Colostomy and Colotomy.—The colon has been opened both through an in cision in the lumbar region and directly through the abdominal wall. Before the introduction of antiseptic technique lumbar colotomy was the preferable operation, because the posterior wall of the colon is not covered with the peri toneum and it is possible to make an opening into it without danger of in fecting the peritoneal cavity. The dis advantages of lumbar colotomy are: it is more difficult to find the colon through the deep lumbar incision; the bowel is less efficiently drained; and fceces passing over the fresh incision tend to produce infection and suppura tion. For these reasons the operation has been abandoned by nearly all sur and will not be described.
Mayas Colostomy.— The method in troduced by Maydl is generally consid ered the simplest and best. The parietal incision may be made at any part of the abdomen which is over the colon, but, as a rule, the descending colon is opened. It is desirable to place the opening in such a position as to be con venient for the patient in the toilet of the artificial anus. About an inch be hind the line of the antero-superior spine and an inch above it is a good point to begin the lower end of the in cision, which should be only long enough to permit the bowel to be drawn out. The fingers inserted through the abdominal incision usually come in con tact with the colon at once, but, if it is not easily discovered, the finger may be carried along the posterior abdominal wall until the mesocolon, which will be the first structure met, is encountered. The bowel is then pulled down from above to make taut the splcnic flexure, and is drawn from the wound far enough so that a stiff rod may be passed through its mesentery. Any smooth stiff antisep tic material will answer, but a glass rod with flanged ends is generally preferred. Iodoform gauze is wrapped around the ends of the rod to prevent displacement; a row of sutures is placed on each side of the prolapsed intestine, including the serous and muscular coats, stitching to gether the two limbs of the flexure as they lie in the abdominal wound beneath the rod. The intestine is then sutured in the parietal wound to shut off the peritoneal cavity and to prevent protru sion. The intestine may be opened im mediately if the symptoms are urgent, but it is perhaps best to postpone open ing it a few days until firm adhesions have formed. If the opening is to be temporary, only about a third of the periphery of the bowel is divided. If a permanent opening is desired, the bowel is cut on a level with the support ing rod. Sufficient mucous membrane should be left to form a pouting anus, at least one-half inch above the level of the abdominal wall. With such a pro
truding anus it is easy to collect the faces with a cup-shaped apparatus; while, if the bowel is cut close to the abdominal wall, ffeces run over the skin, and there is nothing to aid in holding the receptacle.
Intestinal Resection, or Enterectomy. --These terms are used to designate the removal of a section of any part of the intestine, but "colectomy" or "cxcee tomy" is sometimes used to designate removal of the colon or cmcnm.
INDICATIONS.—Resection of the bowel may be performed for removal of malig nant or benign tumors, for gangrene, for extensive wounds and injuries, in some cases of artificial anus, irreducible in tussusception, and occasionally in cases of obstruction from cicatricial adhesions or simple stricture.
Intestinal gangrene usually arises from some form of obstruction caused by in ternal or external strangulation. A few inches may be involved or several feet, or even the whole intestine. The line of demarkation from sound tissue may be distinct, or the gangrenous area may merge into extreme congestion without any definite limit. Whether resection should be performed or an artificial anus established will depend upon the condition of the patient, the extent of the gangrene, and the condition and lo cation of the gangrenous area. Com plete necrosis of a few inches, with healthy bowel beyond, if the patient is in good condition, may always be treated by resection. On the other hand, if an extensive area is involved, with imper fect limitation or with unhealthy bowel beyond, and if the patient is very ill, it may be best to form a temporary arti ficial anus. A discussion of the etiology and symptoms of gangrene from various causes will be found under the head ings of OBSTRUCTION, INTESTINAL, and THROMBOSIS OF THE MESENTERIC BLOOD VESSELS. The same remarks apply to the cause of obstruction.
Experiments on animals led Senn to conclude that the resection of more than one-third of the intestinal canal was productive of a fatal marasmus. Trze bickv maintains that one-half of the in testinal tract may be resected without a fatal issue. Monari has removed seven• eighths of the intestine of the dog with out seriously interfering with metabo lism. The writer studied the subject from a clinical standpoint. Including the case reported in the present com munication he has collected 33 in stances in which more than one metre of intestine has been removed. Nine died soon after operation and 3 after four months. Iri the 21 surviving, the part resected consisted of colon in 2, of ileum and jejunum in 1, and of a por tion of the ileum in the remaining cases.