Skip to main content

Full text of "Intestinal surgery"

See other formats


Google 



This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project 

to make the world's books discoverable online. 

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject 

to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books 

are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. 

Marks, notations and other maiginalia present in the original volume will appear in this file - a reminder of this book's long journey from the 

publisher to a library and finally to you. 

Usage guidelines 

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the 
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing tliis resource, we liave taken steps to 
prevent abuse by commercial parties, including placing technical restrictions on automated querying. 
We also ask that you: 

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for 
personal, non-commercial purposes. 

+ Refrain fivm automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine 
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the 
use of public domain materials for these purposes and may be able to help. 

+ Maintain attributionTht GoogXt "watermark" you see on each file is essential for in forming people about this project and helping them find 
additional materials through Google Book Search. Please do not remove it. 

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just 
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other 
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of 
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner 
anywhere in the world. Copyright infringement liabili^ can be quite severe. 

About Google Book Search 

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers 
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web 

at |http: //books .google .com/I 



I 



iL^^ait@ 



mm^^^s^i^mm 




INTESTINAL SURGERY. 



• • • • >»<* » 



• « *•• • 

• • • • • 



« « 






BT 



K SENN, M.D., Ph.D., 



ATTENDING BUBOBON MXI<WAUKBB HOSPITAIj; PBOFB880B PBIM0IPI<B8 OV 8UBOBBT 
AND SUBOIOAIi PATHOI«OOT, BX7BH MBDIOAIj OOLZ<BOB, 

OHIOAOO, Hill. 




. ' '."if rr .•,'-. ^/>^ 



CHICAGO: 

W. T. KEENEE, 

96 Wasbznoton Stbbbt. 
1839. 



K 



\caJ 



• • •• 

• • • 






• • • • 

• • • 



• m 



• • 



• • •• 



• • 



OOPTBIOHT, 1889, BY W. T. KXBVBB. 






PREFACE. 



There are few subjects in practical siirgery on which opinion is 
more nnsettled than on the best method of treating intestinal 
obstruction and injuries of the gastro-intestinal canal. While the 
following pages are not intended to serve the purpose of a complete 
textbook on Intestinal Surgery, still the author hopes that they con- 
tain some new facts and suggestions which will prove useful to those 
who practice this branch of surgery. 

The first part of the book contains a rdsumd of the best litera- 
. tnre on the surgical treatment of intestinal obstruction, which has 
been arranged in a systematic manner for ready reference. The 
advice given to the surgeon who is confronted by certain anatomico- 
pathological conditions, is based on clinical experience and the 
results obtained by experimental investigation. 

The second part represents the author's own original work, made 
with special reference to the surgical treatment of intestinal obstruc- 
tion, and the diagnosis of perforation of the gastro-intestinal canal; 
to which is added the report of three cases of gunshot wound of the 
abdomen, in which inflation with hydrogen gas proved a positive test 
in making a correct diagnosis, before the abdomen was opened. 

One of the principal objects in publishing these papers in book 
form is a desire to stimulate the young men in our profession to enter 
the field of original investigation, as the author is firmly convinced 
that experimental research constitutes the shortest and safest route 
to the perfection of the principles and practice of intestinal surgery. 

N. Senn. 
MzziWAUKSS, Deotmber^ 1888, 



CONTENTS. 



PAOB 

The Surgical Treatment of Intestinal Obstmction, ... 
[Read before the Oongrees of American PhyvloiaiiB and BnrgeonB, Washington, 1888.] 

I. Definition and Classification of Intestinal Obstmction, - 4 

II. Frequency of Intestinal Obstruction, ... 5 

m. Snrgical Besoorces in the Treatment of Intestinal Obstntotion, 6 

1. Irrigation of the Stomach, .... g 

2. Distention of Colon with Fluids, - • - 8 
8. Bectal Insufflation of Hydrogen Gas, - - - 12 
4. Tnbage of Colon, - - - - - - 16 

6. Manual Exploration by the Rectum, - - - 18 

6. Taxis and Massage, • - - 19 

7. Puncture of Intestines, - - - - - 20 

8. Uniform and Uninterrupted Compression of Abdomen, - 22 

9. Enterotomy, ...... 22 

10. Colotomy, ....... 26 

11. Abdominal Section, ..... 27 

a. Preparation for the Operation, - - - - 82 

b. Aniesthesia, ...... 88 

c. Incision, - - - - - - - 84 

d. Intra-Abdominal Examination, - - - 86 

e. Operatiye Treatment of Obstruction, - - - 48 

1. Intestinal Anastomosis, - • - - 48 

2. Physiological Exclusion by Anastomosis, - 62 
8. Laparo-Enterotomy, - - - • 52 

4. Enterectomy, - - - - 54 

5. Direct Treatment in Strangulation by Band, Diyer- 

ticula. Flexion and Adhesions, - - 57 

6. Toilette of Peritoneal Cavity, - - - 60 

7. After-Treatment, - - - 61 

rv. Anatomico-Pathological Forms of Intestinal Obstruction, 62 

1. Entero-Lithiasis, - - - - - - 62 

a. Biliary Calculi, ..... 62 

b. Intestinal Concretions, - - - - 72 
0. Parasites as a cause of Intestinal Obstruction, 74 
d. FiBcal Obstruction, - - - - - 76 



VI. 



CONTENTS. 



vAom 



Forms of Intestiiial Obstmotion, 



IV. Anatomioo-Pathologioal 

(Contimjiad)^ - - - - 

8. Inyagination, - 

Pathology of Aonte, 

Pathology of Ohronio, 

Treatment, . : . . 

Beotal Insufflation of Hydrogen Gkis, 

Golotomy, .... 

Enterotomy, 

Laparotomy, ... 

Disinyagination, 

Intestinal Anastomosis, 

Resection, - . . 

8. Volvulus, - - - . . 

Treatment, . - . . 

Flexion and Adhesions, 
Ligamentons Bands and Diyertionla, 
Stenosis, - ' - 

1. Congenital, .... 

2. Acquired or Cicatricial, - . . 
Tumors, - - - - 

1. Non-Malignant, .... 

2. Malignant, .... 

a. Sarcoma, .... 

b. Carcinoma, ... 

V. Dynamic Intestinal Obstruction, 

1. Tympanites, - 

2. Peritonitis, ..... 

3. Catarrhal and Ulceratiye Enteritis, 

4. Exyentration, ..... 



4. 

5. 
6. 



7. 



78 

- 88 
86 

- 87 

88 

- 89 
90 

- 91 
94 

- 95 
96 

- 98 
108 

- 104 
110 

^ 121 
121 

- 128 
127 

- 128 
129 

- 129 
181 

- 184 

184 

• 186 

187 

- 188 



An Experimental Contribution to Intestinal Surgery, with Special Refer- 
ence to the Treatment of Intestinal Obstruction, - - - 141 
[Reprinted from **Azmal8 of Surgery,*' by permiflsion.] 
General Remarks on Experiments, - - - . 144 

I. Artificial Obstruction, - - . . - 146 

1. Stenosis, - - - - - - 146 

a. Partial Entereotomy, - - 146 

b. Circular Constriction, ... 147 

2. Flexion, - - 149 

3. Volyulus, - . - - - 151 

4. Inyagination, --.---- 152 

Permeability of Ileo-CaBcal Valve, ... 157 

II. Entereotomy, ....... 158 

Excision of Colon, - • • 161 

Physiological Exclusion, ..... 168 



CONTENTS. VU. 

III. Oironlar Enterorrhaphy, ..... 166 

NothnagePs Test, - - . - -171 

TranBplantation of Omental Flap, ... 172 

rv. Intestinal Anastomosis, - - - - - • 177 

Direotiohs for Preparing Bone Plates, - - 179 

1. Gastro-Enterostomy, --.... igo 

2. Jejono-Heostomy, ..... 133 

8. Ileo-Oolostomy, ...... 139 

4» Beo-Beotostomy, ...... 197 

5. Ck)lo-Beoto6tomy, ...... 193 

y. Adhesion Experiments, * - - - - - 199 

1. Tramnatio Irritation of Serous Snrfaoee, - - - 200 

2. Ghemioal Irritation of Serons Snrfaoes, - 208 
8. Omental Grafting, ...... 2O6 

VI. Gonolnsions, -..--.. 203 

fieotal Insufflation of Hydrogen Gas an Infallible Test in the Diagnosis of 

Visoeral Injury of the Gastro-Intestinal Canal in Penetrating 

Wounds of the Abdomen, ...... 215 

[Bead before the American Medical Association, 1888.J 

L Permeability of the Beo-Gsdoal Valye, - - 218 

1. Beotal Insufflation of Air, ..... 222 

2. Inflation through Stomach Tube, - 225 
8. Pressure Experiments, Beo-GsBcal Valve, ... 227 
4. Pressure Experiments to force Gas through entire Alimen- 
tary Canal, ------ 229 

II. Resistance of Gastro-Intestinal Canal to Diastaltic Force, - 281 

1. Stomach, - - - - - - - 281 

2. Small Intestines, - . . . . 282 
8. Colon, ---.--. 282 

m. Distention of Gastro-Intestinal Canal by Rectal Insufflation of 

Hydrogen Gas, ...... 288 

rv. Hydrogen Gas is Innocuous and Non-Irritating when brought 
in Contact with Living Tissues, and is Promptly Removed 
by Absorption, -" • - 288 

1. Peritoneal Cavity, - - - 288 

2. Pleural Cavity, ------ 289 

8. Subcutaneous Cellular Tissue, .... 289 

V. Rectal Insufflation of Hydrogen Gas in the Diagnosis of Pene- 
trating Gunshot Wounds of the Abdomen, - - 289 

Inflhtion of the Stomach with Hydrogen Gas in the Diagnosis of Wounds 

and Perforations of this Organ, with the Report of a Case, - 249 

Two Cases of Gunshot Wound of the Abdomen, Illustrating the Use of 

Rectal Insufflation with Hydrogen Gas as a Diagnostio Measure, 258 



INTESTINAL SURGERY. 



THE SUEGICAL TEEATMENT OF INTESTINAL 

OBSTBUOTION. 



The operative treatment of intestinal obstruction is in its 
infancy. Since laparotomy for other indications has become an 
established and frequently practiced procedure, a nuinber of the 
bolder and more aggressive surgeons have resorted to direct meas- 
ures for the relief of intestinal obstruction, but like all serious 
operations for otherwise incurable and fatal affections its general 
application has met with strong opposition not only by the laity, but 
also by the profession. The appalling mortality which has attended 
the operations in the hands of even the most competent surgeons has 
been a sufl&ciently strong argument for non-operative interference. 

In this regard the history of laparotomy for intestinal obstruc- 
tion is only a repetition of the history of ovariotomy. During the 
early part of the latter, the mortality was so great that the operation 
was condemned and denounced as a deliberate murder by some of 
the ablest and most influential surgeons. Yet in spite of all opposi- 
tion the good work progressed until by an improved technique, and 
more especially the introduction of antiseptic surgery, ovariotomy 
in the hands of experts has become one of the safest operations in 
surgeiy. To accomplish this hundreds of lives were sacrificed that 
thousands might be saved. The early ovariotomists operated only on 
patients worn out by the disease and often the subjects of additional 
serious visceral lesions caused by the prolonged intra-abdominal 
pressure, the reason for this being the great mortality which attended 
the operation. To-day the danger incident to opening the abdominal 
cavity under proper antiseptic precautions is so slight that patients 
suffering from ovarian tumors are encouraged to have them removed 
as soon as their presence can be diagnosticated, at a time when the 



c 

2 INTESTINAL SURGERY. 

general health remains unimpaired, a change of practice which has 
still farther reduced the mortality of ovariotomy. The mortality of 
laparotomy for acute intestinal obstruction will be reduced to that of 
other intraperitoneal operations as soon as surgeons will recognize 
the importance of operating early, before the patient's strength has 
been wasted by the disease, and before the parts involved in the 
operation have undergone irreparable textural changes. The mor- 
tality of abdominal section in the treatment of the different forms 
of intestinal obstruction will always be great, because the conditions 
which have caused the obstruction are often an intrinsic source of 
danger. In others, the removal of the obstruction necessitates an 
intestinal resection which in itself is a vastly more serious opera- 
tion than the removal of an ovarian tumor. Intestinal obstruction, 
irrespective of its cause, is always followed by a series of consecutive 
pathological changes which independently of the partial, or com- 
plete interruption of the passage of intestinal contents tend to 
destroy life. 

