. TREATMENT--CONTINUED SUTURE. 57 Experiment V.—Longitudinal wound two inches long—continued suture with the everted mucous membrane pared off—the animal killed on the twenty- eighth day. This experiment, as well as the next two, was merely a repetition of the preceding. The wound, situated four feet from the ileo-coecal valve, was of the same length and treated precisely in the same manner, the everted villous membrane being cut off close to the peritoneal surface. The animal, small and rather young, wasin good condition when he was killed on the twenty-eighth day. The post-mortem appear- ances did not differ materially from those observed in the preceding case. The outer wound was healed with a piece of omentum in it, and the inner was also nearly repaired, but the suture was only partially detached, being retained by a small slip of mucous membrane. There was no adhesion between the folds of the intestines, or between these and the wall of the abdomen, nor any contraction of the caliber of the tube. In short, the cure was complete. Experiment VI.—Wound two inches long—continued suture—the everted mu- cous membrane pared off—the animal killed on the twenty-eighth day. The subject of this operation was a small young slut; and the wound, not quite two feet from the ileo-coecal valve, was treated as in the two last experiments. The next day a large piece of omentum, dark, bloody, and covered with dirt, was found protruding from the external wound; it was immedi- ately encircled with a ligature, and excised. The animal, notwithstanding this untoward circumstance, speedily conva- lesced, and was allowed to live until the twenty-eighth day, when she was killed. The internal wound was nearly healed, but a part of the suture still remained, a few of the stitches not having ulcerated away. The larger part of the thread was lying loose in the bowel, incrusted with solid fecal mat- ter. The whole would probably have been detached in a few days. The small bowels were slightly united to each other 58 WOUNDS OF THE INTESTINES. and to the omentum by plastic lymph, and the outer wound was thoroughly cicatrized. The animal had not lost any flesh from the effects of the operation. Experiment VII.—Wound two inches and a half long—continued suture—the everted mucous membrane pared off—the animal killed on the tenth day. The dog was large, several years old, and had fasted twenty- four hours. The wound, situated along the convex surface of the ileum, within two feet of the ccecum, was two inches and a half long^ and closed as in- the preceding experiments, the mucous membrane protruding through the interstices of the stitches being carefully pared away on a level with the serous surface of the bowel. About five ounces of blood were lost during the operation, which was somewhat pro- tracted, owing to the inordinate resistance of the animal. The bleeding had not ceased when the bowel was returned. No untoward circumstance occurring, and the cure being con- sidered established, the dog was killed on the tenth day. A large plug of omentum filled the external wound, the edges of which were already firmly united. The small bowels were extensively adherent to each other and to the epiploon; the suture retained its hold throughout the greater part of its extent, and a layer of lymph occupied the interval between the villous margins of the breach. The tube at the seat of the injury contained fecal matter, and presented no contrac- tion. The marks of acute peritonitis which generally super- venes upon a lesion of this kind, had entirely disappeared; or, rather, no more inflammation had existed than was necessary to effect the reparation. Experiment VIII.—Wound one inch long—continued suture introduced be- tween the mucous and muscular tunics—the animal killed on the fifteenth day. Wishing to ascertain whether the edges of the wound could not be more perfectly approximated by carrying the needle between the muscular and villous tunics, or, in other-words, through the cellulo-fibrous lamella, described in a previous part TREATMENT—CONTINUED SUTURE. 59 of this essay, I instituted this and the following experiments. Drawing a loop of the ileum from the abdomen of an old tarrier, I made a longitudinal incision, one inch in length, along its convex surface, not far from the coeCum, and sewed it up by carrying the needle, as just intimated, between the villous and muscular tunics. As had been anticipated, my expectations were not disappointed. The operation, without being more painful or protracted than when executed in the ordinary manner, had the effect of bringing the surfaces of the incision into the most perfect apposition. No severe indisposition followed, and the animal was permitted to live until the fifteenth day, when he was killed and his body care- fully inspected. On laying open the bowel, which was closely attached to two adjacent coils, as well as to the omentum, the suture was found to be only partially detached, and to be incrusted with small nodules of fecal matter. The continuity of the villous surfaces was re-established through the medium of a thin, narrow band of lymph, which was removed by maceration for two days in water. There was no abnormal redness either in the mucous or in the serous coat of the bowel, nor any contraction of its caliber. The continuity of the serous lips of the wound was unusually perfect. The outer opening was healed, a process of omentum being pro- longed into it. Experiment IX.—Wound one inch and a half long—continued suture intro- duced through the cellulo-fibrous lamella—the animal killed at the end of the thirty-fifth day. The subject of this experiment, a large dog, several years of age, had fasted for twenty-four hours. The wound, occu- pying the inferior extremity of the ileum, was eighteen lines in length, and closed precisely as in the preceding experi- ment. The animal vomited several times within a few min- utes after the operation, and appeared considerably exhausted. The next morning, however, he had recovered his wonted activity and cheerfulness, and rapidly convalescing, remained in e it induced fatal inflammation. The lymph which con- nected the convolutions of the bowel was firm, dense, and partially transformed into serous texture. The dog was in good condition, and considered out of danger until the occur- rence of the accident which carried him off. Experiment III.—Longitudinal wound one inch and a half long—four sutures— recovery. From a full-grown tarrier a fold of the small bowel was TREATMENT--METHOD OF LEMBERT. 139 drawn, and an incision, an inch and a half long, made upon its convex surface, directly opposite the mesentery. The edges of the wound were brought together by four sutures, which had the effect of preventing any protrusion of the vil- lous membrane. The dog suffered apparently no inconveni- ence from the operation, taking food and drink as before. A month after, the cure being considered as fully established, he was set at liberty. Experiment IV.—Longitudinal wound half an inch long—two sutures—the ani- mal killed on the seventeenth day. A small pup, not more than about four months old, formed the subject of this experiment. The wound, only six lines long, was made along the convex surface of the intestine, as in the preceding experiment, and closed by two sutures. The animal was a good deal indisposed for the first forty-eight hours, but he gradually recovered his health and appetite, and lived until the seventeenth day, when I had him killed. The external opening was perfectly healed with the interven- tion of a narrow strip of omentum. The small intestines were slightly adherent to each other, and the internal wound was beautifully cicatrized. Both sutures had disappeared, and the villous portion of the breach was perfectly repaired. No contraction of the injured part was discoverable. Experiment V.—Longitudinal wound three-quarters of an inch in length—three sutures—the animal killed at the end of the tenth day. The subject of this experiment was a small dog, probably two or three years of age, into the ileum of which, about its middle, I made a longitudinal wound three-fourths of an inch in extent, and brought the edges together by three sutures at equal intervals. The animal bore the operation well, and soon recovered his wonted energy and spirits. He was killed at the end of the tenth day, the cure being considered as established. 140 WOUNDS OF THE INTESTINES. The abdominal wound was nearly healed, with a process of epiploon interposed between its inner lips. A small fold of this apron-like membrane was also united to the outer surface of the intestinal wound, and the affected bowel had contracted pretty extensive adhesions to several of the adjacent convo- lutions. On laying open the tube the villous edges were found to be in close contact with each other, with only a par- tial re-establishment, however, of their continuity. The sutures still retained their hold, and were buried, as it were, in the substance of the mucous membrane. The latter was perfectly healthy both above and below the seat of the lesion, and the canal itself was in no respect diminished. Experiment VI.—Longitudinal wound two inches and a half in length—eight sutures—the animal killed at the end of the seventeenth day. From a very large and healthy dog, shortly after he had eaten a hearty meal, I removed a fold of the upper portion of the jejunum, and made a longitudinal incision, two inches in extent, along its convex surface, directly opposite the mesentery. The edges of the wound were approximated with eight sutures, equidistant from each other. The animal was exceedingly restive during the operation, which was in consequence somewhat protracted, and he lost several ounces of blood. For the first few hours he appeared languid and exhausted, but he rapidly recovered, and was killed at the end of the seventeenth day, being at the time in good condition. The outer wound was perfectly healed with a plug of epiploon between its inner edges. The bowels were free from adhesions, except at the seat of the injury, the surface of which was covered by a small slip of omen- tum. The caliber of the tube was of the normal size, and the reparation complete. The villous margins of the wound were, however, a good deal more elevated than common; but it was evident that they were every where continuous with each other. The marks of the sutures were still visible. The wound had diminished in length about half an inch. TREATMENT--METHOD OF LEMBERT. 141 The mucous coat was perfectly sound, and unpuckered. The arrangement of the parts is tolerably well seen in the draw- ing. The dark line in the centre represents the ridge formed by the junction of the lips of the wound, which, as has just been stated, were firmly united through their entire extent Experiment VII.—Longitudinal wound of the ileum three inches in length- twelve sutures—recovery—the animal killed at the end of the twentieth day. The subject of this experiment was an old dog, of mode- rate size, which had fasted for twenty-four hours. The wound was three inches in length, and occupied the lower surface of the small gut, two feet from the ileo-coecal valve. The sides of the solution of continuity were approximated by means of twelve sutures, placed equidistant from each other. The ope- ration was tedious, and the dog was considerably exhausted before he was removed from the table. During the afternoon he was indisposed to move about, but the next morning the re-action seemed to be completely established, and from this time he rapidly convalesced. He was permitted to live until the expiration of the twentieth day. On dissection the following appearances were observed. The abdominal wound was entirely cicatrized, and a thick 142 WOUNDS OF THE INTESTINES. plug of the epiploon intervened between its inner margins. The injured bowel was firmly united to a process of the mes- entery, to the omentum, and to the neighboring knuckles, by smooth and organized bands of lymph, strongly resembling the serous tissue. The peritoneal lips of the wound were scarcely discoverable; and as to the villous, they were not only in close contact but inseparably blended together. In fact, the restoration could not have been more perfect. The cicatrice, raised in the form of a narrow ridge, was not more than two inches and a quarter in length, the mucous membrane was no where puckered or diseased, and the tube retained its natural volume. All the sutures had disappeared, though the marks of some of them were still visible, and the villous edges were somewhat elevated, owing to interstitial deposits of plastic lymph. The animal was in good condi- tion, having suffered little or no emaciation from his con- finement. Experiment VIII.—Two wounds, one longitudinal and the other transverse, the first one inch long, the second three-quarters of an inch—each opening closed with three sutures—recovery—the animal killed at the end of twenty- eight days. Into the ileum of a small and very old dog I made two in- cisions, about eighteen inches from the ileo-coecal valve. One of the wounds was longitudinal, twelve lines in extent, and situated upon the convex surface of the gut, five inches from the other, which was horizontal, and three lines shorter. Each opening was closed by means of three sutures, equidistant from each other. The dog had fasted for twelve or fifteen hours before the operation, from which he seemed to suffer severely. Notwithstanding this, he rapidly regained his health, and remaining well and in good order, he was killed on the twenty-eigth day. The outer wound was perfectly healed, without the inter- vention of the omentum. The bowels had contracted firm and extensive adhesions to each other, as well as to the apron- like lamella just mentioned, but the lymph by which they were produced was quite smooth, organized, and in process TREATMENT--METHOD OF LEMBERT. 143 of absorption. The sutures had disappeared from both wounds, even to the most minute trace, and the edges of the latter, both serous and villous, were continuous with each other through the whole of their extent and beautifully united. The longitudinal breach was somewhat diminished in length , but the other retained its original size. In both, the cicatrice presented a smooth, rounded, and slightly elevated appear- ance. The mucous membrane was free from puckers, and the diameter of the tube natural. Experiment IX.—Two wounds, each an inch in length—one opening closed with Lembert's, the other with the continued suture—recovery. In the month of January last, in presence of the medical class, I removed a portion of the small intestine from the abdomen of a small fat dog, eighteen hours after he had taken food, and made two incisions along the convex surface of the tube each fully an inch in length. The lips of one of the wounds were approximated by three points of Lembert's, those of the other by the glover's suture; the contact in each being very close and intimate, so as to prevent the possibility of faecal effusion. Having cleared away the coagulated blood, the parts were returned into the abdomen, and the edges of the outer wound retained by several points of the interrupted suture. The animal was kept on light diet for the first three or four days, with milk and water for his drink. No untow- ard symptoms occurring, and the cure being considered as fully established, he was set at liberty on the fifteenth day. c.—Oblique Wounds. Experiment I.—Oblique wound of the sniall bowel one inch and a half long- five sutures—the animal killed at the end of the twelfth day. The subject of this experiment, a moderate-sized slut, ap- parently several years old, had fasted for twenty-four hours. The incision was two feet from the ileo-ccecal valve, and ex- tended obliquely across the gut from one side of the mesen- 144 WOUNDS OF THE INTESTINES. tery to within a few lines of the other for one inch and a half. Five sutures, equidistant from each other, were introduced, which had the effect, when tied, of accurately closing the opening in its entire length. No untoward symptoms super- vened upon the operation, and the animal was killed at the end of the twelfth day, in good health and condition. The outer wound was perfectly healed with a portion of omentum prolonged into it. The bowels were entirely free from adhesions, except at the seat of the lesion, which was covered with a small mass of adherent epiploon of a red color. The affected part of the tube was of the natural width, and contained a small quantity of mucous and faeculent fluid. The villous edges were not only in contact with each other but firmly consolidated, their continuity being thoroughly re-estab- lished, except at the upper extremity of the breach, where there was a depression about half a line in diameter. Experiment II.—Oblique wound of the small bowel one inch and three-quar- ters long—six sutures—the animal killed at the end of the twelfth day. This experiment was merely a repetition of the preceding. The animal, a small young slut, had fasted for twenty-four hours, and the wound, which was one inch and three-quarters long, extended obliquely from one side of the mesentery to the other. Six sutures were employed at equal intervals. In making the outer opening the bladder was accidentally punc- tured, followed by a free escape of urine, but no unpleasant symptoms afterwards. At the end of the twelfth day, the animal, being in good health, was killed. The outer wound had healed through the intervention of a piece of the omentum, as in the preceding experiment. There was no adhesion of the intestines to each other, to the wall of the abdomen, to the other viscera, or to the epiploon, ex- cept at the seat of the injury. Two sutures remained in the wound, one being loose, the other slightly attached. The villous edges were separated from each other, without any apparent effort at re-union. The bowel, which retained its natural width, formed a sort of cul-de-sac just above TREATMENT-- METHOD OF LEMBERT. 145 and below the wound, seemingly from the vicious attachment of the omentum. The villous membrane was healthy, and covered with thick, viscid mucus. All the other viscera were sound. The wound in the bladder was beautifully cica- trized. Experiment III.—Oblique wound one inch long—four sutures—the animal killed at the end of the twenty-second day. The animal which formed the subject of this experiment was very small and not more than nine or ten months old: he had fasted for twenty-four hours. The wound, an inch long, was situated one foot from the ileo-coecal valve, and closed with four sutures. Speedy recovery ensued, or, rather the animal did not seem to be affected by the injury, and he was permitted to live till the end of the twenty-second day. The appearances revealed by the examination so nearly re- sembled those in the last two experiments that it is scarcely necessary to specify them. The outer opening had, as usual, a process of omentum in it, and a small process was also attached to the intestinal wound, which was beautifully cica- trized, the continuity of the villous surfaces being completely re-established. It had diminished about one-fourth in length. The diameter of the tube, however, was natural. The dog was in good order. Experiment IV.—Oblique wound of the ileum two inches long—six sutures— recovery—the animal killed at the end of the thirteenth day. The dog was old and of middle size, and made much resis- tance during the operation, which was consequently somewhat tedious. The experiment was witnessed by Dr. Dodson, Dr. Richard Ferguson, and several other medical friends. The incision, extending obliquely from one side of the mesentery to the other, was two inches in length, and closed by six points of suture equidistant from each other. The dog soon recovered from the effects of the operation, and was allowed to live until the expiration of the thirteenth day. 13 146 WOUNDS OF THE INTESTINES. The outer wound presented nothing unusual. It was pretty firmly cicatrized, with a process of omentum projecting between its inner lips. The injured bowel, intimately con- nected to several neighboring coils by plastic lymph, was dis- tended with semi-fluid fascal matter. All the sutures, except two, had escaped; the villous edges of the wound were beau- tifully united throughout their entire extent, and had an eleva- ted, tumefied appearance; there was no puckering of the mucous membrane, and the cicatrice was less distinctly marked than in some of the other cases. The tube retained its natural dimensions. It should have been stated that the wound had diminished in length fully half an inch. 10.—Method of Denans. In 1826, Mons. Denans, a surgeon of Marseilles, proposed the employment of three hollow metallic cylinders, in the belief that the serous surfaces of the divided ends of the gut could thereby be kept more effectually in contact than by any other proceeding.