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Page 1: #holecysto-Intestinal, Castro-Intes- tinal, Entero-Intestinal … · 2015-04-10 · #holecysto-Intestinal, Castro-Intes- tinal, Entero-Intestinal Anastomosis AND APPROXIMATION WITHOUT

#holecysto-Intestinal, Castro-Intes-tinal, Entero-Intestinal

AnastomosisAND

APPROXIMATION WITHOUT SUTURES(Original Research)

KY

J. B. MURPHY, M.D.CHICAGO, ILL.,

PROFESSOR OF CLINICAL SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS, CHI-CAGO ; PROFESSOR OF SURGERY, POST-GRADUATE MEDICAL SCHOOL AND

HOSPITAL; ATTENDING SURGEON TO, AND PRESIDENT OF,THE MEDICAL STAFF OF COOK COUNTY HOSPITAL ,*

ATTENDING SURGEON TO ALEXIAN BROTH-ERS’ HOSPITAL ; VICE-PRESIDENT OF

NATIONAL ASSOCIATION OFRAILWAY SURGEONS,

ETC.

Reprinted from the Medical Record, December io, 1892

NEWYORKTROW DIRECTORY, PRINTING AND BOOKBINDING CO.

201-213 East Twelfth Street1892

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Cholecysto-Intestinal, Gastrointes-tinal, Entero-Intestinal

AnastomosisAND

APPROXIMATION WITHOUT SUTURES(Original Research)

BY

J. B. MURPHY, M.DCHICAGO, ILL.,

PROFESSOR OF CLINICAL SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS, CHI-CAGO *, PROFESSOR OF SURGERY, POST-GRADUATE MEDICAL SCHOOL AND

HOSPITAL; ATTENDING SURGEON TO, AND PRESIDENT OF,THE MEDICAL STAFF OF COOK COUNTY HOSPITAL ;

ATTENDING SURGEON TO ALEXIAN BROTH-ERS’ HOSPITAL ; VICE-PRESIDENT OF

NATIONAL ASSOCIATION OFRAILWAY SURGEONS,

ETC.

Reprintedfrom the M EDI CAL Record, December 10, 1892

NEWYORKTROW DIRECTORY. PRINTING AND BOOKBINDING CO.

201-213 East Twelfth Street1892

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CHOLECYSTO - INTESTINAL, GASTRO - INTES-TINAL, ENTERO-INTESTINAL ANASTOMO-SIS, AND APPROXIMATION WITHOUT SUT-URES. (ORIGINAL RESEARCH.)*

Mr. President and Gentlemen : Intestinal surgery oc-cupies a very advanced place in the category of greatsurgical questions of the present day. Medical literatureteems with reports of successful cases operated on, andnot a few of the disasters are also placed on record. Allover the world investigators are trying to solve the manyperplexing problems that accident and disease of the gas-tro intestinal tract present to them for consideration.That this subject has had such exhaustive considerationduring the last decade, and that it is still a theme forspirited controversy and discussion, carries with it theimplication that many vital points are yet unsettled andneed further investigation, experimental and clinical.The results of experiments on lower animals have beenconducive to great improvement, both in principle andtechnique of treatment of intestinal lesions in the humansubject. Fair results are obtained in the treatment ofbullet wounds of the intestines at present. At least aneffort is made by the surgeon to repair the injury.

The questions above all others on which the professionis divided are, “ What are the best means and methodsof producing agglutination of surfaces and preventingsubsequent contraction at the point of adhesion ? ” Ifmeans can be devised—i, to hold the surfaces in con-

* Read before the Mississippi Valley Medical Association, October15, 1893.

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tact; 2, while in contact, to produce a speedy and per-manent adhesion of the surfaces; 3, to keep an openingsufficiently large for the free passage of intestinal con-tents; 4, to produce, as a result, a cicatrix that will notcontract to any great extent, and by the contraction pro-duce complete or partial obstruction—we will have over-come the great barriers that still remain between us andideal success in intestinal surgery.

The marvellous ingenuity displayed in plans devisedfor intestinal approximation and anastomosis is worthy ofthe greatest success, and that success would have beenrealized were it not that some of the following complica-tions occurred :

“ The suture was imperfectly applied;the bowel sloughed through at line of suture; the in-duced invagination increased after the operation untilcomplete obstruction was produced; openings in the bone-plates and disks were not in apposition ; the ends of thebone-plates caused pressure, atrophy, and perforation ;

the catgut sutures were too rapidly absorbed; lastly, andwith appalling frequency, prolonged operation producedfatal shock,” and many other well-known obstacles, notnecessary to mention here, intervened

To overcome these obstacles and thus lessen the riskto the life of the patient, I have devised a mechanicalmeans to dispense with the need of sutures, the necessityof invagination, the possibility of non-apposition, thedanger of sloughing through of disks, the too rapid di-gestion of the catgut, the almost insurmountable diffi-culties of technique of operation, the prolonged and fatalexposure of the abdominal contents, and the protractedanaesthesia. How much I have accomplished by my la-bor I desire you to be the judges, after I have demon-strated to you the results of my experiments, and per-formed for you a gastro-enterostomy and an end-to-endapproximation of intestine by means of the device I herepresent to you, to be known as the Anastomosis Button.

The buttons are made in three sizes. A button con-sists of two small circular bowls (Fig. 1); size No. 2

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measures as follows: Diameter, 23 rom. ; depth, 8 mm.There is ‘ 4 sweated ” into a circular opening, 12 mm. indiameter, at the bottom of one bowl, a cylinder 15 mm. inlength, with female screw thread on its entire inner surface.The cylinder extends perpendicularly from bottom ofbowl. There is an opening in the male bowl in which is“ sweated ” a similar and smaller cylinder of a size to

Fig. i.—Appearance of Button with and without Spring-cup Attachment

easily slip into the female cylinder. There are two brasssprings soldered on either side of the inner surface of thelower end of the male cylinder, which extend almost tothe top, where small points of them protrude throughopenings in the cylinder; these points are designed tocatch the screw-thread, when the male cylinder is pressedinto the female cylinder, and thus hold the bowls to-gether at any point desired. To separate them again theyare simply unscrewed. A small brass ring, with a thin

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though not cutting edge, to which is attached a wirespring, is placed in the male bowl and retained in po-sition, projecting 7 mm. above the edge of the bowl.This is held up by the wire spring, and is there for thepurpose of keeping up continuous pressure until the en-tire tissue between the edges of the bowls is cut off.This spring attachment is absolutely necessary only whenthe stomach is operated on. There are four openings, 5mm. in diameter, in the side of each bowl, for the pur-pose of drainage. By this, it will be seen, we have twohemispherical bodies held together by invaginating cylin-ders (Fig. I).* These hemispheres of the button are in-serted in slits or ends of the viscera to be operated on.A running thread is placed around the slit in the vis-cus, so that when it is tied it will draw the cut edgeswithin the clasp of the bowl. A similar running threadis applied to the slit in the viscus into which the otherhalf of the button is inserted, and the bowls are thenpressed together. The pressure atrophy at the edge ofthe bowl is produced by the brass ring supported by thewire spring. The opening left after the button has lib-erated itself is the size of the button.

This differs from all other previous devices in the fol-lowing particulars or combinations thereof: 1, It retainsits position automatically ; 2, it is entirely independent ofsutures; 3, it produces a pressure atrophy and adhesionof surfaces at the line of atrophy; 4, it insures a perfectapposition of surfaces without the danger of displace-ment ;s,it is applicable to the lateral as wr ell as to theend-to-end approximation ; 6, it produces a linear cicatrixand thus insures a minimum of contraction ; and 7, in theextreme simplicity of its technique, which makes it a spe-cially safe instrument in the hands of the everyday practi-tioner as well as the more dexterous specialist. We willnow consider its application.

