suture and that of Lembert, without awarding a preference to either, except, indeed, the whole cylinder of the intestine were divided, in which case he would prefer the glover's suture, "especially in young subjects, in whom the canal is very narrow, or in persons in whom the bowel is overloaded with fecal matter at the moment of the injury," as “in a case of this kind the inverted edges might occasion serious obstruction, from the manner in which they project into the interior of the canal." (p. 157.) For our own part, we would certainly prefer Lembert's suture, or that of Gely, in every case where we deemed a suture applicable. We confess, however, that we do not think it is yet satisfactorily determined what is the most advisable course to pursue when an intestine is completely divided by a recently-inflicted wound, and we are by no means satisfied but that the safest course, in such an event, is to establish an artificial anus, taking care so to dispose the extremities of the intestine as to favour attempts to subsequently heal the wound; to discuss this point suitably would, however, at present carry us too far. Dr. Gross, we may here observe, states in the next chapter (for he is eminently unmethodical in his arrangement and discursive in his observations) that he would deem it advisable "in extensive longitudinal or oblique wounds, to excise the affected part, and treat the case like one in which the tube is completely divided in the first instance especially where the opening is more than two inches in length." (p. 171.) In this opinion we can by no means coincide; Dr. Gross's reasons for adopting it are-that extensive wounds take a long time to heal, that the canal may become permanently contracted, that adhesion in them is seldom complete, that numerous sutures are a source of irritation, and that mischief must result from the protracted manipulation necessary to apply them. We do not dispute the force of those reasons, but most assuredly they apply a fortiori, one and all, to complete division of the intestine, and, if valid, the necessary inference from them is, that extensive wounds of the intestine, and still more complete division of it, should be treated, not by suture, but by the establishment of an artificial anus. It has been objected, and not without some reason, to Lembert's suture, that the wound is not securely closed unless the points of suture are tolerably close, and that the danger of inflammation increases with their number. M. Gely, to obviate this inconvenience, has proposed a modification of Lembert's suture, which purports to combine the advantages of so thoroughly closing the wound as to obviate all danger of either immediate or secondary effusion; of presenting such an arrangement of the suture that neither the knot nor any portion of it is visible on the peritoneal surface, and that it must certainly pass into the intestine; and finally, of being easily executed and applicable in every case. This suture may be practised with one or with two needles. When two needles are employed, which is the preferable mode, one of them is inserted a line or so behind, and external to one of the extremities of the wound, is carried parallel to the wound for two or three lines in the cavity of the intestine, and is then brought out on the peritoneal surface again: precisely the same is done with the opposite needle; the threads are then crossed, the left needle is now introduced into the puncture through which the right needle has just passed, and a stitch similar to that first made is taken with it, and a like stitch, in like manner, is made with the right needle. As many stitches : are thus made, parallel to each side of the wound, as its extent may require, and it then only remains to tie the threads and tighten the stitches sufficiently; this is accomplished by pulling the threads at each point where they cross the wound with a dissecting forceps, at the same time inverting the lips of the wound, which soon become so perfectly coapted that the thread is completely concealed between them; finally, the extremities of the thread are knotted and cut close, and the knot is as effectually concealed as the rest of the suture. The needles should be fine, but a little larger than the thread, to permit the latter to run with freedom; when the needles are crossed, it is not indispensable to pass them exactly into the orifice which the opposite one has traversed, and it both facilitates and hastens the operation to tighten and knot the threads each time they are crossed in complete division of the intestine this is indeed indispensable. This mode of suture may, perhaps, seem difficult when thus described, but it is really easily performed, as we have ascertained by trial; the essential point is to make the corresponding stitches at the opposite sides of the wound of equal length, as otherwise the wound is puckered. It is unnecessary to describe the manipulation when a single needle is employed. M. Gely states, that when the completely divided intestine of a dog is united by his method the resulting valve produces nearly complete temporary obstruction; but the valve gradually diminishes, and perhaps it may finally disappear, as we find, that in one of his experiments, five and a half months after complete division of the intestine, the valve had disappeared round half the circumference of the bowel, and in the other half resembled one of the valvulæ conniventes somewhat thickened. The suture applied in this way is detached very slowly in one experiment it was found adhering in the wound two months after having been applied. M. Gely's experiments on animals with this suture are scarcely sufficiently numerous, but so far