1. If the first of these conditions is indispen sable, it follows that the chance of recovery with artificial anus is inversely as the acuteness of the symptoms and the rapidity of their pro gress. As it is the inflammation of the intes tines that destroys the patient, it is pretty evi dent that after it has reached a given point, no operation performed on the hernia and no evacuation of the contents of the bowels can arrest its progress, or cause the absorption of the lymph, or of the sero-purulent fluid that has been effused into the peritoneal cavity. In operating on the living subject within twenty three hours after the first appearance of the hernia, I have found the intestine sphacelated in this case, when the stricture was divided, the discharge from the intestines within the ab domen was trifling in quantity, and in order to relieve the patient, I was obliged to introduce a gum-elastic tube for a considerable way into the superior fragment of the bowel. Ile died on the subsequent day, and on examining the body the front of the intestines seemed to be one macs of plastic lymph, which obliterated every appearance of convolution, and must have glued together the bowels in such a manner as to prevent the possibility of a peristaltic motion. In a case so aggravated no hope could be enter tained from the establishment of an artificial outlet. It can now he easily imagined how persons of a very advanced age,* and in whom the symptoms of strangulation are mild and chronic, recover with artificial anus, in short that such a consummation is most to be ex pected in the cases to which the name "incar cerated" has been applied, whereas in most instances of " strangulated" hernia its occurrence is unlikely, and in many altogether impossible.
2. The second great requisite for the esta blishment of an artificial anus is, that adhesion shall take place between the bowel and the peritoneum, either at or immediately above the neck of the sac, so that when the stricture is free and the alvine discharges allowed to escape, it will be impossible for the gut to withdraw itself within the cavity, or be removed from the external aperture. This adhesion has, I think, been generally supposed to occur " during the inflammation which precedes the gangrene,"" but is nevertheless probably always not only subsequent to it, but to the separation of the unsound and sphacelated parts ; and the at tachment is, not between the contiguous and opposing smooth surfaces of the serous mem brane, but between the divided edges of the sound portions of the tube remaining after the slough has been thrown oil; and the part of the neck of the sac adjacent to them. I have ope rated on a great number of gangrened hernia', and never found such an adhesion to have pre viously existed, neither have I ever met with it on dissection, and I cannot conceive the possi bility of a spontaneous return after sphacelus (an event that but too frequently occurs) if the parts were thus attached together. Assuredly if such adhesions were formed at so early a period, they ought to be much more frequently found, and they would be amongst the most calamitous complications that could attend a hernia ; for they would offer an almost invinci ble obstacle to its reduction, or supposing the bowel to have been pushed up by force, such a sharp angular fold would be formed as must prevent the passage of its contents and create an internal strangulation. Nor is the consider
ation of this fact practically unimportant, if it leads us to adopt every possible precaution that may conduce to the undisturbed progress of this adhesive process, and at the same time warns us not to he too sanguine in our expecta tions. I have (as I have said) operated on a vast number of cases of gangrened hernia, not one of which recovered with artificial anus: some, the great majority, perished, as has been remarked, in consequence of the inflammation within the abdomen havingreached an incurable height ; some others sank exhausted and died, the system being apparently worn out and incapable of a recuperative effort : others still, from a retraction of the divided end of the bowel and the escape of its contents into the cavity ; and one, from a cause which, ash has not been mentioned by any pathological writer, may be noticed here. On the spontaneous separation of the sphacelated bowel, a frightful and incon trollable hemorrhage took place, some of which flowed into the peritoneal cavity, and was found after death diffused through the convolutions of the intestines.
When a ease has been so fortunate as to permit of the formation of an artificial anus, after the mortified parts and putrid sloughs have been removed a cavity is seen, generally irregular and puckered at its edge, leading down to and communicating with the injured intestine, from which the fteeal discharge is constantly triekling,and as there is often a suffi cient space for a portion of this to lodge and remain, it may prove a source of troublesome and dangerous ulcerations. In a short time the mucous membrane becomes everted and protrudes, often, if neglected, to the extent of several inches : it is a true prolapsus of the membrane, not very unlike the prolapsus ani in appearance. At the bottom of the cavity al ready mentioned, are the orifices of the intes tines, the superior of which is the larger, as it is from it the discharge proceeds, whilst the inferior is small and so contracted as frequently to be discovered with difficulty. The partition between the orifices is formed by the juxta position and adhesion of the sides of the intes tine: it is termed the " eperon" by Dupuytren, and is larger and more obvious when a portion of the bowel has been completely removed so as to divide the tube into two parts, smaller when only a knuckle has been pinched up and gangrened without engaging the entire circum ference. To this " eperon" and double partition the mesentery is attached, and the functions of this membranous ligament are said to exert a very important influence on the progress and after-consequences of artificial anus.