LAPAROTOMY AND COLOTOMY, WITH FORMATION OF ARTIFICIAL ANUS FOR OBSTRUCTION OF INTESTINES.

BY WILLIAM A. BYRD, M.D.,

ILLINOIS.

MR. CHAIRMAN AND GENTLEMEN:

It is because I believe it to be an act of professional duty peremptorily required by the unsettled position of this operation. in the minds of the most eminent surgeons, that induces me to report the following case for your consideration and criticism :

January 14, 1880, I was called by Dr. Joel G. Williams, of Fowler, Illinois, to see Mr. John B. Gilmer, of Coatsburg, Illinois. The patient was a farmer, aged 43, who had been suffering with enteritis for some three months, but for some three weeks before I saw him he had ceased to have any discharges from his bowels, except blood and mucus. He had been seen by several physicians, all of whom pronounced his case hopeless, except Dr. Williams, who, thinking laparotomy offered some hope, telegraphed for me. I found the patient emaciated, and worn out with pain and the want of sleep. There had at times been vomiting, but it was not a constant symptom, and at no time was it stercoraceous. The abdomen was tympanitic and so greatly distended as to almost prevent breathing and greatly crippling the action of the heart. Having four or five years ago successfully relieved a patient, who had typhoid fever, of excessive tympanites, for Dr. Francis Drude, with the aspirator, I decided to try the same treatment in this case. The needle was passed into the abdomen at its most prominent and resonant part, about two inches above the umbilicus, and a large quantity of gas withdrawn, causing great relief. I now decided that the obstruction was in the left iliac region, and that lapar

otomy offered about the only chance for his life. The obstruction had before been supposed to be situated at the ileo-cæcal valve. Injections had been resorted to, and a soft rubber tube passed up the rectum, which folding or rolling up on itself left the impression that the obstruction was higher. I was so deceived myself. The patient was so much relieved that he wanted any farther interference deferred.

16th. Was sent for again, and found the tympanites nearly as great as before, and the patient anxious for an immediate laparotomy. It being late in the afternoon, and wishing to operate antiseptically, I aspirated again, and ordered a drachm of fluid extract of opium per rectum, and promised to return early the next morning. I requested Drs. J. A. Wagner and E. B. Montgomery to accompany me, but Dr. Montgomery was prevented by an obstetrical case.

17th. At 9 A. M. we commenced the operation, first washing the patient's abdomen with carbolized water, one to forty, and shaving the abdomen. The assistant's hands were carefully washed in carbolized water, then oiled with carbolized olive oil. Drs. Joel G. Williams, J. A. Wagner, II. C. Skirvin, and Messrs. Chas. M. Gilmer and Richard Powell acted as assistants. Putting the patient under the influence of ether, the abdomen was opened for eight inches in the median line when the distended bowels poured out. The distension of the bowels was so great that before a proper search could be made for the obstruction the gas had to be removed with the aspirator, which was done by inserting the needle of the aspirator into different points of the intestines until they collapsed. Two knuckles of ileum and the sigmoid flexure of the colon were now found bound down in the pelvis and occluded by a band passing from one knuckle of the ileum over and including three-fourths of the diameter of the other knuckle, then splitting like a Y and inclosing the colon. The band was very vascular and about the size of my little finger, and round at its commencement, flattening and spreading out fan-shaped before it became attached to the peritoneum over the left ileum and sacrum. Where it passed over and was attached to the second knuckle of ileum it was about an inch and a half wide. I ligated the round part of the band with carbolized silk, divided it between the ligature and second portion of ileum, then cut off the ends of the ligature near the knot and dropped the pedicle. The second knuckle I enuclea

ted, having considerable hemorrhage. The blood oozed up from the whole of the denuded surface of the bowel. This was at length stopped by repeatedly applying sponges squeezed out of hot water. The adhesions over the colon were so firm, and so intimately connected with the great pelvic vessels, and so deep in the pelvis as to prevent my seeing what I was doing, that I decided the safer plan would be to make an artificial anus in the left iliac region. This I did by making an opening two inches and a half long, through the walls of the abdomen, just internal to, and above, the internal abdominal ring; then passing four threaded needles through the colon, an inch and a half apart longitudinally, and three-quarters of an inch apart transversely, and carrying them through the opening and stitching the colon by that means to the edges of the opening so as to prevent fecal extravasation into the abdominal cavity; then opening the colon through the hole in the abdomen between the stitches. When the colon was opened, from a quart to three pints of feces poured out and a like amount passed during the night. The bowels, which had been kept wrapped up in flannel wrung out of warm water during the operation, were now carefully cleaned and replaced, and the central abdominal incision closed with twelve carbolized silk sutures. A strip of rubber dam two inches and a half wide was dipped into carbolized water and laid over the abdominal wound, and held in place by three pieces of adhesive plaster, three inches wide, passed around the whole body, exerting even pressure from the ensiform cartilage to the anterior superior spinous processes. Over these, and covering the whole abdomen, absorbent cotton three inches deep was laid and held by a broad flannel bandage snugly applied. The operation was conducted under a spray from a DeBeer's antiseptic steam atomizer, the solution being one of carbolic acid to twenty of distilled water. The whole operation occupied two hours, and when finished the patient seemed about dead, but was revived by hypodermic injections of dilute alcohol and the application of hot irons and bricks around the body.

