W. H. A Jacobson.

The operations of surgery; a systematic handbook for practitioners, students and hospital surgeons .. online

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great a tendency amongst writers on colotomy to teach that, if it is
done sufficiently early, and if its immediate risks are survived, the
relief is always decided and the patient's condition always a most
satisfactory one.

Some of these instances of incomplete relief — viz., persistent passage
of motions over the malignant disease, and teasing diarrhoea from
the artificial and natural anus, have seemed to me to be due : (1) To
the lower communication with the bowel being too patent, sometimes
no doubt accounted for b}^ the fact that the colon at the spot where
it has been drawn into the Avound, owing to the shallowness of the
loin or the length of the meso-colon, is scarcely kinked or bent at all ;
this leads to escape of faces over the malignant growth and much
pain and teasing diarrhoea. (2) To persistence of the growth in the
bowel below, causing a profuse sanious discharge. (3) To the growth
extending upwards towards the wound, or to the bowel having been
opened only just above the growth.

As a rule, the more complete the failure of previous treatment, the
more painful, difficult, frequent, and unsatisfactory the action of the
bowels, the greater the tendency of distension of the sigmoid or lower
intestines generally, the more frequent the attacks of gripings and
partial obstructions, which herald in the tormina of a complete
miserere; the younger the patient, and thus the longer the natural
prospect of active life, the more plain are the indications for colotomy.
On the one hand, certain special evils * call loudly for the relief which
the operation may give — viz., a patulous or invaded sphincter allow-
ing of involuntary escape of flatus and faeces, multiple fistulse giving
rise to foul sanious discharge, keeping the patient (perhaps a woman
of scrupulous cleanliness) in a constantly filthy condition, and lead-
ing to a brawny, painful condition of the buttocks, which thus readily
become the seat of cellulitis and its allies ; i^rojection of the growth

* To quote only two sjiecial wretchednesses — e.g., when a lady cannot rise from her
easy-chair without an esca|:e of flatus or faeces taking place from a powerless sphincter,
or when a man is threatened with agonies of pain from the carcinoma eating back-
wards and involving the sacral nerves, and causing caries of the sacrum, with fistulse
and fold discharge.


downwards through the anus, leading not onl}'' to a patulous sphincter
and its consequent wretchedness, hut also to irksome or painful sitting.
On the other hand, certain conditions contraindicate the operation
— viz., exhaustion of strength, evidence of secondary deposits in the
peritoneal cavity, liver, lungs, or pleura , absence of much pain or
obstruction from first to last,

(3) Annular stricture of the sigmoid colon.

(4) Malignant disease of the large intestine higher uj) — viz., in the
splenic or hepatic flexures.

(5) Pelvic tumors pressing on the rectum.

(6) Results of pelvic cellulitis narrowing the rectum.

(7) Chronic intestinal obstruction due to any of the above causes.

(8) Vesico-intestinal fistula.

Lumbar colotomy is j)erformed in cases of communication between
the large intestine, esi^ecially the rectum, and the bladder, to prevent
the passage of fseces into the bladder, with its results of cystitis, ago-
nizing obstruction of urine, and passage of flatus from the urethra
without notice and beyond control.

Such a fistula is much more frequently met with between the sig-
moid or rectum and the bladder ; if between the latter and the rectum
the communication may be found by the finger, or by passing a duck-
bill speculum and injecting colored fluids.* Too frequently malignant
in character, it is occasionally of a simpler nature — e.g., dysenteric,
etc., and so, perhaps, curable. Thus, in Mr. Holmes's case (Med. Chir.
Trans., vols. xlix. and 1.) the ulceration between the sigmoid and the
bladder was not malignant, colotom_y for fifteen months was most
successful, but a permanent cure was prevented by similar ulceration
taking place between the caecum and bladder which caused death.
Whether the cause is malignant disease or no, the life which lies before
the patient is scarcely tolerable.

The opening is far more frequentlv valvular in nature — i.e., while it
admits of the passage of fa?ces into the bladder, urine very rarely passes
per anum.

