John Duncan
1873 The Lancet  
THE treatment of artificial anus has at various time! attracted considerable attention. Till a comparatively recent date its pathology was imperfectly understood; bul the recognition of the septum as the main obstacle to closure and the methods for overcoming that obstacle adopted by Schmalkalden, Physick, and Dupuytren greatly elucidated the subject, and marked a very decided advance in prin. ciple and practice. Still, however, in a certain number of cases the destruction of the septum is not
more » ... ollowed by obliteration of the abnormal orifice, and in these circumstances surgeons resort to plastic operations, of which the main characteristics are a bewildering variety and a great absence of success. I venture to add to the list yet another method, because I think it presents fewer chances of failure than any hitherto devised. It rarely falls to the lot of a surgeon to consider the treatment of a case to which such an operation may be applicable. I make no apology therefore for illustrating my proposal by a solitary example. It possesses at least the merit of completeness, and assuredly exhibits no undue haste on my part to anticipate the efforts of nature. The patient was a domestic servant, aged forty-five, whom I was asked to see by Dr. Inglis in April, 1869. She had been ill for a week before sending for Dr. Inglis, and had supposed her illness to be a bilious attack, unconnected with the swelling in her left groin, as this had often previously come and gone without causing discomfort. I found it to be a femoral hernia already red, swollen, and emphysematous. An incision exposed a loop of the intestine gangrenous in its entire circumference, and rent on its convex surface. I divided the stricture and left the bowel in situ. The patient slowly recovered with an abnormal anus capable of admitting two fingers, and through which alone the fseces were discharged. She was advised to await a possible natural contraction of the orifice, and I did not again see her till June, 1870. In the interval she had worn a truss, which, however, retained the fseoes very imperfectly, and during the whole time there had been no passage by the rectum. The artificial anus had not diminished in size, and the septum was distinct and prominent. The orifice of the lower portion of the bowel had contracted somewhat, but was large enough to admit the little finger. Instead of using the enterotome, I passed a double silver wire through the septum, about an inch and a half above its free margin. It was left loose for two days, and then one of the wires was gradually tightened, until on the eighth day it ulcerated its way out. The other wire had meanwhile, as I anticipated, become slightly imbedded by xeunion of the deeper parts, and it now fulfilled the purpose for which it had been left, in being drawn out through the recent adhesions. The same day fseces passed by the rectum, and after a week of considerable irritation, solid motions were regularly and naturally established. The patient was sent to the country, with instructions to remove the truss only for purposes of cleanliness. I again saw her in December, 1871, and was disappointed to find that still no contraction of the orifice had taken place, although (the truss being regularly worn) all the fseces passed by the natural route. Irepeated the former operation, including in the wire nearly an inch more of the contiguous walls of intestine. The condition of affairs was not thereby improved, and it was plain that the septum was no longer an impediment to closure. In April, 1872, I therefore performed the following operation. Having thoroughly cleared out the bowel by purgative and enema, I dissected up the mucous membrane all round the abnormal orifice for more than half an inch, invaginated it, and sewed the raw surfaces together by six points of interrupted catgut suture, which were then cut short. I next pared freely the margin of the skin, and brought it together by means of silver wire. During the after-treatment the parts were relaxed by keeping the thigh flexed. The diet was restricted to milk with lime-water. On the eighth day, finding the wound entirely united, I removed the stitches. A little froth issued from the small openings left by the removal of a corner stitch. These openings remained patent for some weeks, notwithstanding the use of the hot wire. Nothing but gas, however, escaped from them, and they ultimately soundly healed. The patient remains in every respect perfectly well, and it is now a year since the closure was effected. Such an operation is, of course, only possible when the artificial anus is of large size ; but it is precisely in these cases that other methods are least successful. The advantages which I claim for it are, that it presents to the faeces the normal mucous surface of the bowel, that it diminishes the strain upon the stitches, and that it largely increases the depth of raw surface, by the adhesion of which the pressure from within is to be resisted. It seems to me theoretically sound, and in this case at least was practically successful. Edinburgh. I Nulla antem est alia pro certo noscendi via, nisi quamplurimasetmorborum et dissectionum historias, tum aliorum, tum proprias collectas habere, et inter se comparare.—MoB&A6Ni De Sed. et CauB. Morb., lib. iv. Proaernium. SUCCESSFUL operations for the remedy of extroversion of the bladder are of comparatively recent date, although numerous attempts had been made to relieve by surgical interference the distressing effects of this malformation. Dr. Daniel Aynes, of Brooklyn, U.S., appears to have been the first to succeed in covering the bladder with integument borrowed from the abdomen; but it is to Mr. John Wood and Mr. Timothy Holmes that we are chiefly indebted for the elaboration of an operation which has conferred such material benefit on these sufferers. The notes of the following cases are supplied by Mr. Wm. Rose, surgical registrar. CASE I.-George E-, aged seventeen, was admitted on March 6th, 1872, with ectopia vesicse, and wide separation of the pubes. The patient's sister had a similar mal. formation, but died when fourteen days old. On March 16th Mr. Wood performed his usual primary operation, which is fully described in Case 2. The case did not progress satisfactorily; and on the 23rd the lateral flaps were found in a sloughing condition. Two pins were used to unite these flaps; but, in spite of every effort to keep them together, they contracted, and left a large granulating interval. ' On the 27th of April the secondary operation was performed, but again sloughing took place in the upper part of the scrotal flap, leaving an opening through which urine passed. After a futile effort to close this opening, the patient was on July 15th sent into the country to recruit his health. On Nov. 8th the patient was readmitted. There were firm healthy cicatrices at the site of the former operations, but the opening at the upper and left angle still remained, through which urine dribbled, though the greater portion passed through the ordinary way. While in the country the patient passed a uric-acid calculus the size of a pea. Nov. 13th.-Two flaps were made, one from the newlyformed prepuce (originally scrotum), and another, from above the fistulous opening, was turned down and covered by the former, the two raw surfaces being apposed. The two flaps partially united, but a small quantity of urine still oozed through. Jan. 15th, 1873.-A small aperture remaining, two more flaps of adjacent integument were dissected up and closed over it. 22nd.-Erysipelatous inflammation had set in about the
doi:10.1016/s0140-6736(02)26179-6 fatcat:vvx6w7kdvjf5bj63pa4dhvtx7i