HERNIA. 



740 



intestine, from which the faecal discharge is 

 constantly trickling, and as there is often a suffi- 

 cient space for a portion of this to lodge and 

 remain, it may prove a source of troublesome 

 and dangerous ulcerations. In a shon time 

 the mucous membrane becomes everted and 

 protrudes, often, if neglected, to the extent of 

 several inches : it is a true prolapsus of the 

 membrane, not very unlike the prolapsus ani in 

 appearance. At the bottom of the cavity al- 

 ready mentioned, are the orifices of the intes- 

 tines, the superior of which is the larger, as it is 

 from it the discharge proceeds, whilst the 

 inferior is small and so contracted as frequently 

 to be discovered with difficulty. The partition 

 between the orifices is formed by the juxta- 

 position and adhesion of the sides of the intes- 

 tine : it is termed the " eperon" by Dupuytren, 

 and is larger and more obvious when a portion 

 of the bowel has been completely removed so 

 as to divide the tube into two parts, smaller 

 when only a knuckle has been pinched up and 

 gangrened without engaging the entire circum- 

 ference. To this *' eperon" and double partition 

 the mesentery is attached, and the functions of 

 this membranous ligament are said to exert a 

 very important influence on the progress and 

 after-consequences of artificial anus. 



Not only is the superior portion of the intes- 

 tine (that which is in relation with the stomach) 

 larger, but its extremity being fixed by the new 

 adhesions, the progress of its contents is greatly 

 facilitated, and according to Dupuytren actually 

 accelerated as to time. The inferior or rectal 

 portion, not performing its functions, becomes 

 diminished in calibre, and contains a white, 

 pulpy, albuminous material, which is sometimes 

 discharged by stool, but may remain undecom- 

 posed within it for months or even years. The 

 contracted condition of this portion of the gut 

 is of the highest importance to be attended to 

 in all instances where a recovery is possible or 

 likely to be attempted. This disposition of all 

 hollow structures in the body to accommodate 

 themselves to the bulk or quantity of their con- 

 tents has been already noticed, and to obviate 

 the inconveniences likely to arise from such 

 diminution, the older surgeons* strongly recom- 

 mended the use of enemata, in order, amongst 

 other advantages, to preserve the intestine in a 

 sufficient state of distension. 



The progress and termination of a case such 

 as has been under consideration may be ex- 

 tremely variable. The aperture may be situa- 

 ted in the lesser intestine so high up or so near 

 the stomach that the space to be traversed by 

 the aliments and their period of detention are 

 shortened : their digestion is then incomplete 

 and nutrition so far impaired that the patient 

 sinks gradually, and dies from the effects of 

 inanition ; or a permanent artificial anus may 

 be established without a hope or a chance of the 

 natural passage ever being restored ; and this 

 seemed at one time to have been the great 

 object of surgical practice in these cases, for we 

 find M. Littre, a celebrated French surgeon, 

 actually tying up the lower portion of the gut 



* See Louis' Memoir, loc, citat. 



when he could find it, as if to preclude for ever 

 a possibility of the continuity of the tube being 

 restored. This is a most deplorable condition, 

 yet have patients endured the annoyance of a 

 permanent discharge at the groin for a great 

 length of time ; and in the Museum of the 

 School in Park Street, there is a preparation 

 taken from a man who had thus existed for 

 upwards of ten years. There is a curious in- 

 stance mentioned by Louis in which something 

 resembling the regular action of a sphincter was 

 clearly observable, and although the discharge 

 of the faeces was involuntary, yet it was periodical, 

 and the gut once evacuated remained closed 

 until a new accumulation took place. This 

 person, of course, was comparatively free from 

 that constant trickling of faeces which is the 

 patient's chief annoyance, and which, if not 

 palliated by some ingenious contrivance, abso- 

 lutely renders his life loathsome. 



The natural passage of the faeces has been 

 restored. This is so desirable, so fortunate a 

 consummation, and its practicability so clearly 

 established by the circumstance of its being oc- 

 casionally accomplished solely by the operations 

 of nature, that it can be no matter of surprise 

 if surgeons have laboured to attain it and dili- 

 gently observed the entire process. An intes- 

 tine of which a portion has sloughed away is 

 placed in a very different condition from one 

 that has been simply wounded. When an en- 

 tire loop of bowel has been removed, the two 

 portions within the abdomen passing down to 

 the neck of the sac lie more or less parallel to 

 each other, or approach by a very acute angle : 

 they are in the same degree perpendicular to 

 the ring, and between them is that double parti- 

 tion termed "eperon" or buttress by Dupuy- 

 tren, and the " promontory" by Scarpa. Now as 

 the intestines are fixed and fastened in this posi- 

 tion, the canal can never again become conti- 

 nuous in directum, and therefore any material 

 that passes from the upper into the lower 

 portion must do so by going round this inter- 

 vening promontory. Even when only a small 

 fold or knuckle has been lost, although the 

 complete continuity of the tube is not destroyed, 

 and the partition is less evident and prominent, 

 still an angle must inevitably be formed of suffi- 

 cient acuteness materially to impede the pro- 

 gress of the faeces. In neither case, then, can 

 the wounded edge of one portion of the intes- 

 tine come to be applied to that of the other, 

 nor can adhesion or union by the first intention 

 ever be accomplished between them. In lieu 

 of this, however, the edges of the intestine be- 

 come united with the peritoneum opposed to 

 them, which must of necessity be the neck of 

 the sac, and then if the external wound can be 

 healed, a membranous pouch or bag is inter- 

 posed between them, of a funnel-shape, and 

 which serves as a medium of communication 

 and of conveyance for the faecal matters from 

 one portion of the tube into the other. 



Reflecting on this pathological condition of 

 parts, it will not be very difficult to explain some 

 of the varieties observed in cases of artificial anus. 

 The chief obstruction to the re-establishment of 

 the canal is the intervention of the promontory. 



