No. 1439.

MARCH 29, 1851.

LecturesON

SOME OF THE MORE IMPORTANTPOINTS IN SURGERY.

(Delivered before the Medical Society of London.)BY G. J. GUTHRIE, ESQ., F.R.S.,

LATE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND;CONSULTING SURGEON TO THE WESTMINSTER HOSPITAL, ETC.

Treatment of wounds of the abdomen and intestines. Divisionof the alimentary canal. Valvula conniventes. Villi in thesmall intestines. The glands in the intestines.

MR. PRESIDENT,-I have selected, for this evening’s lecture,the Treatment of Wounds of the Abdomen and Intestines, forthe same reason as on the last occasion; for although thesubject ought to be as well understood as the present state ofour knowledge admits, it is nevertheless otherwise; arising Isuppose from the circumstance that these accidents are of in-

frequent occurrence, and it is therefore possible may not beso well taught or studied as others to which the surgeonexpects to be more often called, or into the nature of whichhe may more frequently inquire. A summary view of theleading facts connected with them may not therefore be

unacceptable to the Society.I shall confine myself, with respect to the anatomy of the

parts within the walls of the abdomen, to the intestines, ofwhich, by the aid of Mr. Quekett, I have much to show, whichwill I hope be interesting to those who have not had time toattend to the subject.The division of the alimentary canal, below the stomach,

into small and large intestines, is useful, not only from thedifference of structure, but of function. The small intestinesinclude the duodenum, jejunum, ileum, the large intestines,the csecum, with its appendix vermiformis, the colon, and therectum.

If an intestine be divided circularly, in any part, its wallswill be found to be composed of three principal coats or tunics,which are, commencing from the inside-the mucous, the mus-cular, and the serous or peritonaeal, each being separated fromthe other by a layer of areolar tissue. A diagram thus madewould show a transverse division of the intestine, and eightdistinct, if not all different parts. Beginning from without-viz., serous or peritonaeal, areolar or sub-serous; longitudinalmuscular, areolar; transverse muscular, areolar or sub-mucous, and epithelial. The mucous coat in man having apeculiarity not observable in animals, of ledges or shelvesprojecting into its cavity.When the mucous coat of the duodenum is examined with

the naked eye, the first part of its course presents a tolerablysmooth appearance, gradually, however, becoming irregular in Itransverse folds, which are so numerous, marked, and regular,in the jejunum and ileum, as to have obtained, from the

I’earliest times, the name of valvulse conniventes. They aremost strongly marked in the jejunum, and gradually disappeartowards the lower part of the ileum, the inner surface of thelarge intestines being still smoother than any part of thesmall, although, in the colon, large pouches or cells are formedby a peculiar arrangement of the muscular coat. The prepa-ration No. 716, in the museum of the College of Surgeons,shows the valvular conniventes, the upper half white, thelower half a brilliant red, the vessels being filled by injection.Preparation No. 713 shows twenty valvulas conniventes in fiveinches of the jejunum, or four to an inch, each valve beingcomposed of a fold of the mucous coat, lined above and belowby areolar texture, containing its vessels and nerves. Thesevalves never extend completely around the inside of the in- ’,testine, and rarely more than half or two-thirds, although ithey sometimes bifurcate, as may be seen in the preparations.These valves, as well as the whole mucous membrane, have a i,velvety appearance, which has obtained for this coat the ’,name also of villous, as well as mucous-a peculiarity which iswell marked in the injected preparation.Valvulm conniventes are peculiar to man; none exist in the

ourang-outang or chimpanzee. In the frog, there are valvularfolds, appearing, at first sight. like the valvulse conniventes of

the human subject; but on a careful examination, they arefound to be mere elevations, without villi. In the tort< &Iuml;3ethere are similar folds, running, however, in a longitudinalor opposite direction. In the rhinoceros, Mr. Quekett hasshown, in some beautiful preparations, the mucous membraneraised up into villiform processes, somewhat like valvulse con-niventes, or large villi; but they are not villi, as each processis covered with other projections, which are really villi. Avalvula connivens consists of two layers of mucous membraneand submucous tissue, but the muscular coat is not continuedinto them.When this part is examined microscopically, the velvety

