the serous and mucous coats. For this
reason, we find that in gangrenous her-
nias, in which the strangulating bowel
has practically closed all connection be-
tween the peritoneums of the incarcerated
coil and that of the gut above, the bowel
within the abdomen, is much con-
gested and often mottled in appearance.
Many times, indeed, there are dark spots
on its surface which indicate a possible
circiunscribed gangrene. This condition
may exist for a considerable distance
from the point of constriction, and the
surgeon is often in doubt about the future
of such cases.

Where the gut affected lies within the
abdominal cavity, and the process is acute,
we find, in the earliest stage, a congestion
of the bowel with the exudation from its
blood vessels of more or less serum.
Especially in cases of obstruction will this
congestion spread rapidly over all of the
adjacent viscera. In typhoid and other
ulcerative processes it may not become
apparent until perforation has taken place.
As soon as this occurs, or when in ob-
struction the disease reaches the stage of



beginning gangrene, the progress of the
septic inflammation is marked by a
frightful velocity, and if not relieved at
once ends usually^ in a few hours in death.




No. I Gangrenous Hernia.
A, pprtion that has sloughed.

When these cases are operated on early
and the patient recovers from his condi-
tion of imminent danger, there remains a
false anus of formidable character,
through which there is a constant dis-
charge of bowel contents. The gtit,
where it passes through the abdominal
wall, becomes adherent and the abdomen
closed. Within the abdomen the inflam-
mation gradually subsides and disappears
or; as not mfrequently happens, assumes
a chronic character. In either case, exten-
sive adhesions occur, binding the viscera
together and to the abdominal wall. The
bowels become matted together and lose
their freedom of motion and, in some
cases, the efferent branch becomes ob-
structed or possibly obliterated at points
betow the fistula. ,



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August, 1904. TREATMENT OF INTESTINAL FISTULA^McGRAW. 329



If the abdomen is opened for the pur-
poses of repair, some months after the
false anus has become estabhshed, the
surgeon will be confronted with a mass
of red intestines, whose peritoneal coat
is hidden by granulations. The coils of
bowel are widely adherent and very fri-
able and efforts to detach them will fre-
quently cause their rupture. At a later
stage the redness may disappear, but the




No. 2 The anastomosis made and the gangrrenous portion

of intestine removed. The ends are fastened

in the wound.

adhesions become more firm, until finally
the bowel walls become so blended
together that it becomes impossible to
distinguish one from the other or to sep-
arate them.

The friability of the gut wall will per-
sist, even then, in the immediate neigh-
borhood of the fistula. As time goes on
the afferent limb of the bowel wmU retain
its normal calibre but the efferent limb,
from disuse, will become smaller in size
and will undergo an atrophy of its walls.
This difference in calibre between the two



limbs is a serious hindrance to end to end
anastomosis.

In this connection, it may be well to
remark that the false anus, through which
all of the bowel contents are discharged,
has, in some respects, a widely different
pathology from a faecal fistula through
which there is a leakage of only a small
portion of those contents. In the latter
case the passage of the faeces through the
efferent branch serves to keep that portion
of the bowel dilated, and thus prevents
its contraction and atrophy. The two
limbs of the bowel, being of nearly the
same diameter, can be easily operated on
by an end to end anastomosis, if resection
should seem advisable. In the former
case, the difference in the calibre of the
two bowel sections and the uncertainty
as to the patulous condition of the efferent



No. 3



Shows anastomosis between g^leum and colon.
The fistula is at A.



portion, materially complicates the situ-
ation. It is not altogether uncommon in
these disastrous inflammations to find
more than one pQitBld ©iif (obstruction. It



330 TREATMENT OF INTESTINAL FISTULA— McGRAW. Jour. M. S. M. S.



would be evidently useless to unite the
two limbs of the intestine if the distal
limb were obstructed lower down by
bands of organized lymph or by flexions.