* One cylinder is placed into each extremity of the tube, which is then invaginated; the other cylinder, namely, the third, a little narrower than the rest, is next introduced, first into the upper and then into the lower, so as to confine and compress the inverted edges, and serve as a sort of rod for their support. Two of the cylinders are each three lines long, and the other or intermediate one six lines; and each end of the gut is inverted about two lines. To fasten these cylinders Denans employs several points of suture, which embrace the lips of the wound and assist in maintaining them in accurate apposition. When the opera- tion is completed the ends of the threads are cut off close to the peritoneal surface, and the parts returned into ihe abdo- men. The agglutination of the approximated structures is soon effected, and the inverted extremities of the bowel, de- prived of their vitality by the pressure of the apparatus, rap- * Kecueil de la Societe de Medecine de Marseille, No. 1. 182B TREATMENT--METHOD OF DENANS. M" idly slough off. The metallic ferules, thus set free, are dis- charged along with the faeces. The accompanying engravings will more fully explain the nature of Denans' apparatus and the manner of securing it in the intestinal tube. Figure 1 shows the approximation of the two ends of the bowel, with the small cylinders in their interior; figure 2, the situation of the middle or long *4S WTOVNDS OF THE INTESTINES. ferule; figure 3, a vertical section of the bowel, and the pas- sage of one of the ligatures, to maintain the apposition of the serous surfaces; figure 4, the appearance of the parts after 4 they have been brought together, and the manner of introdu- cing the suture in this stage of the operation. It is said that this mode of treatment furnished only one successful case in four. In a memoir presented to the Royal Academy of Medicine of Paris, Denans states that in the first experiment the ferules did not pass out of the bowels until seventeen days after the operation. In the second case he TREATMEM'--METHOD OF DENANS. 149 wrapped up a small bone in a piece of bread, which was given to the dog, and the instruments were voided at the end of eight days.* Denans, having recently simplified the above method, now restricts himself exclusively to the three ferules, which are so closely fitted into each other as to obviate the necessity of the suture. The new process is thus described by Dr. Charles Phillips of Liege.f There is, first, a circular row of springs similar to those used as clasps for ladies bracelets. Secondly. the outer ferules are of a conical form, the base of each having a border a line in extent, which, although covered by the re- flected intestine, still holds the springs of the inner ring which pass beyond it. By this arrangement the practitioner escapes the difficulty experienced in using the suture. When the first spring is once adjusted, it is only necessary to reflect as much of fthe bowel as is considered requisite; an advantage which prevents the tumefaction of the edges of the wound and the formation of a fold at the inside of the ferules, which, it is alledged, was the constant cause of the want of success of the original method. Without having apparently any knowledge of the pro- cess of Denans, above described, a very similar practice was proposed, a few years ago, by Mons. Baudens, of France. His account of it is to be found in his work on Gun-shot Wounds, published in 1836. It is certanly less complicated than that of his countryman, but whether it will ultimately be found to possess any decided advantages over it is a circumstance which it is impossible to predict. Baudens uses only one metallic ferule with a ring of gum- elastic, instead of three, as is in the process of Denans. The ferule, moreover, differs from that of Denans in being concave on the back, where it is formed into a groove to adapt it to the gum-elastic ring which embraces it like a clasp. The following is the manner in which the apparatus is applied. • London Lancet for 1834-'5, p. 202. f Ibid, p. 202. 13 * 150 WOUNDS OF THE INTESTINES. The elastic ring is introduced a quarter of an inch within the upper end, the lips of which are immediately inverted, and consequently folded over the instrument, which thus lies in the angle formed by the gut. The ferule is next engaged in the lower end, to the extent of two lines, when the ring is drawn down over it, and the bowel is ready to be reduced into its natural situation. Baudens states that he has employed this method successfully on dogs, and that he would not hesi- tate, if occasion offered, to resort to it in the human subject. A distinguished writer in the Dictionnaire de Medecine et de Chirurgie Pratiques, Mons. L. J. Sanson, in summing up the advantages of the different methods of treatment of wounds of the intestinal canal, gives a decided preference to that of Denans. He seems to think that it will insure more perfect apposition of the divided ends, and that it is better cal- culated also to prevent contraction of the affected bowel,»so apt to follow, as he supposes, some of the other procedures. He does not, however, support his arguments by any experi- ments or observations, and they should therefore be received for what they are worth—merely as so many closet speculations. Mr. Lawrence,* in speaking of this method, very justly re- marks that "a patient who could survive the infliction of such surgery must be endowed with great tenacity of life." 11.—Method of Reybard. The next method that claims our attention is that of Mons. Reybard, of Paris, an account of which was published in 1837, in his "Memoir on Artificial Anus."f The object of it, as set forth by the author, is to effect a temporary obliteration of the wound and to maintain the bowel in strict relation with the wall of the abdomen. For this pur- pose a ligature, armed with two sewing needles, is passed through a light wooden cylinder, perfectly smooth on its ex- * Treatise on Ruptures, p. 356. f See Vidal, Traite de Pathologie Externe, T. 4, p. 503.—Velpeau, Medicine Operatoire, T. 4, p. 135. TREATMENT--METHOD OF REYBARD, 151 terior, and from fifteen to sixteen lines in length by eight or nine in diameter. Thus arranged, and having previously, like Ramdohr, detached a small piece of the mesentery along the concave surface of the tube, the cylinder is intro- duced into the intestines, where it is fastened by carrying the needles from within outwards through the lips of the wound, about a quarter of an inch from its margin. The extrem- ities of the ligature, crossed and twisted together, are passed, by means of a crooked needle, through the abdominal mus- cles, at a short distance from the edge of the outer opening. The double thread is now held by an assistant until the sur- geon has reduced the bowel; when, taking it in his left hand, he pulls it, and satisfies himself that the injured part is in exact apposition with the abdominal parietes. The opera- tion is completed by separating the ligatures, and tying them over a small compress lying parallel with the inner lip of the wound. In an experiment performed after this method the sutures were cut away at the end of forty-eight hours, and the following morning the wooden cylinder was expelled along with the faeces.* * Vidal, op. cit. T. 4, p. 503. 152 WOUNDS OF THE INTESTINES. Fig. 3 shows the appearance of the parts ready to be returned into the abdominal cavity. Not having repeated the experiment of Reybard, I can- not speak of it from personal observation. It appears to me, however, to be entirely too complicated, to say nothing of the danger which must necessarily arise from the presence of a foreign body, such as he suggests, and which, it may be supposed, might easily be retained in the alimentary ca- nal, causing severe, if not fatal, inflammation, ulcerative absorption, or insurmountable obstruction to the passage of the faeces. It has, moreover, I believe, never been em- ployed in the human subject, and it is obviously nothing but a modification of the process of Duverger, Sabatier, and other surgeons, who recommend the use of a piece of trachea, or other hollow body. Such a proceeding is en- tirely too mechanical, and would have been better suited to the dark ages than it is to the nineteenth century. 12.—Method of Amussat, Thomson, Choisy and Beclard. As if there were no end to the devices of surgeons for the cure of wounds of the intestines, Professor Amus- sat, of Paris, has recently proposed another, apparent- ly highly ingenious, which deserves to be mentioned here more on account of its novelty than from any probability that it will ever be employed in the human subject. Lika that of Lembert, Denans and Jobert, its object is to plac« the two serous surfaces in contact with each other, to facili- tate the adhesive process, and prevent the effusion of stercoraceous matter. The idea originally suggested itself TREATMENT--METHOD OF AMUSSAT. 153 to Amussat from observing, on repeating the celebrated experiment of Mr. Travers of encircling the bowel with a ligature, with what rapidity the continuity of the tube is re-established at the seat of the constriction, and how little the operation interferes with the comfort of the animal, or the transmission of the faeces. The apparatus which he was led to employ in the first instance was simply a piece of elder- tube, half an inch long, with a narrow central groove, and a diameter somewhat less than that of the intestine. This being introduced into the divided ends of the gut, with the precaution of making the lower overlap the other, as in the operation of Chopart and Desault, a ligature was applied around the parts corresponding with the groove, and drawn with sufficient tightness to cause their strangulation. The result, however, was unsuccessful. The adhesions, from the imperfect approximation of the serous surfaces, failed to ac- quire the proper degree of solidity, and hence, when the con- stricted parts were detached, the edges of the wound separa- ted from each other, and the animal promptly perished from the effects of faecal effusion. To obviate this accident, Amussat applied to each end of the elder-tube a small conical ferule, which he fastened by means of a small strip of adhesive plaster, the base of the one being turned towards that of the other. By this arrangement he obtained a deep groove, instead of a superficial depres- sion, as in the other contrivance. Two ligatures, six inches long, each passed through a straight needle, and placed oppo- site each other on the edge at the truncated top of one of the ferules, complete the apparatus by which the strangulation is effected. Thus arranged, the operator introduces the elder- tube into one of the ends of the bowel, where it is secured by passing the needles from within outward through its tunics. The other extremity, held open with several forceps, is then transfixed with both needles together in the same direction, an inch from the lip of the wound, when by means of the two threads the intestine is gradually drawn over the remain- der of the foreign body, or, rather, high enough to overlap 154 WOUNDS OF THE INTESTINES. the other portion to the extent of a few lines. A waxed cord is now applied around the central groove of the apparatus, and drawn with sufficient firmness to strangulate the parts which it embraces. Any redundant substance beyond the cord is to be removed with the scissors, otherwise it will interfere with the union of the serous surfaces, the grand object of the ope- ration. In a few days the constricted parts slough, and the apparatus, being thus set free, is expelled along with the faeces. Dr. Charles Phillips, to whom I am mainly indebted for this account of the above method, states that it will prove successful in four cases out of five, when performed with proper precaution. I have not deemed it necessary to repeat it on any of the inferior animals, from a conviction that it is obnoxious to the same objections as the process of Denans, without any compensating advantages. Like the operation of Ramdohr, of which, after all, it is merely a modification, it requires a previous separation of the mesentery, to facilitate the invagination of the upper into the lower end; to say nothing of the complicated nature of the apparatus, which cannot always be obtained on the spur of the moment, and which few practitioners will keep on hand in expectation of such an occurrence. Soon after the above method was made public, Dr. Alex- ander Thomson, of Paris, suggested certain modifications in the construction of the apparatus, which, however, have only been employed, I believe, on the dead subject. It is impos- sible, therefore, to say how they might answer in the living. The tube, as improved by Thomson, consists of two pieces, instead of one, which are joined together by an ebony ring, a third of an inch long. The base of each tube is hollow, and marked by a groove two lines in depth by one and a half in width. When united, they present a ridge of two or three lines. "The moveable cone is pierced with two holes at its border for allowing the introduction of two ligatures. Two other waxed threads pass through the substance of the tube, upon which the other cone is fixed. The end of the groove TREATMENT--METHOD OF CHOISY. 155 formed by the union of the two cones is made somewhat rough, for the purpose of keeping a more firm hold upon the intestine. The moveable cone is fixed upon a handle, which extends about three quarters of an inch beyond its truncated extremity. At the middle of the handle is a small perma- nent stud, for the purpose of holding the ligatures which are coiled around it. The extremity of the handle serves to open a free passage into the intestine, until it has reached two- thirds of an inch beyond the base of the cone fixed upon the said handle. Close to the stud are two steel arms, furnished with hooks and springs for securing the intestine. A ligature is then placed over the groove in the base of the cone, and tightened so as to produce strangulation of the intestine, the operator cutting off a portion of the extremity beyond the constricted part. The two ligatures are then loosend, by which the cone is set at liberty, a needle is put on each, and they are passed through the strangulated portion of intestine. The same method having been adopted with respect to the other end of the intestine, the two cones are then united in such a way that the ligatures applied for fixing them may be in immediate contact. They are tied, and cut off near the knots, and the intestine is returned into the abdomen."* Another modification of Amussat's method was proposed by Mons. Choisy, in a thesis which he presented to the Fac- ulty of Paris, in 1837, for the degree of doctor of medicine. It consists simply in invaginating the divided bowel, and tying it over a piece of trachea. In performing the operation the foreign body is introduced into the superior extremity, where it is fastened by the glover's suture, after which the thread is carried from within outwards across the inferior end, the latter being thus made to cover a portion of the former. The ligature is then applied around the parts, as in Amussat's process, and drawn sufficiently tight to effect their strangula- tion.t Choisy has performed this operation several times * London Lancet for 1835, p. 204. f Velpeau, Medecine Operatoire, T. iv, p. 139. 156 WOUNDS OF THE INTESTINES. successfully upon dogs, but whether it has been repeated by other surgeons I have not been able to learn. Beclard, author of the "Elements of General Anatomy," suggested, many years ago, a mode of treating wounds of the intestinal canal, which, from the success that attended it in some of the inferior animals, he thought might be advantage- ously applied to the human subject.* It is certainly much more simple than that of Amussat, or the modifications of it by Thomson and Choisy, and if I could be induced to employ any process of the kind, I should unhesitatingly give it the preference. The method under consideration consists in in- troducing one end within the other, without the intervention of any foreign body, and in encircling them with a ligature drawn with moderate firmness. The serous surfaces are thus brought into close apposition with each other, and the cord, cutting its way through the coats of the intestine, falls in a few days into the tube, where it is discharged along with the faeces. Such is an accurate and impartial account of the various and diversified methods of treatment of wounds of the intes- tinal canal. Of the estimate to be placed upon them, I have already expressed my opinion, excepting in a few instances, where the facts I have presented are competent to speak for themselves. My conviction is that there are but two sutures which should ever be thought of in the management of this class of injuries, namely, the continued and the interrupted, with the modification of the latter proposed by Lembert. The manner of executing them has been already explained, and it is not necessary, therefore, to say any thing further on the subject in this place. Whichever of these sutures be employed, the operator should * Chelius, Traite de Chirurgie, T. i, p. 176. Paris, 1835. TREATMENT--CONCLUSION. 157 never lose sight of the important principle of closing the opening in the bowel in such a manner as to prevent the escape of faecal matter. By guarding against this occurrence, the patient will run comparatively little risk of perishing from peritoneal inflammation. When the wound is trans- verse, and involves the whole cylinder of the tube, I should prefer the continued or common interrupted suture to the method of Lembert, especially in young subjects, in whom the canal is very narrow, or in persons in whom the bowel is over-loaded with faecal matter at the moment of the injury. In a case of this kind the inverted edges might occasion serious obstruction, from the manner in which they project into the interior of the canal. To longitu- dinal and oblique wounds, particularly the former, the expedi- ent of Lembert is admirably adapted. The operation is very simple, the sutures easily retain their hold, and the divided edges are more speedily re-united than by any other method. In reflecting upon the results of the experiments which have been offered in illustration of the use of the above sutures, it should not be forgotten that an operation which is perfectly successful upon an inferior animal, may, when performed upon the human subject, be followed by the worst consequences. In the one, disease is exceedingly rare; in the other, it is not only frequent, but capable of assuming a vast variety of forms, and of sapping the foundations of life when least expected. In the one, peritoneal inflammation is not only uncommon, but, when developed, seldom attains any considerable height; in the other, it is not only easily excited, but extremely apt to terminate fatally. Aware of these facts, the surgeon should always scrupulously guard against the infliction of unnecessary injury; the stitching should be done as gently as possible; and all rough manipulation should be carefully avoided. After the parts have been reduced the external wound should be closed by several points of suture, and every effort made to avert peritoneal inflammation, the great source of danger in injuries of this kind. It has been alleged that longitudinal do not unite with the 14 158 WOUNDS OF THE INTESTINES. same facility as transverse wounds. "There is a curious dif- ference," observes Sir A. Cooper,* "in the facility with which a longitudinal and a transverse wound of the intestine unite. It has been already shown that the transverse heal readily, but with respect to the longitudinal, they have a contrary tendency." In illustration of this assertion, he cites two ex- periments by Dr. Thomson, of Edinburgh, in which death oc- curred from the extravasation of faecal matter, in less than forty-eight hours. The wound in each was an inch and a half long, and closed by four interrupted sutures, with the precaution, in one, of sewing up the interstices with a fine thread. In an experiment performed by himself, in which the incision was of the same length as in the preceding cases, and in which he had recourse to the continued suture, the animal recovered. My own experience by no means coincides with that of the great English surgeon. We have already seen that, in the twenty-seven experiments above detailed, there were only two deaths, notwithstanding the great extent of the wound in some of them. I have no reason to believe, as Sir A. Cooper apprehends, that the sewing up of a longitudinal wound produces a greater degree of constitutional irritation than that of a transverse one; at all events, I have never witnessed any result of the kind. The experiments which he adduces from Dr. Thomson in support of his opinion were evidently not executed with the requisite precaution. A wound an inch and a half long cannot, as a general prin- ciple, be returned with safety into the abdomen with only four interrupted sutures; faecal effusion will be almost in- evitable, especially if the canal happen at the time to be loaded with ingesta, or if the animal be permitted to take much drink or food after the operation. In the second ex- periment the dog died, not because the parts had not been duly approximated in the first instance, but because the su- tures, interrupted as well continued, had lost their hold, and * Anatomy and Surgical Treatment of Hernia, p. 51. TREATMENT—CONCLUSION. 