appearance is found to consist of innumerable small pro-cesses which have been called villi, each villus being composedprincipally of a very thin transparent membrane, termed byMr. Bowman, basement membrane, by Mr. Goodsir, germiralmembrane, forming a. sheath or case, enclosing within it anartery, vein, a capillary plexus, and an absorbent vesseltermed lact"al. A nerve has not been discovered, although itis presumed to exist. These villi are longest in the duodenum,and gradually diminish in number and in size from to ofan inch. Between these villi or projections, holes or open-ings are observable, termed the follicles of Ijieberkuhn, whofirbt described them; they resemble inverted villi,being in someinstances as deep as the villi are long. Theyare unlike the villifound throughout the intestines. The villi in every part, iii.common with all mucous membranes, are covered, and thefollicles are lined by epithelium, which in this instance isthe columnar, situated on the basement membrane, eachcolumn being attached by its parietal extremity. A layer ofthis epithelium extends between the villi, and down to thelower part of each follicle, each column being, generally speak-ing, shorter and rounder than when covering the villi.The office of the epithelium of the villi has been stated by

Mr. Goodsir to be p7-otective, that of the follicles, to be sec7vtive.It has been shown by his researches, which are published inhis "Anatomical and Pathological Observations," (Edinburgh,1845,) that the opinions entertained by Mr. Cruikshank andDr. William Hunter, that lacteals had open mouths on thesurface of the villi, and which opinions may even now betaught as well as believed by some persons, were erro

neous. That, on the contrary, a villus composed as Ihave described, is seen when duly magnified to have a,

bulbous extremity, without an opening, and to be covered byepithelium, when the intestine is in a state of quiescence, un-called upon for any purpose of digestion. When digestioncommences, the epithelium is separated and thrown off. Mr.Goodsir says, " As the chyme begins to pass along the smallintestine, an increased quantity of blood circulates in thecapillaries of the gut. In consequence of this increased flowof blood, or from some other cause with which I am not yetacquainted, the internal surface of the gut throws off theepithelium of both vflli and follicles, which are intermixedwith the chyme in the cavity of the gut. The cast-off epitheliumforming 2oths of the covering of the villus, is of two kinds, thatwhich covers the villi, and which, from the duty it performs,may be termed protective, and that which liaes the folliclesis the columnar of Dr. Todd, the cylindrical of Henle, theprismatic of Mr. Bowman, and is endowed with secretoryfunctions," may be termed secj-et&Iacute;1.Je, each column having 0,

nucleus situated at different parts of it, and bulging out thatpart.The villi being now turgid with blood, erected and naked,

and covered by the chyme mingled with the cast-off epithelia,commence their functions. The summit of the villus becomesat first somewhat flattened, and crowded under the basementmembrane with a number of new formed asd perfectly spheri-cal vesicles, varying from 1000 to less than 2000 of an inch insize. Towards the body of the villus or the inner edge of thevesicular mass, minute granular or oily particles are situatedin great numbers, and gradually pass into the granular textureof the substance of the villus. As the process advances, lactealvessels are shown passing up from the root of the villus, sub-dividing and looping as they approach the spherical mass,which in this stage has become more distinctly vesicular,although no distinct communication can be detected betweenthem. The bloodvessels and capillaries in injected preT1J.ra.-tions are now seen, coloured red and running up to the base-ment membrane, looping with each other immediately beneathit, and ending in one or more venous trunks. The vesicles,quite distended, and grouped in masses, push forward themembrane, and give to it, by these inequalities, an appear-ance resembling that of a mulberry.The minute vesicles above noticed fulfil the important

