and lower part of the intestine protrude at once, there are two projections, and the stools are discharged from the middle of the upper end of the intestine. From this protrusion often arise very painful draggings in the belly, which prevent the patient keeping himself upright, and compel him to bend the upper part of his body almost horizontally forwards. In this complication of artificial anus, the symptoms are always more severe, digestion is highly affected, wasting makes quick progress, and leads to marasmus, if the local relations of the parts be not changed.

917. Fæcular fistula and artificial anus may be consequence of penetrating wounds of the belly, accompanied with injury of the intestine or with a protrusion which runs on to gangrene, also of gangrenous ruptures, of abscesses, of foreign bodies in the intestinal canal, and so on, by which either only one part of the wall of an intestine, or an entire coil of intestine is destroyed, in which case adhesion with the peritoneum takes place, at the circumference of the destroyed gut, and the effusion of stools into the cavity of the belly is prevented.

[TEALE gives in his essay a very good tabular account of cases of artificial anus resulting from these various causes.]

918. Upon the different position and state of the upper and lower portions of the intestine in artificial anus depends, whether the cure can be effected merely by the natural powers, or by the simultaneous assistance of art, or only by the intervention of an operation. The destroyed intestine, together with the corresponding part of the peritoneum, to which it adheres, retracts into the belly, where it forms a funnel-like cavity, which, in proportion as it enlarges, directs the passage of the stools from the upper end of the intestine into the lower. This, however, cannot happen in artificial anus, which forms after penetrating wounds of the belly, after old umbilical and ventral ruptures, when either the injured gut heals up with the edges of the outer wound, or the hernial sac becomes firmly adherent with the aponeurosis and abdominal coverings, and the extensible cellular tissue, which surrounds it in other ruptures, is deficient, consequently the adherent piece of intestine cannot retract into the belly sufficiently to form the funnel-like cavity by which the communication of the two ends of the intestine is produced. The cure of artificial anus in this way most readily occurs, when only part of the wall of the intestine is destroyed; but when both ends of the gut, between which a coil has been destroyed, are so connected and held by the mesentery, that they lie more or less parallel, and form an acute angle, a projecting partition is thereby formed which prevents the communication between the upper and lower ends of the intestine. If the projection of this partition cannot be removed by the retraction of the pieces of the bowel, the restoration of the natural passage of the stools is possible by destroying this partition.

The retraction of the piece of intestine specially depends on the movements of the bowel and the dragging of the mesentery, which, stretched like a cord from the back of the partition projecting between the openings of both portions of intestine to the spine, is always striving to retract the piece of adherent bowel. Thus is easily seen the effect which the recumbent posture and motion have upon the cure of artificial anus. DUPUYTREN (a) had two cases in which, by this dragging, the adhesions of the intestinal portions were torn through, and effusion of fæculent matter into the cavity of the belly caused. Examination after death of persons who have died of other diseases many years after the cure of artificial anus either by nature or art, shows the intestine either connected by a fibro-cellular band with the place of the artificial anus, or these (a) Leçons Orales.

connexions destroyed and the intestine floating freely in the cavity of the belly. In a case of artificial anus at the femoral ring, in a woman, which withstood the usual remedies, a spontaneous cure took place during pregnancy, (WEDEMEYER,) which DuPUYTREN attributes to the gradual retraction of the intestine from the external opening and the lengthening of the funnel-like cavity.

[LALLEMAND (a) had the opportunity of examining an intestine seven years after performing DUPUYTREN'S operation for artificial anus upon it; and of which the external scar in the skin had twice given way after violent exertion, discharging fetid pus mingled with gas and fæcal matter, but subsequently closed. He gives the following account of the appearances he met with :-"There was found in the left inguinal region an oblique fistulous opening leading into the canal, of the size of a crow-quill. Round this, to the extent of five or six lines, was a thin shining cicatrix, in which wrinkled folds of the surrounding integuments terminated. A portion of ileum, not differing from the usual appearance of the intestines, was adherent to the left inguinal region by two slender columns. One of these, four lines long by two in width, contained the canal of communication between the fistula and the cavity of the intestine. This canal passed through the inguinal ring, which was short and nearly direct. The other was an ordinary slender fibrous adhesion. There were several ulcerations of the mucous membrane towards the ileo-cæcal valve. As soon as the fistulous communication had passed through the ring, it began to enlarge and assume the funnel-shape, and was quickly lost in the cavity of the intestine. When the latter, which presented the usual circular figure was laid open, a slight prominence marked the situation which had been occupied by the edge: the mucous membrane was just the same here as elsewhere."