159 thus allowed the wound to gap, and the faeces to escape into the peritoneal sac. In the experiment performed by Sir A. Cooper himself, in which the edges of the solution of con- tinuity were secured by the uninterrupted suture, no effusion could occur, and the consequence was that the animal quick- ly recovered. The conclusion, therefore, which I would draw from my researches is, that longitudinal wounds, instead of uniting less easily than transverse, generally adhere with more facili- ty, that they do not produce a greater degree of constitu- tional irritation, or local disturbance, and that they are not more liable, if as much so, to be followed by contraction of the caliber of the tube at the seat of the injury. The same remarks I consider as applicable to oblique wounds. In nine cases of this kind, treated by the continued and interrupted suture, or by the method of Lembert, there was not a single death, any unusual symptom, or any diminution of the affected cylinder. 160 WOUNDS OF THE INTESTINES. CHAPTER III. Of the Treatment of Wounds of the Intestines by Ligation and Excision. In operating for sphacelated hernia it occasionally happens that the constricted bowel contains a small aperture, caused either by the strangulation, or by the efforts which the sur- geon is obliged to make to effect the reduction. The gut may also be accidentally wounded by the knife in attempt- ing to divide the stricture, by neglecting to draw down the sac, and holding up the abdominal muscles. A number of examples of this kind are mentioned by authors. One is recorded by Mr. Lawrence in his Treatise on Ruptures, and another, which occurred in the practice of Cloquet, is cited in a previous part of this inquiry. When this acci- dent happens, and the aperture is small, Sir Astley Cooper advises a treatment somewhat different from that which is proper when the tube is mortified in its entire cir- cumference. Instead of excising the affected parts, and bringing the edges together by means of the suture, the sur- geon should pinch up the margins of the opening with a pair of forceps, and then include them in a fine silk ligature, drawn sufficiently tight to divide the mucous mem- brane. The bowel should afterwards be returned to the mouth of the sac, and the ease managed upon general princi- ples. The preternatural orifice must not be more than three or four lines in diameter, otherwise it will not only be diffi- cult to prevent the ligature from losing its hold, but the ope- ration will be likely to be followed by undue and injurious contraction of the gut. The following experiments and cases will exhibit this ope- ration in a more forcible point of view. Of the latter, two oc- curred in the hands of Mr. Lawrence, the other in those of Sir Astley Cooper, with whom, I believe, the practice origi- TREATMEN T--LIGATION. 161 nated, and to whom surgery is indebted for some of its most ingenious and substantial improvements. Experiment I.—Having opened the abdomen of a small slut, and exposed a fold of the ileum, I made an incision, half an inch in length, along its convex surface, and secured it by means of a strong silk ligature tied firmly round its sides. Some difficulty was experienced in preventing the thread from slipping; it was drawn with considerable firm- ness, and when the ends were cut off it was found to be nearly concealed from view by the apposition of the serous surfaces. The bowel was then returned, and the outer wound closed in the usual manner. The animal did not ap- pear to mind the operation, which was soon over, and she was permitted to live until the ninth day. It is unnecessary to mention all the particulars of the post-mortem examina- tion. Suffice it to say that the small intestines were slightly agglutinated to each other and to the omentum, and that the latter projected into and assisted in closing the outer wound. The bowel at the seat of the injury was remarkably firm, and presented numerous red points. The ligature had disappear- ed, and the edges of the wound were about three lines apart at their centre, without any contraction of the caliber of the tube. The bottom of the wound was consequently formed by a neighboring convolution protected only by a thin layer of lymph of a yellow-greenish appearance, from the admix- ture evidently of bilious matter. Experiment II.—The incision in this experiment was transverse instead of longitudinal, but of the same extent as in the preceding. It was situated in the small bowel, about two feet from the ileo-coecal valve, and the difficulty experienced in encircling it was still greater than in the former case. One end of the ligature being cut off near the peritoneal surface, the other was brought out at the external wound, which was closed in the usual way. The animal, a small pup, soon recovered from the shock of the operation, and was killed twenty-three days after, the ligature having been detached towards the end of the first week. The outer wound was completely cica- 14 162 WOUNDS OF THE INTESTINES. trized, with a process of omentum adherent round its mar- gins, as well as to the convolutions of the small intestines. The latter were strongly united to each other at several points, particularly at the seat of the injury, which was almost per- fectly repaired, the mucous membrane being deficient over a space not exceeding the diameter of a split pea. The bowel retained its normal dimensions, and the animal was in good condition at the time he was killed. Case I.*—John Shall, sixty years of age, was admitted into St. Bartholomew's Hospital, on the 2d of Novembel 1826, with strangulated inguinal hernia. The tumor was hard and painful, the abdomen was tender on pressure, and there was a sense of tightness across the navel, with con- stant nausea and occasional vomiting. The pulse was small and frequent, and the symptoms in all respects urgent. All attempts to replace the parts by the taxis having failed, Mr. Lawrence proceeded to operate eight hours after the bowel had come down. The swelling contained a portion of small intestine in front with a large mass of omentum behind, and the stricture was caused by the neek of the sac, which encir- cled the protruded tube like a tight cord. On withdrawing the intestine gently, an opening was discovered in it just above the part that had been compressed, and which had probably been made by the bistoury in dividing the stric- ture. The sides of this aperture, which was very small, be- ing held with the dissecting forceps, a ligature was firmly tied around it, after which the ends were cut close to the knot. A piece of omentum, which had been long protruded, and which it was found difficult to return into the abdomen, was removed with the knife, and the divided vessels, six or eight in number, secured in the usual manner. The integuments were brought together by three or four sutures, assisted by strips of adhesive plaster. Soon after the operation the bowels were evacuated with senna, and blood was twice taken from the arm. On the 6th of November the sutures * Lawrence's Treatise on Ruptures, p. 301-3. TREATMENT--LIGATION. 163 were removed from the outer wound, and on the 13th the lig- atures came away from the omentum. It is needless to add that the patient rapidly recovered. Case II.—In another case, in which the bowel was wounded, Mr. Lawrence * pursued the same method. It was a large enterocele with the intestines greatly disten- ded and the abdomen so very tense that it was difficult to re- place the parts and prevent them from re-descending. The symptoms were not relieved by the operation, and death ensued within two days. The ligature was completely covered by a thin smooth layer of lymph, and so concealed that there was difficulty in finding it: the small wound in the bowel was closed. Case III.—Joseph Curtis, a butcher, twenty-one years of age, was brought into Guy's Hospital, on the 9th of Decem- ber, 1808. He had a tumor in his left groin, which was very hard and tense, and gave considerable uneasiness on pressure. Along with this was violent pain in the stomach with vomiting of green bilious matter. Various attempts were made at reduction, but they all failed, and the opera- tion was therefore at once determined upon by Mr., after- wards Sir Astley Cooper. About four inches of the small intestines were found in the sac, of a dark reddish color, with the testicle at the lower part. The stricture, situated at the mouth of the sac, was divided in the usual manner; a fluid of a yellowish appearance escaped, and on turning up the gut an opening was discovered, which was immediately laid hold of with a pair of forceps, and tied with a ligature. The parts were then returned, and the abdominal wound secured by five stitches assisted by adhesive strips. The patient bore the operation well, and seemed much better after it. For the first ten or twelve days, however, his sufferings were severe, but he gradually surmounted them, and was discharged cured on the 17th of January, 1809, a little more than three months after his admission.t t The Anatomy and Surgical Treatment of Abdominal Hernia, Part i, p. 45. Second edition. 164 WOUNDS OF THE INTESTINES. In commenting on this case, Sir Astley Cooper uses the following language: "We had the pleasure and satisfaction to see the patient completely recovered from an operation, the circumstances attending which were remarkable, and such as will tend to throw much light upon a subject hither- to but little understood." The above plan, so happily employed by Sir Astley Cooper and Mr. Lawrence, has doubtless been adopted, if not ac- tually executed, by numerous other surgeons. "Many years ago," says Prof. Gibson,* in speaking of Sir Astley Cooper's procedure, "I performed a similar operation in a case of hernia, and with equal success." Mr. Syme, of Edinburgh, recommends the same practice;"]" which may now, indeed, be considered as being fully sanctioned both by observations on the human subject and experiments on the lower animals. Such is the treatment which should undoubtedly be pur- sued by the surgeon when he meets with an aperture of small size in the strangulated bowel. When the gangrene, how- ever, involves the entire cylinder of the tube, a different mode of management must be resorted to. Under these cir- cumstances, the affected parts should either be excised, and the edges approximated by suture; or they should be freely opened, and maintained in contact with the abdominal wound, to afford a ready outlet to the faeces. The experience of the profession has not yet fully determined, I think, which of these methods should be adopted to the exclusion of the oth- er, or whether both are not occasionally justifiable. Sev- eral examples have already been cited in which excision was practised with the most complete success. The memor- able case of Ramdohr is of this kind. An analogous one is recorded by Baudens, an'I mentioned under the head of Lembert's process of sewing up wounds of the intestines. The case which occurred in the hands of Dieffenbach is also in point. The sphacelated part was at least three inches in * Institutes of Surgery, vol. i, p. 119. Philadelphia, 1838. t Principles of Surgery, p. 262. Second edition. TREATMENT--EXCISION. 165 length; the whole of which was removed with the knife, and the divided extremities secured by suture. The man lived nearly a month after the operation, and would have completely recovered but for some imprudence in his diet. In another case four inches of mortified intestine were re- moved, and the patient, a young man, recovered* Many examples of a similar description are on record, but it is not necessary to refer to them more particularly in this place. The practice of excision derives support from what is oc- casionally witnessed in intus-susception of the intestines, in which large pieces of the tube are detached without any det- riment to life. In my museum of morbid anatomy is a pre- paration of this kind, presented to me by my friend Dr. Dawson, of Ohio, in which a portion of the colon, twenty- nine inches long, was discharged by a child six years of age, who, notwithstanding, made a most rapid recovery. This patient, as I have been recently informed, is still living and in perfect health, three years after the above occurrence. Thirty-five cases of a similar nature, collected from the writings of different pathologists, have been reported by Dr. Thompson of Europe.f The length of the eliminated pieces varied from six inches to upwards of three feet: they gener- ally involved the whole cylinder of the bowel, and nearly all had a portion of mesentery attached to them. In one in- stance there was a mesenteric ganglion, in another a pro- cess of omentum. The average duration of the disease was between four and five weeks. In twenty-two of the cases the evacuated portion appertained to the small bowel, in the other to the large, or jointly to this and to the former. The caecum was affected alone in one instance, the colon in two, the jejunum in three, the ileum in eleven. The following case may be adduced as throwing additional lio-ht upon this interesting and important subject. It occur- * Sir A. Cooper on Hernia, p. 37. tEdinburgh Medical and Surgical Journal, Oct. 1835.—See also the author's Elements of Pathological Anatomy, vol. ii., p. 260. 166 WOUNDS OF THE INTESTINES. red in the practice of Dr. McKeever, of Dublin, and will be found recorded in the fourth volume of the London Med- ico-Chirurgical Review. A young robust woman, after having been in labor for upwards of thirty hours, was delivered with the crotchet, on the 29th day of July, previously to which a rent had taken place high up in the posterior part of the vagina, which extended round the neck of bladder, and communica- ted freely with that viscus. On the following day, in the afternoon, one of the attendants observed a shining sub- stance hanging from the external parts, which was found, on the fifth of August, when Dr. McKeever first visited her, to be nearly a yard and a half of her small bowel coiled up under her, black, apparently putrid, and full of openings. Her belly at this time was much swollen, and excessively painful; her stomach rejected even the mildest articles of diet; the bowels were still obstinately confined; the pulse was small, intermitting and tremulous; and her countenance was pallid and ghastly: in short, she had every appearance of being in a moribund state. It being too late to return the parts, the treatment was merely palliative. On the follow- ing day, the protruded portion of the intestine had a soft doughy feel, was more shrivelled, and, instead of being black and livid, it was of a dirty ash-color. The constitutional phenomena were as before. On the seventh day the mortified parts, measuring precisely three feet and eleven inches, were detached, and the woman was nearly free from alarming and distressing symptoms. The vomiting and hiccough had ceased, her pulse was regular and of good strength, the counten- ance much improved, and the abdomen, though still much swelled, less tender to the touch. She had also a copious discharge of faeces by the vagina, being the first alvine evac- uation she had since her delivery. From this time she gradually mended. Her countenance improved, the secretion of milk became abundant, and the excrementitious matter was of a healthy color, smell and consistence. Three years after the occurrence of the acci- TREATMENT--EXCISION. J 67 dent, she could walk a dozen miles without inconvenience, and had become fat. For two years after her confinement she had no discharge whatever from the rectum, the residue of her food being altogether voided by the vagina. About the end of that period, however, she was attacked with vio- lent bearing-down pains, accompanied by tenesmus, and after half an hour's severe suffering, she passed by the natu- ral route a large quantity of dark, pitch-colored faeces, of the consistence of balls of firm wax. It is unnecessary to give further particulars. Suffice it to say that the woman was afterwards safely delivered of a small child, and that the faeces have ever since been discharged in the natural way. The above case requires no comment. It is, in all re- spects, one of the most extraordinary on record, and affords convincing proof that injuries attended with the loss of large portions of the alimentary canal, are not necessarily fatal. Coxe's Museum contains a case, from the London Philosoph- ical Transactions, of a boy who had his bowels protruded, and fifty-seven inches cut off by a cart, who, nevertheless, recovered his health in six or seven months. To these observations I add the following experiments as having a direct bearing upon the subject under considera- tion. Experiment I.—From a small but full-grown dog two inches and a half of the ileum were removed, near its junction with the large bowel, after which the edges of the wound were brought together with six interrupted sutures, introduced equidistant from each other, and made with a common needle and fine silk. The extremities of the ligatures were cut off close to the knots, and the parts being restored to their natu- ral situation, the abdominal wound was secured by several stitches. Several ounces of blood—perhaps four or five— were lost during the operation, and the animal appeared to be somewhat faint. In the evening he was dull and drowsy, and indisposed to move about; but in the morning he was observed to be better, and from that time he rapidly recover- 168 WOUNDS OF THE INTESTINES. ed. Four months afterwards, being in good health, and the outer wound perfectly healed, he was killed. Externally the bowel was smooth and natural, with no trace whatever of the former injury, excepting the attachment of a very small pro- cess of the epiploon. Had it not been for this circumstance it would have been exceedingly difficult, if not impossible, to find the seat of the wound. The mucous membrane was of the natural color; there was not the least contraction of the tube; and the situation of the breach was indicated merely by a very narrow oblique line or depression. No adhesions existed between the bowels or between them and the walls of the abdomen. See pi. fig. 8. Experiment II.—In a second experiment five inches of the ileum were excised, and the lips of the breach maintained in contact by seven interrupted sutures, with the ends cut off close to the serous surface. The divided mesenteric vessels bled so freely during the operation that it became necessary to secure them with a ligature, which, however, lost its hold in attempting to replace the bowel. The dog, which was small, and not more than about a year old, died in thirty hours from the protrusion of eighteen inches of the small bowel, which was lacerated near its middle, of a dark livid complex- ion, and apparently sphacelated. Externally the wounded surface was slightly coated with plastic lymph, as well as par- tially covered with adherent omentum, and the parts above and below were of a deep rose tint. The mucous lining im- mediately around the seat of the injury was of a purple color; and there was a small coagulum where theligature had slipped from the mesenteric vessels. No faecal matter had found its way into the peritoneal cavity; the sutures had retained their situation; the lips of the wound were in contact with each other, both internally and externally; and it was obvious enough that the animal had perished from the protrusion and consequent inflammation of the ileum. The cause of this accident was the premature detachment of the stitches in the outer opening. TREATMENT--EXCISION. 169 Experiment III.