CHAPTER IT. (Part 10)

Excision with the surgeon's eyes open to the fact that he is dealing with peritoneum may perhaps be done with success under such circum- stances. At all events it is a very different matter from excision of this variety of prolapse under the impression that it is the one previously described, and contains no peritoneum, as the following case will show. Van Buren' jsajrs: " I have reliable information of a case in which the 1 Op. cit., p. 240. « Op. cit., p. 60, 122 DISEASES OF THE BECTTTM AND ANUS. removal of a * compete prolapse ' of long standing, in a child, was quite recently undertaken by a hospital surgeon of mature years. The protest of a junior colleague led the operator to pass some deep sutures, in deference to a fear expressed as to the probability of intestinal protrusion, but he was confident that the tumor consisted of mucous membrane alone, and proceeded to remove it. Notwithstanding the deep sutures, protrusion of several coils of small intestine did occur, and the child died, in collapse, within twenty-four hours." In this form of the disease, the surgeon m&j find it better after mature deliberation not to attempt a radical cure, but to confine his efforts solely to palliation. The following case illustrates the danger of attempted removal of a part of the mass in an old and extensive prolapse. Case XI. — The patient was an elderly man who had a prolapsus as big as a cocoa-nut always coming down, and rendering his life a burden. He had already been operated upon twice by a hospital surgeon, but in vain. The patient was then sent to me, and, formidable as the case looked, I determined to undertake it. I applied the clamp deeply in three different directions. There was a great deal of bleeding and I had to apply the cautery over and over again before I could stop it; and then, just as I was finishing the operation, a most untoward event occurred — severe vomiting, as the result of the anaesthetic, took place. The pro- lapsus was forced still further down; and before I and my assistants could return the parts, the violent action of the abdominal muscles was such that the weakened coat of the bowel gave way, and a knuckle of small intestine actually protruded through the rent thus made. I carefully returned this as soon as the vomiting ceased, and anxiously waited the result. Our house-surgeon, Mr. Newmarch, watched the patient with great care and treated him with great skill, keeping him constantly under the influence of opium, and locking up his bowels for several days. The result was not a single bad symptom of any kind. On the first action of tiie bowels there was no protrusion, nor afterwards; and as soon as the man was fairly recovered I removed three longitudinal folds of skin from the anus, so as further to tighten the parts. The man was completely cured. Now, the lesson this case teaches is this — not to employ an agent which could cause vomiting; because, of course, in such a terribly severe case as this it is absolutely necessary to clamp deeply, and thus weaken the bowel. It was a most unlooked-for accident, not likely to occur again; in fact, it is hardly reasonable to expect to meet with another such a case for operation. I have, however, been called to cases as bad or worse, but where no operation could be recommended." * Dr. Kleberg has utilized the elastic ligature in operating upon severe cases of prolapse: and, it may be, that if the mass has to be removed at » Henry Smith, Lancet, Mar. 15th, 1880. PROLAPSE. 123 all, the method he describes is the preferable one. The operation is per- formed as follows. ^ Case XII. — Operation. On the previous day a dose of castor oil was given, and on the morning before the operation an enema of luke-warm water was administered high up the bowel. Immediately before, a glass of wine and one grain of opium were given. After the patient had pressed down the gut as far as he could he was placed on the operating table in the lateral position with the pelvis raised and shoulders turned downward. Ohiorof orm was then administered. In two cases Kleberg has operated without chloroform because the patients were in such a miserable condition that he was afraid to narcotize them thoroughly, and an incom- plete narcosis has all the dangers of profound anaesthesia and none of its advantages. After the chloroform, he says, ^ I carefully examined about the rectum at the junction of the skin and mucous membrane in order to discover the sphincter ani — a procedure that was more difficult than one would think, because it had become so stretched and atrophied that I could only make it out by feeling under the fingers the coarser fibres running across the longitudinal axis of the bowel. Of anything like the normal muscle there was nothing to be discovered. An assistant, at this point, surrounded with all the fingers the pro- lapsus from above, the points of the fingers being directed towards the free end of the prolapsus, and pressed as hard as possible into the gut at a point perhaps half an inch below the supposed sphincter. Immediately in front of the ends of the assistant's fingers I then placed a good, fresh, unf enestrated drainage tube of rubber, one and one half lines in diameter, around the prolapsus, and drew it only as tight as seemed necessary to stop the circulation. The elastic ligature was brought to the necessary tension by means of an easily-untied slip-knot of silk thrown under it. The assistant now had both hands free ; and from this time on the operation was performed under the carbolic spray. A few lines beneath the ligature I now made a longitudinal incision two inches long through the prolapsed gut, and in this way