Success in relieving these conditions
must come, if at all, by a careful study
pi the obstacles which we have to contend
with in each individual case. Let us
see what these obstacles are and con-
sider how we may overcome them by the
most rational method. I will discuss,
first, the simplest form, in which we meet
with intestinal gangrene, that presented
by the strangulated hernia. We have here
an intestine which has been killed by a
constriction which has occluded the blood
vessels while, at the same time, it has
prevented the passage of the contents of
the affected coil, or of its surrounding sac,
into the peritoneal cavity. It is simpler
than an internal obstruction, because the
worst products of the disease are confined
outside of the abdomen. In such cases,
a operative measures are postponed until
gangrene has taken place, we will have
almost always a patient who is nearly
moribund from pain, shock and septic
absorption. This condition, however,
marks all cases in which extensive
destruction of an intestine has occurred,
from whatever cause.

It is a condition which warns the sur-
geon that he should do what is absolutely
necessary, in as short a time and with as
little violence as possible. When the her-
nial sac is opened and the fluids contained
are evacuated, the bowel is found to be
swollen and black. It may be so soft and
disorganized as to rupture on slight trac-
tion. When the constricting band has
been cut and the bowel drawn out of the
abdominal cavity, that portion which has
lain within the cavity will be found to be
more or less mottled and discolored. In



very bad cases there may be on its sur-
face black spots indicating an approach-
ing gangrene. This discoloration may
be limited to a few inches or may extend
a foot or more up the intestine. When
operating on such cases, the surgeon after
opening the sac should disinfect, as thor-
oughly as possible, all of the diseased area
before cutting the constricting tissues.
After the stenosis has been relieved and
the bowel drawn out, the very serious
question arises as to the disposal of the
gangrenous coil. The surgeon in decid-
ing this, has to consider the general con-
dition of the patient and the local condi-
tion of the gut. As the general condition
is almost always very grave, the meas-
ures adopted should be such as take the
least time and make the least demand on
the patient's strength.

It is evident that a resection of the
mortified bowel and end to end anasto-
mosis, by any method whatever, although
successfully practiced in a few cases, must,
under these circumstances, be exceedingly
hazardous. On the other hand, to con-
tent ourself with the least dangerous
method of treatment, that of fastening
the bowel in the wound and permitting it
to discharge through a false anus, is to
look forward, in case of recovery, to still
another dangerous operation for the relief
of the injured bowel. ,

Some three years ago I proposed to
obviate the necessity of a second opera-
tion by a simple method of procedure,
to be carried out at once, before the bowd
was fastened into the wound. It was
simply to draw the bowel out of the
wound until a portion was reached that
was nearly normal in appearance, and
then to make a lateral anastomosis be-
tween the two limbs with an elastic liga-
ture. The idea was to pr^ide.a passage



August, 1904. TREATMENT OF INTESTINAL FISTULA— McGRAW. 331



for the contents of the bowel, apd thus
enable the false anus, no longer needed
for the evacuation of the faeces, to heal.
After the ligature had been applied, the
bowel was to be disinfected and all that
seemed in condition to recover pushed
back into the peritoneal cavity. That
part which was mortified, and that which
appeared dangerously near mortification,
was to be fastened outside of the abdo-
men, by stitching it to the abdominal wall.
The immediate result'of such a procedure,
if the patient recovered, would be the
relief of the distended bowel by means of
the false anus and the gradual subsidence
of internal congestion. When that had
taken place and the ligature had cut
through, it was hoped that the fistula
would spontaneously heal or, should that
fail to occur, could be made to heal by
inverting the ends of the protruding
bowel — a simgle operation of little
danger.

The only patient upon whom I have
had an opportunity to try this method in
recent hernia was too far gone to recover,
and died a few hours after the operation.

This one is the only case, as far as I
know, in which this operation has been
done as a primary operation in hernia.

As a secondary operation it has been
successfully performed by Dr. W. T.
Henderson, of Mobile, Ala. Dr. Hen-
derson's case, published in the Mobile
Medical and Surgical Journal, November,
1903, was that of a negro, thirty-one
years of age, upon whom he had operated
for strangulated (right inguinal) hernia.
On the ninth day after the operation,
fourteen inches of the small intestine
were discharged through the wound. At
the expiration of the fifth week, the abdo-
men was opened at the outer border of
the right rectus abdominal muscle and the



proximal limb of the ileum was united to
the ascending colon by an elastic liga-
ture. Up to this time no faeces had
passed from the rectum since the hernia
was operated on. On the fourth day after
this second operation, faecal matter began
to pass from the rectum, and by a letter
written about six weeks afterwards, I
was informed that the false anus had very
nearly closed, there remaining only a
minute opening at its former seat.