—Finally, in a third experiment the por- tion of ileum cut away measured eleven inches and a half. The edges of the divided extremities were brought together, and maintained in apposition by means of the continued su- ture, made with fine sewing silk, well waxed, and armed with a delicate needle. Several of the mesenteric arteries were surrounded with a ligature, which was brought out at the ori- fice in the wall of the abdomen. The dog, large, and several years old, became sick soon after the operation, which was both tedious and painful; at the expiration, however, of twenty-four hours he took food, appearing lively and even cheerful. He continued thus until the eighth day, when he was observed to be seriously indisposed, and early on the following morning he died. On inspection, the inner lips of the wound were found to be in a soft, pouting condition, slightly covered with mucous, but nofaecal matter, and without any perceptible attempt at restoration; the suture was still in its place. Three folds of the intestines were glued together at the seat of the injury, and the parts there were somewhat red, as the effect of in- flammation. Numerous petechial spots were observed upon the parietal portion of the peritoneum; and the serous and muscular tunics, both of the small and large bowel, presented, in several situations, a singularly lacerated aspect. The vil- lous membrane in the vicinity of the wound was softened, and covered with a considerable quantity of thick, ropy mu- cus. The stomach and other organs were healthy. There was no obstruction from faecal matter, or any contraction of the caliber of the tube. It will be seen from the foregoing statements that only one of these experiments terminated favorably, namely, the first, in which the excised portion of intestine amounted only to two inches and a half. In the second, the animal might pos- sibly have recovered had not the sutures of the external wound given way, and thus permitted the escape of the bowel, which was subsequently lacerated, and seized with vio'ent inflammation. In the third experiment, in which 15 170 WOUNDS OF THE INTESTINE?. nearly one foot of the intestine was removed, the dog seem- ed to suffer severely from the shock of the operation; and, although re-action soon took place, he finally perished, on the ninth day, from the effects of his wounds. How the lacera- tion of the serous and museular tunics of the large and small bowels was induced, it is impossible to conjecture; nor is it easy to determine how far, or in what degree, it influenced the fatal event. In two experiments of this kind by Dr. Smith of St. Croix, the results were of the most gratifying nature. In one, the excised portion of the small intestine—probably the ileum— measured two inches; in the other, two inches and a half. In both cases he made use of four interrupted sutures, placed a equal intervals, with the ends cut off at the knots. The ani- mals were killed on the twentieth day, when the union was found to be so perfect that it was difficult to discover the seat of the injury. In one, all the ligatures were detached; in the other, one still remained. The results of these observations and experiments are in the highest degree interesting, as they tend to establish an import- ant practical precept. Cases occasionally occur in which the bowel is so much injured, cut, bruised or lacerated, as to be inevitably followed by gangrene, if the parts be not promptly excised, and treated in conformity with the principles here laid down. In extensive mortification from strangulation it becomes, as we have already seen, a question whether the affected portion should be removed by the knife, or the sepa- ration of it be intrusted to the efforts of nature. In the lat- ter case, even supposing that the patient would run no risk from the effusion of faecal matter into the peritoneal sac, he would still be subjected to that most loathsome of all dis- eases, an artificial anus; in the former, the injured structures would be placed in the same relations as those of a common incised wound, and the chances of recovery would therefore be incomparably greater. In intus-susception, where one por- tion of bowel falls into another, and where the included piece is finally detached by sloughing, nature performs the same TREATMENT--EXCISION. 171 operation precisely that the surgeon does under the circum- stances in question, with the difference merely that she is much longer in accomplishing her object; which, however, is not less effectual in the end. The practice, then, would seem to be sanctioned, not only by reason and analogy, but by experiments on the inferior animals and observations on the human subject. Would it be good practice, in extensive longitudinal or oblique wounds, to excise the affected part, and treat the case like one in which the tube is completely divided in the first instance? My opinion is that it would, especially where the opening is more than two inches in length. My reason for this conclusion is, that wounds of this extent require an unusually long time to heal, that the canal may become perma- nently contracted, and that the adhesive process is rarely so perfect as when the.aperture is smaller. In addition to this, as was before remarked, there must necessarily be more irritation from the great number of sutures, to say nothing of the immedi- ately bad effects occasioned by the protracted manipulation necessary to apply them. In an experiment, the particulars of which are detailed in another page, and in which the wound was three inches and a half long, death was evidently produced by the ulcerative action of the adventitious substance which formed the bottom of the opening, and which was conse- quently in direct contact with the contents of the tube. The abnormal aperture was nearly the size of half a dime. The animal lived till the end of the thirteenth day, and was con- sidered entirely out of danger, when the perforation occurred which led to his death. Altogether eleven sutures had been used, of which only two remained. This case, although a solitary one, is sufficient, I think, to show the impropriety of employing so many sutures, or, rather, the inexpediency of attempting to save the affected part in extensive injuries of the intestinal canal. Littre, an old French surgeon, was of opinion that the best practice, when the bowel is completely severed, whether by accident or mortification, is to bring the superior end out at 172 WOUNDS OF THE INTESTINES. the external opening, for the purpose of establishing an artifi- cial anus, and to return the other into the peritoneal cavity, having previously tied it to effect its obliteration. The inevit- able result of such a procedure would be to consign the pa- tient to a miserable existence, as it would deprive him of all chance of recovery, and leave him- with an infirmity that renders him disgusting to himself and to those around. It really becomes a question, as has been justly observed by Mr. Lawrence, whether life itself be desirable, if burthened with the discharge of faeces through the groin or some other region. A more rational and less objectionable method was pro- posed by La Peyronie. It consists in passing a double thread behind the wound through a fold of the mesentery, and retaining the ends of the bowel at the outer aperture, by fastening the extremities of the ligature to the surface of the abdomen with adhesive strips. This operation, like that of Littre, is always followed by an artificial anus; but, instead of being rendered incurable, as necessarily happens in the latter case, it generally yields to judicious management. Several examples in which this expedient was successfully resorted to are on record. I select the following as one of the most recent and interesting. A man at the assault of Cairo, in 1799, was wounded by a ball in the abdomen, which entered on the right side, and perforated the ileum. The two ends of the bowel were rup- tured, separated from each other, and tumefied; the superior being turned upon itself, so that it looked like the prsepuce in paraphymosis, and caused complete obstruction of the tube. By four small incisions with the crooked scissors, Baron Lar- rey, the reporter of the case, divided the neck of the strangu- lated intestine, and restored it to its proper situation. He then passed a ligature into the portion of the mesentery cor- responding with the two ends of the canal, which he returned as far as the edge of the wound, which he had previously taken care to dilate. After dressing the parts, he waited the result. For the first few days the symptoms were unpro- mising, but they gradually abated in severity, the alvine TREATMENT--EXCISION. 173 evacuations daily improved, and in about two months the ends of the ileum were in apposition and ready to adhere. The wound was afterwards dressed with a plug, according to the ingenious plan suggested by Desault, and the soldier ulti- mately left the hospital completely cured.* In a case mentioned by La Peyronie himself, the patient was about sixty-three years of age, and the bowel was affected with mortification from strangulation. The whole of the sphacelated part was cut away, and a thread passed through the mesentery, by which the ends of the gut were kept in apposition with the external opening. The faeces were void- ed through the artificial anus until the thirty-sixth day, when they began to resume their natural route, and in four months the ulcer was completely healed. Subsequently, however, an abcess formed at the seat of the cicatrice, followed by a new rupture.f The practice commonly pursued by surgeons, when the bowel is mortified in its entire cylinder, is to pull it gently down, and make a large incision into it, to afford a free out- let to the faeces. The artificial anus thus established gradually diminishes in size, and after some months disappears, the alvine matter, in the meanwhile, resuming its natural route. Upon the propriety or impropriety of this practice it is not necessary here to insist. Further observation can alone settle the question. When there is much inflammation be- yond the sphacelated parts, it would probably be wrong to pursue any other treatment; if, on the other hand, the tube is nearly, or quite sound, I should not hesitate to excise the mortified structures, and to approximate the ends by the suture, in the manner already explained. * Memoirs of Military Surgery, translated by Dr. Hall, vol. i, p. 320. t Boyer, Traite des Maladies Chirurgicales, T. viii, p. 136. 15 "• 174 WOUNDS OE THE INTESTINES. CHAPTER IV. Of Artificial Anus. It must be obvious that the term "artificial," applied to this affection, and in vogue among American and British authors, is rather ill chosen. In its etymological sense it merely implies some production of art, as an artificial leg, or an artificial eye; while in surgical language it denotes the effect of some operative or mechanical procedure, as the formation of an artificial pupil. By most of the French writers it has been superseded, in reference to the present topic, by the word "preternatural", and this is unquestionably preferable, in all respects, as it is much more expressive of the true nature of the malady which it is intended to designate. Equally ap- propriate is the term "accidental," used by some of the conti- nental surgeons. The word artificial, in fact, should be restricted to that form of the affection, in which the abnormal outlet is established mechanically, for the purpose of affording relief when there is some insurmountable obsta- cle in the rectum, or lower bowel. In employing the term "artificial," therefore, in connexion with the present subject, I am governed rather by the established usage of the profes- sion than by the rules of sound criticism. Artificial, accidental, or preternatural anus may occur in any part of the abdomen; but, as it is generally produced by gangrene of the bowel, from the pressure which is exerted upon it by hernial stricture, it is by far most frequently met with in the inguinal, scrotal, femoral, and umbilical regions, particularly the first two. For the same reason we find that the small intestine is much oftener involved than the large, which is fixed or attached, while the former is loose, floating, and consequently more liable to protrusion. Occasionally, though rarely, the abnormal anus has its seat in the lumbar region, high up in the iliac, the hypochondriac, or even the epigastric. Three causes mainly give rise to this affection, namely, ARTIFICIAL ANUS—CAUSES. 175 strangulated hernia, accompanied with mortification of the bowel, penetrating wounds, and stercoraceous abscess; the frequency of their occurrence being in the order in which they are here enumerated. A blow or kick on the abdomen may so contuse, bruise, or injure the bowel as to lead to the establishment of an artificial anus. Jobert saw a case in which an opening was formed in this way between the ileum and the vagina,* and examples of a similar kind have been witnessed by others. When the bowel is extensively divided by a sharp instru- ment, and the wound is managed improperly, or left to itself, the patient either perishes from peritoneal inflammation caused by faecal effusion; or adhesions take place between the gut and the adjacent parts, and the contents of the tube issue at the external orifice. The latter always happens when this accident is treated in conformity with the method of Palfin, Bell, and Scarpa, who advise the inner wound to be kept in apposition with the outer, by a ligature passed through the mesentery. Stercoraceous abscesses are induced by various causes; sometimes by ulcerative action, often by external violence, and occasionally by the irritation created by the presence of a foreign body, as a needle or pin, a fish or chicken bone, or a piece of coin. In either case, as soon as the matter is dis- charged, whether spontaneously or by the efforts of the sur- geon, the faeces escape at the abnormal aperture, either wholly or in part, and the patient is affected, not merely as some have pretended, with an intestinal fistula, but with a genu- ine preternatural anus. Large faecal accumulations have sometimes been mistaken for this kind of abscess; the knife or lancet has been plunged into them, and the disease in question has been the consequence, or the individual has died from peritoneal inflammation. Artificial anus is occasionally cono-enital, in which case it is usually seated at the umbili- cus. Mortification, like penetrating wounds, may affect the entire circumference of the bowel, or only a part of it. The * Maladies du Canal Intestinal, T. ii, p. 95. 176 WOUNDS OF THE INTESTINES. extent of the lesion will exert a material influence upon the restorative process, and in this respect the disease might not inappropriately be divided into partial and complete. The external orifice of an artificial anus exhibits no uni- formity in respect to its size and configuration. In many cases it is rounded, in some ovoidal, and in most irregular. In its diameter it varies from a few lines to an inch and a half or even two inches; being usually smaller in traumatic cases, or in such as result from penetrating wounds, than in those which are produced by ulceration, abscess, and especi- ally by gangrene. The margins of the opening are thick, bevelled, depressed, or inclined towards the centre, where they are in close contact with the mucous membrane of the two ends of the bowel, the junction between them being indicated by a reddish line; they have a raw, flesh-colored appearance, and are covered with numerous granulations, which are often very painful, and so irritable as to bleed upon the slightest touch. The matter which they secrete, and which is seldom very abundant, does not differ from that of other sores under similar circumstances. In cases of Ions standing, or where the faecal discharges are unusually acrid, the edges are very much indurated, inflamed, highly sensi- tive, and studded with fungous vegetations, some of them the size of a split-pea, or even half a dime. In a third series of cases, perhaps, they are elevated, hard, and almost insensible. The skin in the immediate vicinity of the opening, as well as for some distance beyond it, is red, inflamed, chapped, fissured, excoriated, or ulcerated, and so tender frequently that the patient cannot bear to have it touched, wiped, or washed, however gently this may be done. The depth of the outer orifice, or the distance between the skin and the bottom of the intestinal aperture, varies from three to twelve lines. It is always less when the disease is produced by a wound than when it is caused by gangrene; much will also depend upon the natural thickness of the wall of the abdomen, and the degree of plumpness or emaciation of the individual. Lallemand met with an instance where the distance between the two points was nearly two inches, ARTIFICIAL ANUS--EXTERNAL ORIFICE. 177 and in another, which fell under the observation of Delpech, it was upwards of three inches.* The external orifice is occasionally multiple, that is, instead of a single opening there are several. In this case there are usually fistulous tracks, which communicate with the main outlet, and sometimes even with each other. Velpeau mentions an instance in which there were not less than five or six distinct apertures, and another, not less remarkable, is related by Dupuytren.f This perforated and cribriform state of the parts is generally produced by some of the sterco- raceous matter insinuating itself among the muscular fibres and cellular substance of the abdomen before the margins of the external orifice are sufficiently protected by the new adhesions. An abscess soon forms, preceded by an erysipe- latous blush of the skin, and followed by a discharge of puru- lent matter, almost insupportably foetid in its character. The union between the two ends of the bowel and the cir- cumference of the outer orifice is effected through the me- dium of plastic matter, and constitutes an indispensable ele- ment of the disease. The inflammation, preceding and accompanying the effusion, always begins in the serous sur- faces of the parts, from which it gradually extends to the other structures, as the mucous membrane, the muscles, cellu- lar substance, and the skin. The plastic matter, soft and glu- tinous'at first, is soon organized, and thus opposes an effec- tual barrier to the effusion of faecal matter into the abdominal cavity. Subsequently it undergoes all the changes that lymph experiences, under favorable circumstances, in other situations. The extent of this adhesion varies, in different cases, from half a line to a line; it rarely amounts to half an inch, or, indeed, even the fourth of an inch, and in proportion as it is firm or otherwise will it be able effectually to resist the influence of such causes as have a tendency to separate the gut from the wall of the abdomen. Dupuytren met with two cases in which the union was so feeble that the intestine lost its hold, and the patients died from faecal effusion. * Diet, de Medicine, T. iii, p. 347. t Diet, de Medicine, T. iii, p. 346. 178 WOUNDS OF THE INTESTINES. When the artificial anus supervenes upon strangulated her- nia, the formation of these adhesions usually precedes the death of the bowel; in the traumatic variety of the affection, on the contrary, they are established after the reception of the injury, and hence the greater frequency of fatal effusion in the latter than in the former. As the adhesions extend only a small distance along the gut, a cul-de-sac is formed, the opening of which looks towards the belly, and into which the abdominal viscera may protrude, so as to complicate the disease. Immediately around the inner margins of the outer orifice are, as was previously stated, the two ends of the bowel; lying generally side by side, like the tubes of a double-bar- relled gun. Each opens by a distinct orifice, of which the upper, in time, becomes much the larger; they are bounded by a sort of villous rim, are irregularly rounded in their form, and are separated from each other by a septum or partition. The upper orifice gives passage to the faeces, and, as it is unprovided with a sphincter muscle, the patient has no con- trol whatever over their escape. Even mechanical means will not always obviate this inconvenience, and the utmost attention to cleanliness does not defend the surrounding parts from the effects of the acrid discharges. The lower orifice, of the same size at first as the upper, is generally very nar- row, puckered up, and sometimes even difficult to be found, especially when it has ceased for a long while to receive faecal matter. The upper opening is temporarily closed when the corresponding extremity of the bowel is touched with a probe or finger, or exposed to a few drops of cold water. When thus irritated it presents very much the appearance of the anus of the horse, the mucous lining being everted and corrugated by the peristaltic action of the muscular fibres. The two ends of the bowel, at first similar in size, by de- grees undergo important changes. The upper continually giving vent to faeculent matter, bile, mucus, and even ingesta, receives a preternatural quantity of blood, and hence gene- rally acquires a considerable increase of volume and strength; its coats are thicker than in the normal state, the muciparous ARTIFICIAL ANUS--ENDS OF THE BOWEL. 