* Buttons can be procured from surgical instrument makers, orfrom J. J. Ryan & Co., manufacturer, 80 W. Monroe Street, Chicago,

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Cholecysto Enterostomy. Gall-bladder and IntestinalFistula— Gall-bladder and Intestinal Anastomosis. —Theidea of this operation was suggested by nature in establish-ing pathologically a fistula between the gall-bladder andthe intestine. In this way the surgeon was guided to thebest means of relief where an occlusion of the duct wasproduced by the pressure of an impacted concrement, aneoplasm, a cicatricial band, or any pathological lesionwhich would render the common duct impervious. Whilenature had thus blazed the way, surgeons were slow totake advantage of its suggestion. The first one to advisethis method was my late lamented friend, von Nussbaum,of Munich, 1880. He expressed himself in the followingwords ;

“When the escape of gall through the naturalduct is no more possible, the question arises can we notmake an artificial connection between the gall bladderand intestine through which the gall can again escape intothe intestinal tract,” etc. 1

The first to work out a feasible plan for the attainmentof this ideal result was von Winiwarter. 2 Between the20th of July, 1880, and the 14th of November, 1881, hehad under his care a man, with occlusion of the ductuscholedochus, on which he operated six different times,and finally succeeded in establishing a fistula between thecolon and the gall-bladder, after sixteen months of labor.His original plan was to perform the operation in twosittings, but all sorts of difficulties beset his way. It iswonderful what energy and persistence both the operatorand patient showed to overcome ail impediments. Afterthe publication of his most difficult task it was six yearsand a half before a surgeon was found who had thecourage to undertake a similar operation, when Kappeler 3

undertook to follow in the footsteps of Winiwarter, butto do the operation in one sitting.

In the meantime there were several experiments madeon animals, with the hope of discovering a means of mak-ing a communication between the gall-bladder and theintestine at one sitting. Gaston, in 1883, experimented

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on five dogs, with elastic suture, which was so placed asto approximate the gall-bladder and intestine, andaround this a row of serous sutures to protect the peri-toneum. He hoped by the elastic pressure to producean atrophy and establish a fistula. The results wereunfavorable. In one the sutures sloughed through; twoended in peritonitis ; one in abscess between coils of in-testine—here the ligature sloughed through into thegallbladder, and left but an extremely small opening;and in one, at the end of the eleventh day, there wasfound sufficient adhesion and the fistula was established,the ligature being found in the intestine. In 1884he used a similar ligature on a young dog, in the samemanner, with a good result. In 1886 he made severalsimilar experiments, with the addition of ligating the com-mon duct, but the dogs only lived a few days, dying ofextensive gall-infiltration in the liver.

G. Harley 12 suggested the approximation with the for-mation of fistula from the gall-bladder to the intestineby means of sutures and caustic potash. He arranged anumber of sutures in a small circle, about the size of adollar, holding the gall-bladder to the bowel, but beforecompleting the circle mentioned, cauterized the centrewith caustic potash, then completed the circle with sut-ures, and in that way hoped to produce a fistula of thegall-bladder and have an adhesion by plastic exudationsurrounding it. He claims to have had good success inanimals.

Colzi, in 1883, put in a circle of sutures similar loHarley’s, but before the final suture made an incision inthe centre into the gall-bladder and duodenum, also li-gating the choledochus. The animals tolerated the op-eration without any apparent disturbance in the diges-tive functions.

De Page, in 1887, performed the same experiment asColzi, on three dogs, without ligating the choledochus.In one the suture sloughed through; another died ofperitonitis; the third was killed at the end of six weeks

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and showed an atrophy of the gall-bladder, but no fistula.Finally, Daslre,* in his communication to the Physio-logical Congress at Basel, in 1889, published bis experi-ments, wherein he succeeded in uniting the gall bladderto the intestine for the purpose of studying what effect itwould have on digestion. Of this I will speak later.

So that we see to the date above mentioned experimentsrepresented three different types : Ist, The formation offistula by chemical destruction ; 2d, by pressure atrophy—the elastic ligature; 3d, careful suturing, with subse-quent incision within the circle produced by the sutures.

Up to July, 1890, there were nine “ cne sitting” op-erations performed lor the establishment of a gall bladderand intestinal fistula in the human subject; the first byMonastyrski, May 4, iBS7. s The incised gall-bladderand jejunum were approximated by two rows of suturesin serous coat. The patient died on August 4th. Thefistula was found patulous. Second, Kappeler, 8 on July6, 1887, after incision of gall-bladder and duodenum,approximated with a suture of serous and mucous coats,after the method of Woelfler—recovery. Third, Socin,6

on November 19, 1887, after incision of gall-bladder andintestine, united them with sutures of mucous and serouscoats—recovery. Fourth, Fritzsche, 7 on April 24, 1888,operated for impaction of gall-stone in choledochus,united incision of gall-bladder and intestine with catgutsutures of mucous coat and silk sutures of serous coat.Patient died on May 4th. Large amount of blood inperitoneal cavity. Fifth, M. Robson, 8 on March 2, 1889,after incision of gall-bladder and colon, united mucousand serous coats with chromicized catgut sutures—re-covery. Sixth, Terrier, 9 August 13, 1889, after incisionof gall-bladder and duodenum, approximated with tworows of sutures, put in drainage-tube, and sutured thegall-bladder to abdominal wound—recovery. Seventh,Courvoisier, 1 March 28, 1890, secured a portion of thegall-bladder, and with serous sutures approximated it tothe colon, after having made a ductotomy ofcholedochus

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and removed several stones with curette from the ductushepaticus—recovery.

The priority of the operation certainly belongs toMonastyrski, for he performed his operation about amonth before Kappeler, but did not publish it untileleven months after the operation. Of the seven opera-tions performed, four were for carcinoma of the head ofthe pancreas, one for carcinoma of the duct at its orifice,and two were for impaction of gall stones—those of Ter-rier and Courvoisier. The technique in all of the aboveoperations was somewhat similar, the suture being usedas the means of approximation, Terrier using a rubbertube to keep the opening patulous, which was passed onthe eighth day. The seat of the operation in Terrier’scase was the duodenum;in Monastyrski’s, the jejunum,2 m. below the duodenum; in Kappeler’s, 226 ctm. abovethe caecum; in Fritzsche’s case 3m. below the pylorus.

There remain the cases of Bardenheuer, n who per-formed two operations where he united the gall-bladderto the duodenum with an elastic suture in the centre anda single row of silk sutures around it, expecting that theelastic suture would produce a pressure atrophy, and thata fistula would remain. The first case—impacted gall-stone—terminated fatally at the end of four weeks, andthe fistula was not yet established, nor had the gall-blad-der adhered to the intestine, a biliary fistula opening intoperitoneal cavity. The second, he writes to Terrier, wasdone in the fame way, with the same result. To thislist, taken from Courvoisier, may be added two byCzerny, 10 of whom one died of hemorrhage and the othersurvived the operation, and my three, of which I willspeak later, making, up to date, in all, fourteen cases ofcholecysto-enterostomy of “ one sitting.” Of these fourdied as the result of operation—Fritzsche’s, two of Bar-denheuer, and one of Czerny; five died as a result ofthe malignant diseases from which they were suffering;and five survived—Terrier’s, Courvoisier’s, and three ofmine.

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Since writing the above I find a case reported, July 3,1892, by Dr. E. Lambotte, of Schaerbeek, Belgium, 13 inwhich he had an external biliary fistula following chole-cystostomy. He drew out a piece of the colon throughan incision in the abdomen close to the fistula, and thenapplied Dupuytren’s enterotrite in the manner that thatauthor used it for the repair of an artificial anus, finallyperforming a plastic operation to close the externalopening, in all three operations. The patient survivedthe very tedious operative procedures. This case doesnot belong with the class of “one sitting” operations.Also, a case by Korte, reported to the Berlin MedicalSociety, May 27, 1891, in which the suture was used forapproximation. Three operations, recovered.

The various operators, in commenting on the techniqueof the operation, all agree that it is one of extreme diffi-culty ; and, while the experience of the others was not astrying as that of Winiwarter, it was always most difficultof performance with suture and occupied an hour or up-ward to complete the operation.

