Classic Articles in Colonic and Rectal Surge U MARvt~," L. COR,~k~N, M.I)., Editor

JOHN

B. M U R P H Y , 1857-1916

M.D.

John B. Murphy was born in Appleton, Wisconsin, December 21, 1857, the son of Irish immigrant pioneers. Ite was an outstanding student in the Appleton School System and actually taught some of the classes. He entered the Rush Medical College graduating in 1879, winning the "first place" position as intern at the Cook County tlospital. In 188.2, following two years o f medical practice, he traveled for eighteen months through Europe, coming under the direction of BiUroth in Vienna. Upon his return to practice in Chicago, he became known as a bold, Brilliant surgeon and teacher, an indefatigable worker and innovator. Although he was often the subject of controversy, he was always respected. In succession he became Chief Surgeon at the Mercy Hospital, Ctdcago: Professor of Surgery, Northwestern University Medical School; Chief of the Editorial Staff of the journal, Surgery, Gynecology and Obstetrics; and President of the American Medical Association. tie was founder and regent of the American College of Surgeons and a recipient of numerous honorary titles, including Fellowship in the Royal College of Surgeons of England and Knighthood in the Order of St. Gregory. His writings were diverse and numerous and include treatises on gunshot wounds of the abdomen; appendicitis; ileus; and vascular, pulmonary, neurologic, and orthopedic surgery. His interest in experimental surgery brought forth the anastomotic button, which though controversial even in his day, can stilJ be appreciated as an ingenious method of circumventing some of the risks of conventional suture technique. Murphy died August 11, 1916, at the age of 58. CHOLECYSTO-INTESTINAL, INTESTINAL, ANASTOMOSIS,

GASTRO-

ENTERO-INTESTINAL AND

WITHOUT (ORIGINAL

~{R. PRESIDENT AND GENTI,EMEN: I n t e s t i n a l s u r g e r y

APPROXIMATION

occupies a very a d v a n c e d place in the category o f great surgical questions o f the present day. Medical literature teems with r e p o r t s o f successful cases o p e r ated on, and not a few o f the disasters are also placed on record. All o v e r the world investigators are trying to solve the m a n y p e r p l e x i n g p r o b l e m s that accident and disease o f the gastro-intestinal tract present to t h e m for consideration. T h a t this subject has had such exhaustive consideration d u r i n g the last decade, and that it is still a t h e m e for spirited c o n t r o v e r s y a n d discussion, carrics with it the implication that m a n ) vital points are vet unsettled a n d need f u r t h e r investigation, e x p e r i m e n t a l and clinical. "l-he results o f exp e r i m e n t s on lower animals have been conducive to great i m p r o v e m e n t , both in principle and technique of t r e a t m e n t of intestinal lesions in the h u m a n sub-

SUTURES. RESEARCH.)*

Bv ,J. B. M U R P H Y ,

M.D.,

(:HlCAGO. i LI... PROFESSOR OF C L I N I C A l . SURGERY, COLI,EGE OF PHYSICIANS AND SURGEONS. CHICAGO: PROFESSOR OF SURGERY, P O S I - G R A D U A I E MEDICAL SCIIOOL AND HOSPIFAI.; ATTENDJN(; SURGEON TO, AND PRES1DENIOF. T H E MEDICAL STAFF OF COOK COUNTY HOSPITAL: A T I E N D I N G SI-RGEON TO A L E X I A N B R O T H E R S H O S P I F A L : V I C E - P R E S I D E N T OF N A T I O N A l . ASSOCIATION OF RAILWAY SURGEONS. ETC.

* Read before the Mis.sissippi Valley Medical Associatio.~t. October 15, 1892.

0012-371)6:"81/0 i 00/005 i $00.96 @ A merican Society of (ioh)n and Rectal Surgeons

51

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Dis. C~.,I. & Rec:.

