Three Cases of the Separation of the Epiphysis at the Head of the Femur
Boston Medical and Surgical Journal
which frecal matter almost constantly escaped. The right testicle was drawn up nearly into the external ring. The skin was infiltrated, cedematous and red, and there was considerable inflammation in the adjoining parts. His discomfort was so great as to be quite unbearable and life hardly worth living. He spent all his time in bed, wiping up with cloths the discharges which were constantly escaping through the numerous fistulre. After a careful study of the case, in spite of which it was
... which it was impossible to make out definitely the condition of the bowel ends or the direction of the sinuses, it was decided best to attempt the restoration of the alimentary canal. The history and physical examination made it quite apparent that the bowel had sloughed to a greater or less extent, but it was impossible to say that there was not still existing some communication to account for the occasional passage of freces by the rectum. The foul condition of the parts was so marked that it seemed unduly hazardous to open the abdominal cavity through the sinuses. There was no improvement in this respect, however, after constant and prolonged daily efforts at cleanliness, both on the part of the nurses and of the patient. The operation was planned with especial reference to the necessarily foul condition of the parts and the great danger of infecting the peritoneum. My hope and intention was to lay open the numerous sinuses by one long incision, curette them, and by some means to establish a communication between the upper and lower segments of the bowel from their interior. On exposing the external ring, I found two constricted openings side by side, into both of which it was quite feasible to introduce the index finger. Both segments were adherent to each other and to the surrounding parts. In separating the adhesions between the bowel and the abdominal wall for the purpose of making an anastomosis between the adherent segments, the peritoneal cavity was opened. During these manipulations several ounces of fetid pus welled from below the ring and apparently polluted every part of the wound,' including the prolapsed healthy intestine. The chief objection in this case to resection and suture had been the danger of infecting the abdominal cavity by the foul discharges of the sinuses and tho septic condition of the parts. The force of this objection was lost iu separating the adhesions, and I determined at once to make a complete resection of the exposed ends. About two inches of bowel were cut off from each end with the scissors, together with a wedge-shaped piece of mesentery. The bowel ends were held by assistants while interrupted Lembert sutures were applied in a single row, both to bowel and mesentery. The joint seemed very perfect and satisfactory. The bowel was then returned to the abdominal cavity and kept directly under the abdominal wound by means of iodoform gauze, which was placed just in contact with the line of suture throughout its whole extent. It will be seen that the approximated bowel ends and sutured mesentery were everywhere protected with gauze, and that the line of suture was everywhere provided with gauze drainage in case one or more sutures should give way. The external wound was also packed with iodoform gauze and aseptic dressing of cotton tightly swathed outside the whole. During the operation there was frequent and thorough irrigation with warm water. The time of the operation was one hour ; of applying the suture twenty minutes. On the following day the patient was in a remarkably good condition, bright and cheerful. On the second day he passed gas through the rectum for the first time since June. On the sixth day he was put on extra diet. He had a large movement of tlie bowels, and said he felt " first-rate." The wound was clean and granulating. The gauze was taken out, little by little, until November 12th, when it had been almost entirely removed. The wound was granulating, with still some slight redness and induration about the margin. On November 15th the last piece of gauze was removed and tho wound much closed up. On December 11 th, the wound was perfectly solid, and the patient felt perfectly well iu every way. The bowels were moved nearly every day. He was transferred to Waverley, and has remained well ever since. This case seems to me to be of value from the fact that the foul condition of the wound did not infect the peritoneum, and that it was possible to go through the manipulations of an extensive operation without ill results attending. The foul condition of the parts in this case led me to select a method by which, if possible, the peritoneal cavity could not become infected. The only way in which this could be done was to make an anastomosis between the proximal and distal ends of the intestine by working from the interior. The success of this procedure would depend obviously upon adhesions between their peritoneal surfaces. For, in the absence of such adhesions, it would be impossible to establish a safe communication by any imaginable method of intestinal suture. Careful attempts in this direction were followed by separation of adhesions and exposure of the peritoneal cavity. It would have beeu impracticable to establish satisfactory communication in this way, and I believe valuable time was lost in attempting it as a preliminary measure. Even if successful, it does not follow that the sinuses will become closed, nor that the anastomoses will remain permanent or efficient. When the peritoneum has become thus exposed to tho danger of infection, we must choose between anastomosis and end-to-ond suture. The latter method I . believe to be better, because it seems to me quite as quickly applied, and as secure, while there is practically no danger of stricture. The great danger in both methods is from giving way of the stitches and frecul extravasation. By applying gauze to the line of suture this danger is reduced to a minimum, for such good drainage is provided that nothing more than a temporary iistulous track is likely to remain.