The dilatation of the intestinal tube on the proximal side of 
the seat of obstruction may give rise to such a degree of abdom- 
inal distention as to destroy life from suspension of important 
fuActions by mechanical pressure. In acute obstruction, the violent 
peristalsis on the proximal side of the occlusion causes an increased 
afiOlux of blood to the portion of bowel the seat of exaggerated phys- 
iological function, which after cessation of peristaltic action remains 
as an intense venous and capillary engorgement. During the paretic 
stage the blood vessels in the intestinal wall have lost their extra 
vascular support, hence transudation and exudation readily take 
place into the paravascular tissues, which, combined with the 
capillary stasis attending this stage of the inflammatory process, 
often results in gangrene. The intestinal wall, in a state of inflam- 
mation, becomes permeable to pathogenic micro-organisms which 
are always present in the intestinal canal, and which after passing 
through the entire thickness of its walls enter the peritoneal cavity 
and induce septic peritonitis, — a frequent immediate cause of death. 
These facts are cogent reasons for adopting surgical measures in all 
cases of intestinal obstruction due to mechanical causes as soon as 
a probable diagnosis can be. made. If this were done, the two 
greatest sources of immediate danger attending and following 
laparotomy, shock and septic peritonitis, if not entirely avoided, at 



OPERATIVE TREATMENT OF INTESTINAL OBSTRUCTION 3 

least would be less likely to occur, and the tissues the seat of oper- 
ation would be in a favorable condition for direct treatment and 
repair. An abdominal section in the treatment of intestinal obstruc- 
tion is always necessarily attended by some shock, and it is therefore 
of the utmost importance to perform the operation at a time when 
the organs of circulation and the nervous system are still in a condi- 
tion to successfully resist the immediate effects of the operation. 
Death from septic causes can only be avoided by operating at a time 
when the intestinal canal at the seat of obstruction and on its prox- 
imal side is still in a condition capable of resisting infection and of 
undergoing a satisfactory process of repair in case it becomes 
necessary to incise, or resect during the operation. The statistics 
of operations for intestinal obstruction will improve as soon as we 
shall be able by improved methods of diagnosis to make an early 
positive diagnosis and to adopt in the treatment positive surgical 
measures before the prospects of a recovery 'have been rendered 
improbable, if not impossible, by days and weeks of useless, and 
worse than useless, internal medication. True intestinal obstruction, 
whatever its cause may be, is as strictly a surgical affection as 
strangulated hernia and remediable only by the same kind of surgi- 
cal treatment. Physicians should recognize this fact and should 
call into counsel a surgeon as soon as a probable diagnosis of 
intestinal obstruction can be made. To let a patient die of the 
consequences of a removable cause of obstruction without an c^era- 
tion is a reflection upon the advances of modem aggressive surgery. 
The difficulties which surround the diagnosis and the present 
imperfect technique of the operative procedures in cases of intes- 
tinal obstruction are not only responsible for the heretofore late 
operations, but also to a great extent for the many failures. Ways 
and means for more accurate diagnosis will have to be devised by 
more careful clinical observations and by experimental research, 
while new and improved methods of operation must be devised and 
their merits and safety tested by experiments on animals. I am con- 
vinced that accurate experimental work of this kind will render 
essential information in the diagnosis of the obscure causes of ob- 
struction, and will point out more clearly the indications for opera- 
tive treatment, while improved methods of operation will have to 
be studied exclusively in this manner. The obstacles which the 
surgeon encounters in the diagnosis and treatment of many cases of 



4: INTESTINAL SURGERY. 

intestinal obstruction often appear instirmountable, but they will be 
greatly diminished in the future by facts which will be revealed 
by the results of experimental investigation. Abdominal surgery 
was founded and developed on American soil, and in the part which 
refers to the treatment of intestinal obstruction, ample scope is left 
for the exercise of the genius and perseverance of the younger 
members of the profession in this country, who would do honor to 
the memory of our McDowell, our Sims, and our Gross by honest, 
faithful, unselfish, original work. 

I. Definition of Intestinal Obstrnction. 

Intestinal obstruction, occlusion and strangulation have been 
used as synonymous terms. Some authors wish to draw a line of 
distinction between cases of intestinal obstruction and intestinal 
strangulation, including under the former term all cases where the 
obstruction is caused by a tumor, enterolith, or intussusception, 
while internal hernia, volvolus, and constriction by a band are 
included under the head of strangulation. For practical purposes 
such a distinction is superfluous, as any cause which mechanically 
interferes with the passage of intestinal contents produces intestinal 
obstruction, and if it cannot be removed by ordinary means should 
be treated by abdominal section. The classification into true and 
false obstruction, from a surgical standpoint, should also be aban- 
doned, as \)perative interference is only indicated in cases of obstruc- 
tion due to the presence of mechanical obstacles, such as foreign 
bodies, tumors, or intussusceptum in the lumen of the bowel, or to 
cpmpression of the lumen by tumors, flexion, twisting, and bands of 
constriction. Inflammation of the tunics of the bowel and diffuse 
peritonitis may give rise to symptoms resembling obstruction, but in 
such cases the obstruction follows as a sequence of an antecedent 
or accompanying inflammatory lesion, and is due to dynamic dis- 
turbances and not to mechanical occlusion, and the indications for 
treatment are to combat the inflammation and to restore peristaltic 
action, combined with mechanical means to relieve the abdominal 
distention. A more important classification remains to be mentioned 
by which all cases of true intestinal obstruction are divided into 
acute and chronic. This distinction must be maintained for many 
reasons. In chronic obstruction the symptoms usually develop very 
slowly as the occlusion becomes more complete. During the early 



FREQUENCY OF INTESTINAL OBSTRUCTION . 5 

part of the affection the intestinal walls above the seat of obstraction 
undergo compensatory hypertrophy, dilatation taking place very 
slowly nnless the chronic suddenly merges into the acute form, an 
event which is always announced by a complexus of symptoms charac- 
teristic of acute or subacute obstruction. Chronic obstruction is more 
frequently met with in persons advanced in years, and the seat of 
obstruction is usually located in some part of the large intestines. 
The acute form is caused by some pathological conditions which 
suddenly narrow, or obliterate the lumen of some portion of the 
intestine, usually above the ileo-csecal valve, and often without any 
premonitory symptoms gives rise to a complexus of acute symptoms 
almost pathognomonic of this affection. The sudden interruption 
of the passage of intestinal contents is followed by violent peri- 
staltic action of the bowel above the seat of obstruction in a vain 
attempt to clear the intestinal tract, which from muscular exhaus- 
tion and the distention from the accumulation of intestinal con- 
tents finally gives rise to paresis and the textura] changes pre- 
. viously alluded to. In the treatment of such acute cases prompt 
action constitutes an essential element of success, as in a few 
hours, or days, the patient becomes utterly prostrated, and the 
bowel at and above the seat of obstruction has undergone irrepar- 
able pathological changes. These are the cases that demand early 
surgical treatment, and that now claim our special attention. 

II. Frequency of Intestinal Obstruction. 

An examination of the statistics of Leichtenstem^ shows that, 
external hemisB and malignant tumors being excluded, one death 
from intestinal obstruction takes place in every three to five hun- 
dred deaths from all causes in hospital practice. This statement 
is based upon the records of the late Dr. Brinton, of liondon, and a 
nxmiber of large hospitals on the European continent. 

Hilton Fagge^ has shown from an examination of the records 
of four thousand autopsies in Guy's Hospital, from 1854 to 1868, 
that fifty-four, or about one-fourth per cent., were cases of intestinal 
obstruction. 



* Ziemssen's Oyolopeadia of the Praotioe of Medioine, Amerioan Transla- 
tion, Vol. VIII. 

^ Gny's Hospital Reports, 1869. 



6 INTESTINAL 8UROERY. 

Heusner^ from his own investigations regarding the frequency 
of intestinal obstruction maintains that annually out of every one- 
hundred thousand individuals, from five to ten suifer from this 
affection, and that one to every three to five hundred deaths is 
attributable to this cause. These statistics show the importance of 
intestinal obstruction in its medical and surgical relations, and it is 
hoped that by their aid new light may be shed upon a class of 
affections which heretofore, only too often, have baffled the skill of 
both physician and surgeon. 

III. Snrgical Resources in the Treatment of Intestinal 

Obstruction. 

I. Irrigation of Stomach. 

The accumulation of intestinal contents above the seat of ob- 
struction acts deleteriously in several ways: 1. n causes violent 
peristaltic action of the intestine above the seat of obstruction. 
2. It exhausts the patient's strength by causing persistent retch- 
ing and vomiting. 3. It is one of the causes which produces 
distention of the intestine. 4. It favors fermentative and putre- 
factive changes in the intestine by the fluid serving the purpose of 
a nutrient medium for pathogenic micro-organisms. In my experi- 
ments on animals where I made complete obstruction I never 
witnessed such persistent vomiting as in man. I attributed this 
difference to the fact that animals thus treated refuse, as a rule, 
both food and drink, and that the intestinal canal in proportion to 
the size of the abdominal cavity is much shorter than in man. 
Patients suffering from acute intestinal obstruction should abstain 
from taking either food or drink, as digestion and absorption are 
almost, if not completely, suspended, and the accumulation of 
fluids cannot ^ail in aggravating the symptoms. 

Kussmaul^ has introduced a new and exceedingly valuable 
therapeutic measure in the treatment of intestinal obstruction in 
the use of the elastic stomach- tube. By the siphon action, of the 
tube, gas and the fluid contents of the stomach and upper portion 
of the intestinal canal are evacuated, and thus abdominal distention 
is relieved and the hydrostatic pressure in the intestine above the 

^ Deutsche Med. Wochensohrift, 1887. 

2 Berl. Klin. Wochensohrift, Nos. 42, 43, 1884. 



SURGICAL RESOURCES IN TREATMENT. 1 

obstruction diminished. He claims for this measure the following 
advantages: 1. Intra-abdominal tension is diminished and thus the 
first condition secured for the correction of the mechanical difficulties 
which have caused the obstruction. 2. It relieves the distention of 
the bowel above the seat of obstruction and consequently also the 
pressure of the intestines against each other, a condition which 
cannot fail to impair peristaltic action. 3. Finally, what is most 
important, by evacuating the accumulated contents it diminishes 
the violent peristalsis. He reports the case of an adult where an 
intestinal obstruction due to an invagination had lasted twenty-three 
days and which yielded to daily irrigations of the stomach. A 
portion of the intussusceptum sloughed and was found in the stool. 
The patient died later of peritonitis which may have started from 
the seat of invagination. 

Bardeleben^ in a paper on the treatment of acute intestinal 
obstruction, praises the utility of irrigation of the stomach as a 
palliative means, but speaks at the same time of the danger inci- 
dent to .the employment of such a temporizing measure, as too much 
valuable time may be lost before a curative treatment is adopted. 
He reports a case in which irrigation afforded such absolute relief 
that the operation was postponed until it could be no longer of any 
avail. Kuester expects from irrigation of the stomach prompt pallia- 
tive effects, but warns not to persist with it in cases where the seat 
and cause of the obstruction can be ascertained. Hahn looks upon 
it as a curative agent only in cases where the obstruction is due to 
koprostasis in the large intestines, and he claims that in such cases 
irrigation of the rectimi would lead more promptly to the desired 
result. 

.Schlegtendal^ claims that lavage of the stomach in the treat- 
ment of intestinal obstruction fulfills a threefold therapeutic indica- 
tion: 1. It prevents distressing symptoms; 2. alleviates them when 
they are present; and in some cases 3. cures the disease. 

Behn' mamtains that irrigation of the stomach, as devised by 
Kussmaul, in the treatment of intestinal obstruction not only empties 
the stomach of its contents, but it also evacuates a certain portion 
of the intestinal canal above the seat of obstruction. In two cases 

1 Ueber Hens. Berl. Klin. Wochenschrift, Nos. 25, 26, 1885. 
' Frauenarzt, 1887. 
>Fort8chritte der Medioin, 1887. 



8 INTESTINAL SURGERY. 

of intestinal obstruction, where this expedient was resorted to after 
the abdominal cavity was opened, he observed that a considerable 
portion of the dilated intestine was emptied of its contents. 