as they go are favorable to the method. M. Gely has, also, twice applied his suture in the human subject. The first case was that of a sailor, who received a wound in the left lumbar region, through which about a yard of small intestine protruded; the prolapsed bowel presented two small wounds exactly opposite to each other, having been transfixed by the knife; each wound was secured according to the method already described; the intestine was reduced, and the patient recovered without having presented any very serious symptoms. In the second case, M. Gely inflicted a small wound on the intestine during an operation for strangulated hernia; he secured the wound by a stitch of his suture, returned the intestine, and the patient recovered. We may here mention that M. Hip. Nunciati of Naples, has proposed a spiral suture, by which the serous surfaces of the lips of the wound of the intestine are inverted and brought into contact; it may be that the account we have seen of this method is imperfect, but it seems to us quite analogous to the modification of Lembert's suture already proposed by Dupuytren. M. Nunciati's suture, is performed with a single thread, which is carried along the wound alternately from left to right, and from right to left, and then, by pulling the extremities of the thread, one at each angle of the wound, the lips of the wound are inverted and brought into close conM. Nunciati is said to have treated three cases successfully in this way, but we are not acquainted with their particulars. (Bulletin de l'Acad. Royale de Méd., Sept. 1845, p. 1041.) tact. None of the old sutures are applicable in wounds with loss of substance, involving a portion only of the circumference of the intestine; but M. Gely maintains that his method is perfectly suited for such a case. When so applied, the intestine must of course be flexed on itself, and the more so, the greater the loss of substance. The resulting curvature of the bowel, M. Gely maintains, from the results of experiments on animals, does not cause any obstruction or other inconvenience, even when the inflected portions of the bowel are placed parallel to each other. Again, if two orifices, with loss of substance, should exist in the intestine, M. Gely proposes that they should be brought in contact by means of his suture, which is as easily applied to two orifices as on the two margins of one aperture. But the few observations we have to make on this head may conveniently find place in a brief notice of Dr. Gross's third chapter, entitled "Of the treatment of wounds of the intestine by ligature and excision." This chapter relates entirely to the conduct which should be pursued when a portion of intestine is gangrened in a strangulated hernia. Dr. Gross first alludes to the case of a minute orifice in the intestine, and notices the practice of encircling it with a ligature, which we have already referred to; but we may here allude to a case which shows that a ligature thus applied does not uniformly make its way into the cavity of the bowel. A man received a sabre wound in the abdomen, two and a half yards of the bowel protruded, and at one point, near the mesentery, presented a wound about the size of that commonly inflicted in venesection; it was uncertain whether this wound penetrated all the coats of the intestine; but Dr, Kothe, to render matters secure, pinched up the wound in a forceps and included it in a small circular silk ligature, which he cut close to the knot. All went well till the sixth day, when peritonitis set in, and the patient died on the ninth day. On dissection, the ligature was found lying loose on the surface of the jejunum, and though the intestines were removed from the body, no trace of the wound could be found, though it was supposed to have pierced the bowel, as the patient had passed bloody stools. The failure of the ligature to cut into the bowel, in this case, may have arisen from its not having been applied sufficiently tight, but this, of course, is matter of conjecture. (Lond. Med. Gaz. 1827-8, vol i, p. 807, and Rust's Magazine, 1828.) As to the practice to be adopted when a considerable portion of intestine is gangrened, Dr. Gross cites several cases to show that patients may survive the loss of even several feet of the intestinal canal. Among these, he alludes to Mr. Needham's case in the Philosophical Transactions,' as being that of a boy who had fifty-seven inches of his bowel "cut off by a cart;" but that is not exactly the fact; the case, indeed, is a curious one, the pressure of a cart passing over the abdomen forced a large portion of the intestine, with part of the mesentery, out of the anus. Every attempt at reduction failed, as the bowel was constantly again protruded by retching, and on the third day, as the parts appeared to be mortified, Mr. Needham cut them away. The greatest loss of intestine we recollect, where the patient survived, occurred in an operation for hernia by Arnaud, who cut away "more than seven feet" of gangrened bowel (A Dissertation on Ruptures, pp. 341 et seq.); but all this has really nothing to do with the matter at issue; if an intestine is gangrened it is already lost, and the only question is, shall the surgeon suffer an artificial anus to form, or endeavour to restore the continuity of the canal. In considering this question, Dr. Gross leaves out of sight that an opportunity of interfering in the latter way really very seldom occurs, for the bowel has commonly become adherent above the mortified part, and we believe no surgeon disputes the rule that such adhesions are not to be disturbed. But suppose the bowel is not adherent, which Dr. Gross seems to assume is the usual condition of things, he