Site of the Proposed Colotomy. — In some cases, especially
where intestinal oljstruction is threatening from malignant disease, the
surgeon ma}^ be in doubt as to tlie site of the disease, and therefore on
which side to operate. It is quite impossible to make fixed rules for
advice, but the following will help in doubtful cases :

(1) The proportionate frequency of stricture in different parts of the large

* The following plan, based upon one made use of by Mr. Lnnd [Hvnt. Led. 1885,
p. 91), would very likely be useful — viz , to pass into the rectum a bougie round which
is wound a strip of Hut well soaked in starch and water and dried, and then to inject into
the bladder some diluted iodine solutiuu. A j-tain of starch iodide on tiie bougie would
show the position of the fistula.



intestine. The frequency of disease in the rectum and sigmoid flexure,
as compared with any other part of the large intestine, and, generally
speaking, the frequency of disease in the left side of the arch formed
by the large intestine, as compared with such disease in the right side,
are well known.*

(2) The Use of Large Injections. — Dr. Fagge {loc. supra cit., p. 318),
thus writes on this subject: " Several writers, and especially the late
Dr. Brinton, have laid stress on the value of large injections as an aid
to diagnosis. The observer I have named has even laid down definite
rules for our guidance in this respect. ' It is quite singular,' he says,
' how trustworthy I have found the conclusions thus arrived at. For
example, with a maximum injection of a pint of warm, bland liquid,
the obstruction in an ordinary male adult may be referred to a point
not lower than the upper third of the rectum. A pint and a half, two
pints, three pints, belong to corresponding segments of the sigmoid
flexure. The descending and transverse colon accept a larger, but more
irregular, quantity. In one case, in which it was evident that the
stricture occupied the upper part of the ascending colon, nine pints of
injection were always found to be the maximum.'" Dr. Fagge points
out that the correct determination of this point requires much care, as
(a) some of the fluid measured may escape in the injection; and (6)
a stricture may be pervious to fluid injected from beloAV, though the
intestinal contents may be unable to pass through it from above.
Thus, in a case in which there was a mass of disease in the sigmoid
flexure, just above the pelvis, 4 pints of water were injected per rectum ;
of this a small portion only returned, the greater part passing through
the stricture and adding to the accumulations above it. I would add
one more caution with regard to these injections. Patients, in much
misery, and having submitted to one or two rectal examinations, will
sometimes ask for an ancesthetic. Such an aid must be used with great
caution if there is already abdominal distension. There is not only a
danger of adding seriously to the distension, and thus further weak-
ening or rupturing parts which may be already near the point at which
they give way — e.g., a caecum with " distension ulcers " — but an antes-
thetic, especially chloroform, has additional dangers in such cases as
these, where, in a patient probably no longer young, the action of the
heart and lungs are interfered with by the upward pressure against
the diaphragm,

(3) The distance to ivhich a long bougie or rectal tube passes is of very
little value, and needs only the briefest mention here, because the sur-

* Dr. Fagge, in drawing attention to this fact {Guy's Hosp. Reports, 1868, p. 314),
quoted the following statistics from Dr. Brinton : "Of 100 cases, 4 are in the Cfecum,
10 in the ascending colon, 11 in the transverse colon, 14 in the descending colon, 30
in the sigmoid flexure, and 30 in the rectum." The statistics of Dr. Fagge and M.
Duchaussoy confirm the above.


geon is still called to cases in which he is assured that the obstruction
cannot be in the rectum or low down in the sigmoid flexure, as a long
bougie has been easily passed its full length. This fallacy, which is
due to the bougie bending on itself, is more frequent than the other
one, in which the arrest of a bougie by one of Houston's folds misleads
into the belief that a stricture exists low down.

(4) The form of the abdomen may give valuable conclusions. Thus
Dr. Fagge {he. supra cit., p. 319), gives a case of cancer of the hepatic
flexure, in which it was observed during life that the cajcum and
ascending colon were distended, and not the descending colon. Again,
he observes that when the rectum or the sigmoid flexure is the seat of
obstruction, the lumbar regions and the epigastrium are no doubt
generally prominent, and the course of the colon is more or less
plainly marked out. That these conclusions are only valuable if not
too implicitly relied upon, is shown by the fact that cancer of the
rectum may be present, with vomiting, peristalsis, and borborygmus,
and yet there may be no general distension of the abdomen, no filling
out at all of its sides: on the other hand, a prominent epigastrium
and the appearance of a large horizontal coil of intestine here may lead
to the conclusion that the transverse colon is distended, the disease
being, nevertheless, in the ilium, a distended coil of which has rivalled
the colon itself.