While reading of the great difficulties experienced bythe operators mentioned in performing this operation, Irealized that the profession was sorely in need of somemore simple and perfect means for the approximation ofthe gall bladder and the intestine ; and, after tryingseveral devices, I succeeded in producing and perfectingthis anastomosis button, which I think fulfils all of theindications. The button is inserted in the followingmanner :

An incision is made from the edge of the rib, two incht sto the right of, and parallel to, the median line, extend-ing downward three inches. The gall-bladder is drawninto the wound, also the duodenum. The duodenum iscleared of its contents by gentle pressure with finger.My short intestinal compression forceps are placed uponthe duodenum to prevent the escape of gas and fluidsafter the incision is made. A needle with fifteen inchesof silk thread is inserted in the duodenum, directly op-

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posite its mesentery and at a point near the head ofthe pancreas. A stitch is taken through the entire wallof bowel, one-third the length of the incision to bemade. The needle is again inserted one-third the lengthof the incision from its outlet, in a line with the first, andbrought out again, embracing the same amount of tissue asthe first (Fig. 2). A loop three inches long is held here,and the needle is inserted in a similar manner, making two

Figs. 2 and 3. —Showing Running Thread before and after Incision in Bowel.

stitches, parallel to the first, in the reverse direction, andone-eighth of an inch from it, coming out at a point nearthe original insertion of the needle (Fig. 2). This forms arunning thread, which, when tightened, draws the incisededge of the bowel within the cup of the button. In thegall-bladder a similar running thread is inserted. An in-cision is now made in the intestine, two-thirds the lengthof the diameter of the button used. The button isslipped in, as I will show you in my demonstration, therunning string tied, and the button held with the forceps.

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The contents of the gall bladder are withdrawn with anaspirator. An incision is then made in the gall-bladderthe same length, and between the rows of sutures, thebutton is inserted in a similar manner, and the runningstring tied. The serous surfaces to be approximated arescraped with the edge of a scalpel. The forceps are re-moved and the button is held between the fingers andpressed together (Fig. 4). A sufficient degree of press-ure mast be used to bring the serous surfaces of the gall-bladder and intestine firmly in contact and compress thetissues. The elastic pressure of the spring cup of thebutton produces a pressure atrophy of the tissue em-braced within the cup, and leaves an opening as large asthe button, the button dropping into the bowel and be-ing passed through the intestines.

It takes about as long to describe the operation as toperform it. The time occupied with the first lady onwhom I operated was eleven minutes, from the enteringof the peritoneal cavity until the closing of the same.On dogs I was from eleven to eighteen minutes in per-forming the operation, the latter time being on the firstdog, before I had made the various improvements in thetechnique and button. The operation is more difficult toperform on the dog than on man, as it is more difficult tobring the gall-bladder into the wound.

To show that this operation is one that the busy sur-geon will be frequently called upon to perform, now thatthe technique is so simple, I have only to remind you ofthe number of cases of chronic jaundice from obstructionof the common gall duct, requiring some operation forrelief, and to draw your attention to the defects of theoperations now in vogue, namely, the unpleasant andsometimes dangerous sequence of cholecystostomy, anexternal biliary fistula, which may of itself be a menaceto life, and require a second operation even more criticalthan the first, as is shown in the following reports byCourvoisier; also the difficulties and dangers of chole-cystectomy.

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T?\g.a,. —■Buttonas

HeldvAren'Pressed.

TogetherBertormlna

CWWrystoenterostomy.

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The effect of a permanent fistula of the gall-bladderand constant escape of bile secreted, as frequently fol-lows cholecystostomy, is different, depending, first, on thequantity of bile that escapes from the opening, and,second, what proportion is admitted into the intestinaltract. This fact has been lost sight of by many of thesurgeons that have operated, and had an external fis-tula remain, which accounts for the great differences ofopinion as to gravity of biliary fistula. Where the fistulaof the gall-bladder only allows a portion of the bile toescape, the patient and animal, as in Dastre’s experi-ments, can live without suffering from the loss; that is,they are capable of digesting with a much smaller quan-tity of bile than they naturally excrete. But if we letthe entire quantity of bile escape through a fistula, thepatient soon succumbs. This is thoroughly demonstratedby the twelve cases collected by Courvoisier. 1 In oneof these cases, reported by Krumptmann, 12 the averagedaily quantity of bile escaping through the fistula was 230gm.; still the patient lived eight years in this condition.Where such an able authority as Courvoisier classesthis with his cases in which there was an escape of theentire quantity of bile, it may appear presumptuous toquestion the propriety of placing it in that class ; but asthe quantity is so much below the average given by physi-ologists, and as the effect on the patient was at such va-riance with the more reliable cases, I must ask you toanalyze it. For example, some estimates of the quantitydaily excreted are—by Wittich, 532 c.c.; 14 by West-phalen, 453 to 266 gm.; Ranke, 652 c.c.; Murchison,40 ounces. When compared with that given by Krumpt-mann, we are certainly justified in doubting its reli-ability, and in not placing it with unquestionable cases.All patients died where the entire quantity of bile se-creted escaped through the fistula, and where a largequantity escaped the patients became emaciated andsick. Therefore a safe means of allowing the gall tore-enter the intestine should be welcomed by the surgeon

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and patient. This operation will produce the same revo-lution and favorable change in the surgery of the gall-bladder that the intra-abdominal treatment of pediclesdid in the treatment of tumors of the uterus and its ap-pendages.

The following experiments were performed on the gall-bladder :

Experiment 4.—June 5, 1892; male dog, weight 70pounds. Abdomen shaved, incision three inches long, inthe median line. The duodenum was easily reached —asit passes from the end of the stomach close to the liver—-and brought into the wound; the gall-bladder was alsodrawn forward and held with the forceps. The incisionwas made in the gall-bladder and one-half the button in-serted ; a running thread was placed around the circum-ference of the opening, and the thread tied ; the gall-bladder was allowed to recede. An incision was madeinto the duodenum, parallel to the bowel, opposite itsmesentery, large enough to admit the button. A runningthread was sewed into the edge of the incision, one-halfof the button inserted, and the running thread tied. Thebutton was pressed together. The approximation wasperfect; time, eighteen minutes. The dog had no un-pleasant symptoms until the third day, when he appearedsick and refused to drink. On the fifth day he was muchimproved, and on the sixth he had completely recovered;he was playful as if nothing had happened to him. OnJuly 10th, thirty-five days after the operation, he waskilled. The button had escaped, and the opening wasfound large enough to admit the little finger from thegall-bladder into the intestine (Fig. 5), There was nofood nor hair in the gall-bladder, as a valve was formedon the intestinal side of the opening by two folds of themucous membrane closing over it, permitting the bile toflow out, but preventing the entrance of anything from theintestine. This valve (Fig. 5) could not have been moreperfect had it been prearranged. The gall-bladder was verymuch contracted. You can examine the result in specimen.

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Experiment 5. June 12, 1892; black male hound,weight 55 pounds. Operation performed the same as inExperiment 4. Some bile escaped into the peritonealcavity. The attachment of the gall-bladder to the liverwas torn slightly in the effort to bring it further forwardinto the opening. The button worked admirably. Time,sixteen minutes. The dog did not suffer in the least after

Fig. 5. —Opening with Valve, on Intestinal Side, after Cholecysto-enterostomy.

the operation, being playful and able to eat at all times.August 22d he was killed. A perfect union was foundbetween gall-bladder and duodenum. The gall-bladderhad contracted to about the size of the common duct.The opening between intestine and gall-bladder wouldadmit the end of the little finger, A valve similar to thatdescribed in Experiment 4 was found. Neither hair norfood was found in the gall-bladder.

Experiment 7. —June 14, 1892 ; St. Bernard, female,

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weight 100 pounds. Cholecysto-gastrostomy, operatedin the same manner as in Experiment 4, only using thestomach in place of the intestine. No escape of bile orgastric fluid into the abdominal cavity. A little difficultyexperienced in approximating the ends of the button onaccount of the thickness of the wall of the stomach.Time, seventeen minutes. Dog sick the following da)-,would not eat or play. On the x7th all symptoms haddisappeared. August 9th, killed dog ; found gall-bladderfirmly united to the stomach; little finger could be in-serted into the stomach from the gall-bladder (Fig. 6);there was neither food nor hair in the gall-bladder, whichwas somewhat contracted. No cholecystitis nor cholean-gitis. The dog did not seem to suffer any inconveniencefrom the gall passing into stomach.