As secondary operations for false anus,
due to much more formidable internal
constrictions and ulcerations, I have to
report two cases, both due to the courtesy
of Dr. J. B. Kennedy, of Detroit:

G G , age 35 years, was ad-
mitted to Grace Hospital August 10,
1903. He had been ill during three
weeks with typhoid fever and had had a
severe diarrhoea during the last week,
Aug. 6th.

On admission, his abdomen was found
much distended and very tender. The
pulse was 122 ; the temperature, by axilla,
97° F. Respiration 21. Surface of body
cold and clammy; patient in collapse.
Diagnosis was made of perforating
typhoid ulcer. On August 11th the abdo-
men was opened in right iliac region. A
large quantity of thin faecal matter and
pus escaped, and upon examination of the
ileum, seven distinct perforations were
discovered near the caecum. No attempt
was made to close the perforations but
rubber drains were inserted and the ab-
dominal wound left entirely open. He re-
mained at the hospital until Oct. 5th,
1903, at which time all of the perfora-
tions had closed except one about the size
of a silver quarter dollar, located about
three inches from the caecum. The
patient, at this time, had gained much
strength, but r^iUgfcJ ^l^^^egte^^



332 TREATMENT OF INTESTINAL FISTULA- McGRAW. Jour. M. S. M. 8.



operation for the closure of the fistula.
On October 5 th he was removed to the
Wayne County poor house.

It was not until January, 1904, that he
consented to an operation for the closure
of the false anus. On January 3d I found
him much emaciated and very w-eak.
There was a large opening in the right
iliac region through which there was a
constant discharge of faeces. I operated
on him with the assistance of Dr. J. B.
Kennedy, Dr. John J. Marker and Dr.
James.

A longitudinal incision was made
through the outer edge of the right rectus
muscle. The intestines were found
matted together and very red. The
afferent limb of the ileum was located
and drawn as far up as the strong adhe-
sions w^ould allow. It was united to the
ascending colon with an elastic ligature
after the usual method. This part of the
operation was rendered very difficult by
the immobility of the bowel and the neces-
sfty, caused thereby, of working below
the abdominal surface. In passing the
ligature, an accident occurred, which
probably will never occur again, and
which may have been responsible for the
subsequent death of the patient.

I used the McLean needle, in which the
rubber is secured by a ferrule, which
passed over the needle and ligature.
After the rubber cord had been tied, it
was noticed that the ferrule had escaped
from the needle and, on searching, it was
found lying on the rubber cord, between
the ileum and colon. After the needle
had passed through the ileum, the ferrule,
which was a little too large, had slipped
up on to thfe rubber and had not foUpwed
the needle through the colon. The ques-
tion now arose whether it were better to
withdraw the ligature and insert a fresh



one or to surround the ferrule with Lexn-
bert stitches and leave it in situ. Fear-
ing, in the friable condition of the bowel,
lest I should rupture it by further mani-
pulation, I decided upon closing it in and
leaving it undisturbed, hoping that it
would pass into the bowel and thus
escape.

A rubber drain was inserted and the
wound closed around it. On January
7th, the fourth day after the operation,
faeces began to pass from the rectum and
continued to do so until he died, on Janu-
ary 26th. A day or two later, a small
amount of thin faeces was noticed dis-
charging from the wound, and this, too,
persisted at intervals during the rest of
his (ife.

He eventually died of exhaustion, on
January 26th, nineteen days after the
operation.

In the postmortem examination, at
which I was not present, the bowels were
found inextricably matted together. The
ferrule, with the attached rubber, was in
the peritoneal cavity.

I think that this patient would have
recovered, had it not been for the acciderjt
with the ferrule, which prevented the per-
fect union at the point of anastomosis,
which is the normal result of the ligature
operation. As it was, the faecal discharge
through the wound was slight, and that
through the false anus had nearly alto-
gether ceased before he succumbed.

From the fourth day after the operation
he had regular faecal discharges frqjn the
rectum.