179 follicles are larger, the lining membrane is of a deeper red, and the peristaltic action is inordinately energetic. The lower extremity, on the contrary, having no longer any active function to perform, falls into a state of atrophy. Its tunics are pale, flaccid, and attenuated, its caliber is consider- ably diminished, though not obliterated, and its mucous glands are wasted and almost imperceptible. The canal con- tains a soft, whitish, gelatinous looking substance, which is evidently the product of an imperfect secretion, and which is voided by stool at intervals of two, three, or four months. The intestine, notwithstanding these alterations, still pre- serves its tubular form, however long the faeces may have been discharged through the abnormal aperture. That this is the fact has been proved by repeated dissections. Thus, Lecat examined the body of a female who had labored under this malady for twelve years, and in whom the inferior por- tion of the gut, or the part comprised between the natural and artificial outlet, was still pervious, though much con- tracted. Similar observations have been made by Desault and Dupuytren. The latter opened a patient, two years after the establishment of an artificial anus, and found that the tube not only remained pervious, but that it had experienced comparatively little diminution. The following case, how- ever, observed by Mons. Begin, of Paris,* shows that the obliteration of the intestine, although extremely rare, is not impossible. The patient was eighty years of age when he died,and for more than half this period he had labored under an artificial anus, seated in the left groin, and communicating with the arch of the colon. The superior extremity of the bowel only opened at the external orifice, and gave passage to the faecal matter. No aperture, corresponding with the other end, could be discovered either in the cicatrice or in the surrounding parts. The gut itself was converted into a hard, solid, whitish cord, not thicker than a common quill, which * Diet, de Med. Chir. Pratiques, T. iii, p. 133. 180 WOUNDS OF THE INTESTINES. passed to the left kidney, from which it descended, after sev- eral turns, to the anus, increasing somewhat in size as it ap- proached its termination. The inferior part was still pervi- ous, and contained a little whitish mucus; the upper for the length of six or eight inches, next to the abnormal aperture, was completely obliterated; and the intermediate portion was so contracted as scarcely to admit a small probe. This atrophy or wasting is not confined to the lower por- tion of the bowel, but often affects the corresponding part of the mesentery and even the lymphatic ganglions. As might be supposed, it is always more marked in old than in recent cases. In artificial anus, caused by a gangrened rupture, the two ends of the bowel are surrounded and closely embraced by a sort of membranous pouch, to which Scarpa, who first de- scribed it, has applied the name of infundibulum or funnel.* It is formed by the prolongation of the peritoneum which constituted the neck of the hernial sac, and varies very much in its shape, dimensions, and direction, its base being at the bowel, and the apex at the skin. It is generally very firm and dense in its structure, and from one to two lines in thickness, according to the extent of the previous inflammation; exter- nally it is intimately united to the margins of the abnormal opening, and internally it presents a smooth villous surface, not unlike that of an old fistulous track. The faeculent mat- ter from the upper orifice is poured into this cavity, and thence, when the artificial anus is closed, it is carried, after describing a half-circle, into the lower end of the canal. This membranous pouch is always wanting when the disease is the effect of a penetrating wound, and occasionally even when it is the consequence of a gangrened hernia: in both cases the gut adheres immediately to the edges of the opening in the muscles and integuments. The most interesting cir- cumstance connected with this funnel-shaped cavity is the influence which it exerts upon the reparative process, or spon- * Treatise on Hernia, Memoir Fourth, p. 288. ARTIFICIAL ANUS--INTERVENING SEPTUM. 181 taneous cure, which is always so much the more prompt and perfect in proportion as it is larger and longer. Interposed between the two extremities of the intestine, and formed by the juxta-position of their sides, is the ridge, septum, or partition, which Scarpa has described under the eperon, spur, or buttress. It consists of two angular or cre- scentic folds composed each of four lamellae, of which the inner two are of a serous nature, and firmly united together by plastic matter, for an extent varying from one to six, eight, or even twelve lines. The outer layers are of a mucous char- acter, and are continuous with the lining membrane of the * a a, Opening of the artificial anus, and point of union between the skin and the mucous membrane; b, upper end of the intestine; c, lower end of the intes- tine; d, the septum, eperon, or ridge, formed by the walls of the two contigu- ous cyUnders; e e, parietes of the bowel; /, the ligament or cord formed hy the mesentery; g, the cul-de-sac between the peritoneum of the intestines and of 'he abdominal walls, into which hernia; occasionally protrude. 16 1S2 WOUNDS OF THE INTESTINES. tube, of which they form a part. Dividing the bottom of the funnel, where it is situated, into two unequal parts, this sep- tum juts out nearer to the surface of the abnormal opening in proportion as the loss of intestinal substance has been more considerable, and the change in the direction of the tube more marked. It is small, and scarcely perceptible, when the gut has been merely pierced by a wound, or slightly affected by an eschar, but large and prominent, when the lesion, whatever it may be, involves the whole circumference of the canal.-* In the former case, the two orifices of the bowel are separated by a kind of gutter or groove, which di. rects the transit of the faecal matter from the one to the other, and greatly facilitates the attempts at cure; in the latter, the septum forms a projecting angle or buttress, which conducts the contents of the upper orifice towards the abnormal outlet, and which nothing but art can break down or surmount. When the two lamellae of which this septum is composed are viewed posteriorly, or from within the belly, we find that they gradually recede from each other, leaving thus a trian- gular interval between them, the apex of which corresponds to the point of separation, and the base with the abdominal cavity. The surfaces of these lateral layers, which are, in fact, nothing but the parietes of the affected cylinders of the bowel, are invested by a reflection of the peritoneum, and afford attachment to a process of the mesentery. From the manner in which this membrane is stretched between the spinal column and the concave side of the intestinal convolu- tions, it follows that it is always more or less dragged on when the gut is protruded from the belly, forming a sort of cord by which the body is inclined forwards, and the tube drawn inwards. A constant traction is thus kept up, which varies in degree in different cases, and which has occasion- ally been sufficient to destroy the adhesions between the howel and the wall of the abdomen, causing fatal effusion into the cavity of the peritoneum.! Dupuytren, who has devoted * Dupuytren, Diet, de Med. and Chir. Pratiques, T. iii, p. 130. t Dupuytren, Legons Orales, T. ii, p. 207.—London Medico-Chir. Review, vol. ix, p. 315. ARTIFICIAL AM S--NATURE OF THE DISCHARGE. 1 S3 much attention to this subject, states that this tension of the mesentery is continued long after the malady is removed. Several individuals who had been cured of artificial anus, were subsequently re-admitted into the Hotel-Dieu, where they died of other diseases. On dissection it was ascertained, contrary to what might have been expected, that the bowel, instead of being adherent to the walls of the abdomen, was free and unattached; a solid fibrous cord, however, being still stretched between them. This last was only a few inches in length by several lines in thickness, greatly attenuated at the middle, invested by peritoneum, and formed entirely of con- densed cellular substance. Had these individuals lived a lit- tle longer this band would, doubtless, have been gradually destroyed, and every vestige of the malady ultimately dis- appeared. The matter which issues at the abnormal opening varies in its properties according to the length of time it is retained in the bowel, the nature of the food, and the state of the pa- tient's health. Generally speaking it is soft, semi-fluid, or even quite liquid, of a greenish color, and composed of an admixture of faeces, bile, and intestinal secretion, together with ingesta. Its consistence is always less when the artifi- cial anus involves the jejunum or the superior extremity of the ileum than when it affects the lower portion of the small bowel, the ccecum, or the colon. In the former case, too, it has less stercoraceous odor, and occasionally contains a con- siderable quantity of pancreatic juice. The frequency with which it is voided is materially influenced by the nature and quality of the food, as well as by the manner in which it is prepared, and by the distance which intervenes between the abnormal aperture and the stomach. When the artificial anus is situated near this organ, it commonly passes off with- in an hour or two after eating, whereas, if it be lower down it may not be voided for five or six hours, or perhaps not oftener than three or four times a day. The evacuations, as was before intimated, are always involuntary, and are gene- rally effected with considerable rapidity, being accompanied 184 WOUNDS OF THE INTESTINES. with a peristaltic movement of the upper extremity of the gut and a sort of rumbling noise, especially when there is an escape of air. The quantity of faecal matter flowing along the abnormal opening, like its quality and the frequency of its discharge, must necessarily be influenced by a variety of circumstances. Of these the most important are the amount of food, the ex- tent of the intestinal lesion, and the size of the septum be- tween the two ends of the bowel. Most persons laboring under this disease eat voraciously, often, indeed, three or four times as much as they did before; they are always hungry, have an enormous appetite, and are never satisfied. This is particularly the case when the ingesta are retained only for a short time. Hence there is a proportionably large accu- mulation of faeculent matter, and as this cannot pass from one intestinal orifice into the other, in consequence of the mechanical obstacle interposed between them, most of it, if not all, escapes at the abdominal opening. The pernicious influence which the brief sojourn of the alimentary matter exerts upon the system is not always so great as might be supposed. Indeed, not a few instances are related in which the patients not only retained their health and strength, but even grew fat. In the generality of cases, however, the effects are quite the reverse. The food is re- tained too short a period to be properly acted upon by the digestive organs; the function of chylification is impaired; nutrition is carried on imperfectly; the body is emaciated, and there is a proportionable failure of the physical powers. In extreme cases, that is, where the general health is other- wise affected, or where the passage of the aliment is exceed- ingly rapid, the patient has sometimes perished from inani- tion. Another very serious inconvenience to which persons laboring under artificial anus are subject is the protrusion of the extremities of the gut. This often amounts to a real prolapsus, and is liable to occur, no matter what may have been the cause of the disease. It may affect one or both ARTIFICIAL ANUS--PROLAPSUS OF THE MUCOUS COAT. 1S5 ends, but the upper is more frequently involved than the lower, though the reverse is said to be the case by Boyer, not, however, with any foundation in truth. The extent of the prolapsus varies, in different cases, from three to eight inches; more rarely it amounts to a foot, or even a foot and a half. In its diameter the tumor seldom exceeds two and a half or three inches. It is more or less conical in its shape, contract- ed at the base, and perforated at the extremity by an irregu- larly rounded opening. The everted mucous membrane is at first only preternaturally red and vascular; by degrees, how- ever, it becomes thickened, rugose, indurated, and completely hypertrophied. In this respect it experiences the same changes of structure as the villous coat of the rectum in pro- lapsus of the anus. The swelling, which is commonly much larger in the erect th'an in the recumbent posture, frequently possesses so little sensibility that it may be touched or hand- led without pain. At times, however, it is excessively ten- der, and may then become a source of real suffering, depend- ing more, perhaps, upon the state of the system than upon that of the part immediately concerned. Strangulation of the prolapsed intestine occasionally occurs, and, although the stricture by which it is produced, may generally be easily relieved by an operation, yet in several instances it has ter- minated fatally. Sabatier, in his Memoir on Artificial Anus, quotes two examples from Puy, a surgeon of Lyons, where death was caused in this way; an instance of a similar kind fell under the observation of Flajani, and another is mentioned by Le Blanc, in the second volume of his "Operations de Chirurgie." In a case narrated by Mons. Veiel,* the divis- ion of the stricture did not prevent death. From this rapid sketch of the nature, anatomy, symptoms, and complications of artificial anus, it is obvious that, in whatever light it be viewed, it must be regarded as one of the most distressing affections to which we are liable. Indepen- dentlv of its filthy and disgusting character, the patient has * Archives Generales de Medicine, 2d series, T. vii, p. 542 16 ' e stated that the age of the patient and the state of his health exercise considerable influence on the prognosis. Treatment. The treatment of artificial anus naturally divides itself into palliative and radical. The first consists in promoting the comfort of the patient, by strict attention to cleanliness, pre- venting too early an escape of the ingesta, and combating ;uch accidents or complications as may arise during the pro- gress of the malady. The radical treatment has for its object the re-establishment of the natural course of the faeces, and »he obliteration of the opening in the wall of the abdomen. These topics involve important principles, and therefore re- quire separate consideration. it is a question which ha& not yet been definitively settled how soon, after the occurrence of an artificial anus, we are warranied in attempting a radical cure. Several examples are now on record where, by premature interference of this ^ind, the patients lost their lives. Death, under these cir- :um*tances, may be produced by a variety of causes, but the ARTIFICIAL ANUS—TREATMENT. 187 most common, perhaps, is the want of adhesion in the sides of the opening which is made in the eperon or intervening septum, and the consequent escape of faecal matter into the abdominal cavity. Another source of mischief is the imper- fect union between the ends of the bowel and the margins of the abnormal outlet. Indeed, it appears to me that, until this union is fully established, or is so strong and firm as to ren- der it impossible for it to give way under the traction of the enterotSme or the manipulations which are necessary to in- troduce the seton, it would be highly improper, with a view to a radical cure, to do any thing calculated to jeopard the result by faecal effusion into the peritoneal cavity. We have no means, unfortunately, of ascertaining how soon the plastic matter, by which the union in question is effected, becomes organized, and capable of withstanding such forces as have a tendency to break up the new connexions. Nev- ertheless, there is reason to believe, from what we know in regard to the changes which coagulating lymph experiences in other parts of the body, that several month?, probably from three to six, are necessary for the purpose. Prior to this period, therefore, I would deem any surgical interference officious und unadvisable, particularly in relation to,the ente- rotdme of Dupuytren, or the modification of this instrument by other practitioners. The method of Desault, of which we shall presently speak, may be advantageously resorted to much earlier, and consequently before the adhesions between the contiguous parts have acquired all the strength of which they are capable. There is, therefore, a period, unless a spontaneous cure should in the meantime supervene, of several months during which the patient must bear with his loathsome infirmity, and suffer all the inconveniences arising from the effusion of faeculent and other matters. This, however, is not all. The case may be such, as, by its very nature, to preclude the pos- sibility of effecting a radical cure by any means of which we are in possession; or the patient may, from timidity or other causes, be unwilling to submit to an operation of any 188 WOUNDS OF THE INTESTINES. kind. In either event, it is the duty of his attendant to make his situation as comfortable as practicable. The first and most important object to be attended to, in a case such as we have imagined, is to prevent the escape of fascal matter at the artificial anus; or, if this cannot be done, to apply some apparatus for receiving and retaining it. When the disease has been caused by a wound, or when the bowel has been only partially destroyed by gangrene, the former of these indications is generally easily fulfilled by means of a piece of gum-elastic, several lines thick, shaped like a nipple-shield, and large enough not only to cover the external orifice, but to extend some distance beyond it. This, being soft and flexible, readily accommodates itself to the various movements of the body, and answers the purpose much better than leather, tin, brass, or sheet-lead, recom- mended by some surgeons. It should be retained by a grad- uated compress and bandage; or, what would be better, a common truss with a broad pad perforated in the centre for receiving the knob on the gum-elastic plate. To derive full benefit from this apparatus it might be so constructed as to have a projection on its posterior surface, carefully fitted into the abnormal opening, which it would thus more effectu- ally close, at the same time that it would prevent the pro- trusion of the bowel, so liable to occur when the parts are imperfectly supported, or when the patient is in the erect position. When the faeces can not to be made to pass along the nat- ural channel, in consequence of the inordinate size of the septum between the two ends of the bowel, the patient may generally be rendered very comfortable by wearing an appa- ratus for their reception and temporary retention. The older surgeons were in the habit of using, for this purpose, recep- tacles of leather, or horn, which were fastened round the body by bandages of particular construction. These contri- vances, however, rarely fulfilled the intention for which they were constructed, as it was found not only difficult to adapt them accurately to the parts, but from the facility with which ARTIFICIAL ANUS--TREATMENT. 