Experiment 13.—July 7, 1892; black dog, weight 65pounds. Cholecysto-enterostomy. The gall-bladder wasbrought into the opening without lacerating its attach-ment to the liver, and the running thread inserted ; oper-ation completed as above. Some escape of gall into theperitoneal cavity. Time, sixteen minutes. Killed dog,August 23d ; found the gall-bladder contracted to a tubenot much larger than the ductus cysticus ; opening into in-testine admitted the little finger. Valve formed by foldof intestinal mucous membrane. Water would flow freelyfrom the side of the gall-bladder into the bowel, butwould not flow from the bowel into the gall-bladder onaccount of this valve. Neither hair nor food in the gall-bladder.

Experi7nent 18.—August 2, 1892; white female dog,weight 95 pounds. Cholecysto-enterostomy ; ligature ofcommon duct ; operation otherwise as above. Time,eleven minutes. Result examined August 6th. Founda perfect adhesion of gall-bladder to bowel; button inposition. Hair and food in gall-bladder.

Experiment 21.—August 30, 1892; red and whitehound, weight 90 pounds. Cholecysto-enterostomy.Time, fourteen minutes. No difficulty experienced ; the

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dog had no unpleasant symptoms following. Killed onSeptember 14th; found perfect union of gall-bladder tobowel. Partial atrophy of tissue in clasp of button ;

button in position; hair and food in gall-bladder; gall-

Fig. 6.—Opening in Stomach after Cholecysto-gastrostomy.

bladder about the normal size. This dog was killed thusearly to find what changes would take place in fourteendays.

Report of Cases.—Case I.—A. Q , aged thirty-five, female ; admitted to the medical department ofCook County Hospital, May 27, 1892. Transferred to

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the surgical division of the hospital, June 10, 1892, andcame under my care. Gave the following history : Dur-ing the last fifteen years has had stomach troubles ; painand tenderness in the ep: gastrium; the attack would lastfrom two to four days, was almost always accompanied byvomiting, not by jaundice. Had pain in back since child-birth ; suffered from chronic constipation. One of theseattacks was accompanied by jaundice for the first time,December 14, 1891. At that time had constant and in-tense pain for twelve hours, and an aching pain and tender-ness in the epigastrium for two months following it.Jaundice cleared in about two months. During the pastfew months the attack of stomach trouble would lastfrom twelve to twenty-four hours. In February thepresent attack began, accompanied by jaundice andsevere pruritus, which has been constant from that timeup to date. These symptoms increased in severity up tothe time she was admitted into the hospital. While inthe medical department her jaundice was constant; hermental condition became very much impaired and heremaciation rapidly increased.

Condition when Admitted to the Surgical Department.—The patient intensely jaundiced; very much emaci-ated ; has a point of tenderness in the right hypochon-driac region just below the margin of the rib ; no tumorto be felt. The urine contains a large quantity of bile,no albumin. The patient suffers from considerable men-tal derangement, very slight elevation of temperature.

June nth,—l decided to perform cholecysto enteros-tomy by means of ray anastomosis button, which I hadused for the first time on a dog six days previous. Anincision three inches long was made, three inches to theright of the median line, extending directly downward.The gall-bladder was found distended, non-adherent, andcontained a large number of small calculi. Two calculiwere found in ductus choledochus and allowed to remain.Duodenum and gall-bladder were both drawn into thewound; an incision was made in the duodenum and half of

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the button inserted. A running thread was put in the gall-bladder, an incision made, and the other half of the but-ton inserted. The gall-stones were not removed. Therewas considerable escape of gall, as gall bladder was notaspirated before putbng in the button. The buttonwas then pressed together without any difficulty, and themass dropped into the abdominal cavity. Time fromthe opening of the peritoneum until the closing of same,eleven minutes. After the operation the patent showedno unpleasant symptoms; temperature at no time ex-ceeded ioo° F., and in fourteen days from the operationshe was allowed to walk about the ward. The jaundicerapidly disappeared, and three weeks after the operationthere was no trace of bile in the urine. The patient wasof a very hysterical temperament after her mental con-dition improved ; she noticed that she was an object ofobservation and became so erratic that we could notcontrol her at the hospital and were compelled to dis-charge her five weeks alter the operation. Up to thattime she states that “ she has not passed the button.” Shewas apparently well in every particular. The buttonused in this case was very imperfect compared with thepresent one.

October 28th.—Patient was examined by Dr. H. R.Wittwer. He’ found the jaundice had not returned ;

there was no bile in the urine, and the patient was in ex-cellent health. He could not ascertain whether she hadpassed the button or not.

The following case was referred to me by Dr. Hoel-scher, who with Drs. Wiener and Lee assisted me in theoperation.

Case ll.—Mrs. B , aged thirty eight, widow, hasthree children. Parents still alive, aged seventy-six andseventy-four respectively. Brothers and sisters well; nohistory of any hereditary disease.

Dr. Hoelschersaw the pat ent for the first time October7, 1892, and found her as follows: “ Healthy, well nour-ished appearance ; pain of sudden onset in the epigastric

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region, and from this point it gradually extended over thewhole abdomen. She had vomited the contents of thestomach and some bile on two occasions after the seizurewith pain. Bowels were constipated and had been inthis condition two or three days before the seizure. Vesi-cal tenesmus and diminished quantity of urine. Gave nohistory of any previous pain, gastric disturbance, jaun-dice, or colics.”

On examination found a tumor in right hypochondriacregion, extending downward into the iliac region and ter-minating in a rounded smooth end] could be distinctly feltin lumbar region, was movable and tender on pressure;there appeared to be a deep fissure between the tumor andthe liver, no fluctuation apparent, bowel or colon not over-lying the tumor. The diagnosis could not be determined,but it was presumed to be some lesion of the kidney, soit was decided to make an exploratory laparotomy.

October 19th.—I made an incision three inches long,from the edge of the tenth rib directly downward towardthe border of the ilium. The tumor was exposed andfound to be a very much enlarged gall-bladder with largecalculi within. The viscus was very oedematous, red, andthickened. It was decided to make a cholecysto-enteros-tomy with my anastomosis button (No. 2). The gall-bladder was aspirated, and the running thread inserted.The running thread was then inserted into the duodenumand the intestine incised and the male half of the buttoninserted, the female half was then placed in the gall-bladder through a slit made between the running thread,and the button closed. The gall bladder measured atleast 1 ctm. in thicknessand was very oedematous. Therewas no difficulty in inserting the button. The gall-stoneswere allowed to remain, as I do not consider it necessaryto remove them unless they are larger than the button.They will pass out after the button escapes.

October 20th.—Temperature, roi° F; pulse, 96.Vomited considerably during the night and complainedof headache, which seemed to be effects of the an-

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aesthetic. There was no pain nor abdominal tender-ness.

October 21st.—At 5 p.m. yesterday the vomiting ceased,and the patient is feeling very well this morning.

October 27th.—The patient has had no unpleasantsymptoms since October 20th. This morning (eight daysafter operation) in the stool were found two large gall-stones. The larger one weighed 117 grains (7.8 gm.); itslongest diameter 1 inch, its shortest | inch. The secondstone 102 grains (6.8 gm.); its longest diameter - inch,its shortest f inch. It will be noticed that the shortestdiameter of the larger stone measures exactly the sameas the diameter of button used. The patient is feelingvery well and is sitting up in bed. Complete primaryunion. Button passed eighteen days after operation.

Case 111. Cholecysto-enterostomy with Button No. 1.

—This case was referred to me by Dr. J. H. Hoelscher,who gave me the following history : Mrs. Z , agedthirty-six, married, six children. Enjoyed perfect healthuntil twenty-two years of age ; at that time, three monthsafter childbirth, had an attack, of short duration, ofsevere epigastric pain and vomiting. It was not accom-panied or followed by jaundice. Ever since that attackshe has had digestive disturbances, as distress followingcertain kinds of food, eructations of gas, constipation,loss of appetite. Four years ago she had a similar at-tack of pain in the epigastrium, accompanied by vomit-ing. From that time on the pain returned every five orsix weeks, up to five months ago, when she noticed a con-stant aching pain and tenderness in the right hypochon-driac region, that persisted until the present time. Thepain and soreness were very much increased after work-ing in a stooping posture. She has suffered much fromgeneral debility, and complains of slight and frequentchills. Throughout the entire progress of her diseasejaundice was never present. The urine was tested sev-eral times for her with negative results. She does notgive a distinct history of having had “hepatic colic.”