The second case was, in many respects,
peculiar :

J S , a Polish boy of fourteen

years, was brought into the Solvay Hos-
pital at Delray on January 31st, 1904,
with symptoms of appendioitis. He had

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August, 1904. TREATMENT OF INTESTINAL FISTULA— McGR AW. 333



had several previous attacks but none so
severe as this one. He was operated on
by Dr. J. B. Kennedy on February 2nd,
who found the appendix immediately on
opening the abdomen, and removed it.
It was adherent to the neighboring struc-
tures btit not suppurating. The wound
was closed and healed, but the boy did
not recover from his pain or bloating.
This continued, with pbstinate constipa-
tion, and finally faecal vomiting, until
February 7th, when I was called to see
him.

I found him in great pain and with
abdomen enormously distended. His
pulse was 130 but his temperature only
one degree above normal. On Dr. Ken-
nedy's invitation, I re-opened the wound
for the purpose of examining into the
condition of the bowel.

I had hardly opened the peritoneum
when a great gush of faeces indicated a
rupture of the bowel. On drawing the
caecum and lower part of the ileum out
of the abdomen, I found, two inches
above the ileo caecal valve, a firm stricture
of the ileum, which had nearly closed the
gut. It was just above this that the rup-
ture occurred when the adhesion gave
way which bound the bowel to the abdom-
mal wall. The gut above the stricture
was enormously dilated and much dis-
colored.

After evacuating the faeces and clean-
sing the abdomen, I connected the ileum
at a point ten inches above the ileo-caecal
valve with the ascending colon by a rub-
ber ligature and fastened the ruptured
end in the wound.

The boy at first did well and on Febru-
ary 11th, the fourth day after the opera-
tion, had a good faecal movement through
the rectum. From this time until his
death, Feb. 15th, the faeces ceased to pqss



throug^h the false anus and were dis-
charged per rectum. He, however, con-
tinued to be bloated, to suffer pain and
vomit, and finally died of exhaustion. At
the autopsy there was found a perfect an-
astomosis, but in the ileum, twenty inches
above the ileo-caecal valve and ten inches
above the seat of anastomosis, there was
found a constriction and above the con-
striction an opening through which faeces
had recently been discharged. I was my-
self not present at the abduction but judge
from the description obtained that the
constriction at this point did not com-
pletely close the gut but produced, never-
theless, sufficient disturbance to cause
thinning and rupture of the tissues
above.

In severe inflammations of the bowels,
with false anus, the possibility of stricture
in the efferent portion of the bowel must
always be inquired into before operating,
as failure would be assured before hand
if the afferent were united to the efferent
branch at any point above such a con-
striction in the distal limb. In this case,
death occurred from a partial stenosis and
eventual perforation of the bowel, in the
afferent limb, ten inches above the anas-
tomosis. The question arises in such
cases, whether one ought rather to accept
the chance of the existence of such a con-
dition, as I did, and close the operation
as soon as possible, or, on the other hand,
waste valuable time and strength while
informing one's self of the state of the
bowels above and below the point of op-
eration.

The question whether a stricture exists
in the efferent branch of a false anus
should always be decided by injecting in
it large quantities of colored water or
other material, whose passage from the
rectum would prove the patulous condi-

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334 THE INFLUENCE OF BREAST FEEDING— CHAPIN. Jour. M. S. M. S.



tion of the bowel. When the false anus
involves the upper part of the small bowel,
nutriment should be injected into the dis-
tal limb while preparing the patient for
the operation.

The two cases which I have reported,
though both fatal, one from a prevent-



able, the other from a non-preventable
cause, were both successful in opening the
passage between the afferent and efferent
bowel, and in obviating the passage of
faeces through the false anus. In both
cases the false anus had begun to heal
before death cut the matter short.



THE INFLUENCE OF BREAST FEEDING ON THE INFANT'S

DEVELOPMENT.*

HENRY DWIGHT CHAPIN,
New York City.



Clinical results the world over have
demonstrated that the milk of the healthy
mother is the best food for the infant up
to the normal time for weaning. It is the
natural food for infants and this fact
alone should cause us to believe that a
superior or even an equally good food
can not be produced artificially.