leans to the opinion that, "when there is much inflammation beyond the sphacelated parts, it would probably be wrong to pursue any other treatment" than to suffer an artificial anus to form, but "if, on the other hand, the tube is nearly or quite sound, I should not hesitate to excise the mortified structures, and to approximate the ends by the suture." (p. 173.) M. Gely thinks that his suture may be applicable in cases of gangrened intestine, when a portion only of the cylinder is involved; but if an entire zone of the tube is destroyed, he prefers the establishment of an artificial anus, but, at the same time, proposes an expedient which seems to us extremely plausible and well worthy of consideration, as probably presenting the advantages of the suture without its dangers: this expedient is, to unite by his suture the extremities of the intestine, not completely, but in a third or one half, of their circumference only; obstruction to the course of the fæces would be thus avoided, and the bowel favorably placed for healing the artificial anus. M. Gely further asks, might not a notch be cut in the free border of each of the portions of intestine thus united. This would be, in fact, anticipating the action of Dupuytren's enterotome on the eperon. M. Gely has found this answer perfectly on dogs, but speaks with fitting reserve as to its application in the human subject. Dr. Gross's fourth and last chapter, is on "Artificial Anus," and in it the pathology and treatment of the affection are fully and clearly considered. This chapter cannot be expected to present very much novelty, and but a few points call for observation. Dessault, Noel, and others, have succeeded in curing artificial anus by obliterating the prominence of the eperon by pressure, applied directly on it by tents. Dupuytren also tried, but was compelled to abandon more forcible pressure on the eperon. Since Dr. Gross wrote, Mr. Trant communicated to the Surgical Society of Ireland an extremely ingenious instrument, which seems admirably suited for accomplishing everything that can be achieved by compression on the eperon; this well-devised contrivance presents the great advantage, that while very considerable pressure can be exerted on the eperon, there is not the least danger of the force applied tearing the adhesions of the bowel to the abdominal parietes, because the bowel is pressed from within outwards against the parietes of the abdomen, with a force equal to that exerted on the eperon. This instrument perfectly succeeded in Mr. Trant's hands in one case of artificial anus, and we have little doubt that future experience will confirm its utility. (Dublin Med. Press, vol. xiii, p. 305.)* Dr. Gross mentions the unsuccessful attempts of Bruns, Liotard, and Blandin to obliterate an artificial anus by approximating with sutures its edges previously rendered raw by the knife or by caustic. Cooper, in his folio work on Hernia, mentions two other similarly unsuccessful attempts. Dr. Gross also notices the successful autoplastic operations of Mr. Collier and M. Blandin, an unsuccessful attempt of the same kind by Velpeau, * As an adequate idea of this ingenious instrument could scarcely be conveyed by a mere verbal and also the method of the last surgeon, which consists in uniting by suture the raw edges of the opening, and facilitating the approximation of the parts by making a semi-elliptical incision on each side, and about an inch from the preternatural orifice. There are some other very interesting cases in which artificial anus has been latterly cured by autoplasty, either alone or combined with other methods, and which show what perseverance may accomplish in remedying this lamentable infirmity. Dr. Gross quotes Reybard's treatise on artificial anus, but does not advert to his cases, further than to say that two of his patients rapidly recovered after the application of his enterotome, whereas of his three cases one only was cured by the enterotome, a second remained unimproved, and in the third, which recovered after a series of autoplastic operations, the enterotome was not used at all. This last case is the remarkable one already description, we copy, by permission of the proprietor, from the Dublin Medical Press' the accompanying figures, which both represent the instrument itself, and also exhibit it as applied in the treatment of artificial anus. Fig. 1 represents the position of the eperon after the third application of the instrument with it in situ A. The upper or ventricular portion of intestine. B. The anal or lower portion of intestine. c. The mesentery, by its retraction towards the spine, assists the propeller E in removing the eperon F from the preternatural opening. D. The instrument introduced into the cavity of the intestine, with the propeller E pressing back the eperon r towards the spine, whilst the expanded wings GG on the inside, and the shield H on the outside, act as a forceps in retaining the intervening parts in close apposition, so as to prevent any separation of the anterior surface of the intestine from the parietes of the abdomen, whilst the propeller is pressing back the eperon towards the spine. Fig. 2 represents the instrument with its wings expanding, and the propeller pushed forward, as in the cavity of the intestine, during application. A. The body. BB. The right and left wings. cc. The screws by which the respective wings are moved. D. The propeller. E. The concave extremity of propeller. F. The end of propeller by which the concave extremity is pressed against the eperon. G. Screw for fixing propeller. H. Shield which is moveable. 1. Screw for fixing shield. Fig. 3. 3. The key by which the different screws are turned. |