CLASSIC A R I I C L F S

.ject. Fair results are o b t a i n e d in the t r e a t m e n t o f bullet wounds o f the intestines at present. At least an e f f o r t is m a d e b,v the surgeon to r e p a i r the injury, T h e question above all others on which the profession is divided is, " W h a t are the best m e a n s a n d m e t h o d s of p r o d u c i n g agglutination o f surfaces a n d p r e v e n t i n g s u b s e q u e n t contraction at the point o f a d h e s i o n ? " I f means can be d e v i s e d - - I , to hold the surfaces in contact; -',, while in contact, to p r o d u c e a speedy and p e r m a n e n t adhesion o f the surfaces; 3, to keep an o p e n i n g sufficientl,v large for the free passage o f intestinal contents; 4, to p r o d u c e , as a result, a cicatrix that will not. contract to any great extent, a n d by the c o n t r a c t i o n p r o d u c e c o m p l e t e o r p a r t i a l o b s t r u c t i o n - - w e will have o v e r c o m e the great barriers that still r e m a i n betx~.een us and ideal success in intestinal surgery. T h e marvellous ingenuity displayed in plans devised for intestinal a p p r o x i m a t i o n a n d anastomosis is worthy o f the greatest success, and that success w o u l d have been realized were it not that s o m e of the following complications o c c u r r e d : "'The s u t u r e was i m p e r fectly applied; the bowel sloughed t h r o u g h at line o f suture; the induced invagination increased after the o p e r a t i o n until complete obstruction was p r o d u c e d ; o p e n i n g s in the b o n e - p l a t e s and disks were not in a p p o s i t i o n ; the e n d s o f the b o n e - p l a t e s c a u s e d pressure, atrophy, and perforation; the catgut sutures were too rapidly absorbed; lastly, and with appalling frequency, p r o l o n g e d o p e r a t i o n p r o d u c e d fatal shock," and m a n y other weU-known obstacles, not necessary to m e n t i o n here, intervened. T o o v e r c o m e these obstacles a n d thus lessen tile risk to the life o f the patient, I have devised a m e c h a n ical means to dispense with the n e e d o f sutures, the necessity o f i n v a g i n a t i o n , the possibility o f n o n apposition, the sloughing t h r o u g h o f disks, the digestion of" the catgut, the ahnost i n s u r m o u n t a b l e difficulties o f technique of operation, the p r o l o n g e d a n d fatal e x p o s u r e o f the a b d o m i n a l contents, and the p r o t r a c t e d anaegthesia, t t o w m u c h 1 ha~e acc o m p l i s h e d by m,v labor I desire you to be the judges, after I have d e m o n s t r a t e d to you the results of my e x p e r i m e n t s , a n d p e r f o r m e d f o r you a g a s t r o e n t e r o s t o m y a n d an e n d - t o - e n d a p p r o x i m a t i o n of intestine by means of the device I here present to you, to be known as the Anastomosis Button. T h e buttons are m a d e in three sizes. A b u t t o n consists o f two small circular bowls (Fig. ~): size No. '2 m e a s u r e s as follows: Diameter, 2 3 ram.; depth, 8 ram. T h e r c is "'sweated" into a circular o p e n i n g , 1 ~ ram. in diameter, at the b o t t o m of one bowl, a cylinder 15 ram. in length, with female screw thread on its entire inner surface. T h e cylinder extends p e r p e n d i c u l a r l y

]an.-Fcb. !981

\ Ftc,. 1. tachment.

A p p e a r a n c e o f B u t t o n with a n d without s p r i n g - c u p at-

f r o m bottom o f bowl. T h e r e is an o p e n i n g in the male bowl in which is "sweated" a similar and smaUer cylind e r o I a size to easily slip into the f e m a l e cylinder. T h e r e are two brass springs soldered on either side of the inner surface o f the lower e n d o f the male cylinder, which e x t e n d almost to the top, w h e r e small points o f t h e m p r o t r u d e t h r o u g h o p e n i n g s in the cylinder; these points are d e s i g n e d to catch the screwthread, when the male cylinder is pressed int.() the female cylinder, a n d thus hold the bowls t o g e t h e r at any point desired. T o s e p a r a t e t h e m again they are simply unscrewed. A small brass ring, with a thin t h o u g h not cutting edge, to which is attached a wire spring, is placed in the male bowl a n d retairmd in position, projecting o n e - e i g h t h of an inch above the edge of the bowl. T h i s is held up by the wire spring, and is there for the p u r p o s e o f k e e p i n g u p continuous p r e s s u r e until the entire tissue between tile edges o f the bowls is cut off. T h i s s p r i n g a t t a c h m e n t is absolutely necessary only w h e n the stomach is o p e r a t e d on. T h e r e are f o u r openings, 5 ram. in d i a m e t e r , in the side o f each bowl, for the p u r p o s e o f drainage. By this. it will be seen, we have two hemispherical bodies held t o g e t h e r by i n v a g i n a t i n g c y l i n d e r s (Fig. 1). T h e s e h e m i s p h e r e s o f the b u t t o n are inserted in slits or ends o f the viscera to be o p e r a t e d on. A r u n n i n g t h r e a d is placed a r o u n d the slit in the viscus, so that when it is tied it will draw the cut edges within the clasp of the bowl. A similar r u n n i n g t h r e a d is a p p l i e d to the slit in the viscus into which the o t h e r half of the b u t t o n is inserted, and the bowls are t h e n pressed together. T h e p r e s s u r e a t r o p h y at the e d g e o f the bowl is p r o d u c e d by the brass ring s u p p o r t e d bv the wire spring. T h e o p e n i n g left a f t e r the b u t t o n has liberated itself is the size o f the button.