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office of absorption, by drawing into their cavities through theirwalls, by a process called enrlO81nUsis, that portion of the chymenecessary to form chyle; and when filled with it they burst ordissolve, their contents being thus discharged into the textureor substance of the villus, fit to be taken up by the granularvesicles interspersed among the terminal loops of the lactealsand communicating with their trunks, running up from theroot of the villus in their centre. Absorption is then shown tobe effected by closed vesicles, and not by vessels opening onthe surface of the villus.The d&eacute;bris, and the contents of the dissolved chyle-cells,

&c., pass into the looped network of lacteals, as in otherlymphatics. When the gut contains no more chyme, the flowof blood to the mucous membrane diminishes, the developmentof new vesicles ceases, the lacteals empty themselves, thevilli become flaccid, and the cast-off epithelium is reproduced,apparently from the nuclei in the basement membrane, in theintervals of digestion, showing that this function should onlybe induced at regular periods, the presumed special use ofthe epithelium being to prevent, in a measure, the absorptionof any effete or other matters which might exert a deleteriousinfluence on the system, the epithelium of the follicles nowsecreting a mucus which may be considered protective.The first or receiving stomach of the porpoise, of which

there is a beautiful preparation in the Museu’n of the College,is lined by a thick coating of epithelium, not being intendedfor digestion; the digesting portion of the stomach, on thecontrary, is highly vascular, and to all appearance devoidof epithelium, thus giving support to the view-! entertained ofthe use of the epithelium in the human intestine.

In the large intestines there are no villi, but the whole sur-face is covered with follicles, which must be capable of ab-sorbing as well as of secreting, as it is now ascertained that

persons can b3 nourished and kept alive for many weeks bynutritious enemata which do not pass into the small intes-tines.In the largest animals, such as the whale and the elephant,

the villi and the follicles are smaller than in man and in manyother of the lesser animals, such as the rabbit and the hedge-hog. In the elephant a tolerably high power of the microscopeis required to make them out. On viewing the surface of themucous membrane of man injected under the microscope, theappearance of the villi and the opening of the follicles betweenthem in the small intestines is very distinct from that of thelarge intestines, in which there are no villi, but merely theopening of the follicles. The common fowl, and most birds ofthe gallinaceous order, are exceptions to the rule, villi beingfound in the large intestines, of a larger size in the lower partof each csecum, but which diminish both in number and size,as they approach the caecal extremities, where the structureis follicular only.The villi of the small intestines in many birds and animals

confined in the Zoological Gardens, are. subject to a diseasefrom which many die. It commences by a deposit in thevilli, which become enlarged to three or four times their ori-ginal size, sometimes beginning in a single villus, at others, inclusters of villi, in which case the disease usually goes on form-ing large masses, nearly an inch in length, which after a time Isoften like tubercles, and finally terminate in ulceration andrupture of the muscular and serous coats of the bowel.The mucus of the intestines is coagulable by acids gene-

rally, and is solidified by the acetic, although it is dissolved bynone. When dried, it differs from the mucus of the Schnei-derian membrane in not swelling up and becoming transparenton the addition of water, unless an alkaline solution is added.Caustic potass dissolves it.On examining the mucous membrane of the stomach, its

follicular structure is immediately seen, the follicles resemblingmuch in appearance those of the intestine; but in the stomachminute tubes are found opening into the bottom of each fol-licle, fulfilling in all probability, a different -office, the folliclesbeing lined by columnar epithelium, the tubes by spheroidalor glandular epithelium, and it is therefore presumed thatthe gastric juice is secreted by the tubes, the mucus by thefollicles. The tubes differ in the middle and lower parts ofthe stomach, by being longer or deeper-seated, and more nume-rous as they approach the pylorus, showing in all probability,a difference of function between the upper and middle, andthe pyloric, or lower extremity of the organ.The intestines are supplied with glands, not apparently for

the purposes of absorption, but of secretion, which require at-tention. They are the duodenal of Brunner, the agminatedof our countryman Nehemiah Grew, and of Peyer, and thesolitary, which are found in the lower part of the small, and inthe whole course of the large intestines.