Half drachm doses of fluid extract of opium were given per rectum, as often as necessary, to keep him slightly narcotized. Injections of two ounces of milk and half an ounce of whiskey were given every two or three hours. His pulse would fill up and become slower after each injection. By the mouth he was given teaspoonful doses of milk and lime-water every half hour.

This treatment was faithfully carried out by Dr. Williams until the third day, when he was allowed larger quantities of milk and lime-water by the mouth. By the end of a week he was permitted to take solid food sparingly.

His condition rapidly improved, with the exception of the tenesmus and passage of small quantities of mucus per rectum, to relieve which ten drops of fluid extract of opium in a little starch water were required two or three times a day by injection. Wishing to overcome the constriction in the colon to permit the closing of the artificial anus, I visited him Feb. 17th, and tried with small bougies to effect a passage, but failed. March 22d, he came to Quincy, and the next day and the day after I made ineffectual attempts to get through. These efforts, though very gently and carefully made, caused him to have some fever, from which he recovered in two or three days and returned home.

April 15th, I visited him, without notification, with Dr. Williams, and found that he had been engaged the previous day hauling fence-posts, and he had intended going that morning several miles after a wagon load of lath, from which he was dissuaded by his wife on account of the inclemency of the weather. We gave him ether, and I inserted my left hand into the rectum and the two first fingers of my right hand into the colon through the artificial anus, and gradually worked the finger-tips of each hand toward the other until the obstruction was overcome and I was enabled to pass two fingers through the strictured portion. This I was the more easily enabled to accomplish on account of there being a large ulcer upon the lower surface of the stricture. After breaking down the very large flabby granulations with which it was filled, there was but a very thin band of obstruction to overcome. A long drainage tube was passed through the bowel, emerging from the anus and artificial anus, and tied over the groin; this was used as a guide for the passage of rectal bougie morning and evening.

The most of his feces passed per anum from the time of the dilatation of the stricture. The artificial anus had exhibited a great tendency to close up, causing much pain when the feces passed through it.

The treatment of the case before I was called had been somewhat varied-purgatives, opium, and chloroform by inhalation. After the tympanites became excessive the treatment was with

opium and chloroform by inhalation-the chloroform affording the most relief.

The conclusions I arrive at from considering this case are: that no one should be allowed to die from intestinal obstruction, and I am not prepared to exclude intussusception, without at least an exploratory incision to make sure that operative interference could afford no relief.

If there is much distension of the bowels with gas, it should be evacuated with the aspirator, as paralysis may be produced by prolonged over-distension, thus defeating the aim of the operation.

If there is occlusion that it is not advisable to overcome on account of exhaustion of the patient from prolongation of the time the abdomen is open, or other complications, an artificial anus should be made and the obstruction treated, if possible, more safely at some future time.

Proper rectal alimentation and medication very materially aid in the patient's recovery.

In submitting this case it is perhaps well to state, as a plea for even a slight right to pass judgment upon abdominal section for whatever cause, that I have now made the section, including operations for strangulated hernia and ovariotomy, eighteen times with the loss of but three patients. All of those three were cases where the section was made for strangulated hernia. One of the fatal cases was eighty-seven, another seventy-six years old, and the remaining one was a man in the last stages of consumption that I only saw once, and that the night I operated.

I believe in true conservative surgery, not that kind that stands considering about an operation until all hope of a successful issue has passed away, but true conservatism that gives a patient all the possible chances of life.

I would like to quote the opinions of such distinguished surgeons as Ashhurst, Gross, Agnew, Hamilton, and others, if time would permit, but will close with a quotation from Mr. Thomas Bryant, made before the Cincinnati Medical Society Jan. 13th, 1880, by Dr. Carson, while discussing an able paper on "Intestinal Obstruction," read by Dr. Wm. B. Davis: "I hold that in all cases of acute intestinal obstruction that resist medical treatment, operative relief should be resorted to as soon as a

1 Boston Medical and Surgical Journal, Feb. 26th, 1880, p. 202.