Not only is the superior portion of the intes tine (that which is in relation with the stomach) larger, but its extremity being fixed by the new adhesions, the progress of its contents is greatly facilitated, and according to Dupuytren actually accelerated as to time. The inferior or rectal portion, not performing its functions, becomes diminished in calibre, and contains a white, pulpy, albuminous material, which is sometimes discharged by stool, but may remain undecom posed within it for months or even years. The contracted condition of this portion of the gut is of the highest importance to be attended to in all instances where a recovery is possible or likely to be attempted. This disposition of all hollow structures in the body to accommodate themselves to the bulk or quantity of their con tents has been already noticed, and to obviate the inconveniences likely to arise from such diminution, tire older surgeons* strongly recom mended the use of enemata, in order, amongst other advantages, to preserve the intestine in a sufficient state of distension.
The progress and termination of a case such as has been under consideration may be ex tremely variable. The aperture may be situa ted in the lesser intestine so high up or so near the stomach that the space to be traversed by the aliments and their period of detention are shortened : their digestion is then incomplete and nutrition so far impaired that the patient sinks gradually, and dies from the effects of inanition ; or a permanent artificial anus may be established without a hope or a chance of the natural passage ever being restored ; and this seemed at one time to have been tire great object of surgical practice in these cases, for we find M. Littre, a celebrated French surgeon, actually tying up the lower portion of the gut when he could find it, as if to preclude for ever a possibility of the continuity of the tube being restored. This is a most deplorable condition, yet have patients endured the annoyance of a permanent discharge at the groin for a great length of time ; and in the Al useurn of the School in Park Street, there is a preparation taken from a man who had thus existed for upwards of ten years. There is a curious in stance mentioned by Louis in which something resembling the regular action of a sphincter was clearly observable, and although the discharge of the fxcessvas involuntary, yet it was periodical, and the gut once evacuated remained closed until a new accumulation took place. This person, of course, was comparatively free from that constant trickling of faces which is the patient's chief annoyance, and which, if not palliated by some ingenious contrivance, abso lutely renders his life loathsome.
The natural passage of the faces has been restored. This is so desirable, so fortunate a consummation, and its practicability so clearly established by the circumstance of its being oc casionally accomplished solely by the operations of nature, that it can be no matter of surprise if surgeons have laboured to attain it and dili gently observed the entire process. An intes tine of which a portion has sloughed away is placed in a very different condition from one that has been simply wounded. When an en tire loop of bowel has been removed, the two portions within the abdomen passing down to the neck of the sae lie more or less parallel to each other, or approach by a very acute angle : they are in the same degree perpendicular to the ring, and between them is that double parti tion termed " eperon" or buttress by Dupuy tren, and the "promontory" by Scarpa. Now as the intestines are fixed and fastened in this posi tion, the canal can never again become conti nuous in directum, and therefore any material that passes from the upper into the lower portion must do so by going round this inter vening promontory. Even when only a small
fold or knuckle has been lost, although the complete continuity of the tube is not destroyed, and the partition is less evident and prominent, still an angle must inevitably be formed of suffi cient acuteness materially to impede tire pro gress of the faces. In neither case, then, can the wounded edge of one portion of the intes tine come to be applied to that of the other, nor can adhesion or union by the first intention ever be accomplished between them. In lieu of this, however, the edges of the intestine be come united with the peritoneum opposed to them, which must of necessity be tire neck of the sac, and then if the external wound can be healed, a membranous pouch or bag is inter posed between them, of a funnel-shape, and which serves as a medium of communication and of conveyance for the fatal matters from one portion of the tube into the other.
Reflecting on this pathological condition of parts, it will not be very difficult to explain some of the varieties observed in cases of artificial anus. The chief obstruction to the re-establishment of the canal is the intervention of the promontory.
If it is so large or otherwise so circumstanced as entirely to impede communication, and if in this condition it is neglected, the discharge must take place at the groin, and the disease is permanent. Such, I believe, is the history of most of those unhappy beings who have borne about them for years this loathsome and dis gusting affliction, until relieved by a death that could not have proved unwelcome. In a vast number of cases the projection is not so great, and although it may impede and delay, it does not altogether prevent the passage of faeces from one portion of the tube to the other : then as the external wound contracts, the neck of the sac forms into a membranous funnel or canal of communication, and the forces begin to pass. The wound then heals, in some in stances leaving a small fistulous opening through which a limpid, straw-coloured, but fetid fluid constantly distils, whilst in others a perfect and complete cicatrix is formed. But we must recollect what happens in this seem ingly perfect cure before we can fully appreci ate the entire nature of the case, and the degree of danger that always overhangs it. It is evident that the viscus must (at least at first) be firmly fixed at the situation of the cicatrix ; that it no longer enjoys any freedom of motion, and that it forms an angle more or less acute at the place of adhesion. It is also probable that the diameters of the two portions of intestine do not correspond. Hence the process of diges tion is impaired, the patient must study every article of food he consumes, and the slightest indiscretion is followed by colicky pains, flatu lence, and tormina of the bowels; often there is nausea, vomiting, loss of appetite, and a drag ging sensation at the stomach, this latter symp tom being explained by the omentum having formed a part of the protrusion, and become ad herent at the new-formed cicatrix. It often happens that the scar gives way, and a faecal discharge takes place again, the groin thus alternately healing up and bursting out anew. This is more likely to occur in cases where the very small fistulous canal has remained, and therefore many surgeons have regarded this event as more fortunate than where the cica trization has been complete ; for the course of the fistula serves as a guide to direct the burst ing of the accumulation externally, whereas if, as sometimes happens, the intestine should give way internally, its contents are then poured out into the peritoneal cavity, and the result must be inevitably fatal.