The glands of l3rzcnxaer are situated at the commencementof the duodenum, within an inch of the pylorus, and are notvisible until the serous and muscular coats are removed fromwithout. They appear to the naked eye like little white eggsof an insect. Under the microscope each little gland is foundto bf lobulated, and very much resembling a small portion ofa salivary gland or pancreas, each lobule having an excretoryduct, which unites with those from other globules to form onelarger one opening on the mucous surface of the bowel. Thelobules themselves are made up of vesicles, within which thesecretory cells are discernable.The agminated glands of Grew and of Peyer, by the latter

of whom they were more minutely described, occur in ovalpatches at irregular distances throughout the jejunum andileum, and are situated on the side immediately opposite thepart where the mesentery is united to the bowel. Each glandresembles somewhat a Florence oil-flask in shape, the smallend or mouth, which is more or less pointed, projectingthrough amongst the villi or the follicles. They are composedof cells, supplied by capillary vessels, which Mr. Quekett sayshave the peculiarity of being unsupported by areolar tissue,and are termed by him in consequence 1wked. These are theglands which are found more or less diseased after phthisisand fevers which have terminated fatally. The oval form of thepatches is retained, although considerably raised above thegeneral surface of the mucous membrane, and when injectedthe parts around are more vascular, the ulcerated portion beingless so than usual.The solitary glands are best seen in the caecum and appendix

vermiformis. They are well developed in the feetus, project-ing slightly above the mucous membrane. Each gland maybe considered as one of the agminated form, much enlarged,and when the free surface is very flat, an opening may beeasily seen in the centre. These glands are also frequently theseat of ulceration in fever, dysentery, and particularly inphthisis, of which many beautiful specimens have been pre-served at the College. The follicles partake of this disease,and the whole mucous coat may be destroyed. In some casesthere is an attempt at healing, and the edges of the ulcersbecome more vascular, and even villous.The sub-mucous areolar tissue,-the tunica nervosa of

Haller, the fibrous laniel!a of Cruveilliier,-separating yetconnecting the mucous with the muscular coat of the intestine,was described by Cruveilhier as formed of a very distinct net-work, the filaments or lamellse of which can be separated byinflation or infiltration. The fibres of which it is composedare now known to be the yellow elastic, and the white or non-elastic, the latter of which predominate. It is more firmlyconnected with the mucous than the vascular coat, and in itthe bloodvessels and nerves are supported prior to their dis-tribution in the mucous membrane. This submucous tissueor structure prevails also in the stomach, and is often muchaltered by disease, becoming thicker, and assuming a 1ll0.aedense and sometimes an almost gristly hardness. It is an

important part in the surgical treatment of wounds of theintestines. Mr. Quekett, finding it firmer, stronger, and moreelastic in reptiles, more distinct in carnivorous than in herbi-vorous animals or in man, has favoured me with the followingcomparative table :-

1. Alligator. 7. Peccary. 13. Chimpanzee.2. Turtle. 8. Seal. 14. Monkey.3. Leopard. 9. Dog. 15. Bear.4. Cheetah. 10. Cat. 16. Ox.5. Horse. 11. Man. 17. Rat.6. Pig. 12. Porpoise. 18. Rabbit

The muscular coat of the intestines is in two layers, theinternal being composed of fibres running transversely, theouter fibres running longitudinally, and are thickest in theduodenum and rectum. They are of the involuntary or un-striped kind, as opposed to the voluntary or striped, whichare of large size, and characterized by striae running trans-versely and longitudinally. Dr. Martin Barry, in the Philo-sophical Transactions, and DTr. Bowman, in the PhysiologicalAnatomy of Man," article Locomotion, and Dr. Todd, in theCyclopmdia of Anatomy and Physiology," article Muscle,differ as to the cause of these appearances, and to these worksI refer you for the best account of them. They may, how-ever, be considered to be produced by the manner in whichthe fibre is built-viz., by being composed of minute-beadedfilaments, which have received from Mr. Bowman the nameof fibrillse, when shown separated in slips of voluntarymuscle, from which they may be also separated transverselyin discs.The involuntary fibres, on the contrary, are much smaller in

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size, are always more or less flattened, and present no traceof striao or stripes, although the interior appears granular,with an occasional nucleus. The heart is a remarkable ex-

ception to this rule, being an involuntary organ, with mixedfibres differing in size, and resembling in tim respect those ofa voluntary muscle.The peritonseal coat is formed of the white fibres, under a

structureless or basement membrane, covered by tesselatedepithelium, constituting a serous and secreting membrane,on which I need not dwell.