Heusner states that by this means many litres of intestinal 
contents can be removed, pain is relieved, eructation and vomiting 
controlled, peristalsis quieted, the function of the stomach restored, 
suitable nourishment can be taken and assimilated, thus maintaining 
strength and life until the cause of obstruction is removed sponta- 
neously, or through the intervention of surgery. Madelung has 
called attention to the necessity of resorting to irrigation of the 
stomach prior to the administration of an anaesthetic in operations 
for intestinal obstruction, as without such precaution there is danger 
during the attacks of vomiting which are almost sure to be provoked 
by the anaesthetic, of fluid entering the trachea, causing suffocation, 
or later, pneumonia. As an aid in the treatment of intestinal ob- 
struction due to mechanical causes, irrigation of the stomach should 
always be systematically practiced every four to six hours, but as a 
curative measure it should never be relied upon. In my own prac- 
tice I have always combined emptying of the stomach with irrigation, 
using large quantities of warm water rendered antiseptic by the addi- 
tion of salicylated soda, or hypophosphite of soda. The washing out 
of the stomach with a harmless and efficient antiseptic solution, has a 
decided beneficial effect in preventing fermentative and putrefactive 
changes in the intestinal contents above the seat of obstruction. 

2. Distention of Colon with Fluids. 

Evacuation of the colon by copious rectal injections is resorted 
to almost instinctively in every case of intestinal obstruction. This 
procedure has also been employed with the intention of utilizing 
the hydrostatic pressure as a means for the correction of the 
mechanical difficulties which have given rise to the obstruction. 
This method of treatment has given rise to the much discussed ques- 
tion as to the permeability of the ileo-csecal valve to rectal injections 
of fluids, or to the insufflation of air or gases. The majority of 
those who have studied this subject clinically or by experiment make 
the positive assertion that the ileo-caecal valve is perfectly compe- 
tent and effectually guards the ileum against the entrance of both 
fluids and gases forced into the rectum, while others insist that it is 



DISTENTION OF COLON WITH FLUIDS, 9 

permeable only in exceptional oases, and only a few claim that its 
resistance can be overcome by a moderate degree of pressure. 

Heschl^ made a number of experiments on the cadaver and 
satisfied himself that the ileocsecal valve serves as a safe and perfect 
barrier against the entrance of fluids from below. In testing the 
resisting capacity of the coats of the intestine he found that the 
serous coat of the colon gave way first to over-distention, while the 
remaining tunics yielded subsequently to a somewhat, slighter pres- 
sure. The small intestine of a child on being subjected to over- 
distention ruptured first on the mesenteric side, the place where 
acquired diverticula are found. 

Bull^ has found that in the adult one litre of water injected by 
the rectum will reach the csecum, but that the entire capacity of the 
large intestine is from 4 to 5 litres. He is of the opinion that in 
the living body fluid cannot be forced beyond the ileo-csecal valve, 
although ancient and modem experimenters claim to have succeeded 
in the cadaver. He affirms that when the rectum is distended by air 
the ileo-csecal valve is rendered incompetent and the air passes into 
the small intestines. Cantani^ is a firm believer in the permeability 
of the ileo-csecal valve to fluid rectal injections. In one instance he 
treated a case of coprostasis by an injection of a litre and a half of 
oil per rectum, and an hour later a part of the oil was ejected by 
vomiting. He advises that the intestinal tract above the ileo-csecal 
valve should be utilized as an absorbing surface in cases requiring 
rectal alimentation, and when in a diseased condition should be 
treated by topical applications. 

Behrens^ concluded from his experiments that it required the 
insufflation per rectum of one and one-eighth litres of air to reach 
the ileum through the ileo-csecal valve. In his experiments he had 
no difficulty in overcoming the competency of the ileo-csecal valve 
by rectal insufflation of air. 

Debierr^^ made numerous experiments on the cadaver to test 

^Znr Mechanik der Diastaltisohen Darmperforationen, Wiener Med. 
Wochenscrift, No. 1, 1881. 

^Virohow u. Hirsoh's Jahresbericht, B. 2, 1870, p. 180.. 

'Virchow u. Hirsch's Jahresbericht, B. 2, 1879, p. 180. 

^Ueber den Werth der ktLnstlichen Anftreibnng des Diokdarmes mit Gasen 
n. Fltlssigkeiten. Dissertation. Gdttingen, 1886. 

^ La valvnle de Banhin consider^ comme barriere des apotheoaires. Lyon 
M^dioale, No. 45, 1886. 



10 INTESTINAL SURGERY. 

the permeability of the ileo-csBoal valve to rectal injections of fluids 
or insufflation of air. The results which he obtained were not con- 
stant. In some subjects the valve proved only permeable to air; in 
others, to both air and water; while in some no air nor fluids could 
be forced into the ileum by any degree of force. When the intestine 
was left in situ the valve was found less permeable than when 
the intestine had been removed from the body. He attributes the 
different degrees of competency of the valve to variations in the 
anatomical construction of the valve. If both lips of the valve are 
equal in length, or if the lower lip is longer, the valve was foxmd 
impermeable. It proved permeable in cases where the lower lip 
was shorter, contracted, and smaller than the upper. In the last 
instance, the advancing volume of fluid or air lifted the upper valve, 
while in the former structure of the valve, the margins of the lips of 
the valve were approximated, perfectly shutting o£P all communica- 
tion between the colon and the ileum. 

Mr. Lucas ^ enumerates the following objections against forcible 
rectal injections of water as a means to reduce an invagination : 

1. Owing to its weight it exerts much too strong lateral pres- 
sure for the intestine safely to bear, and he has found it easy to 
rupture the bowel after death by forcing in water. 

2. Should reduction have been accomplished the contact of a 
large quantity of water with the large bowel is apt to increase the 
tendency to diarrhoea. He claims, very properly, that gas, on the 
other hand, is a natural occupant of the intestinal canal, and whilst 
its pressure is of the gentlest, its presence excites no unnatural 
peristaltic action. He administers an ansesthetic to the point of 
relaxation before the inflation is attempted. 

Dawson' made a number of experiments on the cadaver and 
came to the conclusion that when the .ileo-caecal valve is in a normal 
condition, it effectually guards the small intestine against the ingress 
of fluids from below. 

Hloway* devised a force-pump which he strongly recommends 
for the purpose of forcing water beyond the ileo-caecal valve in case 
the seat of an intestinal obstruction is located above that point. He 



^On Inversion with Inflation in the Cure of Intnssnsception. The 
Lancet, Jan. 16, 1886. 

2 Lancet and Clinic, Feb. 21, 1885. 

'American Journal of Medical Sciences, Vol. 41, page 168, 



DISTENTION OF COLON WITH FLUIDS, 11 

reports four cases of intestinal obstruction treated by this method* 
three of which recovered. 

Battey^ asserts the permeability of the entire alimentary canal 
by enema, and verifies his statement by the recital of his own clinical 
experience and experiments upon the cadaver. Ziemssen recom- 
mends inflation of the rectum for diagnostic and therapeutic pur- 
poses, and proceeds as follows: A rectal tube about six inches long 
is carried into the anus and fixed by pressing together the nates, the 
patient lying on the back. A funnel is then connected with the 
rectal tube by means of rubber tubing. • For complete inflation of 
the large intestine 3 drachms of bicarbonate of soda, and 4^ drachms 
of tartaric acid are separately dissolved in water and portions of 
either solution alternately added. To prevent sudden over-dis- 
tention of the bowel it is advised to add the solutions at intervals 
of several minutes. A very important use of this method is to 
diagnosticate the position of the contractions, strictures, or occlu- 
sion of the intestine in cases in which it is desirable to operate, and 
also as showing the position of peritoneal adhesions. The res alt of 
his observations has led him to believe that, as a rule, the small 
intestine is completely closed to the entrance of substances from 
the colon by the ileo-csecal valve. Under the influence of deep 
chloroform narcosis, however, this resistance is lessened, and fluids 
can be thrown into the small intestine. 

insufflation of air per rectum in the treatment of intestinal 
obstruction has been known since the time of Hippocrates. Gor- 
ham^ was the first to resort to this method of treatment in England. 
In comparing the effect of enemata to air insufflation, he says: 
''But the effect is totally different, when air is used; its freedom 
from fill irritating qualities, its elasticity and expansibility give it a 
decided preference over enemata." 

In my paper read at the last meeting of the International Med- 
ical Congress' I detailed the results of a number of experiments 
which I made on dogs, to determine to my own satisfaction the 
extent to which the ileo-caecal valve is permeable to fluids forced 

^ Transactions of the American Medical Association, 1878. 

' Observations on Intussusception as it oocnrs in Infants. Gay's Hospi- 
tal Reports, Vol. Ill, p. 830. 

'An Experimental Contribution to Intestinal Snrgery, with Special 
Reference to the Treatment of Intestinal Obstruction. 



12 INTESTINAL SURGERY. 

from below. In three cases where fluid was forced beyond the ileo- 
csecal valve, the post-mortem revealed in two of them, multiple 
lacerations of the peritoneal coat of the large intestine, while the 
third animal sickened immediately after the experiment was made, 
and died from the effects of the injuries inflicted, eight days later. 
These experiments combined with clinical experience leave no fur- 
ther doubt that, practically, the ileo-csecal valve is impermeable to 
fluids from below, and that for diagnostic and therapeutic purposes 
it is imsafe and unjustifiable to attempt to force fluids beyond the 
ileo-csecal valve. In two cases of ileo-colio invagination, in children 
less than two years of age, I succeeded in reducing the bowel by 
steady hydrostatic pressure, while the little patients were under the 
influence of an anaesthetic and held in the inverted position. In 
both instances the invagination had existed for two or three days. 
We should, a priori, expect that air and gases, on account of their 
lesser weight and greater elasticity than water, could be forced along 
the intestinal canal with less force, and for that reason alone, if for 
no other, should be preferred to water in cases where it appears 
desirable to distend the intestine below or above the ileo-csecal valve 
for diagnostic or therapeutic purposes. I shall, therefore, call your 
attention briefly to : 

3. Rectal Insufflation of Hydrogen Gas. 

Hydrogen gas is the lightest of all known gases. ^ I have demon- 
strated by my experiments that this gas is non-toxic, non-irritant 
when injected into the connective tissue and into the large serous 
cavities, and is rapidly removed by absorption. Distention of the 
entire gastro-intestinal canal with this gas by rectal insufflation, both 
in man and animals, was never followed by any immediate or remote 
ill effects. Accurate experiments to determine the force requisite to 
render the ileo-csecal valve incompetent by insufflation of air or gas, 
had previously not been made, and as it is exceedingly important to 
obtain accurate information on this subject, I made a number of in- 
flations in animals and man, estimating at the same time the pressure 
under which it was made, either with a mercury gauge or a man- 
ometer such as is used by gas-fitters and plumbers. The gas was 

Rectal Insnfflation of Hydrogen Gas an Infallible Test in the Diagnosis 
of Visceral Injnry of the Gastro-intestinal Canal in Penetrating Wounds of 
the Abdomen. Jonr. Amer. Med. Association^ June 23, SO, 1888. 



MEOTAL INSUFFLATION OF HYDROGEN QAS. 13 

collected in a four-gallon rubber balloon and the inflation made by 
compressing the balloon. The manometer, or mercury gauge was 
connected by means of rubber tubing with the rectal tube on one 
side and the rubber balloon on the other. Numerous experiments 
showed that when the gas was forced through the opening of a 
stop-cock, the lumen of which was about the size of a knitting- 
needle, compression equal to two hundred pounds (ninety kilogr.) 
would never register more than two and a half to three pounds of 
pressure to the square inch. In the living subject the escape of gas 
from the rectum was prevented by an assistant pressing the margins 
of the anus firmly against the rectal tube. A number of experiments 
made for the special purpose of measuring the resisting capacity of 
the ileo-C83cal valve to the entrance of gas from the caecum into the 
• ileum, showed that in a normal condition the valve in a healthy 
adult person is overcome by rectal inflation imder a pressure vary- 
ing from one and a half to two and one-fourth pounds (.6 to 1.2 
kilo.). This amount of pressure is not sufficient to injure any of 
the coats of a healthy intestine in any part of its course. As the 
result of numerous observations on man and animals, I can state that 
when the inflation is made slowly and continuously there is less 
danger of inflicting injury than when it is done rapidly or inter- 
ruptedly. When the patient is placed fully under the influence of 
an anaesthetic, the ileo-caecal valve yields to a lower pressure than 
when the abdominal muscles are in a state of rigidity, as this inter- 
feres with the requisite degree of distention of the caecum which is 
necessary to effect the separation of the margins of the valve. A 
rubber balloon holding from two to four gallons (ten to twenty litres) 
is the simplest, safest and most efficient instrument for making rectal 
inflnfliatioii both for diagnostic and curative purposes. 