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About three months ago she found small particles, thesize of mustard-seeds, in the feces, which someone toldher were gall-stones. There is no positive evidence thatshe ever passed a gall-stone. Physical examination re-vealed a heart and lungs normal; liver not increased insize. Manipulation reveals a pear-shaped, hard tumor inthe region of the gall-bladder, measuring about threeinches in length, and two in width. It moves synchro-nously with the diaphragm in respiration. On pressureconsiderable pain is produced, and a slight crackling sen-sation is felt by the fingers.

It can be separated from the kidney, and can bemoved considerably from side to side. The diagnosis ofgall-stone was made by Dr. Hoelschcr, and the case wasreferred to me for operation.

Operation, November 23, 1892, assisted by Drs.Hoelscher and Lee, in the presence of Dr. Nicholas Senn,who expressed a desire to see my method used, Dr.Dunne, of Minneapolis, and Drs. Mayo, of Rochester,Minn. The incision was made the same as in Case 11. ;

contracted gall-bladder packed full of gall-stones slippedinto the wound.

A little difficulty was experienced in drawing the duo-denum forward, as some old adhesions existed. Therunning threads were inserted in gall-bladder and duo-denum ; male half of button placed in duodenum, andheld by an assistant. An incision was made in the gall-bladder, which was found so full of gall-stones that halfof the button could not be inserted without removingsome of them. A dozen were quickly picked out withthe dissecting forceps. About twice as many were al-lowed to remain. The female half of the button was in-serted in the gall-bladder and the running thread tied.Button pressed together. Toilet of field of operationwas made with dry sponge and the viscera dropped backinto abdomen. Deep and superficial row of sutures inabdominal wall. Time for entire operation, twenty-oneminutes. The time for inserting the button was not

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25taken. Patient rallied rapidly from the anaesthetic.Pulse after operation, 70, Temperature normal. Nei-ther nausea nor vomiting.

November 25th,—Pulse, 78. Temperature, 100.50 F.Patient complains of slight pain at seat of operation.No tympanites nor abdominal tenderness.

November 28th.—Patient expresses herself as feelingvery well. At no time since the operation has patient’stemperature exceeded 100.5° F. She is allowed to takea quantity of liquid nourishment, but not sufficient to sat-isfy the appetite. I consider her now out of danger.The ease and rapidity with which this operation was per-formed satisfied those who witnessed it, as well as my-self, that the operation of cholecysto-enterostomy by thismeans is relieved of many of its dangers and all of itsdifficulties. Dr. Hoelscher is to be congratulated on hisdiagnosis in this case, in the absence of so many im-portant symptoms.

Gastro-Enterostomy.—The frequency of diseases ofthe pylorus and its surroundings which produce an occlu-sion, partial or complete, of thatorifice, causes the surgeonto be often called upon for the relief of the unpleas-ant and dangerous symptoms arising therefrom. As thediseases themselves are frequently of a malignant char-acter, or of such a nature as to be irremovable, we canonly hope to relieve the patient of the unpleasant symptomof vomiting, and prevent him from dying of starvation.This operation, by which the intestine and stomach areapproximated and an opening for the passage of food ismade, is known as gastro enterostomy.

The difficulty of establishing this opening by means ofsutures has deterred the majority of surgeons from oper-ating, except in desperate cases where the patient pre-ferred death to a continuance of his miserable condition,and was occasionally accommodated with the former by theoperation. The time occupied and the difficulties of thetechnique were so great that many of the patients onwhom the operation was performed succumbed from the

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prolonged anaesthesia and long exposure of the abdominalcontents; or, surviving these, died from a defect in thesutures or sloughing through at the line of suture. Mor-tality before bone-plates were used (with suture), 42.8;with bone-plates, 24.5 per cent. 15 If the surgeon had somemeans by which he could safely and rapidly approximatethe stomach and intestine, I am sure he would often beable to respond in the affirmative to his patient’s plain-tive interrogatory, “ Doctor, can you not do somethingfor this vomiting and starvation ? ” When the doctorhas the means of performiug this operation, even as anamateur, in the short space of nine minutes, and after alittle practice in as low as six minutes, as I have doneon the living patient; when the technique is so simplethat his patient is free from the effect of the prolongedexposure of the abdominal contents, I am sure he willundertake it with pleasure and confidence ; and wouldhave no hesitancy in applying such a simple procedureto rescue his patient from such an extremely unpleas-ant and dangerous condition. True, in the malignantgrowth the disease is not cured by gastro enterostomj 7

,

but that most unpleasant of all symptoms, the constantvomiting, is relieved, and the patient is allowed to leada life of comparative comfort until the end is brought onby general marasmus. The following experiments weremade :

Experiment 16.—July 27, 1892. Black hound, sameas in Experiment 9 ; weight 55 pounds. An incision inthe linea alba from the xiphoid cartilage extending downthree inches. Omentum torn. The under surface of thestomach was exposed and drawn into the wound with thefingers. A loop of jejunum from the neighborhood ofthe left kidney was also drawn into the wound. Therunning threads were inserted in the stomach and bowel.The incision was first made in the stomach, and maleportion of the button inserted, the running thread tiedand cut short. The button was now pressed together,a perfect approximation being produced. The mass

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dropped back into the abdominal cavity. Time, fourteenminutes. July 28th, dog appeared in perfect health; notthe least unpleasant symptom ; playful, and ate as usual.August 23d, dog killed ; found perfect union of stomachand intestine. The tissue clasped within the button didnot completely slough, and the button was held in posi-tion, The reason the tissue did not slough was on ac-count of the thickness of the walls of the stomach. Aftera certain degree of atrophy had taken place pressureceased, and there was sufficient tissue retained betweenthe edges of the button to keep up the circulation intissue within clasp of button. This operation was per-formed with the button before I had the elastic compres-sion ring attached to it, and the fact that atrophy didnot take place was what led to this modification.

Experiment 17.—July 31, 1892, Brown female dog,weight 22 pounds. Gastro-enterostomy. The duodenumwas joined to the stomach near the head of the pan-creas. No gastric fluid nor gases escaped during the op-eration, The button was inserted as above ; no omentalfl ip; two rows of sutures in the abdominal wall. Thedog showed no unpleasant symptoms after the operation.Time, fourteen minutes. August 9th, killed dog ; founda perfect union of duodenum and stomach ; button yetin position, as shown in specimen. The dog was killedthus early to ascertain the degree of atrophy at end often days.

Experiment 20. —August 23, 1892. Brown female,weight 100 pounds. Gastro-enterostomy. Performed inmy laboratory by Dr. Alex C. Wiener. The under sur-face of the stomach was exposed as above, the duodenumbrought forward, the button inserted and compressed.Time, twelve minutes. The dog showed no unpleasantsymptoms after the operation, eating and drinking asusual, and very playful. September 7th, fifteen daysafter the operation, found perfect union of stomach andbowel; button still in position ; partial atrophy of tissueclasped within it.

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Experiment 23.—August 30, 1892. Woolly female,weight 70 pounds. Gastro-enterostomy. Performed inmy laboratory by Dr. C. Fenger. Method of operationsame as above. Time, nine minutes. A new buttonwas used in this operation, and the degree of pressuregreater than in the previous ones. Dog died on thethird day. It was found on post-mortem examinationthat the manufacturer, in his endeavor to make the but-ton light, had made the rim of bowl at one place so thinthat it had a cutting edge, and it cut completely throughthe wall of the stomach and bowel at the time of opera-tion. A similar button was used in another case with thesame result.

I performed the operation of gastro-enterostomy threetimes with the button on the human subject, and Dr.Wiener did it once. In all of the cases we got a primaryadhesion. I will give a detailed report of these cases ina subsequent clinical paper on the subject, which I ampreparing.