opened the sac formed by the drawing down of the peritoneum. Then I seized the elastic ligature with the forceps and fixed it firmy. It was thus an easy matter to push back into the peritoneal cavity a protruding loop of intestine without the slightest bleeding taking place into the wound or any air entering the peritoneal oavity ; because the elastic pressure follows so rapidly all the movements that no opening can exist anywhere. After I had convinced myself that the peritoneal sac was empty, and that no invagination of the intestine was present, but, on the other hand, only that part of the gut which was to be removed lay in front of the ligature, I thrust the largest size Luer's pocket trocar through the pro- ' Ueber die Anwendung der elastischen ligatur zur Operation sehr schwerer P&lle von Prolapsus Recti. Arch. fUr Ellin. Ohirurg., vol. xxiv., p. 840. 124 DISEASES OF THE BEOTUM AND ANUS. lapsus, immediately below the elastic ligature, from before backwards, and passed through the canula two elastic drainage tubes of one and one- half lines in diameter, and, after removing the canula, tied them as tightly as possible, one on the right side, the other on the left. These knots were secured against slipping by means of the knot of silk. The first provision against haemorrhage — the elastic ligature applied after Esmarch's plan — ;was then removed and the prolapsus cut off with fche scis- sors one inch in front of the permanent ligatures. After a few minutes time, during which I kneaded the parts which still remained and lay above the ligatures thoroughly, and as far as possible removed the fluids from them; I covered the parts around the stump with cotton, and soaked that part of the prolapse which still remained above the ligature with a solution of chloride of zinc, dried it, squeezed the soft parts once more, thoroughly applied the chloride of zinc again, and then covered the whole with dry cotton-batting, giving the patient instructions to remove this as soon as it became moist and to replace it with dry, and to give the air all possible access to the parts." No fever followed the operation, and the pain was bearable, with the aid of an occasional opiate. On the next day the parts had so far shrunk as to leave a concavity at the anus where before there had been a bulging. There was no bleeding, no peritoneal irritation, and only slight tenesmus. On the fourth day the first ligature cut out, and the second on the fifth. The rectum was irrigated twice a day with water and permanganate of potash, and on the seventh day a dose of castor oil was followed by a large evacuation while the patient was on his back without pain or haemorrhage. The passage, however, was involuntary. On the fourteenth day the wound was healed, the general condition of the patient excellent, and the evacuations regular but still involuntary. The sphincter at this time began to be appreciable, and there was no protrusion of the bowel, the patient going about and wearing a bandage. One month later he had control of solid faeces, but there was still a slight discharge of mucus ; and after another month he was entirely well. In this case the prolapse was about a foot in length and six inches in diameter. The mucous membrane was spongy, bleeding, excoriated, and ulcerated. The patient had been sick for two years, had been bed- ridden for two months, and was waxy pale. Another case by the same surgeon and the same method ended fatally, but can hardly be considered a fair test of the dangers of the operation, on account of the exceedingly bad condition of the patient. Third and fourth varieties, — These two forms of invagination will be described together because of the fact that they differ from each other not at all in their nature but only in extent and location. It will be ob- served that the word prolapse is now dropped and invagination substi- tuted which more aptly expresses the condition. The essential difference between the disease now to be considered and the forms already described PB0LAP8E. 125 consists in the fact that while in the latter the bowel begins to slip down from its lowest portion at the anus, in the former the lowest portion at the anus remains in its proper position and the bowel from above is tele- scoped within it. Under these circumstances it is evident, as is shown in Fig. 39, that the affected portion of the bowel must consist of three differ- ent and distinct cylinders, an outer one which contains the other two, and two included portions, one of which is the entering and the other the re- turning bowel. When the upper part of the rectum becomes invaginated in this way within the lower, the included portion will appear at the anus as in the cases of prolapse already described, and a distinct sulcus may be felt by the finger between the extruded portion and the mucous membrane which is continuous with that of the anus. The bottom of this sulcus or the point at which the entering portion becomes directly continuous with that into which it enters may also be felt by the finger if it is low enough down; if not, it may be detected by the aid of a soft catheter. This is what is understood by the third variety of prolapse. When a portion of the bowel still further removed from the anus has become invaginated into that immediately below, the included portion mayor may not descend sufficiently near to the anus to be felt by rectal touch, and the sulcus may not be apparent. This constitutes the fourth variety or what is now generally known as intussusception. It is evident that between a case of prolapse in which all the coats of the rectum appear through the anus, and in which a sulcus can be felt by the finger passed