(5) A symptom of some value, if verified by the medical man
himself, is the fact that for some time the motions have Ijeen narrow,
tape-like, broken up, abnormal in bulk, shape, and length. Certain fallacies
diminish, however, the value of the above — e.g., that in cases of
stricture high up, as in the upper part of the sigmoid flexure, there is
probably room for the fteces, after they have got through the stricture,
to collect, till their characteristic form is given them, though we do not
know how far irritation of the intestine and formation of mucus at the
seat of the growth may interfere with this.

(6) A few other points — e.g., constant arrest of borborygmi at one spot,
Jixedpain at oneplace, as in the right hypochondrium — may give useful
indications, while others, such as n, rectal examination, are so obvious as
scarcely to deserve mention.

If, after weighing the above, the surgeon is still in doubt as to the exact
site of the disease of the large intestine, he should not hesitate to j^er-
form right-sided lumbar colotomy. He should not be deterred from
this by the anatomical difficulties^ supposed to exist on this side.
Especially where the colon is at all thickened or distended, the opera-
tion on one side is no more difficult than on the other.

* Eg , a more complete peritoneal coat.


Some Points in the Surgical Anatomy of Colotomy, and
Landmarks Useful in the Operation.— The i)arts cut through,
and the means of recognizing the colon, are fully given below. Atten-
tion will here be drawn to the connection of the peritoneum with the
colon, and on this point we have nothing more accurate than the ob-
servations of Braune.* This anatomist writes : " It is usually stated
that the descending colon lies along the outer border of the quadratus.
.... This is not always correct. At the level of the symphysis be-
tween the third and fourth vertebrse, and at the fourth below the
kidney — and therefore exactly in the field of operation — the quadratus
lumborum covers in the colon posteriorly, and must be cut in order
to reach it. It is only when much distended, a condition which is not
so constant as one Avould expect in operations,t that the intestine in-
creases in breadth forwards and inwards, or overlaps the outer border
of the muscle." Professor Braune goes on to say that, from the im-
possibility of recognizing the peritoneum from its posterior aspect,
success can only be safely calculated on by measuring the distance of
the point of reflection of the peritoneum, and how far from the colon
this position is constant. "As regards the descending colon, which I
here joarticularly refer to after measurements of frozen bodies of full-
grown men, I find that this distance, in a straight line (therefore not
corresponding with the curvature of the wall of the intestine), is from
four-fifths of an inch to an inch, supposing the intestine empty and
contracted (at a level between the third and fourth lumbar vertebrse) ;
further, that the free side of the intestine does not look posteriorly,
but somewhat inwards, exactly towards the angle which the psoas and
quadratus make with each other. If, on the other hand, the small
intestines are much distended, .... the colon, by means of the
traction of the parietal peritoneum, would be rotated on its axis, so
that its free surface would be directed more outwards.

" Should the colon itself be distended, its surface, free of peri-
toneum, Ijecomes considerably larger, and may assume a breadth of
from 2 to 2.5 inches."

It is beyond doubt that the surface free from peritoneum is less
extensive on the right than on the left side, and that a meso-colon is
more frequently met with in the case of the ascending than in that of
the descending colon. The former fact will not cause trouble when
the colon is distended ; the layers of the meso-colon, if identified,
might be parted from each other, but the safest way of meeting these
complications is to perform the operation, whenever possible, in two

* Atlas of Topographical Anatomy (translated by Mr. Bellamy), p. 133.

t Thus in Fig. 2 (Pirogoff), p. 131, of Prof. Braune's book, where the intestines are
shown much inflated with air, the ascending colon is well distended, the descending
somewhat collapsed.


stages, and on all occasions to adopt the most stringent antiseptic
precautions possible.
Landmarks (Fig. 101).

1. The lower border and tip of the last rib.

2. A point * inch behind the centre of the crest of the ilium, this
point being found by accurate measurement along the crest between
the anterior and posterior superior spines (Allingham).

3. A line drawn vertically up from the last-mentioned point to the
last rib. This gives, with sufficient correctness, the line of the outer
edge of the quadratus, and the position of a normal colon.