(To be continued.)

ON A CASE OF IMPERFORATE ANUS.BY F. LE GROS CLARK, ESQ., F.R.C.S.

ASSISTANT-SURGEON TO, AND LECTURER. ON ANATOMY AT, ST. THOMAS’SHOSPITAL.

ON Jan. 20th, 1851, I was called to the neighbourhood ofGravesend to see a newly-born infant, who was the subject ofimperforate anus. I met Mr. Armstrong, of the above town,with whom I had the pleasure of acting throughout the treat-ment of the case.The child, a male, was well developed, and apparently per-

fect in every respect: for the anus presented a natural appear-ance, and was pervious to the extent of about half an inch,and sufficiently capacious to allow the introduction of the littlefinger. On reaching the extremity of this cul-de-sac, (for suchit proved,) the finger was arrested by a firm, unyielding, mem-branous obstruction, against which not the slightest impulsecould be felt, when the abdomen was pressed upon, or whenthe child cried. The infant was at this time barely two daysold; but as it was evidently beginning to suffer from generaldistress, and rejected everything that was taken into thestomach, it was deemed desirable at once to take some stepsfor its relief.The child was held on the nurse’s lap, with the nates rest-

ing on her knees. Using my left fore-finger as a guide, I in-troduced along it a straight narrow bistoury, with which Iperforated the obstructing membrane, and then passed theknife upwards and backwards to the extent of an inch ormore in the median line. Some venous blood but no meconiumfollowed. I then introduced a director, but still no meconiumcould be detected. A slight impulse, however, was feltagainst the end of the director when it was pressed firmly up-wards, and counter-pressure was applied to the abdomen. Iregarded this as a doubtful evidence of an approach to the in-testine ; certainly as not possessing the same diagnostic valueas a more general impulse and fulness would afford, when felton the surface by the finger. Yet, as there seemed to be noalternative but the miserable one of abandoning the child, orthat of making an artificial anus, I again took the bistoury,and guided it along the director upwards, backwards, and alittle to the left side, to the extent of another inch. On with-drawing the two instruments together, meconium followed inabundance, with very little blood. The little finder couldnow reach the bowel. The relief was immediate, and the firstmeal, taken half an hour afterwards, was retained on thestomach. It was thought advisable, as the opening was a freeone, not to interfere at first by the use of tents or bougies.The case went on uninterruptedly well for more than a

week, the motions being passed freely and easily, as Mr. Arm-strong reported to me; and the state of the child was in everyrespect so satisfactory, that he did not consider himself justi-fied in interfering locally, until, on the evening of the 28th,sickness and straining, without relief from the bowels, led himto make an examination, when he found the artificial openingso far closed as to render the introduction of a No. 8 urethralbougie difficult. The size of the bougie was subsequently in-creased.Though some relief was thus obtained, the progress of the

case was so far from satisfactory, that Mr. Armstrong re-quested another consultation with me; and I accordingly methim on Feb. 6th. On examination with the little finger, theaperture of communication with the bowel could scarcely bedetected, although a No. 12 urethral bougie could be forcedthrough it. The fresh production which now constituted the Iobstruction seemed to be of that solid character which yielded IIby elasticity to the gradual dilating force of the conical bougie,and again closed when it was withdrawn. I introduced adirector, and divided this obstructing mass with a commonhernia-knife, backwards and on either side, to as great an ex-tent as I deemed safe; and then relieved the bowels by intro-ducing a pair of dressing forceps and opening the blades. The Ichild lost a little blood at the time of this second operation,