Another series of experiments on dogs I made in order to deter- 
mine the degree of pressure which is required to force hydrogen gas 
from anus to mouth, the whole length of the gastro-intestinal canal. 
In all of the experiments the pressure fell rapidly after the ileo- 
caecal valve had been opened, but had again to be increased before 
the gas reached the stomach and escaped through the stomach tube. 
It usually required one-half to one pound more pressure to force gas 
through the entire length of the alimentary canal than when it had 
to be forced only through the ileo-caecal valve. Whenever it becomes 
necessary to conduct the hydrogen gas a considerable distance along 



14 INTESTINAL 8UROERY. 

the intestines, or through the entire alimentary canal, it is exceed- 
ingly important to proceed slowly with the inflation, as under slow 
gradual distention, half a pound (.2 kilogr.) of pressure to the 
square inch of surface will accomplish 'in time a great deal more 
without doing harm, than four times this amount of pressure if the 
force is applied quickly and only for a short time. In the dog, rectal 
insufflation of hydrogen gas made under a pressure of one-quarter of 
a pound, if made very slowly and uninterruptedly, the abdominal 
walls being completely relaxed by an aneesthetic, will not only over- 
come the resistance offered by the ileo-csBcal valve, but will prove 
sufficient to force the gas through the whole length of the alimentary 
canal. 

Experiments made on different portions of the gastro-intestinal 
canal when in a healthy condition and removed soon after death, 
proved that laceration did not take place under a pressure of less 
than eight pounds, and often it had to be increased to twelve 
pounds. It was found that the resisting power of the intestinal 
wall is nearly the same throughout the entire length of the canal, 
and in a normal condition yielded to a diastaltic force of from eight 
to twelve pounds of pressure. When rupture took place, it either 
occurred as a longitudinal laceration of the peritoneum on the 
convex surface of the bowel, or as multiple ruptures from within 
outwards, at the mesenteric attachment. The former result followed 
rapid, and the latter slow, inflation. The superiority of hydrogen 
gas inflation over injections of liquids in the mechanical treatment 
of intestinal obstruction is apparent Liquid injections cannot 
safely be forced beyond the ileo-csecal valve, and even in distending 
the entire colon by liquids a great deal more force is required than 
by insufflation with hydrogen gas. Insufflation of hydrogen gas is 
a valuable means of diagnosis in locating the seat of obstruction 
before tympanites has set in and therefore best adapted at a time 
when most needed — during the early stage of intestinal obstruction. 
If the colon dilates uniformly from the sigmoid flexure to the caecum, 
the obstruction must be sought for higher up in the intestinal canal.* 
The passage of gas through the ileo-csecal valve, rendered incompe- 
tent by the distention of the caecum, is always attended by a char- 
acteristic gurgling or blowing sound which is heard distinctly . by 
applying the ear or stethoscope over the ileo-csecal region. Not 
infrequently the sounds are so loud and distinct that they can be 



BEOTAL INSUFFLATION OF HYDROGEN GAS. 15 

heard at a distance of several feet. If the gas passes the ileo-csecal 
valve tmder a pressure not in excess of that required to overcome it 
. in a state of health, and, if after inflation a thorough examination of 
the ileo-csBcal region by inspection, palpation and percussion reveals 
nothing abnormal, the search for the obstruction is continued by 
inflating the small intestines slowly and making frequent examina- 
'tions of the abdomen to ascertain the height to which inflation has 
been made and to study the relative position of the different 
abdominal organs. Inflation is also a useful diagnostic resource in 
locating the obstruction during laparotomy for intestinal obstruction. 
The intestine below the seat of obstruction is always empty, col- 
lapsed and ansBmic as compared with the portion above the obstruc- 
tion. When the obstruction is located high up in the intestinal 
€anal and the tympanites is extensive, the empty portion of the 
small intestines has, by compression, become displaced and is often 
not readily found In such cases the distention of the bowel 
from below will indicate to the surgeon at once the location and 
length of the intestine below the seat of obstruction, and will 
enable him to search for the obstruction from below upwards. 
The manipulation of the healthy intact portion of the iatestinal 
canal in the search for the obstruction is by far a less hazardous 
procedure than the handling of the distended portion above the 
obstruction, rendered paretic, exceedingly vascular, and much soft- 
ened by the obstruction. In cases where we suspect the presence of 
a perforation, inflation with hydrogen gas will demonstrate not only 
its e:dstence, hut also its location. Invagination is rare above the 
ileo-csecal valve, and its location can be determined by inflation with 
hydrogen gas, and if resorted to early, it may prove the means of 
effecting reduction. In ileo-csecal and colonic invagination slow 
and persistent distention of the colon with hydrogen gas, with the 
patients completely imder the influence of chloroform, is the safest 
and most efficient means of effecting reduction and should always 
be resorted to whenever these conditions are recognized or even 
suspected. Bectal inflation as ordinarily practiced, by forcing air 
into the rectum with bellows, or a Davidson's syringe is not devoid 
of danger, as the force employed cannot be accurately regulated or 
estimated. 



16 INTESTINAL SURGERY. 

Bryant^ has collected twenty cases of inyagination treated by 
inflation, in three of which it produced rapture of the bowel below 
the invaginated portion, while in a fourth the child died in collapse 
shortly after the inflation. He does not look upon inflation as a 
proper and safe method of treatment in cases of acute invagination, 
and in the subacute form, it should only be resorted to within the 
first three days, because later on changes in the bowel are almost 
certain to have taken place, which would render this measure fruit- 
less, and probably dangerous. 

Knaggs^ reports the particulars of eight cases of invagination 
where forcible distention of the bowel by air or water was the cause 
of rupture or other serious injury to the bowel. These cases show 
that this method of treatment is attended by great risk in children 
less than one year of age, as six of the eight cases in which harm 
resulted were children less than eight months old. In Symond's 
case the abdomen was opened at once after rupture had taken place, 
and the rupture was sutured. The child, however, was too exhausted 
to rally from the operation, but at the necropsy the sutured bowel 
was able to resist successfully very considerable distention with water. 

Greig' reports five cases of invagination treated by insufflation 
of air, in four of which it proved successful. In some of the cases 
the insufflation had to be repeated. Insufflation of hydrogen gas 
from a rubber balloon is applicable in all cases of subacute and 
chronic invagination and during the early stage of acute invagina- 
tion, that is, before the passive hypersemia in the invaginated portion 
has rendered reduction by this method impossible. Should perfora- 
tion take place, the accident is at once recognized by a uniform 
distention of the abdomen, from the entrance of the hydrogen gas 
into the peritoneal cavity, as well as by a sudden diminution of 
pressure readily felt by the person who makes compression of the 
balloon. The entrance of hydrogen gas into the peritoneal cavity 
is in itself a harmless occurrence, as the gas is non-irritant and 

^ Harveian Leotnres on the Mode of Death from Aonte Intestinal Stran- 
gulation and Ohronio Intestinal Obstniotion. British Medical Journal, 
1884, Nov. 22. 

3 Resection of an Irrednolble and Gangrenons Intnssnsceptioni etc. 
The Lancet, 1887, Jnne 4, 11. 

'On Insufflation of Air as a Remedy in Intnssnsoeption. Edinburgh 
Medical Jonmal, October, 1864: 



TUB AGE OF COLON. 17 

perfectly aseptic. In such cases the insufflation must be followed at 
once by abdominal section and the necessary operative treatment of 
the invagination. 

4. Tubage of Colon. 

Even a few years ago it was as much a mooted point in refer- 
ence to how far fluids could be forced beyond the rectum, as the 
permeability of the ileo-caecal valve is at the present time. 

Von Trautvetter^ made numerous experiments on the cadaver 
to determine how far up into the bowel fluids could be injected 
per rectum. He injected either with an ordinary syringe or through 
a rectal tube. The fluid used was a solution of ferrocyanide of 
potassium, and after the injection chloride of iron was applied to 
different parts of the intestine to test for the presence of the fluid 
injected. Ordinary injections did not pass beyond the lower portion 
of the descending colon, while injections made through a long 
elastic tube reached the csecum. These experiments are only 
alluded to as an illustration of the ideas which were entertained in 
reference to the permeability of the colon to rectal injections, at the 
time O'Bierne flrst advocated the use of the elastic rectal tube in 
cases where it was deemed necessary to make high injections. Some 
authors suggest the introduction of a rectal tube, in the treatment of 
intestinal obstruction as first practiced by O'Bierne, and claim that 
with it they have reached the csecum; but Treves assures us that 
he has made numerous experiments on the cadaver and has never 
succeeded in passing it farther than the sigmoid flexure. * 

Cadge ^ states that even O'Bierne never claimed that the elastic 
rectal tube could be inserted farther than the sigmoid flexure. 
Cadge made numerous attempts on the cadaver and was never 
able to reach the descending colon. In cases where the tube was 
introduced to a depth of twenty to thirty inches, he found that the 
tip of the instrument remained in contact with the intestinal wall; 
and that this portion of the bowel is pushed forward when the end 
of the instrument can be felt through the abdominal wall at a 
higher point. In the administration of ordinary injections, the 

^ Wie weit kOnnen Flttssigkeiten in den Darmkanal per anum hinanf ges- 

pritzt werden? Dentsohes Archiy. f. Elinische Medicin, B. IV., p. 476. 

3 Case of Intestinal Obstmotion, with Remarks. British Medical 

Journal, 1888. 
2 



18 INTESTINAL 8UROERY. 

introduction of a rectal tube is superfluous, as in Hegar's knee-chest 
position the fluid from an ordinary fountain syringe will follow the 
course of the colon and advance as far as the csecum. 

Hegar' seldom found it necessary to elevate the funnel more 
than one foot, a column of water corresponding to this elevation 
being found sufficient to force the fluid as far as the ceecum and as 
he believes sometimes beyond the ileo-csBcal valve. The legitimate 
indications for tubage of the colon are the following: 

1. Detection and location of obstruction below the sigmoid 
flexure. 

2. To relieve gaseous distention of the colon. 

3. To administer high nutrient enemata in cases where it 
becomes necessary to maintain the strength of the patient by this 
method of alimentation. 

5. Manual Exploration by the Rectum. 

The introduction of the whole hand into the rectum as a means 
of diagnosis was devised and first practiced by Simon. This method 
of exploration is applicable only in the adult. Simon and his num- 
erous followers claim that the hand can be introduced sufficiently 
far to enable the surgeon to palpate most of the abdominal organs. 
Nussbaum assures us that he has felt more than once the tip of 
the sternum with the hand employed in the manual exploration by 
the rectum. 

WagstafP^ in his paper "On Intestinal Obstruction" places 
great streiSs on the importance of manual exploration by the rectum 
as a diagnostic measure, as appears from one of his conclusions: 
" That the causes of obstruction can generally be determined by the 
history of present and past illnesses and by thorough external and 
internal examination, and that manual exploration by the recttmi is 
certainly the greatest advance in our means of diagnosis." The 
glowing accounts of the value of this method of exploration were 
soon followed by accounts of disastrous consequences such as rupture 
of the gut and permanent loss of function of the sphincter muscles. 
Manual exploration by the rectum should only be undertaken by 
surgeons with small slender hands, and the examination should 

^ Ueber Einftlhring von Flftssigkeiten in Harnblase nnd Darm. Deutsche 
Elinik, No. 8, 1878. 

> St. Thomas' Hospital Reports. New Series, Vol. IV., 1873. 