189 they imbibed moisture they soon became offensive, and requi- red to be often renewed. The most perfect apparatus of this kind, perhaps, was constructed many years ago, by Juvilie, a celebrated Parisian truss-maker. It is delineated in his "Traite des Bandages Herniaires," and has occasionally been worn with great benefit. In its construction it is exceedingly complicated, and it is scarcely possible to convey a cor- rect idea of it without a plate. It is composed of a com- mon inguinal truss, the pad of which is made of ivory, and rests upon the margins of the artificial opening. To a hole in the centre of the pad is fitted a tube of gum-elastic, which is furnished with a valve, and directs the faecal matter to a silver receiver, fastened to the inner part of the thigh. The silver receptacle is of a flattened conical shape; it is three inches in length by two inches and a half in breadth, and may be unscrewed and emptied without disturbing the rest of the instrument. The valve in the tube opens by its own weight when the patient is in the erect position, but shuts when he lies down, and prevents the accumulated faecal matter from reflowing into the artificial anus. When the apparatus is properly adjusted it is said to answer so well that the patient is able to pursue his ordinary occupation, and to escape the inconveniences arising from the discharge of faeculent and other matter. If, notwithstanding the use of an apparatus of this kind, the faeces are diffused over the surrounding surface, the ut- most attention must be paid to cleanliness. Without this no comfort can be expected. If allowed to remain in contact with the skin, even for a short time, the acrid discharges not only induce pain and irritation, but they render the patient loathsome to himself, and disgusting to his friends. In fact, there is no situation in which a human being can be placed which is more pitiable and distressing, or better calculated to excite our sympathy. When inflammation arises, either in the part itself, or in the neighboring integuments, it is to be combated by frequent ablutions, emollient poultices, and anodyne fomentations. If 190 WOUNDS OF THE INTESTINES. t partakes, as it sometimes does, of an erysipelatous char- acter, it may be necessary, in addition to these means, to use leeches and blisters. The callosities which are so apt to form on the surface of the sore should be removed with the knife or scissors; escharotics are to be avoided, as they always give rise to severe pain, and rarely afford much relief. When the skin is ulcerated, fissured, chapped, excoriated, or studded with pustules, it should be thoroughly cleansed with a soft sponge and tepid water, after which it must be anointed with simple cerate, and covered with a slippery-elm or lin- seed poultice, These dressings are to be continued as long as may be necessary, and renewed twice or three times in the twenty-four hours. Fistulous tracks, when they exist, must be incised, and their edges pared, to put them in a condition favorable to cicatrization. The cure is sometimes much retarded, if not entirely prevented, by the perforated state of the parts; the skin, perhaps, is indurated and disorganized, and faecal mat- ter issues at various points, keeping up constant irritation and distress. In such a case it may become necessary to re- move the affected structures, bowel and all, with the knife, to reduce them to the nature of a simple wound. Inanition is seldom to be apprehended when the artificial anus is seated in the large intestine, or low down in the small. In either event, abundant time is usually afforded to the chyliferous vessels for taking up the nutritious portion of the ingesta, and conveying it to the proper receptacles, be- fore the contents of the tube reach the abnormal outlet. When this, however, is situated higher up, the case may pre- sent a very different aspect, as the chymous matter may escape too soon to enable the system to be much benefited by it. This circumstance is always known by the soft and lactescent nature of the discharge, by the voracious appetite, and by the progressive emaciation. The patient eats three , or four times the accustomed quantity of food, his hunger is never appeased, he is thin and haggard, and has but little strength. To support life, which is occasionally much endan- ARTIFICIAL ANUS--TREATMENT 191 gered by this occurrence, the individual must be kept per- fectly quiet, the diet must be light, nutritious, and easy of digestion, the irritability of the bowels must be allayed by anodynes, and the outer opening must be well protected with an obturator. In bad and intractable cases, threaten- ing life, advantage might be derived from the use of nutri- tious injections. When the bowel becomes prolapsed, as it is apt to do when the opening is not properly closed, the reduction is usually effected with great facility, by placing the patient on his back, and making gentle and well-directed pressure upon the part with the fingers of one hand, while the bowel is held between the thumb and fingers of the other. In more obsti- nate cases, the replacement may be attempted by systematic compression, while the patient is lying on his back; this will have the effect of emptying the protruded gut of its blood, and will often succeed after other and more simple means have failed. When the reduction is impracticable, the gut should be supported by a well adjusted apparatus, and the patient should refrain from laborious exertion, from laughing and coughing, irregularities of diet, and from every thing tending to increase the swelling. When symptoms of stran- gulation arise, the most rigorous antiphlogistic measures are to be adopted; blood is to be abstracted, both generally and locally, the patient is to be placed in the warm bath, and cloths, wrung out of tepid water, are to be constantly applied to the affected part. In a word, the case is to be treated precisely as when the strangulation is produced by ordinary causes. When these remedies fail, relief must be attempted by an operation. The patient lying upon his back, near the edge of the bed, the surgeon takes a bistoury which he passes along the fore-finger of the left hand, and makes a free incis- ion through the integuments around the base of the tumor, which is generally sufficient to remove the stricture. Should this, however, be found not to be the case, it will be neces- sary to extend the incision into the end of the bowel, at its union with the margin of the abdominal orifice. Soon after 192 WOUNDS OF THE INTESTINES. the stricture is divided, the tension of the part subsides, the faeces flow out externally, the pain disappears, and the gut gradually becomes reducible. Artificial anus is susceptible of spontaneous cure. Of this numerous examples are on record, and there is scarcely a sur- geon, at all extensively engaged in practice, who has not met with cases of it. The faeces, after having passed for weeks or months through the orifice in the abdomen, gradually re- sume their natural channel, the artificial anus closes up, and at length all that remains is a small cicatrice, indicating the situation of the former injury. A singular instance of artificial anus, in which a cure was effected during pregnancy, has been related by Dr. Wede- meyer of Hanover.* The woman was thirty-two years of age, and the disease, caused by a gangrened hernia, had exist- ed for seven months, during which it had resisted various methods of treatment. As pregnancy advanced, and the ute- rus ascended into the abdomen, the faecal discharge dimin- ished, and passed proportidnably along the natural route. Towards the close of gestation, nothing issued at the abnor- mal opening, except a little pus and serum, and in two months after her accouchement the parts had completely healed. Before we attempt the radical cure of an artificial anus by any method of treatment, however simple, it is proper that some attention should be paid to the general health of the patient. If this be much deranged, it is obvious that it should be recti- fied, otherwise the case may proceed badly, or even termin- ate fatally. The secretions are to be restored; the diet is to be regulated; the bowels must be moved by mild aperients; and any local irritation that may exist is to be combated by frequent ablutions, anodyne fomentations, and emollient poul- tices. Leeches will seldom be necessary. This preliminary- treatment is particularly called for when we wish to put in * American Medical Recorder, vol. xiii, p. 453. ARTIFICIAL ANUS--TREATMENT. 193 execution the operation of enterotomy, autoplasty, or even the more simple one of the seton. When the abdominal orifice is too small to admit of the ready application of the enterotome, the use of the plug, or the passage of the seton, it must be dilated with linen tents or gum-elastic bougies. The foreign substances should not be introduced too frequently, or too forcibly, or for too long a time; and their use should not be attempted until the parts are divested of their tenderness and irritability. By proceed- ing cautiously in this manner, taking care gradually to in- crease the size of the tent, the abnormal passage may gene- rally be dilated to the requisite extent within from two to four weeks. When the edges of the track are very thick and callous, the treatment will be greatly expedited by excising them. After the operation has been performed, the patient must for sometime lie quietly upon his back, with the legs and knees drawn up, to relax the abdominal muscles and prevent undue compression of the parts. The diet must consist of nourishing broths or light soups, soft boiled rice, tapioca, arrow-root, or boiled milk and grated cracker. For his drink he may use demulcent fluids, as gum water, or flaxseed tea; the bowels should be calmed by anodynes, and the natural stools promoted by stimulating enemata. In short, every thing is to be done to avoid inflammation, both in the parts more immediately concerned, and above all in the peri- toneum. Of the various operations that have been devised for the radical cure of this loathsome and disgusting affection, the first that attracts our attention is the suture. The idea of employing enteroraphy is generally supposed to have origin- ated with Lecat. However this may be, it is certain that a female laboring under this infirmity was under the care of that celebrated surgeon in 1739, and would have been sub- jected to this treatment had she not become tired of the nu- merous attempts that had been made to replace the protruded and adherent gut. 17 194 WOUNDS OF THE INTESTINES. The expedient was subsequently carried into effect by a surgeon of the name of Bruns; but instead of paring the edges of the opening, as had been suggested by Lecat, he contented himself with excoriating them with caustic. The case seemed to be going on favorably, when, on the third day, the ligature lost its hold, and the anus began to gape, followed by a discharge of faecal matter. The patient, un- willing to submit to further trials, was abandoned to his fate. The next attempt at this species of enteroraphy was made by Liotard;* but the result was not more fortunate. He pared the whole circumference of the abnormal aperture, and approximated the raw edges by two points of suture, aided by a favorable position and proper dressings. On the second day the apparatus was observed to be soiled by faecal matter, and on exposing the parts the ligatures were found to have cut themselves out. Professor Blandin, of Paris, in a simi- lar case, was equally unsuccessful. Indeed, Judey seems to be the only surgeon in whose hands the expedient has hitherto had a favorable termination: the artificial anus had existed four months, and the cure was complete.f Desault, in the latter part of the last century, endeavored to cure this disease by compression/]: He was aware that the chief obstacle to the reparative process was the septum between the two ends of the tube, by which the faeculent and other matters were diverted from their proper channel, and forced out at the preternatural orifice in the wall of the abdomen. The removal of this projecting piece constitutes, therefore, a most important indication in the treatment. To fulfil this, Desault used long linen tents, which he introduced and fixed in the two ends of the gut, taking care to renew them as often as they became soiled and offensive, which generally happened once or twice in twenty-four hours. In this manner he gradually effaced the abnormal angle, and * Diss. Sur. le Traitement des Anus Contre Nature. Paris, 1819. t Archives Generates de Medicine, T. i, p. 291. t Surgical Works; Translated by Smith, vol. i, p. 306. Philadelphia, 1814. ARTIFICIAL ANUS--TREATMENT. 195 brought the two cylinders into a straight line; at the same time he dilated the lower orifice, and thus placed it in a more favorable condition for receiving air and faecal matter. Along with these means he kept the outer opening closed by a well-adjusted compress, for the two-fold purpose of prevent- ing the escape of the faeces, and of forcing them on towards the rectum. When the dilatation was sufficiently advanced and the intervening septum nearly effaced, he discontinued the long tents, and merely retained the external plug, apply- ing it more superficially lest it should interfere with the transmission of the contents of the tube, and so become an obstacle to the restorative process. If it succeeds, the good effects of this method are announced by slight colicky pains and rumbling noises in the belly, followed at first by a dis- charge of wind, and soon after by faeculent and mucous mat- ter. In proportion as the natural passages are re-established the outer orifice diminishes in size, and the griping subsides. The cure is expedited by a light but nutritious diet, perfect rest, and an occasional enema. Although this method of treatment has been repeatedly attended with the happiest results, it is obvious that it cannot be employed with a prospect of success in all cases. Of this Desault himself appears to have been fully aware, and he has enumerated the following circumstances as particularly calcu- lated to oppose the cure, or as so many contra-indications: first, where the gut has suffered great loss of substance; secondly, where the intervening septum is too short, promi- nent, or difficult to be broken down; and thirdly, where the ends of the bowel, one or both, have contracted such firm adhesions externally as to render it impracticable to effect their reduction. In addition to these considerations it may be remarked that the process is generally very tedious, and well-calculated to exhaust the patience both of the surgeon and the sufferer. The first instance in which Desault employed this mode of treatment is too interesting to be passed over on the present occasion. The case, in fact, has become memorable in the 196 WOUNDS OF THE INTESTINES. annals of surgery. The following abstract of it is all that my limits will allow me to give. Francis Vialter, a large, strong, and well-built man, a sai- lor and native of Moulins, was injured by the bursting of a bomb in May, 1786. The wound occupied the right side, and extended from about two inches above the inguinal ring to the bottom of the scrotum, where it had exposed the testicle. At the upper angle was a sort of appendix, very red, an inch long, and formed by the divided bowel, which retracted into the abdomen, whenever the parts were washed. In this situ- ation an opening was left in the dressings for the discharge of the faeces. After having wandered about for four years, and visited all the principal hospitals of Europe in vain for relief, he entered the Hotel-Dieu of Paris, on the 29th of Septem- ber, 1790. The upper end of the bowel, from long exposure to the air, the friction of the clothes, and the contact of faecal matter, had acquired considerable thickness, as well as density, and was of a conical shape, nine inches in length. Its base, which was somewhat contracted, seemed to proceed from be- neath a fold of the skin, just above the inguinal ring; while the apex, inclined backwards, reached to the middle of the thighs, and ended by a narrow orifice, through which the faeces flowed. Nothing had escaped by the natural passage since the period of the injury, except a small quantity of whitish, ropy mucus, at intervals of three or four months. The whole surface of the tumor was red and wrinkled, like a villous membrane. On the outer side of this mass was another pro- trusion, much smaller but of the same color and consistence, oval in its form, and puckered like the mouth of a purse at the extremity, where it discharged a little serosity. The pa- tient was extremely emaciated, and compelled, by the violent pains he experienced in the abdomen, to bend himself for- ward when he attempted to walk. An earthen pot, attached to the waist and suspended between the thighs, received the faecal matter. To reduce the swelling of the upper protrusion, without ARTIFICIAL ANUS--TREATMENT. 197 which the bowel could not be restored to its natural situation, Desault used a simple roller, with which he covered the whole tumor from below upwards, by spiral and moderately light turns, leaving merely an orifice at the apex for the pas- sage of the faeces. The effect of the treatment was extraor- dinary; the tumefaction rapidly subsided, and by the fourth day the intestine was in a condition to be replaced. Having accomplished this, he opposed the issue of the excrements by a thick linen tent, three inches long, introduced into the gut, and supported by an inguinal bandage. His idea was to remove this twice a day for the evacuation of the faeces; but in a short time the patient perceived a rumbling noise in the abdomen, accompanied with an acute sense of heat, and wind was soon expelled by the anus. Colicky pains occurred in the rectum, and half a pint of fluid matter was discharged by the natural route. The night following he had a number of evacuations of the same kind, preceded by similar feel- ings, and which left him somewhat languid in the morning. The passages became gradually more natural, the pains dis- appeared, and on the eighth day the tent was discontinued, the external opening being closed by a pledget of lint and several compresses, supported by a truss with a broad flat pad. From this period Vialter rapidly recovered; he regained his flesh and strength, and voided his faeces without pain or in- convenience. A very trivial serous exhalation moistened, without staining, the lint which covered the fistulous orifice in the abdomen. Five months after he left the hospital, in attempting to lift a cask on his shoulders, his bandage broke, and the intestines again protruded, to the length of six inches, through the unhealed opening. The same treatment as on the former occasion was adopted with complete success. A more effectual and less tardy expedient than that of Desault, was proposed, near the close of the last cen- tury, by Schmalkalken, a German surgeon. He has given an account of it in his Inaugural Dissertation, "Nova Methodus Intestina Uniendi," published at Wittemberg in 17 * 198 WOUNDS OF THE INTESTINES. 1798. The operation consists in perforating the septum with a seton introduced by means of a curved needle, and allowed to remain long enough to excite adhesive inflam- mation between the two contiguous cylinders of the bowel. The period necessary for this varies from a week to a fort- night, at the expiration of which the foreign body is with- drawn, and the portion of the partition lying between the outer orifice and the opening of communication excised with a pair of scissors or other suitable instrument. In executing the operation, it is of no little importance that the track made by the instrument is accurately filled by the thread or tape, otherwise faecal matter might be effused into the peritoneal cavity. The seton ought to be carried as high up as possible, and care taken that it do not embrace a neighboring fold of the intestine. Whether Schmalkalken ever performed this operation, of which he must undoubtedly be regarded as the inventor, it is impossible for me to say, as I have not before me a copy of the dissertation in which the account of it originally appeared, nor do I find the subject mentioned in any other work. The probability is that he did not; at all events, very little notice of it was taken even in Germany, while the profession of the remainder of the continent of Europe, Great Britain, and the United States appears to have been profoundly ignorant of it. I make this statement for the purpose of showing that the late Dr. Physick, of Philadelphia, who performed a similar operation in 1809, was not aware that it had been previously proposed, and that he is therefore justly entitled to a share of the credit of the discovery. The case which fell under the observation of Dr. Physick, and which was probably the first of the kind treated by the seton, was that of John Exilius, a Swedish sailor, nineteen years of age, who was admitted into the Pennsylvania Hos- pital in October, 1808, for strangulated congenital hernia.* * See an account of this case, drawn up by Dv. B. H. Coates, and published in the second volume of the North American Medical and Surgical Journal—also Dorsey's Surgery, vol. i, p. 96. ARTIFICIAL ANUS--TREATMENT. 199 The sac being opened, the two coils of the bowel were found to be firmly adherent to the testicle, as well as partially to the abdominal ring, and one of them presented an opening of sufficient magnitude to permit the discharge of a considerable amount of faeces. There were, however, no marks of morti- fication, and the perforation was probably caused by ulcera- tion. The symptoms were but slightly relieved by the divis- ion of the stricture, the patient continued very restless, and only a small quantity of matter flowed through the wound. Another operation was therefore performed, followed by much greater facility for the escape of the faeces. On the 24th of December, the projecting portion of the gut was cut off close to the ring, in the hope that the open orifices thus left would gradually retract within the abdomen. No good, however, resulted from this procedure, nor did any better success at- tend the method of Desault, which was employed soon after. It now occurred to Dr. Physick that relief might possibly be afforded by cutting a lateral opening through the sides of the gut; but not knowing to what extent they adhered to each other, he determined to pass a needle armed with a ligature from one cylinder to the other, about an inch within their re- spective orifices. This operation was performed on the 28th of January, 1809. The ligature, applied with moderate firm- ness, was secured with a slip-knot, and drawn to its original tightness whenever it became loose by the ulcerative action of the parts which it embraced. After three weeks had elapsed, the ligature was removed and the parts in front of the opening which it had made di- vided with the bistoury. No unfavorable symptoms super- vened upon this operation; on the 28th of February the pa- tient had uneasy sensations in the lower portion of the abdo- men, and on the 1st of March he extracted with his own fin- ders some hardened faeces from the rectum. Other evacua- tions followed; the discharge from the groin became^ incon- siderable; and the artificial anus gradually diminished in size. The patient was dismissed from the hospital on the 10th of November, in good health, but with a. fistulous aperture in 200 WOUNDS OF THE INTESTINES. the groin, the hope of an entire closure being abandoned. By wearing a truss with a compress and a large pad, stuffed in the common way, the escape of fasces was completely con- trolled. By the French surgeons the honor of the discovery of this process is generally claimed for Dupuytren, by whom it was executed at the Hotel-Dieu in 1813, without any knowledge apparently that it had been recommended by Schmalkalken, and performed by Physick.