Owing to the varying length of the last rib, the upper end of this
line may meet this bone at its tip, or at a spot a varyiiig distance in
front of or behind this point. It is well to dot the ends of this ver-
tical line with an aniline pencil. The dent of a finger-nail, made
when the patient has been brought under the anaesthetic, will mark
these points sufficiently to begin with, but a little later, in a difficult
case, the surgeon may be glad of having taken ever}'- possible pre-


1. Vertical, of Callisen. This at first sight is the best, as it follows
the above line, and thus corresponds anatomically to the colon, but it
has the disadvantage of giving but limited space, especially in a fat
or deep-chested patient ; and if prolonged upwards, so as to give all
the space possible, it divides the intercostal vessels running with the
last dorsal nerve, and gives rise to troublesome haemorrhage.

2. Transverse, of Amussat.

3. Oblique, of Bryant, modified from the above. One of the two
latter is usually employed; they have the great advantage of being
readily prolonged when more room is required, and the oblique
incision corresponds better with the course of the nerves and vessels.*

It is the one given below.

Operation cFigs. 101, 102).

The patient being turned on to his side (most usually the right)
with a firm pillow under the loin, the parts cleansed, the tija of the
last rib and the point on the crest of the ilium, as given above, being
dotted with an aniline pencil, an incision is made, beginning 2* or 3
inches from the spine, according to the size of the erector spine, a
little below the last rib, and running downwards and forwards for

* Mr. Greig Smith (Abdom. Surg.,p.S96) thinks that this incision helps to prevent
prolapse of the bowel by lying almost trans%'erse to its axis. He gives also the follow-
ing practical hint : " In thin patients, and particularly in women, whose iliac crests
are more prominent than in men, there is a tendency for the upper lip of the wound
to fall inwards, while the lower lip protrudes. This may be obviated by careful appo-
sition, and by not bringing the line of the incision too close to the ilium."^



3 J to 4 inches towards the anterior superior spine. The centre of this
incision should bisect the line given at p. 597 as the line of the colon.
The first cut should expose the muscles, the skin in the posterior
half being thick, and the subcutaneous fat often abundant. The
next may go well into the muscles, the remainder of which should
be then carefully divided with the knife, or torn through with a
steel director, so as to expose the fascia lumborum ; any bleeding
vessels being now secured, this fascia is pinched up, nicked and slit
upon a director. Two retractors being placed on the lips of the
wound, the fat which lies around the kidney and behind the fascia
lumborum is next torn through with two pairs of dissecting forceps.
If the bowel is distended it will bulge up into the wound, pushing
before it the transversalis fascia, and the operation can be readily
completed. If, on the other hand, the bowel is empty, the real diffi-

FiG. 101.

culties of the operation only begin at this stage. The wound being
well opened, the kidney, if it come down below the rib (as it occa-
sionally does, especially in a patient breathing heavily under the
influence of an anesthetic), being kept out of the way by the finger
of an assistant, the intestine is sought for by scratching with a di-
rector, or two pairs of forceps, through the transversalis fascia (Fig.
101) exactly in the line to which attention has been already drawn.
Several layers of cellular tissue may be met with here, and it is now
that most of the difficulty is usually met with, owing to the operator
being afraid of the peritoneum, and to his not opening the trans-
versalis fascia with sufficient decision.

When this has been done, scybala in the colon will in many cases
be felt, but if the large intestine is empty much trouble may be met


with in detecting it and getting it up into the wound, especially if,
close by, the peritoneum is bulging up.
At this stage the following points may be usefully remembered :

(a) The exact position of the line of the colon (pp. 596, 597).

(b) The lower end of the kidney, and its relation to the colon.

(c) The outer edge of the quadratus lumborum (p. 596).

(d) The sensation of thickness as given to the fingers in pinching
up the colon, thus distinguishing large from small intestine.

(g) The feel of scybala if present.

(/) Seeing one of the three longitudinal muscular bands which dis-
tinguish the colon.*

ig) Inflation with air or injection of fluid. f

(h) Mr. Bryant has advised rolling the patient over on to his face
at this stage, so that the colon may be felt to fall on the finger inserted
deep into the wound.

The bowel having been found, its posterior surface is to be drawn
well up into the wound, and if the case is not an urgent one, retained

Fig. 102.