V~iume 24

Nu=,b~ ~

~c

03

CI.ASStC ARI'tCLFS

This differs f r o m all o t h e r previous devices in the following particulars or combinations thereof: 1, I t retains its position automatically; 9, it is entirely indep e n d e n t of sutures: 3, it p r o d u c e s a pressure a t r o p h y a n d adb.esi(m of surfaces at the line of a t r o p h y ; 4, it insures a perfect apposition o f surfaces without the clanger of d i s p l a c e m e m ; 5, it is applicable to the lateral as well as to the e n d - t o - e n d a p p r o x i m a t i o n ; (5, it produces a linear cicatrix and thus insures a m i n i m u m o f c o n t r a c t i o n ; a n d 7, in the e x t r e m e simplicity of its technique, which makes it a specially safe i n s t r u m e n t in the hands of the e v e r y d a y practitioner as well as the m o r e d e x t e r o u s specialist. Wc will now consider its application. lBecause of space limitations, this article has been s o m e w h a t abridged. Passages d i s c u s s i n g the application of the Button to c h o ] e e v s t o e n t e r o s t o m y , g a s t r o e n t e r o s t o m y , and py lorectomy have been deleted. T h e operations described are limited to those requiring intestinal anastomoses.]

End-to-End Approximation of l n t e s t i n e . - - T h e m a n v diseased conditions o f the intestinal tract leading to obstruction, the m a n y accidents resulting in strangulation and local death, the m a n y injuries to the intestinal canal causing solution o f continuity, have led to extensive study a n d n t m m r o u s o p e r a t i v e procedures for the p u r p o s e o f r e s t o r i n g the bowel to its

i

n o r m a l condition, a n d re-establishing the circulation o f its contents. Many have been the m e t h o d s that have been suggested, and still m o r e n u m e r o u s have been the modifications. This has b e e n especially true in the last decade, and still ~,e h a d not attained an ideal means of securing a p e r f e c t union. For centuries e f forts had been m a d e to unite the bowel in its most natural posikion, that is, e n d to end. M o r e recently the tendency in e x p e r i m e n t s has been to unite it laterally. T h e various m e a n s hitherto used to p r o d u c e apposition I will divide into two classes: first, the suture; and, second, the insertion in the bowel of a foreign body as an assistance to the suture. O f tl~e suture I will not speak, except to call y o u r attention to the one recently devised by Dr. M. E. Connell, of Milwaukee, which is certainly worth a trial. Foreign bodies in the s h a p e of cylinders, both soluble and insoluble, such as the trachem of animals, tallow candles, sections o f dried intestine, sections o f elderwood, metallic rings, gelatine a n d r u b b e r tubes, a n d very m a n y o t h e r materials have been used. T h e s e have b e e n tried f r o m time to time, always in c o n n e c t i o n with the suture. Some o f them have r e n d e r e d good service, and still hold a respectable place as an aid to the suture in circular e n t e r o r r h a p h y , as Pail's decalcified b o n e t u b e s , B y r o n Robinson's r u b b e r - t u b e , with which he obtained good results, a n d still later, Jessett's ingenious device. T h e a d v a n t a g e s a n d d i s a d v a n t a g e s o f

./

/

FIG. 8. (!q?). Manner of inserting running thread in end of bowel. Z FIo. 9

(right).

Appearance after draw-

ing running thread around c~linder ot Button.

0t.'

I

54 ,/

CLASSIC ARrlCLES

Fro. 10. AppearanceofendsofbowelwithportionsofBum, p. inserted readx to close.

these various devices you already' u n d e r s t a n d . T h e device which I have shown to you to-day differs f r o m all that have been used before in the following p a r ticulars or combinations o f t h e m ; first, in that it retains its position atttomatically when closed; second, that it p r o d u c e s its u n i o n i n d e p e n d e n t l y o f suture: third, that there is a perfect a p p r o x i m a t i o n of serous surfaces, and that a p p r o x i m a t i o n must r e m a i n until a p r e s s u r e a t r o p h y takes place wt-tere the ends o f the bowel are pressed together. T h e r e are precau-

/ // /

Fro. 11.