DUPUYTREN (b) himself also states that on examining the bodies of many persons who had been subject to artificial anus, but died years after of other diseases, instead of finding the intestine fixed to the wall of the belly, he saw it free and floating in the cavity. "I should," says he, “have fancied I had been mistaken, had not the patient's identity been indisputable, and had I not discovered a fibrous cord stretched from the point of the abdominal wall corresponding with the accidental anus up to the intestine. This cord, some lines in diameter and some inches in length, larger at its extremities than in its middle, covered with peritoneum and entirely formed of cellular and fibrous tissue, without any cavity, was evidently the progressive elongation of the cellular tissue which had united the intestine to the wall of the belly, and the cause of this lengthening could only be the constant dragging of the intestine by the mesentery, in the different motions of the body during life." (p. 208.)

The following account of the dissection of a case of artificial anus, after mortified strangulated rupture, given by SCARPA (c), explains the formation of the funnel:"I found," says he, "that the great sac of the peritoneum had not only become firmly adherent to the portion of the intestinal tube, which had been unaffected by the gangrene behind the inguinal ring, and, properly speaking, in the cavity of the abdomen, but likewise that this sac of the peritoneum, like a membranous funnel, (imbuto membranoso,) extended from the cavity of the abdomen, through the inguinal canal, into the fistulous tube communicating externally by a narrow hole in the groin. Having divided longitudinally the narrow fistulous canal, and the membranous funnel, I saw distinctly that the two orifices of the intestine had remained parallel, without being at all turned towards each other; and a ridge (promontorio) projected between them, which would have been sufficient of itself to prevent the direct passage of the faces from the superior to the inferior orifice. The alimentary matters must therefore have been poured from the upper end into the membranous funnel, and have passed thence, by a half circle, into the lower end of the intestine." Upon the same point DUPUYTREN observes:-" In examining the opening of the skin and the bottom of the artificial anus, a sort of funnel is discovered, the dispositions of which have been best observed and described by the celebrated SCARPA. It is formed of parts, which inflammation and contact have reduced to the same nature, to wit, that of mucous membrane. Its point is at the skin, its base at the intestine; its length, direction, form, and dimensions vary to infinity, and have the greatest influence on the cure of the complaint. The greater its extent and capacity, the greater disposition, in general, has nature to cure this ailment, or to second the efforts of art for that purpose. At the bottom of the funnel are found the most remarkable and important circumstances relating to the artificial anus. There are the orifices of the two ends of the intestinal canal, and there the partition by which they are separated. Of these two orifices, the one belongs to the

(a) Répertoire général d'Anat. et de Physiol. Patholog., vol. vii. p. 133.

(b) Lecons Orales.

(c) Sull' Ernie, Mem. iv. sect. iv.-I have to

acknowledge making use of LAWRENCE's tran-lation (from his work on Ruptures) of this portion of SCARPA as well as that from LALLEMAND.J. F. S.

anus.

upper part of the intestine, is always penetrated by the food and stercoral matter, is the most free and widest of the two. The other is the continuation of the lower end of the bowel, and as it does not receive either alimentary or stercoral matter, or only in very small quantities, it is usually narrow, contracted, and difficult to find. To these orifices succeed the extremities of the intestine, villous, and lined with mucosities within, smooth, covered with peritoneum, and bathed in serosity without, buried in the belly, sometimes crossing, sometimes twisting about each other, sometimes running parallel, but most commonly separating from each other at an angle more or less acute; and they are lost by curving more and more in the circumvolutions of the intestinal canal. On examining the space between the two orifices, a projection, more or less distinctly angular is perceived, and more or less near the entrance of the funnel just mentioned. This projection, the so-called spur (éperon) already perceived and pointed out by SAVIARD and MORAND, results from the application and union, at an acute angle, of the corresponding walls of the two parts of the intestine which abut in artificial *** After a time this spur does not divide the bottom of the funnel into which the two ends of the intestine open, into two equal parts. Continually pressed on by the matters which the upper end brings down, this fold yields to their pressure, and is gradually carried towards the lower end, upon which it advances more and more, till at last it covers its orifice with a sort of valve, which hermetically closes its entrance, and renders its discovery very difficult. Towards the intestinal cavity the spur has constantly a crescentic form, of which the angles directed from the concavity towards the convexity of the new curve of the intestine, are confounded with it, and gradually lost either in the walls of the organ or on the edges of the deepest part of the wound of the belly. On the abdominal surface it is seen doubled, and the two equal halves of which it consists separate and receive the mesentery in their interval." (p. 202-5.) "Thus," says LAWRENCE," the two portions of the bowel lie near together, but are not adherent; they are separated by the ridge called by SCARPA promontorio, and by the French éperon. If we introduce a finger into each orifice, and bring the fingers together, they are separated merely by the sides of the two portions of intestine. When it is described that they are kept apart by an intervening partition, we must remember that there is nothing but the intervening tunics. We might pass an instrument from one end of the bowel into the other, and thus cause a direct communication between them by perforating their coats; but as the bowels are simply contiguous without adhering, we should make a double wound into the cavity of the abdomen." (p. 383.)]