Pylorectomy.—The operation for removal of the py-lorus with a portion of the stomach and duodenum. Theoperation was first performed by Rydyger, but Billrothand Woelfler brought it most prominently before the pro-fession. I will not go further into the history of theoperation, with which you are all familiar. In perform-ing this operation I have deviated considerably from thebeaten path, and proceeded as follows :

After drawing the pylorus into the abdominal wound,ligating the greater and lesser omenta and cutting themoff, I then made a circular incision with the scissors ongroove director, cutting through the muscular and serouscoats of the stomach down to mucous coat, completelyaround the stomach where it was to be excised. I thendenuded the mucous membrane of its muscular andserous coats for half an inch in the direction of the py-lorus. A silk ligature was placed around the mucouscoat at the line of the original incision. A large com-pression forceps was placed on portion of stomach to be

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removed. The raucous membrane was cut off half aninch below theligature. Tnis then presented the appear-ance of a rosette. A puckering stitch was run all aroundthe edge of the mucous membrane and tied. The silkligature was then removed. An interrupted silkworm gutsuture approximated the peritoneal and muscular coatsof the stomach over the corrugated stump of the mucousmembrane, completely closing the end of the stomach.The duodenum was excised an inch and a half below thepylorus, a running thread was placed in position and thebutton inserted. The other half of the button was in-serted in the posterior wall of the stomach, two inchesfrom line of suture, in the usual way, and the buttonpressed together. It was found before placing the buttonin the duodenum that the head of the pancreas camewithin an inch of the pylorus, and that the bowel had tobe denuded of a portion of its peritoneum by looseningthe end of the pancreas in order to allow the button tobe closed. This would not occur in the human subject,as the head of the pancreas is a considerable distancefrom the pylorus.

The advantage of this operation over the one fre-quently performed—that of sewing the end of the bowelin the opening made by the excision of the stomach—is,first, that there is no dead point at the angle of suturebetween the stomach and bowel, which has been thecause of the greatest fatality in this operation; second,the rapid and easy closure of the mucous coat; third,the assurance that there would be sufficient opening forthe easy exit of the contents of the stomach during theprocess of healing, thus preventing tension of the suturesat the end of the stomach; fourth, advantage over thelateral approximation operation by the subsequent mixingof the food with the secretions of the liver and pancreasin about their normal way, and avoiding the danger of thegreat contraction that follows it; fifth, the great saving oftime, the operation in the usual way occupying three andone-half to four hours, while in this method it occupies

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about one hour ; sixth, no possibility of escape of stomachcontents at time of operation ; seventh, that there is butvery little hemorrhage. The following experiments wereperformed :

Experiment 30.—September 14, 1892. Black andwhite dog, weight 60 pounds. Pylorectomy. Ligatuieof greater and lesser omenta; separated the same fromthe pylorus. Complete circular incision was madethrough serous and muscular coats of stomach down tothe mucous membrane. The mucous membrane was de-nuded of its serous and muscular coats for half an inchfrom incision in direction of pj lorus. Silk ligature placedembracing entire mucous layer, incised through mucousmembrane at end of denudation, purse-string stitch placedin raucous membrane, and tied. Ligature removed. In-terrupted silk sutures approximated muscular and serouscoats at same time. Excision of duodenum an inch anda half below pylorus. Running thread placed in bowel,and half of button put in position. It was found thatthe head of the pancreas had to be torn from the attach-ment to the bowel in order to admit of the closing of thebutton. Posterior wall of stomach incised, and otherhalf of button inserted. Button pressed together, andall dropped back into the abdomen. No omental flap.Time was saved in the manner of treating the mucousmembrane of the stomach, which had not hitherto beensuggested. No escape of contents into abdomen. Time,forty-four minutes. Dog killed on September 27th ; aconsiderable quantity of sero-purulent fluid in abdomen ;

the silk sutures at the end of the stomach had suppu-rated ; the mucous membrane was firmly united; thebowel firmly adherent to the stomach; the button in po-sition. On one side a small sinus, leading half an inchfrom the edge of the bowel along the wall of the stom-ach was found, which had not perforated into the ab-dominal cavity. This sinus occurred where the end ofthe pancreas had been torn from the bowel, which ac-counts for the sinus.

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Experiment 32.—October 2, 1892. Black dog, weight90 pounds. Operation performed as in Experiment 30,except that the duodenum was sewed at the end with con-tinuous silkworm-gut suture, and a lateral anastomosis

Fig. 7.—Pylorectomy. Lateral Approximation ofDuodenum to Stomach.

made with the button between the duodenumandstomach,three inches from end of duodenum (Fig. 7). Time,sixty-two minutes. Operation made with new spring but-ton. October 10th, the dog has been sick with influenzafrom the time of the operation until October 9th, whenhe again began to eat. However, on October 151b, thedog succumbed to the distemper. Autopsy showed aperfect union between stomach and bowel, with a linear

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cicatrix. The button had passed; the opening left wasas large as the button and looked as though it had beenpunched out, as seen in this ideal specimen.

End-to-End Approximation of Intestine.—The manydiseased conditions of the intestinal tract leading to ob-struction, the many accidents resulting in strangulationand local death, the many injuries to the intestinal canalcausing solution of continuity, have led to extensive studyand numerous operative procedures for the purpose ofrestoring the bowel to its normal condition, and re-estab-lishing the circulation of its contents. Many have beenthe methods that have been suggested, and still morenumerous have been the modifications. This has beenespecially true in the last decade, and still we had notattained an ideal means of securing a perfect union. Forcenturies efforts had been made to unite the bowel in itsmost natural position, that is, end to end. More re-cently the tendency in experiments has been to unite itlaterally. The various means hitherto used to produceapposition I will divide into two classes : first, the su-ture ; and, second, the insertion in the bowel of a foreignbody as an assistance to the suture. Of the suture I willnot speak, except to call your attention to the one re-cently devised by Dr. M. E. Connell, 16 of Milwaukee,which is certainly worth a trial. Foreign bodies in theshape of cylinders, both soluble and insoluble, such asthe tracheae of animals, tallow candles, sections of driedintestine, sections of elderwood, metallic rings, gelatineand rubber tubes, and very many other materials havebeen used. These have been tried from time to time,always in connection with the suture. Some of them haverendered good service, and still hold a respectable placeas an aid to the suture in circular enterorrhaphy, as Pali’sdecalcified bone-tubes, Byron Robinson’srubber-tube, withwhich he obtained good results, and still later, Jessett’singenious device. The advantages and disadvantages ofthese various devices you already understand. The de-vice which I have shown to you to-day differs from all

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that have been used beforein the following particularsor combinations of them;first, in that it retains itsposition automatically whenclosed; second, that it pro-duces its union independ-ently of suture ; third, thatthere is a perfect approxi-mation of serous surfaces,and that that approxima-tion must remain until apressure atrophy takes placewhere the ends of the bowelare pressed together.There are precautions to betaken in putting in the run-ning thread in the end ofthe bowel. If you care-fully follow the lines indi-cated by the suture (Fig. 8),you will, ist, prevent theeversion of the mucousmembrane; and, 2d, youwill produce an overlap-ping of both layers of theserous coat of the mesen-tery at point a, Fig, 8.

This overlapping is pro-duced, as you will notice inthe figure, by making onetop stitch at that point (a).This approximation of thetwo peritoneal layers of themesentery is of vital im-

Fig. 8.—Manner of Inserting RunningThread in End ofBowel.

portance, as otherwise you would have the muscularlayers of the bowel coming in contact between theedges of the button and get no adhesion. If the running

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thread is properly applied as in Fig. 8, when tied it willhave the appearance of Fig. g, and have a continuous

Fig. 9. —Appearance after Drawing RunningThread around Cylinder of Button.

surface of peritoneumaround the entire edgeof the button.