MANUAL EXPLORATION.— TAXIS AND MASSAGE. 19 

always be made with the patient fully under the influence of an 
ansBsthetic, and always with the utmost care and gentleness. This 
method of examination will enable the surgeon to ascertain the 
location and nature of obstructions below the sigmoid flexure, the 
existence of volvolus at the sigmoid flexure, and to determine the 
presence of pathological conditions in the pelvis which might have 
caused the obstruction. As a therapeutic measure this procedure 
can be employed in the removal of foreign bodies or an enterolith 
within reach of the hand, and in the reduction of some cases of 
intussusception where the invaginated portion of the bowel has 
passed beyond the sigmoid flexure. 

6. Taxis and Massage. 

Hutchinson decidedly opposes early operative interference in 
cases of intestinal obstruction, and expects little from it in those 
which have been some time in existence. He advocates what he 
terms abdominal taxcis, under an ansBsthetic. By abdominal taxis 
he means a thorough kneading of the abdomen, with inversion of 
the patient, shaking him, tossing him in a blanket, and a variety 
of rough performances, the object being to dislodge the bowel, or 
untwist the volvolus. At the same time he advises large enemata 
and cathartics. If these means do not lead to the desired result, he 
waits and keeps the patient on a low diet, and administers opium 
or belladonna internally, and subsequently repeats the abdominal 
taxis. He reports a number of cases successfully treated by this 
method. It is doubtful if any surgeon at the present time could 
be found who would be willing to subject his patients to such primi- 
tive treatment as advised by Hutchinson. In most forms of 
intestinal obstruction such treatment is not only unscientific and 
useless, but attended by great risk to life, as the violent movements 
would not only aggravate the mechanical difficulties which have 
caused the obstruction, but might produce rupture of the distended 
intestine, and could not fail in causing exacerbation of the vascular 
disturbances. Taxis and massage, scientifically practiced, have a 
limited range of application in the treatment of intestinal obstruc- 
tion, as they are applicable only to cases where the obstruction is 
due to the presence of a foreign body, a f secal accumulation or an 
enterolith, and should only be resorted to before these causes have 
developed inflammatory changes at the seat of impaction. A 



20 INTESTINAL SURGERY. 

number of such cases are on record where this treatment proved 
saooessfol. 

StreubeP succeeded, in a boy eleven years of age suffering from 
intestinal obstruction due to the impaction of a mass of cherry, stones 
above the ileo-csecal valve, in removing the cause of obstruction by 
submitting the swelling to gentle massage frequently repeated. 

Marrotte' gives an account of a case of acute intestinal obstruc- 
tion which had lasted for some days when fsecal vomiting set in, and 
in which the usual internal treatment with opiates and chloroform 
afforded no relief, which was promptly cured by palpation of the 
abdomen made for the purpose of locating the seat of obstruction. 
The patient experienced a sensation at the time as though the 
obstruction had given way, and soon afterwards had a number of 
evacuations in which a gall-stone the size of a walnut was found. 
The author refers to five cases of intestinal obstruction caused by 
the presence of gall-stones, collected by Fauconneau-Dufresne. One 
of these cases came under the observation of Mavo. In this case 
the gall-stone was also dislodged by palpation, followed by cessation 
of the symptoms of obstruction and recovery of the patient. The 
remaining four patients died. In cases of fsecal accumulation in 
any portion of the large intestine from the caecum to the sigmoid 
flexure, unattended by inflammation and giving rise to symptoms of 
obstruction, and not amenable to irrigation of the colon, massage 
and taxis should be made while the patient is imder the influence 
of an ansBsthetic, so as to enable the operator to break up the mass 
and to force it onwards in the interior of the bowel to a point where 
peristaltic action is more active. 

7. Puncture of Intestine. 

Advanced cases of intestinal obstruction are always attended 
by great distention of the bowel on the proximal side of the 
obstruction, a condition which causes increased intra-abdominal 
pressure. The tympanitic distention of the abdomen may be so 
great as to destroy life by the suspension of important functions 
trom mechanical pressure. The diaphragm is pushed upwards so 

^Ueber Erkennung nnd Behandlnng der inneren Darmeinklemmimg. 
Prager Vierteljahrsschrift. B. XV, 1868. 

^ Einklemmnng eines Gallen-steines im Darme. Heilnng Dnrch Palpa- 
tion dee BanoheB. Schmidt's Jahrbticher. B. 93, p. 189. 



PUNCTURE OF INTESTINE. 21 

far that death may ensue from asphyxia, or the oirculation is so far 
impeded by compression of the heart as to cause death from syn- 
cope. Great distention of the intestines on the proximal side of the 
obstruction also aggravates the mechanical difficulties which haVe 
caused the obstruction, as the distended bowel under such circum- 
stances forms numerous flexions which interfere with the free pas- 
sage of its contents as far as the obstruction; at the same time the 
distended coils may render the bowel less permeable at the seat of 
obstruction by compression. The anxiety with which surgeons look 
upon extensive tympanites following the course of intestinal ob- 
struction is universal, hence it is only natural that for a long time 
it has been customary to make attempts in affording relief, by 
puncturing the distended bowel through the abdominal wall. A 
small trocar was usually employed for this purpose, but since the 
introduction of the hypodermic needle and the aspirator, a hollow 
needle of one of these instruments has been used. Gases have been 
reported where repeated pimctures not only afforded relief, but 
Anally led to a permanent cure. In some instances the cannula of 
a trocar, after puncture, was allowed to remain until a f secal fistula 
had been established An intestine distended to the extent of 
giving rise to distressing and dangerous intra-abdominal pressure 
is always in a paretic condition, imable to expel its contents, and 
whatever escapes through a needle or the cannula of a trocar is ex- 
pelled by the contraction of the abdominis wall. This applies not 
only to the liquid, but also to the gaseous contents. I have repeat- 
edly satisfied myself during operations on the living subject and in 
animals where the obstruction was caused artificially, that mere 
puncture empties only a limited space not more than six to eight 
inches on each side of the puncture. If aspiration is practiced at 
the same time the effect is doubled; further evacuation is arrested 
by flexions among the distended coils and valvular closure of the 
collapsed segment, at the terminus of the evacuated area. 

The recorded results of puncture of the intestine represent 
largely only the successful cases, while the numerous failures seldom 
find their way into literature. Puncture of a healthy intestine with 
a needle of moderate size is never followed by extravasation, as the 
irritation incident to the puncture always produces muscular con- 
tractions which start from the point of puncture and at once obliterate 
the canal made by the needle. Puncture of a paretic intestine is 



22 INTESTINAL SURGERY. 

always attended by great risk of extravasation, as the muscular coat 
has lost its tonicity, and the track of the needle or trocar is slower in 
closing, or remains permanently patent Numerous cases have been 
reported where a needle puncture gave rise to escape of fsBcal con- 
tents into the peritoneal cavity. As the removal of the tympanites 
is the means, only in exceptional cases, of removing the cause of 
obstruction, and as the puncture of a distended paretic intestine is 
never devoid of risk of causing fsBcal extravasation, the legitimate 
indications for puncture of the intestine are extremely limited. If 
employed at all, this procedure is only applicable to cases where no 
mechanical obstruction is present, and where the rapid distention of 
the abdomen, in itself, constitutes an imminent source of danger. 
Puncture should never be resorted to with a view of removing liquid 
contents; its use should be limited to the evacuation of gases. For 
this purpose one of the smaller needles of an aspirator should be 
used. The point of the needle should be sharp so that it can be 
readily passed through the intestinal' waU. The needle should 
always be thoroughly disinfected by heating it in the flame of an 
alcohol lamp. The point of puncture should always be made at the 
most prominent point and the instrument pushed boldly forwards 
until all resistance is overcome. As soon as gas escapes, the intra- 
abdominal pressure should be increased by gentle and uniform com- 
pression of the abdominal walls. As soon as gas ceases to escape, 
aspiration should be made and continued as long as anything can be 
evacuated, and until the needle is withdrawn, but not at the time it 
is withdrawn. Should it be possible to ascertain the location and 
direction of the part of the intestine to be pimctured, it is advisable 
to make the puncture obliquely in the long axis of the bowel so as 
to guard more effectually against extravasation. 

8. Uniform and Uninterrupted Compression of the 

Abdomen. 

In all cases of intestinal obstruction, but more particularly 
in the chronic form, uniform Arm support of the abdomen affords 
relief to the patient and is one of the best means in preventing rapid 
distention of the intestine above the seat of obstruction. Fixation 
and equable compression are resorted to in other parts of the body 
as the best known means in controlling muscular spasm. It is 



ENTEROTOMY. 23 

only reasonable to expect that the same measures should prove 
useful in retarding, if not in preventing, the violent peristalsis in 
cases of intestinal obstruction, and especially in preventing over- 
distention of the intestine. Equable compression of the abdomen 
should be made before great distention has occurred. Uniform 
compression of the abdomen is best secured by padding the iliac 
regions with absorbent cotton and then enveloping the body from 
the pubes to the tip of the stemimi with broad strips of adhesive 
plaster which should be made to overlap each other. 

9. Enterotomy. 

In 1840 N^laton made the first enterotomy for intestinal ob- 
struction. He conceived the propriety of such an operation from 
Mannoury, who in his thesis in 1819 first called attention to the 
formation of a preternatural anus in cases of intestinal obstruction. 
N^laton taught that by opening the abdomen in the right inguinal 
region and seizing the first distended coil that might present, the 
surgeon almost without exception would establish the artificial 
opening in the bowel near the iloo-caecal region. The mortality of 
enterotomy has been nearly as great as that of laparotomy with 
removal of the cause of obstruction, and on this score alone its 
further application should bo limited to exceptional cases, cases 
where a radical operation is inadmissible on account of the nature 
of the obstruction or the enfeebled condition of the patient. No 
one who under the pressure of circumstances has been forced to 
establish a preternatural anus, has left his patient with a feeling of 
satisfaction, as he must have been sadly impressed with the fact, 
that, at best, he has only succeeded in relieving the urgent symptoms 
of the obstruction, while he has failed in removing the cause, and 
consequently also in restoring the continuity of the intestinal canal. 

A patient with an artificial anus is indeed an object of pity, as 
experience has suf&ciently demonstrated how difficult it is in many 
instances to close the abnormal opening, even after the cause of 
obstruction is subsequently removed or corrected spontaneously, 
without exposing him a second time to the risk of life incident to 
another abdominal section. If the causes which have led to the 

4 

obstruction are of a permanent character, all attempts at closing 
the fistulous opening will, of course, prove worse than useless, and 
the patient is condemned to suffer from this loathsome condition the 



24 INTESTINAL SURGERY. 

balance of his lifetime, without a hope of tQtimate relief. I believe 
I can safely make the statement without fear of contradiction, that 
most of these unfortunate patients would prefer deAth itself to such 
a life of misery. In performing enterotomy the surgeon has no 
means of selecting the most desirable place in the intestine for 
making the opening. The only rule laid down by the text-books, 
and the only one applicable in such a case, is to secure in the wound 
and open, the first distended loop which presents itself. It not 
infrequently happens that the opening is made far above the seat of 
the obstruction, an occurrence which is attended by two inmiediate 
sources of danger: 1. Physiological exclusion of a large portion of 
the intestinal canal, which in the event the patient recovers from the 
operation and the cause of obstruction remains permanent, is followed 
by marasmus, which in itself may prove the cause of a subsequent 
fatal issue. 2. The portion of intestine between the artificial 
opening and the seat of obstruction being the part which has 
suffered the most from the effects of the obstruction remains 
distended and continues to exert the same deleterious effect as 
before the operation. Many able surgeons, even at the present time, 
prefer enterotomy to laparotomy and mention as principal arguments 
in its favor, that it requires less time in its execution and can there- 
fore be resorted to in patients where a radical operation for this 
reason alone would be inadmissible; again, it is claimed that the 
intestine above the seat of obstruction, is not in a co^dition for direct 
operative measures which have in view the restoration of the 
continuity of the intestinal canal. It must, however, not be for- 
gotten that in quite a number of cases the second objection to 
a radical operation does not apply, as the removal of the cause of 
obstruction is accomplished without interrupting the continuity 
of the intestinal canal and, as I shall show further on, in the 
remaining cases, where the cause of obstruction cannot be removed, 
the continuity of the intestinal canal can be restored by making an 
intestinal anastomosis, which can be done without greater immediate 
or remote risk to li^p than attends enterotomy. As the technique of 
radical operations for intestinal obstruction will be improved, the 
indications for enterotomy will diminish. As long as the patient's 
strength warrants a radical operation, enterotomy should never be 
performed. In patients so enfeebled that the administration of an 
anaesthetic would be attended by imminent danger to life, an enter- 



COLOTOMY. 25 

otomy can be made without anaesthesia and under such circumscanoes 
will occasionally save a life which otherwise would be lost. 