* His patient was Francis Auc- ler, thirty-six years old, of excellent constitution, who had been affected from his youth with an inguinal hernia on the left side, from which, however, he had experienced no incon- venience until the 13th of May, when, in consequence of a violent attack of vomiting, it became strangulated. Five days after he was carried, in a state of great prostration, to the Hotel-Dieu, and the stricture carefully divided. The bowel being sphacelated was left at the outer opening, and an artificial anus followed. Through this the whole of the faeces were discharged. Six weeks having elapsed without the prospect of a cure, Dupuytren employed compression, but violent symptoms ensued, and he was obliged to abandon it. He then resorted to the seton. The operation was soon over, gave rise to scarcely any pain, and was not succeeded by any accident. Some days afterwards a skein was substituted for the thread, when flatus began to be expelled by the natural anus. The size of the seton was increased at each dressing, and in less than eight days the patient had a passage from the rectum, preceded by colicky pains. In dressing the sore one day the buttress in front of the foreign body was completely lacerated,' without any other effect than a more easy flow of faeces from one end of the bowel to the other. Stercoraceous matter continuing to escape by the abnormal aperture, Du- puytren excised by means of blunt-pointed scissors, directed on the fore-finger, half a line of the septum which intervened between the two openings. The operation was cautiously re- * Leeons Oralei, T. ii, p, 236. Paris. 1832. ARTIFICIAL ANUS—TREATMENT. 201 peated at intervals of three or four days, the new adhesions were never passed, and the communication was soon so free that the faeces were evacuated entirely by the accustomed channel. Compression was kept up on the artificial anus, and the case was going on well, when Dupuytren, yielding to the entreaties of his patient, who was anxious to expedite the cure, divided the partition higher up than he had done before. In a few hours acute peritonitis supervened, and the man died. On dissection, a large quantity of serum and lymph were discovered in the abdominal cavity, but no ster- coraceous matter, or any opening by which it could have found its way in. The communication between the extremi- ties of the gut was re-established for the space of two inches, and instead of being separated, as they had been previously, they were united by a sort of raphe or cicatrice, the remains of the former septum. In fact, it clearly appeared that, but for the peritonitis, a complete cure would have ensued. Discouraged by this unhappy termination, Dupuytren de- termined to abandon the employment of the seton, and to devise some other expedient. After many trials on animals and the dead body, he finally invented an instrument which he called the enterotome, and which is thus described in the second volume of his surgical lectures. It consists of a screw and two branches, each about seven inches long. One of these, which is called the male branch, as it is received by the other, has a blade four inches in length, three lines in breadth, and half a line in thickness at its edge, which is undulated, and terminated by a spheroidal button. At the junction of the blade with the handle is a mortise several lines in extent; the handle itself is from two to three inches long, and has another mortise four lines broad, which runs nearly from one end to the other. The female branch is somewhat shorter. It is composed of two blades, of the same length, breadth, and thickness as the small blade, which is received in the gutter, groove, or sheath between them. The bottom of this gutter is undulated, to correspond with the 202 WOUNDS OF THE INTESTINES. irregularities of the male branch, and at the extremity is a cavity for lodging the spheroidal button of the latter. At the union of the groove with the handle is a moving pivot, which passes into the mortise of the other branch, and the handle itself is terminated by a hole to receive the screw. This last part of the enterotome, a screw of several threads, is anMnch and a half long, and ends by an oval plate; it is placed in the mortise of the male branch, and fixed in the female, its use being to separate or close at pleasure the two blades. The accompanying wood cut conveys an accurate idea of the na- ture of this instrument. a Represents the male blade, b the female blade, c the joint, d the moving pivot, e the han- dles, and/ the screw by which the branches are shut and locked. Before applying this instrument the surgeon satisfies him- self of the precise situation of the lower opening of the gut, which it is by no means always easy to do, and places the patient upon his back near the edge of the bed, with the abdo- minal muscles completely relaxed. Taking one of the blades ARTIFICIAL ANUS—TREATMENT. 203 he conveys it upon the fore-finger into one of the orifices, to the requisite depth, and gives it to an assistant. The other is then introduced in the same manner into the other extrem. ity of the tube, when they are joined together, like a pair of obstetric forceps, by putting the tenon of the one into the mortise of the other. The partition must be embraced to an extent of one, two, or three inches, according to the nature of the case; and the pressure, which is regulated by the screw, should be strong enough to destroy the vitality of the part the first few hours, as this will prevent pain and inflam- mation. It should afterwards be increased every forty-eight hours, until the enterotome falls off, which it usually does from the seventh to the tenth day, along with the mortified portion of the partition. The operation is rarely attended or followed by any unpleasant symptoms, and the opening which it leaves generally affords free passage to the faecal matter from one extremity of the bowel to the other. From a statement published by Dupuytren in the work previously referred to, it appears that from the time he first employed this instrument until 1824, twenty-one operations had been performed by himself, and twenty by other practi- tioners. Three-fourths of the cases were caused by gangrene from strangulated hernia, and the remainder by penetrating wounds, with more or less loss of substance of the tube. Of the whole number thus treated three only died; one from, supposed faecal effusion into the abdomen, one from indiges- tion, and one from acute peritonitis. Of the thirty-eight that survived, none experienced any ill effects except a few who had colicky pains, nausea and vomiting, but were promptly relieved by effervescing draughts, leeches to the anus, and fomentations to the belly. The success was not equally great-'^n all the cases. Twenty-nine were radically cured in from two to six months, and the rest retained, in spite of all that could be done, fistulous openings, which compelled them constantly to wear a compress and bandage, to prevent the 204 WOUNDS OF THE INTESTINE9. escape of air, mucus, bile, and even faeces. "It would thus appear," says Dupuytren, "that the mortality from the use of the enterotome is one in fourteen; or, if we exclude the case of indigestion, which cannot be fairly ascribed to the applica- tion of the instrument, it is reduced to one in twenty; a re- sult much more favorable than that which usually attends the great operations of surgery." One cause of failure of this operation, as was intimated in a previous page, is the want of adhesion in the sides of the opening made in the eperon, or septum. Velpeau relates the particulars of a case of this kind which fell under his own observation, and similar examples have occurred in the hands of other surgeons. His patient was a man fifty-six years old, who had a crural hernia of the left side since the age of eighteen: it was somewhat bigger than a hen's egg, became strangulated on the 17th of April, and was operated upon on the 27th of the same month. The intestine was found mor- tified, and the faeces soon after commenced passing through the wound. The enterotome, applied on the 14th of May, was removed on the 21st, and the man expired on the 22d, death having been preceded by violent colicky pains, tympa- nites, and great tenderness on pressure of the hypogastric region. The lips of the two ends of the bowel were quite detached, and the margins of the opening in the intervening septum were adherent only on one side. Thus a free com- munication was established between the tube and the cavity of the peritoneum, which had become extensively inflamed from the contact of stercoraceous matter, and was filled with sero-purulent effusion. * It can hardly be doubted that this case would have had a very different termination, had a longer period been allowed to intervene between the application of the enterotome and the operation for the strangulated hernia. The attachments * Velpeau, Medicine Operatoire, T. iv, p. 157. ARTIFICIAL ANUS--TREATMENT. 205 between the ends of the intestine and the parietes of the abdo- men were not sufficiently firm to resist the traction occasioned by the presence of the instrument, and hence the aperture which permitted the faecal matter to pass into the abdomen. The want of union in the sides of the opening made by the enterotome was probably caused by the unhealthy condition of the parts, which indisposed them to adhesive inflamma- tion. Some difference of opinion still exists respecting the pro- priety of closing the blades of the enterotome on their first application so firmly as to destroy at once the vitality of the intervening septum. Dupuytren appears to have pursued this practice in all the cases which he treated with this instru- ment, without experiencing any ill effects from it. In the hands of others, however, the results have not been so suc- cessful. Jobert in particular objects to the plan on the ground of its liability to be attended with severe suffering. In all the cases witnessed by himself the patients were affected with fever, heat of skin, colicky pains, and vomiting; the countenance was livid and contracted, and the symptoms closely resembled those of strangulation. He refers to a case that occurred at the Hotel-Dieu of Amiens, were death was produced by the pressure of the enterotome, and adds that examples of a similar description have been recorded by dif- ferent practitioners.* He, therefore, advises that the instru- ment should be applied rather loosely in the first instance, and gradually tightened until it produces the desired effect. My own experience does not enable me to speak positively on this subject one way or another. In one case in which I employed the enterotome the blades were applied with great firmness, and yet no unpleasant symptoms followed. The practice seems to me to be perfectly rational, and where bad effects follow, the pressure of the instrument may be dimin ished at any moment. *Traite des Maladies du Canal Intestinal, T. ii, p. I'M. 18 206 WOUNDS OF THE INTESTINES. The following is an abstract of the first case in which Dupuytren employed the enterotome on the human subject. Menage, twenty-six years of age, was admitted into the Hotel- Dieu, in January 1816, with an artificial anus in the right groin, produced by gangrene of the bowel twelve months pre- viously. At first the evacuations were passed through the abnormal opening; but eight weeks after the operation, which had been performed for his relief, he was attacked with col- icky pains, and had several natural stools, which afterwards recurred, though at long intervals. On his admission, the artificial anus was at least half an inch in diameter, and sur- rounded by irregular projections of the lining membrane of the gut, while behind a hernial protrusion appeared whenever he exerted himself, and frequently gave rise to invagination of "the intestine. The skin around was raw and sore, the suffer- ing severe, the stench intolerable. Having allayed the irrita- tion of the parts, the blades of the enterotome were sepa- rately introduced, as high as they would go, into each portion of the canal, and closed with considerable firmness. No pain was felt, and the next morning the pressure was in- creased, when slight colic was experienced. In a few days the blades became somewhat moveable. On the sixth, the man had several small evacuations by the natural outlet, and, on the eighth, the instrument fell off, holding in its grasp a membranous band, twenty lines in length by two in breadth. From this period the faeces passed by the rectum, but the artifical anus, though narrowed, still continued open, notwith- standing the employment of pressure, adhesive plaster, and lunar caustic. At length the edges were pared off, and brought together by the twisted suture, aided by a particular instrument. At the expiration of four months the patient was exhibited to the Faculty of Medicine, entirely cured of his infirmity. Several surgeons, impressed with the conviction that the enterotome of Dupuytren does not fulfil all the indications which may be expected from such an instrument, have endea- ARTIFICIAL ANUS--TREATMENT. 207 vored to modify and improve it. It is not necessary to notice all these attempts; I shall glance only at a few of the more important, inasmuch as the principle is the same in all. Liotard,* a French surgeon, recommends an enterotome, the blades of which end each in an oval ring, an inch and a half in length by nine lines in width, and so constructed that the blunt crest of one is received in the corresponding gutter of the other. With this instrument he proposes to cut a hole through the septum, instead of destroying it from before backwards, as in the method of Dupuytren. He alledges that, when thus executed, the operation is followed by a free passage for the transmission of the faeces, and that the two extremities of the gut are more apt to regain their accus- tomed movements in the cavity of the abdomen. On the other hand, it has been urged that this instrument is not only difficult of introduction, but that it is liable to grasp a neigh- boring coil of the intestine or a fold of the omentum. This objection, however, if it is not entirely chimerical, as I am disposed to believe it is, is no more applicable to this con- trivance than to the original; which, as has been seen, often embraces the septum to the extent of two, three, or even four inches, without any ill effects. The only objection that I can perceive is, not to the enterot&me itself, but to the man- ner in which it is used. The portion of the partition left undivided in front, or between the outer orifice and the open- ing of communication, might possibly interfere with the re- parative process, but I am not certain that it would even do this That it would prevent the cicatrization of the sore, and predispose to the formation of a permanent fistula, as some have pretended, is not very probable. The only instance in which, so far as my information ex- * Diss Sur le Traitement des Anus Centre Nature-Diet, de Medicine, T. iii, p. 365-Jobert, op. cit. T. ii, p. 129-Malgaigne, Med. Operat. p 572. 208 WOUNDS OF THE INTESTINES. tends, the enterotome of Liotard was used on the human sub- ject, has been recently related by Blandin.* The disease, in this case, was caused by strangulated inguinal hernia, in which six inches of intestine had become gangrenous. The two extremities of the tube lay parallel with each other; the faecal matter escaping from the superior, which was very tumid externally, and readily admitted the finger. The infe- rior one was more contracted, and its diameter daily dimin- ished. The superior end formed an irreducible tumor, which Blandin comprehended in a ligature, and it sloughed off on the fourth day. He then constructed an enterotome com- posed of two branches, each of which terminated by an oval ring, from eighteen to twenty lines in length, and from six to eight in breadth; the internal surface being marked by alter- nate elevations and depressions. This instrument was intro- duced into the extremities of the bowel, to a depth of four or five inches, and compressed by means of a screw. Absti- nence and rest were enjoined; no bad symptoms ensued; and the enterotome separated on the fifth day. On the same evening the patient voided solid faeces by stool for the first time during an entire month. Gas and a yellowish green fluid continued to escape for sometime at the external orifice; but this gradually ceased, and the cure was completed in two months after the employment of the instrument. Another modification of the enterotome was proposed by the late Professor Delpech of Montpelier.t He was of opin- ion that the original instrument divided the partition to too great extent at one time, and that the application of it was liable to be followed, from the contact of faecal matter, by protracted suppuration, together with ultimate contraction of * Archives Generales de Medicine, T. xii, Nov. 1836.—British and Foreign Med. Review, vol. iii, p. 520. t Observations sur l'Anus Artificiel; Memorial des Hopitaux du Midi, F<5vrier, 1830, p. 76. ARTIFICIAL ANUS--TREATMENT. 209 the parts, and a partial re-production of the ridge. These inconveniences he thought might be obviated by the more gradual division of the intermediate structures; and for this purpose he devised an instrument fashioned somewhat like a compass, with thin, hollow branches, slightly curved, and terminating each in a sort of spoon, an inch long, and pro- vided with a blunt rim. The branches are united by a screw, and are introduced separately into the bowel upon an ebony gorget. The enterotome is then locked and secured by a thread or tape to a bandage round the corresponding thigh. When the spoons are applied it is said that they em- brace the septum to the extent of four inches in depth by up- wards of an inch in breadth.* Nevertheless, Delpech con. siders this instrument as a valuable improvement, and has published a case in which its employment was followed by complete recovery. The most important modification, perhaps, of the entero- tome, if, indeed, it may not be regarded as an entirely new instrument, was suggested in 1827 by Reybard.f It is difficult to convey an intelligible idea of it without the assistance of a drawing. In its general form it resembles a pair of dissec- ting forceps, slightly curved on the surface for two inches, or to within a short distance of its junction with the branches, which are themselves four inches long, and rounded off at the end. The branches, are, moreover, flattened in their entire extent, and fenestrated in the same direction from their ori- gin to within two or three lines of their extremity. Near the handle, on each side of the gutter or slit-like opening just alluded to, are two screws by which the instrument is closed and locked. Introduced into the upper and lower end of the o-ut, they firmly hold and compress the septum, without con- tusing it, or depriving it of its vitality. Adapted to the fenestra of the upper branch is a moveable knife, designed * Diet, de Medecine, T. iii, p. 365. t Memoires sur le Traitement des Anus Artificiels, et des Plaies des Intestines; Lyon et Paris, 1827. 210 WOUNDS OF THE INTESTINES. for dividing the partition to the extent of two or three inches. This section would be attended with hemorrhage, were it not for the pressure exerted by the instrument, which is kept on for about forty-eight hours, or until the adhesions in the adja- cent structures are sufficiently firm. In two cases in which Reybard employed his enterotome, the operation produced hardly any pain, no bad symptoms ensued, and the patient rapidly recovered. Finally, a new enterotome, regarded by some American surgeons as a valuable improvement on that of Dupuytren, was invented in 1835, by Dr. J. R. Lotz, of New-Berlin, in the State of Pennsylvania.