Colotomy in two stages. The bowel is shown secured with pins at the close of the first stage.

there by passing long hare-lip pins through it. There is no need to
pass the pins through the edges of the wound ; they simply lie across

* Mr. H. Allingham {Brit. Med. Journ., April 28, 1888) seems to consider it very
difficult to ensure finding one of these bands without opening the peritoneal cavity.
While I should he the last to make light of the difficulties which may beset this
operation, I feel sure that few surgeons, who have had a large experience of colotomy,
will agree that the above step is needful, especially if the line given by Mr. Allingham's
father be strictly followed.

f Air is most readily made use of. It may be pumped in by a Higgenson's syringe,
a Lister's hand-spray, but, best of all, by the special apparatus described by Mr. Lund
{Lancet, 1883, vol. i. p. 588), which, by means of an elastic ring, secures air-tight
contact with the anus while air is being pumped in, either as an aid in colotomy, or
as a means of reducing an intussusception. In some cases of cancerous disease of the
rectum it will be very difficult to introduce any nozzle for inflation beyond the disease.
In the summer of 1885, when performing colotomy at Guy's Hospital in a patient,
the lower part of whose rectum had been unsuccessfully excised at another hospital, I
found it impossible to introduce any nozzle when desirous of inflating an empty colon.


these, resting on the margins of the wound at either side, a few strips
of iodoform gauze being placed under them, or little slips of cork on
their ends. The pins should be passed through the bowel at a dis-
tance of at least f inch from each other, so as to render easy the
opening of the bowel in a few days' time, and they should not, if it
can be managed, penetrate all the coats of the intestine. The pins
are so fine* that any puncture of the canal itself will probably give
rise only to a little flatus, readily met with iodoform. The mtirgins
of the wound are then carefully closed with silver wire or carbolized
silk sutures, and a few fine ones may be passed between the bowel
itself and the margins of the wound. Dry gauze dressings are then
applied, iodoform being dusted over the bowel and wound. These
dressings will probably not need changing till the fourth day, when
the operation is completed by opening the bowel with a tenotomy
knife between the pins'; this opening may be a small crucial one,
very little but flatus will pass at the time, but a director will show the
presence of fseces, and mild aperients may be given as soon as the
parts are firmly healed. The above raethod of performing colo-
tomy by two stages was introduced at Guy's by some of my
senior colleagues, Mr. Bryant, Mr. Howse, and Mr. Davies-CoUey,
being based on that most important modification of gastrostomy
which Mr. Howse was the first to make use of in this country. Mr.
Davies-Colley brought before the Clinical Society (Trans., vol. xviii.
1885, p. 204) a paper on " Three Cases of Colotomy with Delayed
Opening of the Intestine." It was from him I learnt the use of the
pins t given above. Some operators — viz., Mr. Bryant and Mr.
Howse — have had good results after simply drawing out the knuckle
and leaving it protruding in the wound without any sutures to secure
it, or fixed with torsion forceps, the blades covered with drainage-
tube, applied with just sufficient force to hold up the intestine without
causing sloughing. To apply the right degree of pressure is a matter
of some difficulty, and with regard to the method of leaving a knuckle
without sutures, I agree with Mr. Davies-Colley (loc. sivpra clL, p. 209)
that serious difficulties may arise from the bowel slipping back into
the wound.;}; This is especially likely to occur in a restless patient,

* A good form of pin is mentioned in footnote following.

t In six cases of colotomy which I performed in 1887, I used some pins made for
me by Messrs. Downs. Their steel is sufficiently tempered to be slightly flexile,
thus yielding a little, a point of much importance when the knuckle of the colon has
to be dragged up to the surface of a very fat loin, and thus exerts much tension on
the pins. The flat heads rest comfortably on the skin margins of the wound, without
causing any ulceration.

X In one case which was under my care two years ago, in which, after drawing out
a knuckle of sufficient size, I had been content to fix it with numerous very fine silk


in cases wliere the wound is very deep, and where, owing to the pa-
tient's weakly condition or from suppuration taking place, the intes-
tine does not early become firmly fixed. The great advantage of this
two-stage method is that it defers the opening of the bowel till this
is sufficiently adherent. (2) By this delayed escape of intestinal

Online LibraryW. H. A JacobsonThe operations of surgery; a systematic handbook for practitioners, students and hospital surgeons .. → online text (page 65 of 115)