The operation is performed by making an incision not more 
than two and a half inches in length in the right iliac region, above 
and parallel to the outer half of Poupart's ligament. The tissues 
should be recognized as they are divided, without, however, using 
a director until the subperitoneal fat is reached. This layer is 
divided with a blunt instrument, and pushed aside when the perito- 
neum comes into view. This membrane is seized with a toothed 
forceps or lifted up with a sharp hook, and carefully incised and 
divided upon a grooved director. The peritoneum is united all 
around with the skin by a continued suture. Almost without excep- 
tion, a distended knuckle of intestine, readily recognized by its size 
and color, presents itself in the wound, and is united with the 
external wound; and after it is securely fastened, an incision large 
enough to admit the tip of the index finger is made in the bowel, 
and the margins of the visceral wound sutured separately to the 
external wound by a single suture on each side, so as to secure 
patency of the opening. On incising the bowel the surgeon is often 
disappointed at the small amount of gas and fluid which escapes, 
' and it is frequently several hours before a free escape takes place 
and the abdominal distention begins to diminish. The escape of 
intestinal contents is expedited by the introduction of a large-sized 
N^laton's catheter. 

ID. Colotomy. 

Colotomy will always retain its place in operative surgery 
as a palliative and life-prolonging procedure in the treatment of 
carcinomatous stenosis of the lower portion of the colon, and in 
cases of inoperable carcinoma of the rectum. The recent advances 
in abdominal surgery have rendered the old-fashioned lumbar or 
extra-peritoneal operation obsolete. The modern operation is made 
by opening the peritoneal cavity in the right or left groin, according 
to the indications which are to be fulfilled, and one of its principal 
objects is to terminate the intestinal canal at the artificial anus so 
as to provide absolute physiological rest for the portion of bowel 
below it. The obvious disadvantages of colotomy, as usually per- 
formed, are cited by Maydl^ as the reasons which induced him 

^ Centralblatt f . Ohirnrgie, No. 24, 1888. 



26 INTESTINAL SURGERY. 

to devise the* operation which he has described. He opens the 
peritoneal cavity by Littr^'s incision, and draws a loop of intestine 
forward until its mesenteric attachment is on a level with the ex- 
ternal incision. Through a slit in the mesentery close to the gut 
is inserted a hard rubber cylinder wrapped in iodoform gauze. A 
goose-quill wUl answer the same purpose. This device holds the 
intestine in the wound and prevents its return into the abdominal 
cavity. By means of a row of sutures placed on each side of the 
prolapsed gut, including the serous and muscular coats, the two 
limbs of the flexure, in so far as they lie in the abdominal wound, 
are stitched together beneath the rubber support If the intestine is 
to be opened immediately, it is stitched to the parietal peritoneum 
of the abdominal incision and the latter protected by iodoform coUo- 
dium. If the bowel is to be incised later, the latter is not stitched 
to the peritoneum, but surrounded by iodoform gauze packed in 
beneath the rubber support, the incision of the bowel being made 
four or six days later, after the peritoneal cavity has been excluded 
by Arm adhesions. If the artificial anus is made for lesions incap- 
able of a subsequent removal, a transverse opening, including one- 
third of the periphery of the bowel, is made by the thermocautery, 
drainage tubes are inserted into the two lumina, and the intestine is 
carefully washed out. If the progress of the case is satisfactory the 
bowel is cut through completely in two or three weeks, the rubber 
support serving a useful purpose as a guide in making this incision. 
A few sutures will serve to secure the cut end to the skin. If the 
direction of the muscular fibres has been respected in making the 
abdominal incision, the patient is provided with such an eficient 
sphincter that a large drainage tube is requu'ed to keep the opening 
patulous. Should the artificial anus only be a temporary one, the 
incision in the intestine is' made in a longitudinal direction. When 
it has become desirable to close the artificial opening, the rubber 
support is removed, after which the bowel retracts and the opening 
often closes without any further treatment. If the adhesions are 
too firm for this they are removed and the bowel is sutured and 
returned into the peritoneal cavity. Lauenstein accomplishes the 
same object by suturing first the peritoneum to the skin, thus lining 
the external incision by peritoneum, then drawing out a loop of 
intestine and closing the parietal wound by sutures passing through 
the meso-colon of the prolapsed portion of intestine which is thus 



ABDOMINAL SECTION. 27 

fastened in the abdominal incision; next the serosa of .each limb 
of the prolapsed loop is stitched through its entire circumference to 
the parietal peritoneum. 

An interesting discussion has arisen lately in Germany in regard 
to a step in the operation of colotomy which was described by Knie.* 
So far the operation has been only done on dogs. It consists in 
opening the abdomen transversely in the region of the transverse 
colon, stitching the peritonemn to the edges of the wotmd, drawing 
out the colon, making a slit in the meso-colon near the gut with a 
blunt instrument and closing the abdominal wound with two or 
three sutures, which are passed through the slit in the meso-colon. 
The object of this is to secure a loop of the colon outside of the 
abdominal cavity. This loop is to be carefully stitched at each side 
to the edge of the (now) two abdominal openings, after which it is 
to be opened by an incision, or if the symptoms are not urgent, the 
incision is postponed for a few days until the peritoneal cavity has 
been shut o£F by adhesions. As a general thing Lauenstein's opera-* 
tion will be foimd simplest, and should receive the preference in 
ordinary cases. The modem operation of colotomy is indicated in 
cases of congenital atresia of the rectum when the bowel cannot be 
readily reached from below; also in cases of carcinoma of the sig- 
moid flexure and the rectum not amenable to a radical operation. 
Finally, the operation might become necessary in irreducible colonic 
invagination in which, for anatomical reasons, resection or anasto- 
mosis cannot be done. 

II. 'Abdominal Section. 

A radical operation in the treatment of intestinal obstruction 
embraces the fulfillment of two principal indications: 1. The re- 
moval or rendering harmless of the cause of obstruction. 2. The 
inmiediate restoration of the continuity of the intestinal canal. To 
meet the first indication the cause of obstruction must be foimd, its 
nature determined, and whenever advisable or practicable, removed, 
a step in the opiBration which may be very easy, or may demand a 
most formidable and serious undertaking, more especially in 
cases where the pathological conditions which have given rise to 
the obstruction are of such a nature as to constitute in themselves 
an imminent or remote source of danger, as, for instance, malignant 

1 Gentralblatt f . Ghirnrgie, May 5, 1888. 



28 INTESTINAL SURGERY. 

disease or gan^ene of the bowel from constriction. Abdominal 
section in the treatment of intestinal obstruction has so far been 
attended by a fearful mortality, owing tp the fact that most opera- 
tions were performed when the patients were in collapse, or when 
the parts involved in the obstruction had imdergone advanced and 
often irreparable pathological changes. 

Ashhurst^ tabulated fifty- seven cases of laparotomy for acute 
intestinal obstruction from other causes than intussusception, from 
which it will be seen that only eighteen terminated favorably, so 
that at that time the mortality of laparotomy in cases of intestinal 
obstruction other than intussusception, was over 68 per cent. Most 
of these operations were performed without antiseptic precautions. 

Schramm has collected one hundred and ninety cases of intesti- 
nal strangulation treated by laparotomy, including three cases 
observed by himself in the practice of Mikulicz. He alludes to the 
difficulties encountered in the diagnosis of these cases and pleads in 
favor of early operative interference. Of this number 64.2 percent, 
died, the mortality before the antiseptic treatment of wounds being 
73 per cent., and since that time 58 per ceni The cause of strangu- 
lation and mortality attending each kind may be gleaned from the 
following table: 



27 times, 


Inyagination, 




- 


8 


cured, 


19 died. 


49. " 


Bands, or intestinal diyerticnla, - 


13 


(( 


36 


(( 


16 " 


Adhesions, 




- 


7 


({ 


9 


{( 


11 " 


Reduction en moAsey 


- 


• 


6 


4( 


5 


({ 


10 « 


Torsions, 




- 




(( 


9 


u 


12 « 


Knotting of bowel, 


m 


- 




(( 


8 


(( 


12 " 


Internal strangulation, 




- 




(( 


8 


(( 


7 " 


Foreign bodies, 


- 


• 




(( 


3 


u 


38 " 


Neoplasms, 




- 


16 


(( 


22 


(( 


8 " 


Unknown oanses, - 


- 


- 


5 


(( 


3 


(( 



Curtis^ has collected the cases of intestinal obstruction treated 
by abdominal section since the year 1873, consequently since the 
antiseptic treatment of wounds was introduced. Table I. shows a 
total of 328 cases with 102 recoveries and 226 deaths, the percent- 
age of mortality being 68.9 — a higher percentage than that of 

^ Amer. Jour. Med. Sciences, July, 1874. 

^The Results of Laparotomy in Acute Intestinal Obstruction. Annals 
of Surgery, May, 1888. 



ABDOMINAL SECTION. 29 

Schramm's collection. Table III. shows that in 101 cases, the 
failure of the operation was due directly to the imfavorable condi- 
tion of the patient, who was in a dying condition in 8 cases. In 
the majority of the cases with complications, 41 in all, the fatal 
result was also really due to the condition of the patient, for the 
existence of peritonitis or gangrene of the bowel at the time of 
operation shows that there had been too much delay in resorting to 
operative measures, and most of these cases died a few hours after 
operation. In 28 cases the cause of obstruction was not found, 
or could not be removed, and in 11 the reports are so defective 
that the cause of death cannot be ascertained from them. Of the 
remaining 45 fatal cases, 13 died of shock, in 3 cases the unusual 
length of the operation was probably the direct caude of death, and 
in 17 cases, sepsis, probably due to the operation, was the cause of 
death. In 12 cases the cause could not be definitely learned, but as 
death followed in most of them within 24 hours after the operation, 
it was probably shock and exhaustion. In 247 cases where the cause 
of obstruction was removed, the Aortality was only 62.7 per cent.; 
while in 74 in which it was not done, the mortality was 86.4 per 
cent. In 41 cases where the obstruction consisted of invagination, 
volvolus, adhesions, bands and internal incarceration, in which the 
obstruction was not removed, not a single one recovered, although 
in 16 an artificial anus was made. The greatest mortality attended 
cases where from any cause suturing of the bowel was made, attain- 
ing the extreme point of 86.6 per cent, in 45 cases. The necessity 
for a short operation is well shown by the cases collected by Curtis, 
which give a mortality of 57 per cent, in 190 cases in which the 
operative interference was limited to relieving the obstruction, 
without wounding the bowel, while it rose to 73 per cent, in 15 cases 
in which it became necessary to establish an artificial anus after the 
obstruction had been removed, and to 83 per cent, in 48 cases in 
which the gut had to be sutured. In all these cases the true danger 
lay in the length of the operation, for death resulted from the 
immediate effects of the operation in most of the cases. 

These statistics show the value and importance of early opera- 
tion, as sometimes delay of only a few hours will bring complications 
which not only necessitate more time in their removal, but will at the 
same time necessitate a resection or an anastomosis, which, had the 
operation been done at an earlier date, might have been obviated. 