Jan.-Feh. 1981

tions to be taken in putting in the r u n n i n g t h r e a d in I he end o f the bowel. I f you carefully follow the lines indicated by the suture (Fig. 8), you will, 1st, p r e v e n t the eversion o f the m u c o u s m e m b r a n e ; and, 2d, you will p r o d u c e an o v e r l a p p i n g o f both layers o f the serous coat o f the m e s e n t e r y at point a, Fig. 8.

\

Button.

Dis. Col. g: Root.

Manner of holding Butum and bowel while inserting

"lThis o v e r l a p p i n g is p r o d u c e d , as you will notice in the figure, by m a k i n g o n e top stitch at that point (a). "l'his a p p r o x i m a t i o n of the two peritoneal layers o f the mesentery is o f vital i m p o r t a n c e , as otherwise you would have: the muscular layers o f the bowel coming in contact between the edges o f the button a n d get no adhesion. I f the r u n n i n g t h r e a d is p r o p e r l y applied as in Fig. 8, when tied it will have the a p p e a r a n c e of Fig. 9, and have a c o n t i n u o u s s u r f a c e o f p e r i t c m e u m a r o u n d tile entire edge o f the button. \Vhen inserting the half o f the button to which the circular ring is attached, c o m p r e s s the ring to a level with the bowl, grasp the e d g e of the bowl with the forceps and hold it c o m p r e s s e d while you make the first half of the knot, a n d d r a w the end o f the bowel close about the central cylinder; t h e n c h a n g e the forceps to the e d g e of the cylinder, anti c o m p l e t e the knot. W h e n the button was first devised it was not i n t e n d e d to use it for this p u r p o s e , but I find it ~erx well a d a p t e d to intestinal a p p r o x i m a t i o n , as shown by the follo~-ing e x p e r i m e n t s :

Expe~{me~t t 2 . - - J u l y 7, 1892. Brown female dog, a St. B e r n a r d , weight 8o p o u n d s ; the s a m e as used in Experiment 7- End-to-end approximation of ileum h;~ means of button. T h e bowel was freed o f its contents by gentle pressure with the fingers; it. ~ras incised; a r u n n i n g thread was inserted a r o u n d tile p r o x i m a l end o f the bowel, close to its edge, and the half o f the button inserted (Fig. 1 l); the distal end was treated in like m a n n e r a n d the o t h e r p o r t i o n o f the b u t t o n placed in position and the button pressed t o g e t h e r (Fig,. 12). O m e n t a l flap was placed arouncl the point o f union, and held in place by the silkworm-gut sutures. T i m e o f o p e r a t i o n , tweh'e minutes. T h e d o g showed no u n p l e a s a n t s y m p t o m s after the o p e r a t i o n . J ul? ',7th, e x a m i n e d the r e s u h o f this o p e r a t i o n ; while m a k i n g cmcectomy on the s a m e dog, f o u n d a perfect n n i o n b e t w e e n the e n d s o f the bowel: o m e n t u n ~ a d h e r e n t all a r o u n d ; no a d h e s i o n s h e t w e e n the united intestine and a b d o m i n a l ~,all. T h e r e was no contraction o f bowel at the seat of union, and it was very difficuh t~ m a k e out the line o f a p p r o x i m a t i o n o n the serous surface. T h e b u t t o n h a d ahead~ passed. August 9th, killed dog: f o u n d the bowel as d .f~s c i l"b e o L above. T h e r e were three o p e r a t i o n s on this d o g - chotecysto-enterostomy, end-to-end approximation o f the ileum, a n d caecectomv, with e n d o f small intestine a p p r o x i m a t e d to e n d o f large intestine.

V o l u m e 24

Numi,,~ I

CI_ASSIC ARTICI.ES

Fro. 19. Same as Figure 10, closed.

~15

a r o u n d the c i r c u m f e r e n c e , except at one point where the m e s e n t e r y j o i n s the bowel; here there was a small sinus leading down a l o n g the mesentery. T h e button was still in position. Up to this time in the e n d - t o - e n d a p p r o x i m a t i o n , and in this o p e r a t i o n as well, no particular care was taken to see that the p e r i t o n e u m o f the m e s e n t e r y o v e r l a p p e d , so as to p r e v e n t a portion o f the muscular and m u c o u s m e m b r a n e being compressed between the edges o f the button without having p e r i t o n e u m c o v e r i n g t h e m to form. adhesion. This accounts for the sinus which existed in this case. Experiment ' , 3 . - - S e p t e m b e r 7, 1892. Black curly dog, weight 40 pouncls. E n d - t o - e n d a p p r o x i m a t i o n o f ileum. Small button (No. 1), O m e n t a l tlap. T i m e eleven minutes. S e p t e m b e r 291h, d o g killed; p e r f e c t tmior, o f bowel; o m e n t u m not a d h e r e n t ; o p e n i n g in bowel small, but o f same size as button used, button had passed. ExOerime~t ~ 6 . - - S e p t e m b e r 8, 189:~. B u l l - d o g w e i g h t 55 p o u n d s . O p e r a t e d o n by Dr. F. S.