When inserting thehalf of the button towhich the circular ringis attached, compressthe ring to a level withthe bowl, grasp the edgeof the bowl with theforceps and hold itcompressed while youmake the first half ofthe knot, and draw theend of the bowel closeabout the central cylin-der ; then change theforceps to the edge ofthe cylinder, and com-plete the knot. Whenthe button was first de-vised it was not in-tended to use it for

this purpose, but I find it very well adapted to intestinalapproximation, as shown by the following experiments:

Experiment 12.—July 7, 1892. Brown female dog,a St. Bernard, weight 80 pounds; the same as used inExperiment 7. End-to-end approximation of ileum bymeans of button. The bowel was freed of its contentsby gentle pressure with the fingers ; it was incised ; arunning thread was inserted around the proximal end ofthe bowel, close to its edge, and the half of the button in-serted (Fig. 11); the distal end was treated in like man-ner and the other portion of the button placed in posi-tion and the button pressed together (Fig, 12). Omentalflap was placed around the point of union, and held in

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place by the silkworm-gut sutures. Time of operation,twelve minutes. The dog showed no unpleasant symp-toms after the operation. July 27th, examined the re-sult of this operation; while making cgecectomy on thesame dog, found a perfect unionbetween the ends of thebowel; omentum adherent all around; no adhesions be-tween the united intestine and abdominal wall. Therewas no contraction of bowel at the seat of union, and itwas very difficult to make out the line of approximationon the serous surface. The button had already passed.

Fig. io.—Appearance ofEnds of Bowel with Portions of Button Inserted Readyto Close.

August 9th, killed dog; found the bowel as describedabove. There were three operations on this dog—chole-cysto-enterostomy, end-to-end approximationof the ileum,and csecectomy, with end of small intestine approximatedto end of large intestine.

Experiment 11.—July 5, 1892. Black and white dog,weight 60 pounds. End to-end approximation. Omentalflap. Continuous silkworm-gut suture was used in abdo-men. The dog was not sick after the operation. On July10th, five days after the operation, the dog, in licking thewound, loosened the suture and allowed the bowel to es-

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36cape. He was then killed. The ends of the bowel wereperfectly adherent; a plastic exudate obliterated the lineof union on the peritoneal side of the bowel. The but-ton was found in position (Fig. 13).

Experiment 14.—July 11, 1892. Spotted dog, same asin Experiment 3 (in anbther paper lampreparing) ; weight

Fig. 11.—Mannerof Holding Button and Bowel while InsertingButton.

55 pounds. End-to-end approximation. Button No. 2 wasfound to be too large to be admitted into the bowel andgall-bladder button (No 1.) was substituted. This gall-bladder button, as you see, has an opening not more thanthe eighth of an inch in diameter. I felt veryapprehensivethat this would be plugged by hair. Time, fifteen min-

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utes. The dog was not in the least sick after the opera-tion, and the button was passed on the sixth day. August31st, killed dog; found a perfectly united bowel; omen-tal flap adherent; no adhesion to abdominal wall. Theunion on the mucous side ofthe bowel was so perfectthat the line could be madeout only at one point (Fig.14). No fistula, and nocontraction at point ofunion. Dr. Fenger was pres-ent at the autopsy and de-clared, The union is per-fect.”

Experiment 19.—August9, 1892. Black female dog,weight 70 pounds. End-to-end approximation after ex-cision of six inches of bow-el. Omental flap. Time,nine minutes. August 22d,dog killed; found a unionaround the circumference,except at one point wherethe mesentery joins thebow-el ; here there was a smallsinus leading down along the

Fig. 12.—Same as Fig. io, closed.

mesentery. The button was still in position. Up to thistime in the end-to-end approximation, and in this opera-tion as well, no particular care was taken to see that theperitoneum of the mesentery overlapped, so as to pre-vent a portion of the muscular and mucous membranebeing compressed between the edges of the button with-out having peritoneum covering them to form adhesion.This accounts for the sinus which existed in this case.

Experiment 23. —September 7, 1892. Black curlydog, weight 40 pounds. End-to end approximation ofileum. Small button (No. 1). Omental flap. Time

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38eleven minutes. September 29th, dog killed; perfectunion of bowel; omentum not adherent; opening inbowel small, but of same size as button used, button hadpassed.

Fig. 13.—Appearance after Union when Partial Atrophy of Tissue within Clasp ofButton has Taken Place.

Experiment 26.—Septembers, 1892. Bull-dog, weight55 pounds. Operated on by Dr. F. S. Hartmannin my laboratory. Excision of six inches of ileum withend-to-end approximation. Button No. 1. No omentalflap. Care was taken in inserting the running thread tooverlap the peritoneum at the mesentery. Time, four-

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39teen minutes. October 2d, opened dog’s abdomen;found perfect union ; button had passed; bowel some-what smaller at point of union. The specimen was ex-cised with six inches of the bowel, and another end-to-end approximation made on same dog.

Experi??ient 33.—October 2, 1892. Same dog as inExperiment 26. End-to-end approximation of ileum,after excising specimen from Experiment 26, along withsix inches of bowel. Operated on by Dr. Hartmann.The button was inserted in the usual way. No omental

Figs. 14 and 15.—Appearance of Mucous and Serous Surfaces of Bowel afterUnion.

flap. No scarification. Time, sixteen minutes. October10th, the dog was playful, and ate as usual. October 12th,button was passed. There was no spring in this button,October 15th, dog killed; found perfect union ; no sinus.

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Experiment 28.—August 9, 1892. End-to end approxi-mation of ileum, performed in my laboratory by Dr. H.R. Wittwer. Same dog as in Experiment 21. Timefourteen minutes. Omental flap. September i6tb, dogkilled; found perfect union of bowel. The circumfer-ence of the bowel showed only partial atrophy of portionin clasp of button.

Experiment 29. September 25th, Appleton, Wis.End-to-end approximation of jejunum, button (No. 2).Time, seven minutes. Dog killed seven days after theoperation, and specimen examined*by my preceptor, Dr.J. R. Reilly, of Appleton. He reported a perfect unionof bowel; the atrophy was not completed. The buttonstill in position.

Lateral Approximation or Intestinal Anastomosis.—By lateral approximation or intestinal anastomosis weunderstand the formation of a fistulous opening betweentwo coils of intestine. It is performed where it is desir-able to have the intestinal contents prevented froming through a more or less constricted portion of thebowel, and where the bowel is not sufficiently constrictedto cause gangrene, and it is not necessary to extirpate theconstricted portion. The suggestion for such a commu-nication originated with Maisonneuve. He was also thefirst to operate; both of his cases terminated fatally.The operation was almost completely forgotten untilrB6B, when Hacken made some experiments on dogs,and recently E. Hahn, of Berlin, brought the subjectagain before the profession, and still later great stress wasput on the operation by Dr. Senn. The great fear of theoperation was the accumulation of faeces in the excludedportion of the intestine. This fear has been found to bevisionary, as the experiments recently made on animalsshow that if the bowel is united so that its contents con-tinue in a direct line, that is, without making a sharpcurve, there would be no fear of retention or accumula-tion, providing the anastomotic opening is sufficientlylarge. The operation was first performed with sutures.

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Dr. M. E. Connell, Superintendent of the MilwaukeeHospital, suggested the use of perforated plates (seeSenn’s “Experimental Surgery”), which were subsequentlyused by Dr. Senn in his excellent experiments. The firstplates used were made of wood, gutta-percha, leather, andlead. Subsequently the disks were made of absorbablematerial, as decalcified bone. Now we have many modi-fications of the method, using, in place of the bone-plates,segmented wood, coil of heavy catgut, pigmented rubber,raw potato, and turnip, etc. It was hoped from the- re-sults of the early experiments that the operation uponman of lateral approximation would be fraught withmuch less danger than the end-to-end. But the degreeof contraction following lateral anastomosis, and theinvagination of the distal end of the bowel into its lumenhave increased the danger until it is equal to that of theend-to-end approximation. I have used the buttons forthe lateral as well as the end-to-side approximation.The following are the experiments :

Experiment s.—June 24, 1892. Lateral anastomosisof the jejunum with button. Operation very easily ex-ecuted. Time, seven minutes. Dog had no unpleasantsymptqms. Dog killed July 26th; found a perfect lat-eral union ; opening as large as button. No accumula-tion of faeces in loop, but considerable atrophy. Buttonhad passed.

