ENTERECTOMY AND THE FORMATION OF AN ARTIFICIAL ANUS IN A PATIENT UPON WHOM CŒLIOTOMY WAS PERFORMED FOUR TIMES; REST IN THE TREATMENT OF RECTAL PROLAPSE, AFTER THE FORMATION OF AN ARTIFICIAL ANUS.

CLINICAL LECTURE DELIVERED AT BELLEVUE HOSPITAL.

BY JOSEPH D. BRYANT, M.D.,

Professor of Anatomy and Clinical Surgery, and Associate Professor of Orthopedic Surgery, in the Bellevue Hospital Medical College, New York City, New York.

GENTLEMEN,-The first case which I shall show you to-day has been a puzzle to us at times, on account of the personal peculiarities the patient has frequently displayed. This patient is illustrative of four distinct, full-fledged cœliotomies, besides two other penetrating incisions which cannot be dignified by the use of this expression. The first cœliotomy was done several years ago, and by Kocher, according to the patient's statement. For what exact purpose it was then performed one can only conjecture, but presumably it was for the relief of suspected intestinal obstruction, since when she was seen first by me she had many of the symptoms of this condition. The second operation was performed through the cicatrix of the first one by a surgeon in Connecticut, whose name the patient does not recall. As the patient has never complained of other symptoms than those quite easily attributable to intestinal obstruction, I believe that the reason for the second operation can also be based on this assumption. The third operation was done in the City (Charity) Hospital of New York by an able surgeon, Dr. Norris, only a few years ago, and the necessity for it was based on a similar belief. The fourth was performed by myself about two years ago in Bellevue Hospital, at the site of the preceding ones, for the cure of what was then supposed to be a fistulous communication between the transverse colon and the stomach. The belief in this condition was founded on the fact that when coloring waters and fluid

food were injected into the rectum they were soon discharged from the mouth, attended with vomiting. It should be said that the amount of time was not given to the personal consideration of this case that should have been, as she was committed to my care with the diagnosis already suggested. However, as was suspected, she did not have a fistulous communication. The symptoms already stated were self-imposed by means of the concealment in her mouth, when unobserved, of the material which, when expectorated at the proper time for deception, easily accomplished the purpose.

She possessed the ability of increasing the rectal temperature at will, but in what manner I could not ascertain. A rectal temperature of 110° was exhibited, although it was evident that elsewhere it was scarcely above the normal figure. She asserted that she could take no nourishment by the mouth, which appeared reasonable in the face of the fact of the occasional vomiting of fecal matter. However, inasmuch as but little physical deterioration and general disturbance were noticeable, it was thought she was practising a subtle deception in some manner regarding nourishment. After a little she was placed under strict surveillance and allowed no food whatever. The pangs of hunger soon forced a confession that she had been given food at night by the ward attendants, and had secured it herself, even, while others slumbered. As a sequel of the fourth cœliotomy a fecal fistula developed in the umbilical region, caused by a limited sloughing of the transverse colon at that point. A complete history of this most interesting case of hysteria is published in the Medical Record of October 7, 1892.

While I am not certain of the cause of this sloughing, still, I regard it as dependent on undue exposure of the free surface of the gut, caused by the separation of the adhesions that existed intimately between the transverse colon and the anterior surface of the stomach during the search there for the suspected fistula. Great care was exercised in this respect, and no evidence of denudation was observed at that time. About one year ago I dissected out the fistula, and closed the consequent opening into the colon in the usual manner, hoping to secure primary union. The attempt failed, dependent, as was supposed at the time, on the efforts of the patient to remove the dressings. At a later period I again exposed the opening, and, owing to the undue narrowing that would have resulted from another simple longitudinal enterorrhaphy, the opening in the bowel was extended on either side along the free surface for about two inches, and then closed entirely by the "elbowing" process.

