748 



HERNIA. 



of an artificial anus being formed, the patient 

 and the hernia must be placed under circum- 

 stances so very peculiar that it will be easily 

 perceived how unlikely it is that they should 

 be united and combined in one individual. 



1. Although the protruded viscus has become 

 sphacelated, the inflammation within the ab- 

 domen must not have reached such a height as 

 to preclude the possibility of recovery. 



2. Adhesions must be established between 

 the bowel and the peritoneum either at or im- 

 mediately above the neck of the sac, so that 

 when the stricture is free and the enormous 

 alvine accumulation allowed to escape, it will 

 be impossible for the gut to withdraw itself 

 within the cavity or be removed from the 

 external aperture. 



And in order that the annoyance of the arti- 

 ficial anus should be subsequently removed, it 

 is necessary that the intestine and the perito- 

 neum to which it is adherent should retire into 

 the abdomen, and that the angle between the 

 two intestinal tubes should be diminished or 

 removed. 



1. If the first of these conditions is indispen- 

 sable, it follows that the chance of recovery 

 with artificial anus is inversely as the acuteness 

 of the symptoms and the rapidity of their pro- 

 gress. As it is the inflammation of the intes- 

 tines that destroys the patient, it is pretty evi- 

 dent that after it has reached a given point, no 

 operation performed on the hernia and no 

 evacuation of the contents of the bowels can 

 arrest its progress, or cause the absorption of 

 the lymph, or of the sero-purulent fluid that 

 lias been effused into the peritoneal cavity. In 

 operating on the living subject within twenty- 

 three hours after the first appearance of the 

 hernia, I have found the intestine sphacelated : 

 in this case, when the stricture was divided, the 

 discharge from the intestines within the ab- 

 domen was trifling in quantity, and in order to 

 relieve the patient, I was obliged to introduce 

 a gum-elastic tube for a considerable way into 

 the superior fragment of the bowel. He died 

 on the subsequent day, and on examining the 

 body the front of the intestines seemed to be 

 one mass of plastic lymph, which obliterated 

 every appearance of convolution, and must have 

 glued together the bowels in such a manner as 

 to prevent the possibility of a peristaltic motion. 

 In a case so aggravated no hope could be enter- 

 tained from the establishment of an artificial 

 outlet. It can now be easily imagined how 

 persons of a very advanced age,* and in whom 

 the symptoms of strangulation are mild and 

 chronic, recover with artificial anus, in short 

 that such a consummation is most to be ex- 

 pected in the cases to which the name " incar- 

 cerated" has been applied, whereas in most 

 inslancesof "strangulated" hernia its occurrence 

 is unlikely, and in many altogether impossible. 



2. The second great requisite for the esta- 

 blishment of an artificial anus is, that adhesion 

 shall take place between the bowel and the 

 peritoneum, either at or immediately above the 



* Sec Louis' Memoir on hernia followed by gan- 

 grene. Mem. dc 1'Acad. Hoy. v. 8. 



neck of the sac, so that when the stricture is 

 free and the alvine discharges allowed to escape, 

 it will be impossible for the gut to withdraw 

 itself within the cavity, or be removed from the 

 external aperture. This adhesion has, I think, 

 been generally supposed to occur "during the 

 inflammation which precedes the gangrene,"* 

 but is nevertheless probably always not only 

 subsequent to it, but to the separation of the 

 unsound and sphacelated parts; and the at- 

 tachment is, not between the contiguous and 

 opposing smooth surfaces of the serous mem- 

 brane, but between the divided edges of the 

 sound portions of the tube remaining after the 

 slough has been thrown oft', and the part of the 

 neck of the sac adjacent to them. I have ope- 

 rated on a great number of gangrened hernia;, 

 and never found such an adhesion to have pre- 

 viously existed, neither have I ever met with it 

 on dissection, and I cannot conceive the possi- 

 bility of a spontaneous return after sphacelus 

 (an event that but too frequently occurs) if the 

 parts were thus attached together. Assuredly 

 if such adhesions were formed at so early a 

 peiiod, they ought to be much more frequently 

 found, and they would be amongst the most 

 calamitous complications that could attend a 

 hernia ; for they would offer an almost invinci- 

 ble obstacle to its reduction, or supposing the 

 bowel to have been pushed up by force, such a 

 sharp angular fold would be formed as must 

 prevent the passage of its contents and create 

 an internal strangulation. Nor is the consider- 

 ation of this fact practically unimportant, if it 

 leads us to adopt every possible precaution 

 that may conduce to the undisturbed progress 

 of this adhesive process, and at the same time 

 warns us not to be too sanguine in our expecta- 

 tions. I have (as I have said) operated on a 

 vast number of cases of gangrened hernia, not 

 one of which recovered with artificial anus: 

 some, the great majority, perished, as has been 

 remarked, in consequence of the inflammation 

 within the abdomen having reached an incurable 

 height ; some others sank exhausted and died, 

 the system being apparently worn out and 

 incapable of a recuperative effort: others still, 

 from a retraction of the divided end of the bowel 

 and the escape of its contents into the cavity; 

 and one, from a cause which, as it has not been 

 mentioned by any pathological writer, may be 

 noticed here. On the spontaneous separation 

 of the sphacelated bowel, a frightful and incon- 

 trollable hemorrhage took place, some of which 

 flowed into the peritoneal cavity, and was found 

 after death diffused through the convolutions of 

 the intestines. 



When a case has been so fortunate as to 

 permit of the formation of an artificial anus, 

 after the mortified parts and putrid sloughs 

 have been removed a cavity is seen, genemlly 

 irregular and puckered at its edge, leading 

 down to and communicating with the injured 



* Scarpa on hernia, p. 323. See also Travers on 

 wounded intestines. " Dans les hernies, ces adiie- 

 rcntes precedent \'A destruction des parties, et elles 

 previetment le plus souvent I'epanchement des 

 maiiercs dans le venire/' Diipuytrcn, Lc9ons 

 Oralcs, torn. ii. p. 1!)7. 