Experiment B.—June 14, 1892. Coach, female, weight80 pounds. Lateral anastomosis of ileum ; very easilyperformed ; no escape of gas or fluids ; perfect approxi-mation. Time, sixteen minutes. The dog showed nounpleasant symptoms. July Ist, killed dog with chloro-form. Found perfect union of bowel; moderately largeopening; loop very much contracted; no accumulationof fasces in loop; no adhesion to abdominal wall.

Experiment 9,—June 24, 1892. Black dog, weight 55pounds, same as used in Experiment 5. Excision of twoinches of jejunum. Both ends of bowel sewed with silk-worm-gut sutures. Lateral approximation performed.

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With this experiment the direction of the bowel was pur-posely reversed, to see what effect it would have on theadhesion. The contents of the canal, after passingthrough the fistulous opening, had to move in a directionopposite to its previous course before passing through thefistula. Time for suturing ends of bowels, fourteen min-utes; lateral approximation with button, eleven minutes.

Fig. i 6.—Distal End Joined to Proximal Side of Bowel after Excision (wrongway).

Total time of operation, twenty-five minutes. No omental flap. Scarification of the serous surface before ap-proximation. The dog did not appear sick after theoperation. August 23d, dog killed. Found perfectunion at point of approximation. This is the mosttrying test that a mechanical device for producing adhe-sions can be subjected to. Found small invagination

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of upper portion of distal end ; lower end of proximal por-tion of bowel very much dilated, as was anticipated;mucous membrane inflamed and one spot ulcerated.Considerable hair had accumulated in pouch. This isin accordance with the experiments performed by theother investigators where the current of the intestinalcanal was made to reverse its direction at any point.

Experiment 25. —September 8, 1892. Resection ofsix inches of jeju-num. Approxima-tion of the end of dis-tal portion to the sideof proximal portionof the bowel (wrongway). This is alsoa very severe test onthe adhesion. Ap-proximation to sideone and one half inchfrom end. End ofproximal portion sut-ured with silkworm-gut. Time, eighteenminutes. September2 2d, dog died, as pre-dicted. Proximalportion of the bowelvery much distended(Fig. 16); large accu-mulation of hair and

Fig. 17.—Proximal End Joined to Distal Sideafter Excision of Portion ofBowel (right way).

fseces, as anticipated; button still in position; bowelperfectly adherent at point of apposition.

Experiment 27.—September 9, 1892. Black and whitedog, weight 45 pounds. Approximation of the proximalend to side of distal portion of bowel, right way, afterresection of six inches of jejunum (Fig. 17). Here it wasnecessary to determine which was proximal and whichwas distal end. This is done as follows ; A loop of

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bowel is held between the fingers and parallel to the axisof the body; the finger is slipped along down the side ofthe mesentery ; if it goes to the same side as started theportion toward the head is proximal, if it goes to the op-posite side the portion toward the head is distal. Endof bowel sewed with silkworm-gut suture. Time, nine-teen minutes. Dog killed October 2d. Large piece ofbone found in opening of button, completely closing it.Pressure atrophy of one-half of the circumference of thebowel that was clasped within the button had taken place,so that the fluid passed on in the alimentary canal on theside of the button in place of through the centre. Therewas a perfect union of bowel at point of approximation,as you will see in specimen. The line of union on themucous side could scarcely be discerned. This speci-men shows more perfectly than any other the variousstages of the process of pressure atrophy.

Excision of Caecum with Ileo-Colostomy.—This opera-tion may be necessary, and should be successful in cer-tain cases of carcinoma of the caecum. The removal ofthis portion of the intestine has so far been followed byunfavorable results, but our advanced knowledge of in-testinal surgery should make it a comparatively favorableoperation. The best incision for this operation on thehuman subject should be from the middle of Poupart’sligament down over the tumor through the linea semi-lunaris. Length of incision must be governed by thesize of the tumor. The caecum is drawn out throughthe opening, its mesentery ligated, the required portionexcised, the end sutured, the ileum cut off, and the endof the ileum approximated to the side of the colon. Ex-periment—end of small to end of large intestine.

Experiment 15.—July 27, 1892. Brown female dog,same as used in Experiments 7 and 12. Excision ofcaecum ; running thread put around the entire circumfer-ence of the colon, and the edge drawn within the claspof button No. 3. A similar thread put in the end ofileum and tied; button pressed together. This approxi-

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45mated the end of the small to the end of the large intes-tine. Time, thirty-one minutes. July 28th, dog not invery good condition, refusing to eat or drink. July 30th,dog still sick and declining to eat. From that time ondid very well. August 9th, killed dog. Found a perfectunion of the end of the small to the end of the large in-testine ; button had passed; omental flap adherent;opening of same calibre as that of small intestine (Fig.18). See specimen.

Fig. 18.—Result after Joining End of Small to End of Large Intestine (Excisionof Caecum).

Experiment 31.—August 14, 1892. Black, curly, fe-male dog, weight 125 pounds, lleo-colostomy. Ileumcut off at ileo-caecal valve ; opening in caecum sewed withcontinuous silkworm gut, Lembert suture. Half of but-ton pressed in end of ileum and the other half insertedin an opening made in colon, three inches below theileo-caecal valve, and button joined. Omental flap.Time, sixteen minutes. In closing the abdomen the largeomentum was included in the peritoneal suture. Sep-

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tember 20th, dog had a miscarriage. September 29th,dog died. Autopsy showed the cause of death to bea volvulus around the omentum where it was adherentto the cicatrix in the abdominal wall. Perfect union be-tween ileum and colon (Fig. 19); button in position;atrophy over half of its circumference; no obstructionat the seat of button ; no peritonitis. This is a very

Fig. 19.—Ileo-colostomy after Excision of Csecum (end to side).

instructive case, as it shows one of the complicationsthat may arise from including the omentum with theperitoneal suture of the abdominal wall, so frequentlyadvised and practised by many operators at the presenttime.

Besides the above cases three dogs were lost with theanaesthetic. One dog was sick when brought from the

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pound ; he was operated on the following morning, anddied twelve hours after, never being able to stand fromthe time he was taken from the table. The operationlasted only eighteen minutes, and had nothing to do withthe cause of his death. In every experiment we obtainedunion at the seat of approximation. This is one of themost important points brought out by the button, for itshows that a line of surface contact is just as good as halfan inch for forming an adhesion, and it practically in-sures against contraction where, with a larger approxi-mation surface, contraction would certainly follow. Idesire to express my thanks for, and appreciation of, thevaluable services rendered me in my experiments andoperations by Drs. E. W. Lee, F. S. Hartmann, and H.R. Wittwer, and by Dr. J. H. Hoelscherin placing materialat my disposal; my obligations to Dr. Wiener for usingmy method at an early date and to Dr. E. A. Matthseifor the drawings.

Venetian Building, Chicago, December 9, 1892.

Literature.1 Courvoisier, L G. ; Pathologic und Chirurgie der Gallenwege.

Leipzig, 1890.2v. Winiwarter: Prager Med. Wochenschrift, 1882, Nos. 21, 22.3 Kappeler: Corrbl. f. Schweizer Aerzte, 1887, No. 17, and 1889,

No. 4.4 Dastre : Corrbl. f. Schweizer Aerzte, 1889, No. 20.5 Chirurg. Westnik, 1888, May and June Hefte. Centrblat. Chir.,

1888.6 Socin : Jahrsber. d. chir. Abtheilg. d. Easier Spitals, 1887, p. 60.7 Fritzsche bei Blattmann : Corrbl. f. Schweizer Aerzte, 1890, No. 6.8 British Medical Journal, November, 1889.0 Ferrier : Revue de Chir., 1889, No. 12.10 Czerny: Deut. Med. Woch., No. 23, 1892, p. 516.n Bardenheuer; Tagebl. d. 61. Versammlg. deutscher Natur-

forscher u. Aerzte in Koln, 1888, Ctrbl. f. Chir., 1889, No. 12.12 Harley, G.; 1880.13Lambotte : Le Presse Me'dicale Beige, Brussels, July 3, 1892.14 Landois and Sterling : Physiology. 1890.15 Baracz : Archiv. fur klin. Chir.. Langenbeck, October, 1892.16 Connell: New York Medical Record, September, 1892.

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