Experime'~t l a . - - J u l y 5, 1890_. Black a n d white dog, w e i g h t 6o p o u n d s . E n d - t o - e n d a p p r o x i m a t i o n . O m e n t a l flap. C o n t i n u o u s silkworm-gut suture was used in a b d o m e n . T h e d o g was not sick a f t e r the operation. On July loth, five da~s after the operation, the dog, in licking the wotmd, loosened the suture and allowed the bowel to escape. He was t h e n killed. T h e ends o f the bowel ~'ere perfectly a d h e r e n t ; a plastic e x u d a t e obliterated the line of union on the peritoneal side o f the bowel. T h e button was f o u n d in position

(Fig.

'3).

Experimerat 14.---July 1 l, t89~. Spotted dog, same as in E x p e r i m e n t 3, of which you will h e a r later; weight 55 pounds. End-to-end a p p r o x i m a t i o n . Button No. 2 was f o u n d to be too large to be a d m i t t e d into the bowel a n d gall-bladder button (No. l) was substituted. This gall-bladder button, a~ w_m see, has an o p e n i n g not m o r e than the eighth of an inch in d i a m e t e r . I felt very a p p r e h e n s i v e that this would be p l u g g e d by hair. T i m e , fifteen minutes. T h e dog was not in the least sick after the operation, and the button was passed on the sixth day. August 31st. killed dog; f o u n d a perfectly united bowel: o m e n t a l flap a d h e r e n t ; no adhe-sion to a b d o m i n a l wall. T h e union on the m u c o u s side o f the bowel was so p e r f e c t that the line could be m a d e out only at one point. No fistula, and no contraction at point of union. Dr. Fenger was present at the autopsy and declared, "'The union is perfect." Experimer~t 1 9 . - - A u g u s t 9, 189'-'- Black female dog, weight 7 o pounds. E n d - t o - e n d a p p r o x i m a t i o n after excision of six inches of bowel. ( ) m e n t a l flap. Time. nine minutes. August 92d, clog killed; f o u n d a union

- ..7<~" _ ~ . .

"

Fl~). 13. Appearance after union and partial at:',-L;)h? of tissue v,ithin clasp ot Button i~as taken place.

D{5

CLASSIC ARTICLES

H a r t m a n n in my laboratory. Excision o f six inches o f ileum with end-to-end approximation. Button No. 1. No omental flap. Care was taken in inserting the r u n ning thread to overlap the p e r i t o n e u m at the mesenterv. Time, fourteen minutes. October '_,d, o p e n e d dog's a b d o m e n ; f o u n d perfect union; b u t t o n had passed; bowel somewhat smaller at point o f union. T h e specimen was excised with six inches o f the bowel, and a n o t h e r e n d - t o - e n d a p p r o x i m a t i o n made on same (log.

Experiment 3 3 . - - O c t o b e r e, x89-~. Same dog as in E x p e r i m e n t 26. End-to-end a p p r o x i m a t i o n o f ileum, after excising specimen from E x p e r i m e n t '-,6, along with six i n c h e s o f bowel. O p e r a t e d o n by Dr. Hartrnann. T h e b u t t o n was inserted in the usual way. No omental flap. No scarification, q'ime, sixteen minutes. October toth, the dog was playful, and ate as usual. October 1~th, b u t t o n was passed. T h e r e was no spring in this button. October ~5th, dog killed; f o u n d perfect union; no sinus. Experiment 2 8 . - - A u g u s t 9, 1892- End-to-end app r o x i m a t i o n o f ileum, p e r f o r m e d in my laboratory by Dr. It. R. Wittwer. Same dog as in E x p e r i m e n t _-1. T i m e f o u r t e e n minutes. Omenta] flap. S e p t e m b e r a 6th, dog killed; f o u n d perfect union of bowel. T h e c i r c u m f e r e n c e o f the bowel showed only partial atrophy o f portion in clasp o f button. Experiment 2 9 . - - S e p t e m b e r 25th, Appleton, Wis. E n d - t o - e n d approximation of j e j u n u m , button (No. -~). q i m e , seven minutes. Dog killed seven (lays after the operation, and specimen e x a m i n e d by my preceptor, Dr. J. R. Reilly, o f Appleton, Wis. He r e p o r t e d a a

b ,,' ~ ~.