30 INTESTINAL 8UROERY. 

The older text-books on surgery always cautioned the practitioner to 
postpone the operative treatment of a strangulated hernia for a 
certain length of time which was often consumed in yain attempts 
at reduction, consequently the old statistics of herniotomy present a 
high mortality when contrasted with recent operations. This striking 
contrast was brought about not solely by an improved technique, or 
by the introduction of antiseptic surgery, but it is largely owing to 
the modem teaching that it is dangerous to delay an operation, if 
the strangulation is not relieved by gentle taxis persisted in not for 
hours and days, but only for fifteen minutes, and at the utmost for 
half an hour. Modem surgery recognizes the safety of an early 
operation for strangulated hernia, and the results which have been 
obtained have demonstrated the wisdom of the change in practice. 
Yain and prolonged attempts at reduction of a strangulated hernia 
aggravate the causes which have produced the strangulation, and 
hasten the pathological changes in the strangulated intestinal loop 
which arise from the strangulation. If delay is dangerous in a case 
of strangulated hernia, what caif we expect of a laparotomy for 
intestinal obstruction when postponed until the patient has been 
exhausted, or the local conditions necessitate complicated operative 
measures f In strangulated hernia the destructive changes in the 
constricted intestinal loop, affect by continuity and contiguity prima- 
rily only a limited peritioneal surface, while in intestinal obstruction 
the seat of obstruction is in direct communication with the entire 
peritoneal cavity, which becomes the seat of a rapidly fatal, septic 
inflammation if gangrene or perforation have caused the inflam- 
mation. A recent intestinal obstruction due to a change of 
visceral relations, such as flexion, volvolus, and invagination, if 
subjected to operative treatment before conjocutive pathological 
changes have occurred, would offer but little difficulty to mechanical 
correction of the displacement, and as in such cases the intestinal 
tube would be in a healthy intact condition, the danger of the. 
operation would not be greater than that of an ordinary ovariotomy. 
I think enough has been said in favor of early operation in all 
cases where the signs and symptoms indicate the existence of an 
obstruction which does not yield to milder measures. Gases of 
intestinal obstruction are surgical lesions in every sense of the word, 
and should be treated from the very beginning upon common sense 
gnrgical principles. To temporize with such cases by the adminis- 



ABDOMINAL SECTION. 81 

traiSon of uncertain drags must be looked upon as evidence of 
ignorance or a relic of barbarism. The treatment of a case of 
intestinal obstruction upon the expectant plan until gangrene or 
perforation has taken place, which, if submitted in time to proper 
surgical treatment, might have been cured by one stroke of the 
scissors should be considered as gross negligence for which the 
modem aggressive physician and surgeon can offer no justification 
or apology. The future progress of abdominal surgery will conquer 
the dificulties which now surrotmd the diagnosis and treatment of 
intestinal obstruction. Experimental research and more careful and 
accurate clinical observation will solve the difficult problems which 
now surrotmd us in this as yet unexplored field of surgical labor. 
Laparotomy for intestinal obstruction should not be undertaken 
by every tyro in surgery. He who tmdertakes it should be master 
of the situation, familiar with every detail of the technique of the 
different operative procedures and fully conversant with the manifold 
complications with which he may be confronted. Every possible 
contingency must be fully considered before the abdomen is opened, 
as this is an operation where unnecessary hesitation and loss of time 
weigh heavily in the balance on the side of failure. Like other 
abdominal operations laparotomy cannot be mastered in the lecture 
room or even under the tuition of experienced surgeons. Those who 
expect to perf oi:m this operation must, in the first place, have a per- 
fect knowledge of the structure and relations of all the abdominal 
organs in conditions of health and disease, and must acquire the 
necessary operative skill on the cadaver, and then, what is still more 
important, should make the more important operations on the living 
animal. It is not necessary or even desirable that every physician 
should become a laparotomist, but in every section of the country, 
distant from the medical centers, some one should interest himself 
in this branch of surgery and prepare himself to meet such 
emergencies. Unlike a patient suffering from an ovarian tumor, 
a patient affected with acute intestinal obstruction cannot be trans- 
ported great distances, and as loss of time leads to disastrous 
consequences, it is not always possible to secure the services of a 
surgeon versed in abdominal surgery, from a distance. For such 
contingencies I should recommend that at least one member of every 
county or district medical society should familiarize himself suffi- 
ciently with the details of intestinal surgery so that patients in his 



82 INTESTINAL SURGERY. 

neighborhood may reap the advantages of modern aggressive surgery 
at the proper time and at their own homes. 

a. Preparations for the Operation. 

The most careful and perfect preparations should be made for 
the operation. The presence of at least three reliable and intelligent 
assistants is an absolute necessity. As an exventration may become 
necessary and exposure of the intestines to a cool atmosphere is pro- 
ductive of shock, an equable temperature of from 80° to 85° Fahr. 
should be maintained in the operating room from the beginning to 
the end of the operation. Opinions among operators may still difiPer 
as to the wisdom or even propriety of using antiseptics in a healthy 
peritoneal cavity, but no one at the present day would have the 
courage to oppose the use of strictest antiseptic precautions in secur- 
ing an aseptic condition for everything that will come in contact with 
the wound or the peritoneal surfaces. The operating room must be 
cleared of everything, except the bare walls and windows, and the 
whole of its interior surface washed with a strong solution of subli- 
mate or carbolic acid. The table and stands are disinfected in a simi- 
lar manner. The blankets if not perfectly aseptic can be covered with 
clean linen sheets. Heat is the most reliable, safest and cheapest 
sterilizer, and can be used for the disinfection of towels, napkins, 
instruments and wash-basins. The operator mvst satisfy himself 
of the aseptic nature of everything which is used inside of the 
peritoneal cavity. The abdomen of the patient and the operator's 
and assistants' hands are rendered aseptic by washing with potash 
soap and warm water, and afterwards with a 1-1000 solution of 
corrosive sublimate. The water used for solutions and sponges is 
sterilized by boiling. For the protection of prolapsed intestine com- 
presses of aseptic gauze or napkins are better than sponges, and the 
temperature of the parts is maintained, not by pouring warm water 
on the compresses, but by removing them and applying new ones 
wrung out of warm water. 

The danger of using corrosive sublimate solution within the 
peritoneal cavity is well shown by Klimmell's experience.^ He 
made nine laparotomies, using for the sponges a 1-5000 solution 
of sublimate, and all the patients recovered without an unpleasant 

^Ueber Snblimat-intoxioation bei Lkparatomien. Centrallblatt f. Gbi« 
mrgie, No. 22, 1886. 



PREPARATIONS FOR THE OPERATION, 33 

Etymptom. Then he met with two cases of sublimate intoxication 
in succession, having used a solution of the same strength. One 
of the patients died on the fourth day and the post-mortem 
revealed intestinal lesions characteristic of acute mercurial poison- 
ing. The other patient recovered after a lingering illness during 
which the symptoms of mercurial intoxication were well marked. 
He cautions against the use of sublimate in debilitated, anaemic 
individuals, or in patients sufiPering from renal disease. In cases 
where the peritoneal cavity is in a healthy aseptic condition the 
use of any of the stronger antiseptics is contra-indicated. For 
the cases where septic peritonitis, suppuration, gangrene or perfora- 
tion exists, a two per cent, solution of boracic acid, or a saturated 
solution of salicylic acid (0.3 per cent.) should be kept in readiness 
for flushing the abdominal cavity. Bands of rubber or fine rubber 
tubing should always be on hand, as well as a good assortment of 
aseptic silk, well prepared catgut, glass drains, decalcified perfor- 
ated bone plates, ^and a good assortment of needles and forceps. 
Stimulants and means to make auto-transfusion must never be 
absent,, as prompt interference when symptoms of shock make their 
appearance, may prove the means of restoring the force of the 
circulation until reaction can be established by other measures. 

Weir' suggests the administration of a hypodermic injection 
of 1-100 to 1-80 of a grain of atropia and a large rectal enema of 
brandy before the anaesthesia, for the purpose of increasing the force 
of the heart's action. During the operation the peripheral circula- 
tion is best kept up by placing the patient on a rubber bed, filled 
with hot water, and in the absence of such a contrivance by applying 
to the extremities rubber bags or bottles filled with hot water. 

b. AnsBsthesia. 

A number of American surgeons have recently expressed a 
preference for chloroform to ether as an anaesthetic in abdominal 
operations, as it is less likely to produce vomiting before, during, 
and after the operation. Another serious objection to the use of 
ether, especially in persons advanced in years, is the frequency with 
which bronchitis is produced when this anaesthetic is exclusively 
used. The use of chloroform, however, is also not free from objec- 

^ On the Teohniqae of the Operations for the Belief of Intestinal Obstruo- 

tion. The Medical Beoord, Feb. 2, 1888. 
8 



84 INTESTINAL SURGERY. 

tion. The depressing effect of this anaesthetic on the action of the 

heart is well known, and as the force of the circulation is almost 

without exception seriously impaired in these cases, its prolonged use 

might result in dangerous consequences. The best course to pursue 

is to follow the use of chloroform by ether. The retching and 

bronchorrhcea are prevented by placing the patient first under the 

influence of chloroform and the deleterious effects of the prolonged 

use of this agent are avoided by keeping up the narcosis during the 

operation with ether. From the time the first incision is made until 

the abdominal wound is closed, the patient must be kept profoimdly 

under the influence of the anaesthetic, inasmuch as any interruption 

will cause an unnecessary delay in the operation and may result 

in complications which are not easily remedied. Irrigation of the 

stomach should always precede the administration of the anaesthetic, 

as evacuation of the stomach by preventing vomiting, will guard 

against the entrance of foreign material into the larynx and trachea, 

which might produce asphyxia during the narcosis, or pneumonia 

later. 

c. Incision. 

Differences of opinion still exist among surgeons as to the 
size and location of the abdominal incision. The advocates of 
exventration argue in favor of a long incision through the median 
line. Ktimmell advises that it should be carried from the ensiform 
cartilage to the pubis for the purpose of affording free access to 
every part of the abdominal cavity. On the other hand, a number 
of distinguished surgeons, among them Madelung, Czemy, and 
Obalinski, are in favor of a small incision. Polaillon' is strongly 
in favor of a lateral incision in opening the abdomen for the relief 
of intestinal obstruction in all cases where the seat of obstruction 
can be reached more directly by such incision. He also claims that 
in cases where extensive meteorismus is present, the distended intes- 
tines are more prone to prolapse and are more difficult to return 
through a median than a lateral incision. He thinks that this is due 
to a lesser degree of intra-abdominal pressure in the iliac than in the 
middle abdominal region, and that in the former the muscular fibres 
keep the margins of the wound in contact. He opens the abdomen 
in the ilio-inguinal region by an incision parallel with the fibres of the 
external oblique muscle, and rf occasion requires, this can be made 

^ Qazette M^dicale de Paris. April 25, 1885. 



ABDOMINAL INCISION. 



85 



snffidently large to permit exploration of the abdomen by the intro- 
duction of the whole hand. In lateral laparotomy exploration is 
less easy, but this operation is indicated in all cases of localized 
obstruction, circumscribed adhesion, or when any symptoms render 
it probable that the obstruction exists in one or the other side of 
the abdominal cavity. In case a distinct swelling, the probable 
cause of the obstruction, can be detected in the ileo-csecal region, 
the ascending or descending colon, as will probably be the case in 
ileo-csBcal and colic invagination, volvolus of the sigmoid flexure, 
tumors of the csecum and colon, the incision should be made over 
the most prominent part of the swelling, as such a course affords 
the most ready access to the seat of obstruction and greatly facili- 
tates the operative procedures which may become necessary. In 
reference to these points J. Greig Smith regards it a? only less than 
a surgical calamity to perform median laparotomy for obstruction in 
the colon, since in the majority of cases it must, he says, be supple- 
mented by a transverse or lumbar incision. 

In all other forms of intestinal obstruction, and in all cases 
where it is found impossible to ascertain the nature and location of 
the obstruction, the incision should be made through the median 
line. Not much time should be consumed in making the external 
incision. With successive strokes of a sharp scalpel the tissues are 
rapidly divided until the subperitoneal layer of fat is reached. This 
is picked up and nipped between two toothed forceps; when the 
peritoneum comes into view it is seized and divided in a similar 
manner. The- incision is then enlarged as circumstances may require 
by introducing the left index and middle finger into the peritoneal 
cavity and dividing the tissues between them with a blunt-pointed 
bistoury or scalpel. Haemorrhage is arrested as it occurs by apply- 
ing . hsemostatic forceps to the bleeding points; this in most in- 
stances obviates the application of ligatures. In reference to the 
size of the incision, this will vary in accordance with the difficulties 
which are encountered in locating the seat of obstruction and in 
removing the cause or causes which have produced the occlusion. 
With few if any exceptions it must be large enough to admit the 
introduction of the whole hand. As a rule it may be stated that 
the ease in diagnosis increases with the size of the incision, and the 
danger which attends searching in the dark for the seat of obstruc- 
tion more than overbalances the slight increase of risk incident to a 



86 INTESTINAL SURGERY. 

large incision. Intra-abdominal manual exploration through a small 
incision is, in most instances, an unreliable diagnostic measure, as 
the cause of obstruction may be of such a character as entirely to 
elude such method of examination. It is a well known fact that the 
location of the seat of obstruction, even in the post-mortem room 
after a full abdominal section, has sometimes been found a difficult 
task. A large incision shortens the operation by facilitating the 
intra-abdominal examination and the operative treatment of the 
obstruction, and the immediate risks of the operation are diminished 
in proportion to the shortening of the time required in its per- 
formance. 

d. Intra- Abdominal Bxamination. 