I will explain this method to you. Let us, for the purpose of the

explanation, tie this string tightly around my extended arm, at the seat of the elbow. Of course it is apparent that it causes a constriction there, diminishing considerably the transverse diameter at that point. If an incision be now made along the anterior surface of the arm four or five inches in length, its centre corresponding to the constricted point, through the textile fabrics down to the integument, it is plain that the string (stricture) will be divided. I will now flex the forearm sufficiently to permit the distal extremities of the incision in the fabrics to be properly united with each other, and while in this position will sew securely to each other the opposed divided borders at either side of the opening. If we now substitute the colon for the arm, divide it longitudinally in a manner similar to that in which the textile fabrics are divided, flex the colon on itself at the centre of the incision, and sew the borders to each other, the gut is then "elbowed." This attempt failed also, and, in my opinion, for two reasons: 1. The occurrence of a severe diarrhoea, which was persistent, notwithstanding proper treatment. 2. The absence of suitable peritoneal surfaces at the sewed borders. You should be told now that the previous peritonitis excited by the numerous operations had been followed by entire loss of the glistening surface of the peritoneum, not only of the transverse colon, but of all the small intestines under observation. Adhesions everywhere between the intestines were substituted for normal tissue. This condition robbed the tissues of the intestine largely of the inherent tendency they possess to unite quickly, and likewise so lessened the activity of the nutritive processes of the wall of the bowel, through interference with the circulation, as to hinder union.

The next effort at cure was directed to turning aside the fecal current, in order that the colon might be at rest while undergoing repair. To meet this end an artificial anus was made on the right side, connected with the cæcum. It was hoped that the discharge of the fecal matter through this opening would lead to spontaneous closure of the fistula, and that it would remain healed after closure of the artificial anus. At any rate, the presence of the artificial opening in the cæcum was deemed necessary for the safety of the patient in the event of the performance of enterectomy, or even the use of the enterotome for the removal of the constricted portion of the colon. It was believed that prompt union of the divided tissues would be hindered by the changes in them induced by the inflammation that had followed previous operations. Moreover, the passage of fecal matter through the united gut under these circumstances could not but be highly objectionable and

even dangerous. At once, after the establishment of the artificial anus, the old sinus communicating with the colon began to close, and soon healed entirely, notwithstanding only the lesser portion of the fecal matter escaped by the new opening.

It is in this condition that the patient is now presented to your notice. What can be done to relieve her, and what are the prospects of success? The removal of the intestinal constriction is the urgent indication. If this be done, then the artificial opening will soon close of its own accord. It is estimated that a diminution of one-fourth the transverse diameter of an intestine is not inconsistent with the proper performance of its functions. In this instance a careful measurement of the gut at the time of the first operation established the fact that three-fourths of the normal diameter remained unaffected by the closure of the fistula.

In view of these facts, I have determined to close the artificial opening and await developments. If this course be not adopted, enterectomy with end-to-end-union, division of the intestine at the seat of the narrowing with lateral anastomosis, or the employment of the enterotome, offer the only practical measures of cure. The danger attending either of these acts is so much greater than the simple measure of closure as fully to justify this course, especially since, in case of failure, by reopening the old sinus one can begin over again with but little danger to the life of the patient.

[NOTE.-At the end of a week after the closure of the artificial anus the patient suffered from severe pain at the seat of the old fistula, attended with a small, painful, tender, deep-seated induration at the same site, which was not influenced by large high enemata.

At the end of two weeks the old sinus opened, but of less diameter than formerly. During this entire time the patient's bowels moved freely only with the aid of cathartics or enemata; otherwise nothing unusual was observed. I now intend to re-establish the artificial anus and employ the enterotome for the purpose of cure, as this is believed to offer the safer plan of procedure. Enterectomy with end-to-end union is regarded as unsafe, owing to the loss of normal peritoneal surface and the presence of dense adhesions. Lateral anastomosis is thought to be impossible, on account of the firm adhesions that confine. the transverse colon its entire length.]

The second case is one exhibiting the influence of "physiological rest" on an obstinate prolapse of the rectum which had been already subjected to many well-recognized methods of treatment of an operative nature without a resulting benefit of any kind, through the medium

of an artificial anus. The artificial anus was established with the sigmoid flexure three months ago. At present the following improvements are distinctly appreciable. (1) Pain and tenesmus have nearly disappeared. (2) Mucous and bloody discharges are arrested. (3) The prolapse is scarcely more than one-half its previous dimensions. (4) The sphincter ani is fast gaining tone; before this it was entirely paralyzed. (5) The patient's physical condition is now all that could be wished, and he expresses himself as being comfortable in any posture. About three-fourths only of the alvine matter escape through the artificial opening, the remainder passing by the rectum, aided by small enemata.

I shall continue to observe this patient until the fullest benefits of the measure are thought to be experienced. Please remember that this measure is contemplated only for the worst forms of otherwise irremediable prolapse, the only other remedial measure being amputation of the protrusion.