/

Fms. 1, and 15. Appearance ~)t m t t c o u s bowel after union.

a n d s e r o u s surt-~ces

ot

Dis. C o l & Rec:

Jan-Feb. 1981

perfect union o ! >,owel; the a t r o p h y was not cornpleted. T h e button still in position. Lateral Approximation or Intestinal Anastomosis.--By lateral a p p r o x i m a t i o n or intestinal anastomosis we u n d e r s t a n d the formation o f a fistulous o p e n i n g between two coils of intestine. It is perf o r m e d where it is desirable to have the intestinal contents p r e v e n t e d from passing t h r o u g h a m o r e or less constricted portion o f the bowel, and where the bowel is not sufficiently constricted to cause gangrene, and it is not necessary to extirpate the constricted portion. T h e suggestion for such a c o m m u n i c a t i o n originated with Maisonneuve. He was also the first to operate; both o f his cases t e r m i n a t e d fatally. T h e o p e r a t i o n was almost completely f o r g o t t e n until 1868, when Hacken made some e x p e r i m e n t s on dogs, and recently 1-2. Hahn, of Berlin, b r o u g h t the subject again before the profession, and still later great stress was put on ~he operation by Dr. Senn. T h e great fear o f the operation was the accumulation of fa~ces in the excluded portion o f the intestine. This fear has been f o u n d to be visionary, as the e x p e r i m e n t s recently made on animals show that if the bowel is united so that its contents continue in a direct line, that is, without making a sharp curve, there would be no fear o f retention or accumulation, providing the anastomotic o p e n i n g is sufficiently large. T h e o p e r a t i o n was first p e r f o r m e d with sutures. Dr. M. E. Connell, Superint e n d e n t o f the Milwaukee Hospital, suggested the use o f p e r f o r a t e d plates (see S e n n ' s " E x p e r i m e n t a l Surgery"), which were subsequently used by Dr. Senn in his excellent experiments. T h e first plates used were made o f wood, gutta-percha, leather, and lead. S u b s e q u e n t l y the disks were m a d e o f a b s o r b a b l e material, as decalcified bone. Now we have many modfications o f the method, using, in place of the bone-plates, s e g m e n t e d wood, coil of heavv catgut, etc. It was h o p e d from the results o f the early experiments that the operation u p o n man o f lateral approximation would be f r a u g h t with much less d a n g e r than the end-to-end. But the d e g r e e o f contraction following lateral anastomosis, and the invagination of the distal end o f the bowel into its h u n e n have increased the d a n g e r until it is equal to that o f the endto-end approximation. I have used the buttons for the lateral as well as the end-to-side approximation. T h e following are the experiments:

Experiment 5 . - - J u n e 24, 189~. Lateral anastomosis o f the j e j u n u m with button. O p e r a t i o n very easily executed. Time, seven minutes. Dog had no unpleasant symptoms. Dog killed July 26th; f o u n d a perfect lateral union; o p e n i n g as large as button. No accumulation o f faces in loop. but considerable atrophy. Button had passed.

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Fro. 17. Proximal end joined to distal side alker excision of portion of bowel Iright wavl.

I'.'xperime~it 8.--June ~4, t892. Coach-dog, female, weight 8o pounds. I.ateral anastomosis of ileum: very easily p e r f o r m e d ; no escape of gas or fluids; perfect a p p r o x i m a t i o n . T i m e , sixteen m i n u t e s . T h e clog showed no u n p l e a s a n t s y m p t o m s . Jul~ ]st, killed d o g with c h l o r o f o r m . F o u n d p e r f e c t u n i o n of bowel; moderar.ely large o p e n i n g ; l o o p very m u c h contracked; no accumulation o f fmces ira loop; no adhesiun to a b d o m i n a l ,~all.

adhesions carl be subjected to. !-otmd small mvagination o f u p p e r portion o f distal end; lower end o f proximal portion of bowel very m u c h dilated, as was anticipated; m u c o u s m e m b r a n e i n f l a m e d a n d one spot ulcerated. C o n s i d e r a b l e hair had a c c u m u l a t e d in pouch. This is in a c c o r d a n c e with the e x p e r i m e n t s p e r f o r m e d by the o t h e r investigators w h e r e the current of' the intestinal canal was m a d e to reverse its direction at any point.