The milks of the lower animals contain
the same food elements as breast milk,
viz. : fats, proteids, carbohydrates, min-
eral matter and water, but in different
proportions. Investigation has shown
that the composition of milks of different
species of animals is closely related to the
rapidity with which the young grow, a
milk high in proteid being intended for a
quick growing animal, as might be
expected. The milk of any species has
uniform characteristics and is kept by
nature within certain narrow limits of
variation; this fact has been demon-
strated by many experiments on cows. It
occurred to some dairymen that feeding
fat to cows might increase the amount of
butter fat in the milk, and as high as two
pounds of tallow a day were fed to

♦Read by invitation before the Wayne County
Medical Society, May 30, 1904.



healthy cows, but the increase of fat in
the milk was hardly perceptible. At-
tempts at feeding proteid into milk have
not been successful and the most com-
petent dairy students have come to the
conclusion that it is beyond the power of
man to alter the character or composition
of cow's milk, except by disturbing the
cow's nervous equilibrium or digestion,
or by underfeeding. When normal feed-
ing and nervous conditions are restored
the milk resumes its normal character.
This is exactly what we find in treating
nursing mothers; if they are worn out
and nervous we try to improve their gen-
eral condition; we order easily digested
food, look after the state of the bowels
and have the mother sleep away from the
child where she may rest and not be dis-
turbed; if the mother is overeating we cut
down her diet and order exercise to the
point of fatigue to insure complete meta-
bolism of the food. In a few words, we
try to bring about a normal condition of
the bod]^ and nature does the rest ; we do
not alter the composition of milk, increas-
ing or decreasing one of all of the ingre-
dients at will, as we sometimes think we
do when we successfully treat a nursing

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August, 1904. THE INFLUENCE OF BREAST FEEDING— CHAPIN. 335



mother, but bring about the secretion of
the milk that is normal to that mother.
What is normal for one woman may be
abnormal for another, just as much as
rich Jersey milk would be unnatural in a
scrub cow of no dairy qualities; but
leaving out extremes, the milk of any
species has a fairly fixed type of compo;
sition which shows the nutritive require-
ments of the young of that species.

In artificial infant feeding little diffi-
culty is experienced on the part of the
infant in digesting and assimilating as
much fat and carbohydrates as are found
in breast milk, but great disturbance is
often the result when as much proteid as
is found in mother's milk is given. A
favorite method of overcoming this dis-
turbance has been to reduce the amount
of proteid in the food to one-third to one-
half of that in human milk. When it is
remembered that the blood, brain, heart,
liver, lungs, kidneys and muscles — in
fact the working portions of the body —
are built up from the proteid of the food,
the tremendous advantage that the infant
which is assimilating good breast milk
has over the bottle fed baby, that may be
assimilating not more than one-half as
much vital-tissue building food (proteid)
will be at once appreciated.

Poor nutrition paves the way for sick-
ness. The breast fed infant is not as
susceptible to disease as the artificially
fed baby, and when attacked, re-
covers more promptly, as it has
more vitality and reserve force. Con-
densed milt babies proverbially succumb
to almost any serious illness, and when
the small amount of proteid in highly
diluted condensed milk is considered, it
is surprising that any other result could
be expected, a? the infant has in this food
little from which a strong vigorous body



can be constructed. Too much attention
has been paid in the past to gain in weight
and too little to the character of the flesh.
Many experiments have shown that of
two animals of the same weight one may
be a little dwarf enclosed in a mass of
dropsical, fatty tissue, while the other
may be a giant in comparison, when the
amount of blood, and size and strength of
all the vital organs is determined in both.
This differ_ence is due to feeding too lit-
tle proteid to the dwarfed animal.

From a nutritive standpoint alone the
breast fed infant has a great advantage
over the bottle baby, but it has other
things greatly in its favor also; mother's
milk is more than food, as we think of
food for adults; it is a food that adapts
itself to the infant's developing digestive
tract. What form the mother's milk
assumes after it reaches the stomach
depends upon the state of development of
the stomach; in the early stage of lacta-
tion, the secretion of the stomach is the
rennet ferment which changes the casein
of the milk into a soft, solid mass or curd
which is not digestible by pepsin; the
character of this mass or curd differs with
the kind of milk. When the stomach
secretes hydrochloric acid it combines
with the curd and forms chloride of para-
casein, a compound much denser than
rennet curd or paracasein ; this compound
of curd and acid is readily digested by
pepsin, and gastric digestion commences.
As fast as the secretion of acid and pep-