pas

patient's sufferings were much aggravated by the sage of fæces into the bladder through an opening communicating with the bowel above the stricture'. In a peculiarly distressing case of the same kind, recorded by Mr. Pennell, a communication having formed between the rectum and bladder, and urethra, in which there was an impassable stricture, so much irritation and mischief resulted, that the patient gladly submitted to a similar operation for his relief.

In obstructions of the rectum, an artificial opening for the passage of the fæces may be made into the colon in the left groin by the operation commonly called Littré's; or in the left lumbar region, by an operation known as Callisen's, modified by Amussat. Difference of opinion exists as to which is the better operation, each method being attended with certain advantages and disadvantages. I was at one time disposed to give the preference to Littré's operation, but a consideration of the facts adduced in Mr. Cæsar Hawkins' valuable paper in the Medico-Chirurgical Transactions3, and a further acquaintance with these cases, have led me to the conclusion that the opening of the colon in the left lumbar region is the safer and more advantageous proceeding. The chief objections made to the latter are, the strong disposition of the aperture to contract-the inconvenience of the situation and the difficulty of adjusting any apparatus to close it—and the magnitude of the operation. The first objection may be removed by care in making the opening in the bowel of sufficient size, and in securing its edges to the

1 He recovered from the operation, and returned to his home in Scotland, where he died at the end of five months. The case is recorded in the Medical Times and Gazette, Dec. 18, 1852. 3 Vol. XXXV.

2 Med.-Chir. Trans. vol. xxxiii. p. 255.

outer wound. operation, have complained of inconvenience from the site of the opening and of difficulty in closing it much less than might be expected. And as the persons requiring the operation are rarely stout, being always more or less emaciated by disease, the operation in the loin is not of any great magnitude, indeed, scarcely greater than the operation in the groin. On the other hand, the operation in the loin has the advantage of being external to the peritoneum, and of being attended, therefore, with proportionately less risk than the iliac operation. A table formed by Mr. Hawkins contains fourteen cases of operation for artificial anus on account of non-malignant stricture in the rectum or terminal portion of the colon. The iliac operation was performed in seven, of which four were fatal. The lumbar operation was performed also in seven, but only one proved fatal. The comparison of results in these cases is strongly, therefore, in favour of the lumbar operation*.

Persons who have survived the lumbar

Of these fourteen cases of operation, five were fatal within a month, and nine recovered. Of the latter, one survived five months, one fourteen months, and a third twenty-one months. The remaining six were all alive at the last report, and one was living seventeen years after the operation. Last year I had the opportunity, through the kindness of Mr. Clendon, of Albemarle Street, of seeing one of the survivors, the gentle

4

* It is right to notice that the cases of operation for cancerous stricture of the rectum, in Mr. Hawkins' tables, do not yield results so favourable to the lumbar operation. Of seventeen cases, five were operations in the groin; and of these, two were fatal. Twelve were operations in the loins; six of these were fatal within a month.

man operated on by Mr. Pennell in 1849. He was in good health, able to attend to business and to go into society, and suffered much less inconvenience than might be anticipated.

The descending colon may be opened in the left loin in the following manner. The patient is to be placed upon the face, with a pillow beneath the lower part of the abdomen, in order to render the left flank prominent. The spot where the intestine should be sought for and opened is about two fingers' breadth above the crest of the ileum, and midway between the anterior and posterior superior spinous processes. This spot being kept well in mind, an incision is to be made across the loin, commencing at the outer margin of the erector spinæ and carried outwards for about four or five inches. The layers of muscles are to be cut through down to the transversalis fascia, which is to be divided upon a director. In the loose fat beneath this fascia the posterior wall of the colon will be found. This is to be seized with the forceps and drawn towards the outer wound, and an incision is then to be made into it in the longitudinal direction. This opening should not be less than an inch in length. Its sides are to be secured to the lips of the wound in the skin by two sutures, one on each side. This is an important step in the operation, as it prevents fæcal effusion into the loose areolar tissue, renders the intestinal opening superficial instead of at the bottom of a deep wound, and obviates any after-difficulty in keeping the new anal aperture patent. A branch of one of the lumbar arteries may be wounded and may require to be tied. In cases of rectal obstruction with fæcal distension of the large intestine, this operation may be performed without risk of opening the abdomen, and

in practising the operation on the dead body, I have never found any difficulty in laying open the unloaded colon without wounding the peritoneum; but when the gut is contracted, the opening into it must be made an inch nearer the spine than the spot above indicated. In the case in which I performed the lumbar operation in the mode just described, the wound healed favourably, and the artificial anus remained free for five months afterwards, the period the patient survived it.

The abdomen may be opened in the left iliac region by a perpendicular incision, about three inches in extent, commencing two inches above Poupart's ligament, and an inch external to the course of the epigastric artery. The fibres of the abdominal muscles being cut across will help to keep the wound open. The peritoneum being divided, the distended colon will immediately protrude at the wound. A curved needle, armed with a silk ligature, being passed through the coats of the intestine, above and below, to prevent its receding when emptied of its contents, the bowel may be opened by a longitudinal incision, about an inch in length, in the space between the retaining ligatures.

There is a peculiar form of stricture of the rectum, not generally known, nor fully understood. In cases of the disease, the interior of the rectum is abundantly studded with small excrescences arising from partial hypertrophies or irregular growths of the surface and folds of the mucous membrane. The sensation communicated to the finger passed into the rectum is remarkable, the surgeon feeling a number of rough irregular eminences, more or less hard, thickly lining

the surface.

These excrescences, when numerous, have the effect of somewhat narrowing the canal below the stricture. This is situated further from the orifice than in ordinary cases, usually at a distance of three inches. Some flattened growths, resembling shrunk external piles, but small and redder, are almost constantly found at the margin of the anus in these cases. The changes in the mucous membrane above described are said to occur without any stricture. I have not myself met with any case of the kind. This disease is invariably attended with a profuse discharge from the rectum of pus and slimy matter mixed with blood. There is not only painful tenesmus before a feculent evacuation, but a frequent and urgent desire to void the slimy pus and mucus which collects in the bowel. This was so frequent and so pressing in a gentleman who was under my care, that he was unable to go into society, or ride in a public conveyance, or travel by rail. The copious discharge helps greatly to weaken the patient's powers. They waste faster than persons suffering from ordinary stricture.

I

The

This form of stricture occurs chiefly in women. have met with only one case of it in the male sex. disease has been particularly noticed by Sir B. Brodie, who also observed it chiefly in women, especially in those who had borne children. An incomplete paper giving a short account of this peculiar form of stricture in the rectum, by the late Mr. Colles, has been published recently. In this paper there is a table of sixteen cases, and it is remarkable that thirteen of them were males, a proportion which is quite contrary to

6

"London Medical Gazette, vol. xvi.

• Dublin Quarterly Journal of Medical Science, February, 1854.