919. The treatment of fæcular fistula or artificial anus, consists at first merely in attention to the proper discharge of the stools, in covering the opening with a wad of lint, and the removal of all pressure from it; good nourishing food, and easy of digestion, should be given, and frequent clysters and gentle purgatives. If there be externally several fistulous passages, they must be slit up, the irritation and callosity removed by poulticing and cleanliness of the dressings, and hard, tough, dry callosities, which will not disperse, are to be removed with the knife. If the opening contract too quickly, or the stools cannot escape sufficiently, the opening must be enlarged with sponge-tent or the knife, which, however, is less safe, as the adhesions of the intestine may be easily divided. A sufficiently large pad should be put into the opening to prevent it narrowing; and its introduction is also the only mode of preventing the protrusion of the bowel. If this occur, attempts must be made to return it, and if that be not at once possible, we must try to effect it by continued pressure with a bandage. The patient must be kept in bed, and avoid all exertion. In strangulated protrusion, the stricture must be carefully divided at the root of the protruded part. If under this treatment the excrements be gradually discharged by the natural passage, and so continue for some time, the opening may be allowed to close, gradually, except the patient feels pain in the belly, or uneasiness from collection of stools; it is, however, advisable to keep up a small opening for some time longer by the introduction of a bougie. If the opening close too quickly, or if the stools collect largely at the opening of communica3 A

VOL I.

tion of both ends of the intestine, severe pain occur at the region of the artificial anus, painful distension of the belly, vomiting, and even bursting of the distended bowel, and effusion of fæcal matter into the cavity of the belly. In this case, if the opening be not yet entirely closed, an elastic tube must be introduced, through it, into the upper portion of the intestine, or escape must be afforded to the collected excrement by a sponge-tent or by incision.

[I have had but one case of artificial anus, and that in a boy of about ten years old, and at the navel, the middle of the scar in which projected a little beyond the surface and was perforated by a small hole of sufficient size only to admit a probe. Through this hole a very small quantity of dark-coloured fæculent matter daily escaped, and its acridity kept the edge of the aperture constantly sore. Neither how this had originated (though probably from abscess in the navel) nor how long it had existed can I state, having mislaid my notes; but the child was in tolerable health, though not very stout. Various means were tried without success to induce the hole to heal, among which attempting to form a scab with chalk and calamine powder, and the use of a pad and pressure. It was, however, finally cured by tying a ligature around it as low into the hollow of the navel as it could be depressed. This separated without any inconvenience, the wound healed and the fistula was cured.

KING (a) considers that similar cases (of which he gives two) with that I have just mentioned, depend on a communication with the diverticulum ilei, and founds is opinion on the analogy which exists between the umbilical vesicle of the human subject and the yolk sac of the chick in ovo; in the latter of which "omphalo-mesenteric vessels communicate between the yolk sac and mesentery; and there is also a trace of a tube, on the plan of a diverticulum, opening into the intestine." (p. 467.) The correctness of this view was fully confirmed by examination after death of the first case he relates, of this umbilical fistula which had been cured by making the edges raw and pinning them together. On examination, “ a diverticulum, about three inches long, was found adhering to the umbilicus; and an adventitious cord appears to have compressed the ileum, just below its connexion with the diverticulum.” (p. 472.)

I have also seen another case of aperture, in the navel of a woman about twenty-five years old, from which there was a constant flow of colourless fluid, and free from smell, in such quantity as to wet a napkin through once or twice a day. Whence this fluid came I cannot determine, it could scarcely have been from an intestine; I once thought it might have been obtained from the bladder by passing through an urachus, but it had not any urinary character. She had been subject to it for years, but her health was not at all affected and she was only inconvenienced by it.-J. F. S.

In concluding his review of DUPUYTREN'S operation for artificial anus, LAWRENCE observes:-"Cases of artificial anus must be much more numerous in Paris than in London. DUPUYTREN employed his method in between twenty and thirty instances within a short time. No opportunity has occurred to me of putting it into practice, either at St. Bartholomew's Hospital or elsewhere for several years; and I believe that it has hardly been employed at all in this country." (p. 415.)]