Experime~zt 9 . - - J u n e 24, 1892. Black dog, weight 55 pounds, same as used in E x p e r i m e n t 5. Excision o f two inches o f j e j u n u m . Both ends o f bowel sewed with s i l k w o r m - g u t sutures. L a t e r a l a p p r o x i m a t i o n perfi}rmed. With this e x p e r i m e n t the direction o f the bowel was p u r p o s e l y reversed, to see what effect it would have on the adhesion. T h e contents o f tb.e canal, after passing t h r o u g h the fistulous o p e n i n g , had to move in a direction opposite to its previous course before passing t h r o u g h the fistula. 'I'ime for s u t u r i n g ends o f bowels, f o u r t e e n minutes; lateral a p p r o x i m a t i o n with button, eleven minutes. T o t a l time o f o p e r a t i o n , twenty-five minutes. No o m e n t a l flap. Scarification o f the serous surface b e f o r e app r o x i m a t i o n . T h e d o g did not a p p e a r sick after the o p e r a t i o n . A u g u s t .o3d, dog killed. F o u n d perfect union at point o f a p p r o x i m a t i o n . This is the most trying test that a mechanical device for p r o d u c i n g

FIG. 18. ResulT.after..ioining,_end_of small to end os large intestine (e• or" cmcum'}.

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Experiment ',,5.--September 8, t89'-,. Resection ot six inches o f j e i u n u m . A p p r o x i m a t i o n o f the end of distal portion to the side of proximal portion o f the bowel, w r o n g way. This is also a very severe test on the adhesion. A p p r o x i m a t i o n to side one and onehalt inch from end. End o f proximal portion sutured with silkworm-gut. T i m e , e i g h t e e n minutes. September ~ 2d, dog died, as predicted. Proximal portion o f the bowel very much distended (Fig. a6); large accumulation o f hair and faeces, as anticipated; button still in position; bowel perfectly a d h e r e n t at point of apposition. Experiment 9 7 . - - S e p t e m b e r 9, 1892. Black a n d white dog, weight 45 pounds. A p p r o x i m a t i o n o f the proximal end to side o f distal portion o f bowel, right way, after resection Of six inches o f j e j u n u m (Fig. z7). t-lere it was necessary to d e t e r m i n e which was proximal and which was distal end. This is d o n e as follows: A loop o f bowel is held between the fingers and parallel to the axis of the body; the finger is slipped along down the side of the mesentery; if it goes to the same side as started the portion toward the head is proximal, if it goes to the opposite side the portion toward the h e a d is distal. E n d o f b o w e l s e w e d with silkworm-gut suture. Time, nineteen minutes. Dog killed October 2d. Large piece of bone f o u n d in opening o f button, completely closing it. Pressure atrophy of one-half of the c i r c u m f e r e n c e o f the bowel that was clasped within the button had taken place, so that the fluid passed on in the alimentary canal on the side o f the button in place of t h r o u g h the centre. T h e r e was a perfect union o f bowel at point of a p p r o x i m a t i o n , as

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Jan. Feb. 19Sl

you will see in specimen. T h e line of" union on the mucous side could scarcely be discerned. This specimen shows more perfectly than any o t h e r the various stages o f the process o f pressure atrophy. Excision of Caecum with Ileo-Colostomy.--This operation may be necessary, and should be successful in certain cases o f carcinoma o f the czecum. T h e removal o f this portion of" the intestine has so far been followed by unfavorable results, but o u r advanced knowledge of intestinal s u r g e r y should make it a comparatively favorable operation. T h e best incision for this operation on the h u m a n subject should be from the middle of" Poupart's ligament down o v e r the t u m o r t h r o u g h the linea semihmaris. Length o f incision must be governed by the size o f the tumor. T h e caecum is drawn out t h r o u g h the opening, its mesenterv ligated, the r e q u i r e d portion excised, the end sutured, the ileum cut off, and the end o f the ileum a p p r o x i m a t e d to the side o f the colon. E x p e r i m e n t - e n d o f small to end o f large intestine.