* The blades, which are six inches in length, terminate each by an oval fenestra, twelve lines long by three in breadth, and surrounded by a narrow, solid rim. They are articulated in the following manner. At the upper extremity, or that which in forceps answers to the joint, and also at the middle of one of the blades, are two steel slides, which are fitted into mortice holes in the corres- ponding parts of the other blade. Near each of these slides is a screw, of which the posterior passes through one blade, and simply presses on the other, to regulate the distance be- tween them, while the one at the centre of the instrument extends through both blades, approximates them, and presses the edges of the fenestrae against each other. The mode of applying this instrument does not differ from that of Dupuytren. The blades being unscrewed, and in- serted separately into the intestinal orifices, the two slides are introduced into the mortice holes, and the fenestrae brought upon a line with each other. "The central screw is now in- troduced, and the adjusting screw having been previously turned far enough to allow for the thickness of the double walls of the intestine included between the pinching extrem- ities, the central screw is tightened until the edges of the fenestrae press firmly upon the intervening membranes. By unscrewing the adjusting screw and tightening the central * American Jour. Med. Sciences, vol. xviii, p. 367. ARTIFICIAL ANUS--TREATMENT. 211 one, the pressure can be increased to any requisite degree without destroying the parallel direction of the blades." Dr. Lotz, I believe, has employed this instrument only on one occasion. His patient was a woman forty-one years of age, and the disease, caused by a gangrened hernia, had ex- isted four or five weeks. On the fourth day after the opera- tion, he excised, with a gum-lancet, the portion of the septum corresponding with the fenestrae, and established a direct com- munication between the two ends of the tube. The instru- ment was now gradually slackened, and in a week it was re- moved altogether. On examining the parts, a smooth circu- lar hole was found, about the dimensions of an inch, with the bowel firmly adherent all around. When the case was re- ported, several months after the operation, the faeces passed nearly all by the natural channel, and the patient was far advanced in utero-gestation. Whether complete recovery ultimately ensued, I am not able to state, as no further ac- count of the case has, I believe, been published. Having had occasion recently to treat a case of artificial anus, it occurred to me that an enterot me might be devised, much more simple, and in all respects much better adapted to the purpose, than any of those noticed in the preceding pages. Accordingly with the assistance of Mr. Erringer, an ingenious cutler of this city, I had an instrument constructed, of which the following is a description. In its general ap- pearance it closely resembles an artery-forceps, being com- posed of two blades, and of an intermediate catch. Each blade is five inches in length, and terminates anteriorly in an oval ring, eighteen lines long by eight in width. In thick- ness the ring does not exceed the twelfth of an inch; it is smooth and° convex externally, but the inner surface is un- dulating, or marked by alternate elevations and depressions. The catch by which the blades are closed is situated at the centre of the enterotome, and is furnished with a rack, for the purpose of regulating the amount of pressure when it is applied to the eperon between the two ends of the bowel. The weight of the instrument is scarcely half an ounce. 212 WOUNDS OF THE INTESTINES. The annexed drawing, prepared by my friend Dr Bayless, will explain the nature of this new entero- tome more satisfactorily than any description, how- ever elaborate. Figure 1 represents the two blades, the manner in which they are connected behind, and the rings in which they end in front. When they arte closed, the depressions of one ring receive the eleva- tions of that of the other, and thus prevent the in- strument from losing its hold. Figure 2 exhibits the catch and the arrange- ment of the teeth of the rack. The instrument here de- scribed and delineated, I have not had an opportu- nity of employing upon the human subject. In the case adverted to I used an ente- rotome of a more clumsy construction, the blades of which, connected by a hinge-like joint, were closed by a central screw, and terminated each in an oval ring, about twelve lines long by eight in width, and perfectly smooth at the inner surface, instead of being rough and undu- lating, as in the new instrument. It was applied with great firmness, and dropped off at the end of the sixth day, includ- ing the portion of the septum which it had embraced. No ARTIFICIAL ANUS--TREATMENT. 213 bad symptoms followed the constriction. For the first few hours there was some uneasiness in the part, and the patient, a colored boy, sixteen years of age, complained of slight nausea. These, however, rapidly subsided, and did not sub- sequently recur. As the case is still under treatment, I shall content myself with the following abstract of it, intending to present a more full report at some future period. In December, 1840, as I learn from Dr. Ford, of Somer- ville, Tennessee, the boy was caught in the machinery of a cotton-gin, by which the parietes of the abdomen were torn open at their lower part; the wound extending, on the one hand, from the pubic symphysis to within an inch of the um- bilicus, and, on the other, from a short distance above the anterior superior spinous process,of the ilium of one side to that of the other, forming a large flap, which was drawn up so as to expose the small bowels. The accident was attended with very little hemorrhage. Dr. Brackin, who saw the boy soon afterwards, brought the edges of the wound together by stitches and adhesive straps, aided by a suitable bandage. Perfect quietude was enjoined, and the most rigid antiphlo- gistic regimen adopted. After some days the flap alluded to sloughed off, when it was ascertained, for the first time, that the small bowel had sustained some injury. In a few months the opening had contracted to about one-fourth the original size, the intestine adhered firmly to the margin of the artificial anus, and the passage of faecal matter was easily controlled by a compress and bandage. Several attempts were subse- quently made to close this outlet, but they all proved unsuc- cessful. When the boy was sent to me, last March, the opening, situated on the left side of the median line, nearly midway between, the groin and the umbilicus, was of an oval shape, two inches in its transverse diameter, and fifteen lines in the vertical. The surrounding parts had a raw, excoriated ap- pearance, and the bottom of the ulcer was formed by the two ends of the bowel, lying parallel with each other, the upper orifice being external, the inferior internal. The sore was 214 WOUNDS OF THE INTESTINES. nearly half an inch in depth; the edges were bevelled, or depressed towards the centre, and nearly all the faeces flowed in this direction, except when the parts were protected by a compress and bandage. When in the erect posture, there was, at times, a considerable protrusion of the mucous mem- brane, especially of that of the lower end of the intestine. The intervening septum was well-marked, and formed a seri- ous obstacle to the transit of the faecal matter from one ori- fice to the other. The boy's appetite was good, and his gene- ral health unimpaired. Having destroyed the intervening septum by means of the instrument above alluded to, the faecal matter soon passed, in great measure, along the natural route; but there was no disposi- tion whatever in the opening to contract, owing to the loss of muscular substance. Under these circumstances, I pared away the edges of the protruded mucous membrane of each end of the bowel, and approximated them by several points of the interrupted suture. In this manner I succeeded in obtaining a considerable degree of union; and by repeating the operation, as has been since done a number of times, the opening is so far closed that there is now, June the 20th, only a small slit-like aperture at each angle of the ulcer. By per- severence I shall be able, I think, to effect complete adhesion between the parts, and relieve my patient of his loathsome disease. In 1820, Mr. Collier,* a surgeon of London, conceived and executed the plan of curing an artificial anus by a sort of autoplastic operation. The patient was a male servant, and the aperture, occasioned apparently by a stercoraceous ab- scess, occupied the right groin, being large enough to admit two thumbs. When Mr. Collier first saw him, two or three months after the formation of the artificial anus, it had con- siderably diminished in size, and was surrounded by callous edges. When the bowels were constipated the faeces escaped chiefly by the abnormal opening, but when they were relaxed, * London Medical and Physical Journal, vol. lxiii, p. 466. ARTIFICIAL ANUS--TREATMENT. 215 or under the influence of medicine, nearly all came away by the natural route. After several failures to unite the parts by suture and other means, Mr. Collier determined, if possible, to effect a cure by an operation on the principle of Taliacotius. With this view, having pared away the indurated margins of the sore, and converted them into a raw surface about twice the diameter of the artificial anus, he dissected off an adequate cutaneous flap immediately above it, and placing it over the aperture, maintained it by four stitches. A compress and truss constituted the dressings. Complete recovery ensued, without any unpleasant symptoms. A similar operation was lately executed, with the same happy results, by Mons. Blandin. An account of this inter- esting case will be found in the Memoirs of the Royal Acad- emy of Medicine of Paris, for 1838, and also in the "Gazette Medicale" for July of the same year. The patient was a countryman, aged fifty-two, and the artificial anus, produced three years previously by a gangrened rupture, was situated in the inguinal region of the right side where it communicated with the caecum. Nearly all the faeces passed out at the abnormal opening, which was of a circular shape, and sixteen lines in diameter. There was occasionally also a considera- ble protrusion of the bowel. After the failure of the more ordinary methods of treatment, a quadrilateral flap of the skin and cellular substance was made just below the opening, by three distinct incisions, and dissected up for the space of nearly two inches, being left adherent by one of its edges to the inguino-crural region. The integuments over the supe- rior internal and external margins of the opening were then removed to the extent of about three lines, when the flap was drawn up and put in contact with the parts, with its bleeding surface looking backwards, and the points of suture placed beyond the circle of the artificial anus. A piece of linen spread with cerate, a layer of charpie, a few compres- ses, and a truss with a weak spring, formed the dressings. By the fourth day the flap had perfectly united, both externally 216 WOUNDS OF THE INTESTINES. and internally» except above, where it became necessary at the end of a fortnight to pare away the opposing edges, and bring them together by the twisted suture. The adhe- sion after this operation was almost complete, two little holes only remaining, and these speedily cicatrized under the use of the nitrate of silver. The walls of the abdomen were preternaturally feeble at this point, and required to be sup- ported by a truss. This plan has likewise been tried by Velpeau, but without success. On the second day a yellowish serosity with sterco- raceous air was observed to escape between the sutures, and the flap was seized with gangrene extending from its edges towards the pedicle by which it adhered to the neighboring parts. The operation of Collier appears to be more particu- larly applicable to those cases of the disease which are unattended with an intervening septum, and in which the gut retains its normal caliber, or nearly so. It will also be more likely to succeed where the outer orifice is small, and the margin soft and healthy. Under opposite circumstances it can hardly be attempted with the prospect of a favorable result. Another method, somewhat analogous to the prece- ding, was put in practice a few years ago by Velpeau.* It consists in making two semi-elliptical incisions around the preternatural aperture, about fifteen lines exterior to it, and in approximating the parts, previously made raw, by several points of suture. The new wounds are filled with charpie, and the dressings are completed by the application of a com- press and bandage. The ligatures, which are all introduced before making the lateral incisions, are tied with moderate firmness, and carried through the parts in such a manner as to prevent them from tearing out, or injuring the bowel or peritoneum. This new operation was executed by Velpeau, for the first time, on the 15th of November 1835. His assistant was Dr. Mott, of New York, and the patient a young man from Nor- * Medecine Op6ratoire, T. iv, p. 153. ARTIFICIAL \.\US--TREATMENT. 21 < mandy. As a preliminary step, he pared away the margins of the abdominal aperture, obliquely from the circumference towards the centre, and in such a manner as not to injure the gut, or its mucous membrane. He next introduced four sutures, at intervals of two lines from each other, and with the precaution of not penetrating the abdomen or the intes- tine. A semi-lunar incision, two inches long, and including the skin, cellular substance, and aponeurosis of the external oblique muscle, was now made around each side of the arti- ficial anus, twelve or fifteen lines beyond it. The parts being- cleansed, the operator tied the sutures, and laid a roll of charpie in each lateral wound, to separate its edges, before he applied the dressings. Three days after the operation there was such an accumu- lation of alvine matter as to render it necessary to cut away the sutures. The edges of the sore were washed, and the patient, kept as quietly as possible, was allowed a more liberal diet. On the 30th of December the purulent discharge had almost ceased, and by the 4th of January 1836 the faeces had entirely resumed their accustomed route. To render the cure more certain, the patient remained in the hospital until the 8th of February. The object of this ingenious operation, as will be readily perceived, is to bring the raw margins of the outer orifice in contact with each other, to facilitate their re-union. The artificial anus is thus converted, to use the language of Vel- peau, into a sort of basin, the bottom of which is sensibly smaller than the entrance or mouth. The approximation, easilv accomplished by the lateral incisions above described, has the effect of completely closing the intestinal portion of the orifice. A strict regimen, perfect quietude, and a gentle enema every evening, will promote the cure. In 1827 Mons. Colombe,* a French surgeon, suggested the idea of re-establishing the continuity of the two extremities of the bowel by means of a large gum-elastic tube, slightly 'Biblioth. Med. T. i, p. :>9. ls-27. 19 218 WOUNDS OF THE INTESTINES. curved, and from two to three inches in length. This is in- troduced, first, into one end and then into the other, with the concavity resting against the eperon or septum, and secured by a ligature, passed through its anterior wall, to the outside of the abdomen. It is retained in this situation until the pas- sage for the faecal matter is sufficiently restored, and the ex- ternal aperture nearly closed, when it is removed, and the case managed in the usual manner. This method was tried by Velpeau* in 1831, but his patient died three days after under symptoms of acute peritonitis. The intestine had been perforated at its posterior part, and the tube projected across the opening, but whether as cause or effect, could not be ascertained. Another proceeding which has been lately proposed is ex- cision of the intervening septum. The operation was first performed, a few years ago, by Mons. Raye, a French sur- geon. He seized hold of the eperon or partition between the two ends of the bowel with a pair of polypus-forceps, and cut out a large V-shaped flap with the scissors. No untow- ard symptoms followed the operation, and the patient prompt- ly recovered. The particulars of this interesting case will be found in the "Gazette Medicale" for 1S38. The artificial anus is occasionally found to open into the vagina, as in the interesting cases mentioned by Casamayor and Roux. In the first of these the posterior wall of the vagina was lacerated during a severe and protracted labor. A fold of the ileum, lying in front of the rectum, was forci- bly compressed during the descent of the child's head, and, although it contracted firm adhesions to the tube in question, it became subsequently, like the rest of these parts, involved in gangrene; the deplorable disease alluded to was the conse- quence. To remedy this, Casamayor endeavored to establish a communication between the ileum and the rectum, so as to divert the faecal matter from the vagina, which was nearly obliterated by the wound or rent, and make it pass directly - Medecine Operatoire, T. iv, p. 153. ARTIFICIAL ANUS--TREATMENT. 219 from one of these intestines to the other. He accordimdv constructed a pair of forceps, six inches and a half long, the blades of which were about the diameter of a large quill, and curved in such a manner as to intercept a free space at their base. Anteriorly they terminated each by a ring eight lines long by four in breadth. The patient being placed upon her back, one of the blades was carried along the vagina into the small bowel, about an inch and a half above the abnormal opening, and the other to the same height into the rectum. Having ascertained that the enterotome embraced nothing but the opposed parietes of the intestines, the blades were approximated and locked. No evil consequences ensued. The instrument was removed six days after its application, leaving above the intestino-vaginal orifice an opening through which the faeces flowed directly from the ileum into the rec- tum. From this time the natural stools began to be re-estaL- lished, a small quantity of matter only passing along the vagina. Unfortunately at this period the woman was at- tacked with a violent inflammation of the lungs and pleura, of which she died in four days.* In the case related by Roux the procedure was entirely dif- ferent. After breaking up the adhesions between the bowel and the vagina, he attempted to unite the two ends ol the intestinal tube by suture; but the woman soon died from the effects of the operation.f * Diet, de Med. et de Chir. Pratiques, T. iii, p. 169. t Diet, de Medecine, T. iii, p. :>71. EXPLANATION OF PLATE. Fig. 1 exhibits the outer surface of the small bowel after the application ..i a ligature, the dog being killed on the eleventh day. The transverse line in- dicates the seat of the constriction, and the manner in which the lymph, poured out in consequence of the resultant inflammation, re-establishes the continuity of the tube. The new matter is of a pale straw color, firm, and organized. Page 25. Fig. 2; the internal surface of the same preparation; the mucous mem- brane has a reddish appearance, and near the centre of the constriction is a small yellowish mass of lymph, containing the ligature. Page 25. Fig. 3; the outer surface of the small bowel of a middle-sized dog killed four months after the tube had been encircled by a ligature; the part is smooth and polished, and attached to it, at a, is a small process of omentum. Page 26.—b shows the retraction of the coats of the bowel, and the eversion of the mucous membrane, in transverse wounds. Page 11. Fig. 4 is an internal view of the same section of the tube; the curved line shows the original seat of the constriction; the mucous surfaces are perfectly continuous with each other, the bowel is of the natural caliber, and the re- paration is complete. Page 25, Fig. 5 shows the attachment of the omentum to the outer surface of trie bowel, a very frequent occurrence in- wounds of this tube. Page 29 Fig. 6 exhibits the size and direction of a wound of the small bowel, at the end of the seventeenth day; the extremities are nearly united, and the centre is occupied by a small mass of lymph, of a yellowish color; the mu- cous membrane is slightly thickened and preternaturally red. Page 30. Fig. 7; a longitudinal wound of the small bowel in a more advanced state of cicatrization than the preceding; the lymph has disappeared, the edges of the fissure are nearly in contact, and there is no unnatural vascularity. The animal was killed at the end of four weeks. Page 30. Fig. 8; the appearance of the mucous membrane four months after tne excision of a piece of ileum two and a half inches long; the part is of the natural color, there is no contraction of the tube, and the situation of the injury is indicated by a narrow line, seam, or fissure. Page 16r. &&-1. F&2. Fif/.J. a %-■ ^k')#ii /-"*. rSM Fig. 4. &«"■-: I ■Jjfi*M8TrifT~ /%?. e>. -&0?i$ Tig7. ... ■.■r>::-.Vi',- I V t J i"' £ Fiy.G. i W,: jFigM. WCftters'im NATIONAL LIBRARY OF MEDICINE NLM010016930