around the pro- truded portion; and a case in which the ileum is telescoped through the ilio-caBcal valve and appears at the anus, the difference is one of degree and not of kind. Of this condition there are many degrees, and almost any portion of the bowel from the duodenum to the rectum may become invaginated into the portion next below. The caecum itself may be so loosened from its attachments as to follow the same course, and the orifice of the appendix vermiformis may be detected at the anus by the side of the orifice of the included bowel. In 763 cases of invagination collected by Bulteau,' 220 were of the small intestine; 151 of the large; and 392 ileo-csecal. The mesentery of the two included portions is drawn in with them, and by its attachment and traction gives to them a curve the concavity of which is towards the point of attachment of the mesentery. For this reason the lower orifice of the included portion is not found in the axis of the containing portion, but turned toward some portion of its circum- ference, and is, therefore, often difficult to detect by a digital examina- tion. ' De Tociclusion intestinale au point de vue du diagnostic et du traitement. These de Paris, 1878. 126 DISEASES OF THE RECTUM AND ANUS. The immediate effect of an invagination is to interfere with the pas- sage of faeces, but seldom to entirely prevent their passage, for the faeces do pass and in considerable quantity, forced down through the con- striction by the contraction of the healthy bowel above. Another immediate effect which is due to constriction of the blood- vessels in the included mesentery and in the walls of ihe included portion, is the transudation of serum and consequent swelling of the intestinal walls. By this means the serous surfaces become dark-colored, and the mucous surfaces become infiltrated; blood is effused between the mucdus surfaces of the outer and middle layers, and lymph between the serous surfaces of the middle and internal layers, and after a time these become completely agglutinated. If the constriction be sufficiently severe, the included portions soon become gangienous and slough away, the lumen of the bowel is again established, and a circular cicatrix is left. This is nature's method of cure, and though life is by it saved for a time, in the end the cicatrir thus formed may become a stricture which shall be more surely fatal than the condition from which it arose. The invaginated portion is at first of necessity short; but as the case advances, it may reach to several feet, and in one case' there is a reason to believe that about four yards of in- testine came away, piece by piece, per anum. The disease is twice as common in males as in females, and is greatly* more common in children than in adults. In adults the trouble will generally be found to involve the small intestine; in children, the large. An invagination of the small into the large intestine begins generally at the ileo-C8Bcal valve, which with the vermiform appendix is carried up the ascending, and along the transverse colon, till it may. finally reach the anus and protrude through it, the valve all the time remaining the lowest portion. In these cases only the inner tube is made of small in- testine, the middle and the outer consisting of the large. Strangulation is much more frequent where the outer layer is com- posed of the small than where it is composed of the large intestine; because of the greater tightness of the constriction. In the latter case the congestion may be only moderate in degree and the condition may last many weeks without gangrene or ulceration. This condition is^ known as chronic intussusception. If sloughing occur at all, it may happen at any time after the first week, generally, however, it occurs within three weeks, though it may be delayed for a much longer time. In one case* the separation of frag- ments of intestine extended over an interval of three years. In about one-half of the reported cases a favorable termination has followed spontaneous separation, in the remainder death has occurred ' Peacock: Path. Trans., vol. xv. ' Peacock, loc. cit. PBOLAP8E. 127 after a longer or shorter interval. Several pathological changes may occur. The peritonitis which serves to unite the serous surfaces of the contained portion^ may become general and cause death. The ensheath- ing portion may become ulcerated and perforated, allowing of the extra- vasation of faeces. The ulceration may perhaps be due to the lateral pressure of the end of the contained portion against the side of the cylinder which contains it. * Separation by sloughing leaves the upper end of the ensheathing portion united with the lower end of the healthy bowel, and results in complete amputation of the contained portion. Extravasation may also occur from a deficiency in this union at the time when separation occurs. The causes of invagination are not as yet perfectly understood. It is easy to understand how in the effort which the intestine makes to relieve itself of a polypus or other tumor by its vermicular action, not only the growth itself may be extruded, but also the portion of the bowel to which it is attached; and polypus is one of the recognized causes of this condi« tion. But in the great majority of cases no such palpable cause is to be detected. Except in the case of a tumor it is probably always an accident of sudden occun*ence dependent upon some violent action in that part of the bowel. A collection of gas causing an undue dilatation in one part of the intestine, combined with a violent movement of the abdominal muscles, and a peristaltic movement in the portion just above that which is distended, might, it is easily