920. If with this treatment the cure of the artificial anus be not possible, because the partition between the two openings of the intestine projects too much, the partition must be cut off with the intestinal scissors (enterotome) invented by Dupuytren. For this purpose the position of both ends of the gut are to be most carefully ascertained with a thick sound oiled, or with the finger; to do which, previous enlargement of the external wound with sponge-tent is often necessary. The fleshy growths, which, however, must be carefully distinguished from the intestinal protrusion, are to be removed with caustic, ligature, or scissors. Finding the two openings of the intestine is often attended with much difficulty, because the partition is always pressed against the opening of the lower part by the stools flowing down from the upper, and the former is at last completely closed. The more readily the openings of both portions of intestine are found at the (a) On a Fæculent Discharge at the Umbilicus in Guy's Hospital Reports, Second Series, vol. 1. from communication with the diverticulum ilei; 1843.

bottom of the artificial anus, the more favourable is the prognosis. If thick probes (female catheters) be used for examination, they must be connected externally together after their introduction into the upper and lower end of the intestine, and turned upon their axes, which movement is opposed by the partition. When the ends of the intestine are discovered, the arms of the intestinal scissors should be so introduced into both ends of the gut upon the finger, or on the hollow sound, that when closed at least two and a half inches of the partition shall be taken hold of. The same turn is to be made with the introduced arms of the scissors as with the sounds, to ascertain that they have entered completely. By the screw on the handle of the scissors, they are to be closed only sufficiently to produce a little pain; the handle of the forceps is to be wrapped in linen and fastened to a T bandage. Every day, or every two days, the forceps are to be screwed a little tighter. If little pain follow it is well, but if severe the forceps must be loosened. The patient must take light nourishment, and soothing clysters may be given. Against pain in the belly, oily mixtures, soothing clysters, and applications are to be used, and in inflammatory symptoms, the proper antiphlogistic remedies. According to DUPUYTREN's observations, however, these symptoms rarely occur.

DUPUYTREN's first intestinal scissors crossed each other with a disjoinable lock; but SEILER has modified them by making the arms parallel (a).

LIORDAT'S emporte pièce, for the purpose of removing a larger piece of the partition (b).

REYBARD (c) seizes the partition between the upper and lower end of the intestine with forceps, and divides it by pushing forward his enterotome. The forceps are left attached to produce the union of the corresponding wounds of the intestine.

DELPECH'S enterotome (d) differs from that of DUPUYTREN in each of its branches, being a little curved, and ending in an oval plate an inch in length. When introduced and brought together by the screw, in consequence of the curved form of the branches, such portion only of the intestinal partition is compressed as is enclosed between the two plates. The object is to destroy a smaller portion of the partition at one time, and to repeat the process until a sufficient opening shall be made in it. The form of the opening, DELPECH also holds to be preferable to the lengthened slit made by DUPUYTREN'S instrument.

DESAULT was aware of the partition between the two ends of the intestine preventing the passage of the excrement, and endeavoured to retract and dim nish the protrusion, partly by closing the external opening with a plug, partly by the introduction of long rolls of charpie into the two ends of the gut, which he gradually brought straight, pressed back, and diminished. With the same object SCHMALKALDEN (e) made an opening into the projecting partition, which he endeavoured to preserve by introducing teats, and by careful notching, to increase and establish the natural passage for the excrement. [Our American brethren seem disconcerted at the invention of this mode of treatment being generally assigned to DUPUYTREN. After referring to DESAULT's practice just mentioned, Dr. GIBSON (ƒ) observes :-"A more expeditious and less troublesome operation was proposed and successfully executed by Dr. PHYSICK between the years 1808 and 1809. *** An operation similar to that of Dr. PHYSICK was afterwards performed by DUPUYTREN in Paris, and to him the merit of the proposal is awarded by European writers without the slightest foundation." (p. 316.) Now certainly, though our French neighbours are occasionally not particular in claiming that to which they are not strictly entitled, yet in the present instance, whatever may have been awarded to DUPUYTREN, he himself mentions in a note to his Memoir, SCHMALKALDEN'S dissertation, though without giving particulars, and also specially quotes Dr. PaYSICK'S plan of treatment from DORSEY'S Elements of Surgery, vol. ii. p. 67. He is therefore, so far at least as Dr. PHYSICK is concerned, entirely free from misappropriation. It cannot, however, be denied that PHYSICK'S account is merely the recital of a case and of a novel operation for its relief, without entering into the consideration of the nature and (a) SEILER, above cited, pl. vi. f. 14.

Above cited. (c) Above cited.

FRORIEP'S Notizen, No. 583. p. 169.-Chi

rurgische Kupfertafeln, pl. cclxviii.

(e) Above cited.

f) Institutes and Practice of Surgery, vol. ii. Philadelphia, 1827.