and was very poorly afterwards; but subsequently rallied.Mr. Armstrong has since diligently employed mechanical dila-tation, introducing a bougie daily, and gradually increasingthe size. He informs me that at the present date (March 5)"the child is much improved in appearance, and is obviouslygaining flesh. The water is passed freely, and the bowels aremoved about three times each day, the motions being con-sistent, and of a good colour, free from mucus or blood. Abougie, rather exceeding an inch and a half in circumference,(about half an inch in diameter,) is passed up with great ease."Further on Mr. Armstrong adds,-" I made a careful exami-nation of the rectum with my finger, which I was able to passwith very little difficulty. I found that the hard, dense, almostcartilaginous structures which you felt and incised, when I hadthe pleasure of meeting you before, had greatly diminished,and instead of resisting the admission of the point of the littlefinger, the bowel now admits the whole finger readily. Thestrictured portion is also dilatable, and the surrounding tex-tures are soft, elastic, and yielding. Absorption is evidentlygoing on; and the surface feels soft, as if something like amucous membrane were being formed upon it. There seemsevery reasonable hope that the case will terminate in a perfect

cure."Remarks.-My reason for desiring to place the foregoing

case on record is, not because it is unique, or even, patho-logically, of rare occurrence, but because I regard it as belong-ing to a class of cases in which precedents are peculiarlyvaluable, as affording encouragement and supplying a groundof justification for making a bold attempt to save life. I amaware that these remarks do not apply where consultation isreadily available, and where responsibility may be shared;but to some provincial practitioners, to whom these advantagesare denied, precedents in a case which may occur to thembut once in their lives must, or ought to, have their value.There is, moreover, but little risk of boldness in this instancedegenerating into rashness-an observation which is of rareapplication in surgical practice, and I apprehend there arefew who will deny that many infants, similarly circumstancedto that which forms the subject of this case, have been sufferedto perish for want of decisive measures for their relief.

It is not my intention or desire to enter upon this subjectat large. Suffice it to remark, that all cases of imperforateanus may be classed under two heads-those which may berelieved by an operation similar to that detailed above, and.those in which the imperfection of development precludes thepossibility of reaching the bowel from the anus. In the latterclass of cases an artificial anus is the only alternative, and thismay be made in the groin or lumbar region. The alternative,even if successful, is a miserable one; and the statistics ofsuch cases are not of a very satisfactory nature, even as regardsthe protraction of life. The reader will find some statistics onthis subject, collected in a valuable paper by Mr. Phillips, on." Intestinal Obstructions," in the thirty-first volume of the-4fedico-Cltirtirgical Transactions. Of the former, or curable,class of cases,twoforms present themselves-those in which thegut is reached by simply incising the integuments or occludingmembrane, and those (like the present) where the rectumstops considerably short of its proper termination. I have

operated in one instance where 1 found the anus entirelywanting; and though in this case the superficial structuresrequiring division were about half an inch in thickness, thefluctuating bulging at the proper spot satisfied me of theproximity of the intestine. Nature, almost unaided, com-pleted the cure.

I propose briefly, in conclusion, to point out the practicalinferences to be drawn from the case recorded in this com-munication. I believe the best instrument for opening thebowel to be that which I employed-viz., a straight, narrowbistoury, and the best guide to be the finger, as far as it canreach. Though prepared with a trochar and canula, I pre-ferred, in the second and deeper i-ncision, using a director andthe straight knife. At first I cut in the median line, keepingnear to the sacrum: but in carrying the incision deeper, I feltthe propriety of directing the knife a little to the left side, morder to meet the corresponding inclination of the rectum inthe upper part of its course. The full depth to which theknife was passed before the bowel was fairly opened (includingthe half inch of cul-de-sac) must have been two inches and ahalf. I rather dreaded the possible loss of blood, but tharesult proved that this fear was ungrounded. The communi-cation with the bowel being free, I considered it advisable toallow a short interval to elapse before any mechanical measures.were resorted to for securing the permanency of the opening.In a similar case it would, probably, be desirable not to allowmore than two, or at most three, days to elapse without the