Experiment 15.--July 0.7, 1892. Brown female dog, same as used in E x p e r i m e n t s 7 and t,~. Excision o f c,qecnm; r u n n i n g thread put a r o u n d the entire circ u m f e r e n c e o f the colon, and the edge drawn within the clasp of button (No. 3). A similar thread put in the end o f ileum and tied; button pressed together. This a p p r o x i m a t e d the e n d o f the small to the end o f the large intestine. Time. thirty-one minutes. July ~8th, dog not in very good condition, refusing to eat o r drink. July 3oth, dog still sick and declining to eat. From that time on did very well. August 9th, killed dog. F o u n d a perfect union o f the e n d o f the small to the end o f the large intestine; button had passed; omental flap a d h e r e n t ; o p e n i n g o f same calibre as that o f small intestine (Fig. 18). See specimen. Experiment 3 1 . - - A u g u s t 14, 1892. Black, curly f e m a l e dog, weight a= 5 p o u n d s . I l e o - c o l o s t o m y . Ileum cut o f f at ileo-c,'e.cal valve; o p e n i n g in c~ecum sewed with c o n t i n u o u s silkworm-gut, L e m b e r t stature. Half o f button pressed in end o f ileum and the o t h e r half inserted in an o p e n i n g m a d e in coh)n, t h r e e inches below the ileo-caecal yah'e, and button joined. Omental flap. T i m e , sixteen minutes. In closing the a b d o m e n the large o m e n t u m was i n c l u d e d in the peritoneal suture. S e p t e m b e r 2oth, dog had a miscarriage. S e p t e m b e r z9th, clog died. Autopsy showed the cause o f death to be a xolvulus a r o u n d the o m e n t u m where it was a d h e r e n t to the cicatrix in the abdominal wall. Perfect union between ileum and colon (Fig. 19): b u t t o n in position; a t r o p h y over half o f its circumference; no obstruction at the seat o f button; no peritonitis. This is a very instructive case, as it shows one o f the complications that may arise fl-om including the o m e n t u m with the peritoneal s u t u r e of the

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CLASSIC ARTICLES

a b d o m i n a l wall, so frequently advised arid practised by m a n y o p e r a t o r s at the p r e s e n t time. Besides the above cases three dogs were lost with the anmsthetic. One dog was sick when b r o u g h t f r o m the p o u n d ; he was o p e r a t e d on the following m o r n ing, and died twelve hours after, n e v e r being able to stand f r o m the time he was taken f r o m the table. T h e o p e r a t i o n lasted only e i g h t e e n m i n u t e s , a n d h a d nothing to do with the cause o f his dead-:. Irt every e x p e r i m e n t we obtained union at the seat of a p p r o x imation. This is one of the most i m p o r t a n t points b r o u g h t out by the button, for it shows that a line o f surface contact is just as good as half an inch for f o r m ing an adhesion, and it practically insures against contraction where, with a larger a p p r o x i m a t i o n surface, contraction would certainly follow. I desire to e x p : e s s my thanks for, and a p p r e c i a t i o n of, the valuable services r e n d e r e d me in my e x p e r i m e n t s a n d o p e r a t i o n s by [)vs. E. W. Lee, F. S. H a r m : a n n , a n d H. R. Wittw c r , and by Dr. J. H. t t o e l s c h e r in placing material at my disposal; my obligations to I)r. Wiener for using my m e t h o d at an early date and to Dr. E. A..Matthx:i for the drawings. \:g.xE-rlax Bc:tDixc,. ('n:c.*Go, O c t o b e r ---9, T892. LI I ERATURE, : Courvoisier, L, G.: Pathologic und Chirurgie d e r C,alleuwege. I.eipzig. 1t49o.

59

-" ~. Winiwarter: Prager Med. Vr 188~, Nos, z~, ~ . :J Kappeler: CorrbL f, Schweizer Aerzte, 1887, No. t 7, and 18S 9, No. 4. 4 Dastre: Corrbl. f. Scbweizer Aerzte, t889, No. ':o. Cirrug. Westnik. t88fi, May and J u n e tlefte. G Sodn: Jahrsbel. d. chir. Abtheilg. d. Basler Spirals, J 887, p, 60. v Fritzsche bei Biattmann: Corrbl. f. Schweizer Aertze, 189o, No. 6. B:itish Medical Jour:~a[, November, 1889. ~Revue de Chir,, 1,~89, No. 12. ~0 Czernv: Ap, nals o f Surg,zr,~, October, 189~. ~ B a r d c n h e u e r : -I agebl, d. 61 Versammlg. deutscher Na:urforscher u. Aerzte in K61n, 188~q, Ctrbl. ['. Chit., x889, No. 1'-,. 12 Harley, G.: J88~. ~:~Lambotte: Le Presse *ledicale Beige, Brussels, July 3- 18!)~. :~ Landois and Sterling: Ph}siology. 189o. ~ Baracz: Archi~. f/it klin. Chir., Langenbeck, October, t89"a. a~:Connell: New York .MEr)m~,L RF.(:ORD, September, 189'-,.

Bibliography Murphy jB. Cholecysw-inlestinal, gastro-intestinal, enterointestinal, anastomosis, and approximation without sutures. Med Record 1892:42(24):665-676. [biography] Davis L. J. B. Murphy: Stormy petrel o f surgery. New York: G P Putnam's Sons. .:m j Obstet 1917:75:299-305. Surg Gynecol Obstet 1916:23: [portrait] Davis k.]. B, Murphy: Stormy petrel o f surgery. New York: G. P. Putnam's Sons