The first and most important object of the external incision is 
to enable the surgeon to make a satisfactory intra-abdominal exami- 
nation. Unless a positive diagnosis has been made beforehand the 
first incision is an exploratory one. Exploration of the abdomen for 
the purpose of locating the obstruction and ascertaining its nature is 
a more difficult procedure than in cases of abdominal tumors, and on 
this account the first or exploratory incision must be made at least 
large enough to enable the surgeon to combine ocular inspection 
with manual exploration. 

Smith ^isays: ''The best guide to the seat of operation is not 
manual exploration, but visual examination, assisted, if necessary, by 
extrusion of bowel." 

The surgeon must bear in mind that in nine out of ten cases of 
intestinal obstruction the cause is located in the lower, portion of the 
abdominal cavity, below the umbilicus, and that in the great major- 
ity of these cases it will be found either in the right or left inguinal 
region. 

Bryant lays down the rule that in all abdominal operations for 
intestinal obstruction, when the seat of obstruction cannot be readily 
found, the surgeon should find the ceecum, since it is from it that he 
will obtain his best guide. If this be distended, he will at once 
know that the cause of obstruction is below; if it be found collapsed, 
or not tense, the obstruction must be higher up. The naked eye 
appearances of the intestine that presents itself in the incision, will 
serve a useful purpose in deciding whether it belongs to the part 
of intestine above or below the seat of obstruction. In all cases of 



'The British Medical Jonrnal, Ang. 29, 1885. 



INTRA-ABDOMINAL EXAMINATION. 37 

intestinal obstruction the bowel above the seat of obstruction is 
dilated and congested, while below the obstruction it is empty, pale 
and contracted. The contents of the presenting loop, if distended, 
will also indicate whether it is near or distant from the obstruction; 
if near, it will probably contain fluid faeces and gas; if distant, only 
gas. If the obstruction is located in the lower portion of the small 
intestine, or in any portion of the colon, without exception a dis- 
tended loop above the obstruction presents itself in the wound. 

Fowler^ has called attention to the fact that in all forms of 
intestinal obstruction the empty contracted portion of the intestine, 
corresponding to the part below the obstruction is always found 
in the pelvis, and that it may be most easily reached towards 
the right side. He explains this on the supposition that during the 
violent and continued peristalsis and gradual distention of the 
bowel above the obstruction, the smaller and less active portion of 
bowel below, after expelling its contents, is forced downwards into 
the pelvis, whilst the distended, and therefore specifically lighter 
portions rise to the surface. The pelvis also is too small to hold 
a distended loop. If the seat of obstruction cannot be readily 
found by manual exploration of the regions where it occurs most 
frequently, two methods of further examination present themselves. 
The presenting bowel is drawn forward into the wound and sys- 
tematically examined step by step, as it glides through the fingers 
of the surgeon whp replaces the loops as they are examined. 
This method of examination is only safe and practicable where the 
distention of the intestines is moderate, and the intra-abdominal 
pressure not excessive, so that loop after loop can be drawn for- 
ward, examined and returned without injury to the intestine. If 
this method of examination is selected it would be advisable to 
secure the portion of intestine first examined near the wound by 
passing a strip of gauze through its mesentery, so that in case the 
obstruction is not found in one direction the examination in the 
opposite direction can be made without passing the portion already 
examined again through the operator's hands. Mikulicz attains 
the same object by an assistant holding the first knuckle that ap- 
pears against one of the angles of the wound while the operator 
examines and returns immediately coil after coil until the obstruction 
is found. During the examination prolapse of the intestines is pre- 

' TH^ Lancet, June 30, 1883. 



38 INTESTINAL 8URQBRY. 

vented by an assistant who guards the opening with an antiseptic 
compress, and thus as inspection is progressing unnecessary exposure 
of the intestines is prevented. 

For the purpose of avoiding exventration and its evil conse- 
quences in cases of intestinal obstruction with great distention of the 
abdomen, Madelung^ has recently described a new method of deal- 
ing with the distended intestines. He makes a comparatively small 
incision through the median line and brings the first distended 
knuckle of intestine that presents itself into the wound and by pass- 
ing two fixation ligatures through the mesentery near the gut and 
making traction upon them, draws it forward until both limbs of the 
loop can be ligated with a strip of antiseptic gauze at a point corre- 
sponding to the external surface of the wound. The patient is now 
placed on his side and the prolapsed loop is incised over the convex 
surface and its contents evacuated. The gauze ligature is slowly 
loosened so as to prevent flooding of the wound with intestinal con- 
tents*by too forcible escape of the fluid contents. When the sponta- 
neous escape ceases a N6laton's catheter is introduced into the incised 
bowel for the purpose of facilitating the escape of intestinal contents. 
Fifteen minutes jare spent in efforts aimed at evacuation of the dis- 
tended paretic intestine, during which time anaesthesia is suspended 
in order to effect still further evacuation of the bowel above the seat 
of obstruction by the contraction of the abdominal muscles. After 
all discharge has ceased the visceral wound is cleansed and sutured 
and the ligatures on each side of the wound are tied so as to pre- 
vent undue tension upon the sutures after the gut has been replaced. 
The ligatures are left hanging out of the wound to serve as guides to 
the incised part of the gut after the completion of the intra-abdomi- 
nal examination. The abdominal incision is now enlarged and the 
intestine drawii forward and careful search made for the obstruction. 
If this is not found the incised loop of bowel is brought into the 
wound, the sutures of the visceral wound and the two ligatures 
removed, and an artificial anus established by stitching the intesti- 
nal wound to the margins of the external wound, and the portion 
which is not required for this purpose is also sutured. 

While Madelung's procedure cannot fail in facilitating explo- 
ration of the abdomen by diminishing intra-abdominal pressure 

^ Zur Frage der operativen Behandlnng der inneren Darmeinklemmiingen. 
Archiv. f. Klin. Chirurgie, B. XXXVI, p. 283. 



INTRA-ABDOMINAL EXAMINATION. 39 

it is questionable if the room thus gained is a sufficient recompense 
for the time lost and the additional risks incident to an intestinal 
wound in a place where it is not required. If a laparotomy is 
decided upon in the treatment of an intestinal obstruction, it is 
made for the distinct purpose of finding and removing the obstruc- 
tion; hence if the patient's strength is such as to warrant this 
treatment at all, the surgeon should not close the abdomen with 
the principal object of the operation unaccomplished. How diffi- 
cult it is to find the obstruction in some cases is well shown by 
Madelung, who in several cases where the seat of obstruction 
jsould not be located during life, requested the pathologist when he 
made the post-mortems to locate the obstruction by introducing his 
hand through an incision, allowing him from ten to twenty minutes 
for the exploration; in every instance he failed to find or locate the 
obstruction within the specified time. Where the ordinary methods 
of examination through an incision large enough to permit the 
introduction of the hand prove themselves inadequate in locating 
the obstruction, after a search of from ten to twenty minutes, it is 
useless and unwise to persist in pursuing the same course. Such 
cases should be dealt with by resorting to exventration. This 
method of exploration was first suggested by BEarber, in 1872, and 
practiced by Ktimmell* in 1885. The large incision which he 
advocates is necessarily followed by prolapse of the distended in- 
testines and enables the surgeon to examine rapidly and accurately 
every portion of the intestinal canal with a view of locating the 
obstruction, with little or no risk of inflicting injury during the 
examination. The greatest objection that has been urged against 
it is that it is sometimes exceedingly difficult to replace the in- 
testines even after the cause of obstruction has been removed, as 
the paretic intestines are slow in regaining their normal peristaltic 
action, and that during the attempts at replacement the intestines 
are often injured. 

The proper way to effect replacement is to follow Ktimmell's 
advice and instead of making direct compression, to resort to pro- 
tection of the intestines by covering the whole mass with a warm, 
moist, aseptic compress, the margins of which are tucked in under 
the abdominal incision. In this way the bowels are protected against 

^Ueber Laparotomie bei innerer Darmeinklemmnng. Deutsche Med. 
Wochenschiift, No. 12, 1886. 



40 INTESTINAL SURGERY. 

tihe injurions effects of irregnlar direct pressure an are guided 
back into the abdominal cavity as the wound is closed, by tying 
the sutures, already in place, from above downwards. If uniform, 
diffuse, gentle pressure fails in replacing the intestines, then the 
margins of the abdominal incision should be lifted with blunt hooks, 
an expedient which renders material aid in effecting replacement. 
Shoald the obstacles be so great as to frustrate all attempts at 
replacement it is better to resort to incision and evacuation of the 
most distended portion of the prolapsed bowel, which can be done 
with greater safety and more marked effect than by the plan devised 
by Madelimg. This is well illustrated by a case that recently came 
under my observation, which I will report in brief. 

The patient was a woman forty-eight years of age, the mother 
of eight *children, the last being an infant ten months old. She 
stated that she had suffered during the last year from constipation, 
but had always been promptly relieved by cathfiui;ics. Ten days 
before her admission into the Milwaukee hospital, April 18, 1888, 
symptoms of acute intestinal obstruction appeared, which increased 
in intensity until fsBcal vomiting supervened the day before she 
came under my observation. She had been treated by high injec- 
tions and irrigation of the stomach, the former without any effect, 
the latter affording great relief. The patient was well nourished 
and her general appearance gave rise to no suspicion of malignant 
disease in any of the organs. She had passed nothing per viam 
naturalis since she was taken ill, and the retching and vomiting were 
persistent. The abdomen was uniformly and enormously distended; 
upon the surface of the abdominal wall the outlines of some dis- 
tended coils of intestine could be distinctly seen. The tympan- 
itic distention of the abdomen, interfered with respiration, the 
respiratory movements being shallow and rapid, lips cyanosed and 
extremities cold. Examination per vaginam and rectum revealed 
nothing as to the seat and nature of the obstruction. Percussion 
and palpation of the abdomen yielded the same negative results. 

Laparotomy was performed under the most careful antiseptic 
precautions. The stomach was irrigated and chloroform used as an 
ansesthetic. The operation was performed with the patient upon a 
rubber bed filled with hot water. The first incision was made half 
way between the umbilicus and pubes and large enough to permit 
the introduction of the hand. As soon as the peritoneal cavity was 



INTRA-ABDOMINAL EXAMINATION, 41 



/ 



Opened a loop of small intestiiie, distended to three times its natural 
size and intensely congested, presented itself. This was pushed 
aside and similar loops made their appearance. I now introduced 
my hand and found that the caecum and entire colon were also 
enormously distended, which satisfied me that the obstruction must 
be located low down in the colon, or the upper portion of the rectum; 
but the most careful attempts by manual exploration failed in fur- 
nishing any clue as to the location or nature of the obstruction. The 
incision was enlarged upwards an inch above the umbilicus and down- 
wards lo the pubes for the purpose of effecting complete exventra- 
tion. Two assistants caught the intestines as they prolapsed in 
warm, moist aseptic compresses, and as the abdominal cavity was 
nearly empty I could explore with ease the sigmoid flexure, which I 
had reason to believe was the seat of the obstruction; as this part of 
the colon was only greatly distended, I had to proceed lower down 
with my exploration and finally found a circular carcinoma below the 
sigmoid flexure in the pelvic cavity near the junction of the colon with 
the rectum. 

As resection in this locality was impossible, and as for the 
same anatomical reasons an anastomosis could likewise not be made, 
I was forced to establish an artificial anus. In examining the colon 
with the view of the best locality for making a colostomy, I found 
that the enormous dilatation of this part of the intestine had resulted 
in such an elongation as to force the transverse colon in a downward 
direction nearly as far as the brim of the pelvis. I made an incision 
in the left inguinal region above Poupart's ligament, two inches in 
length and sutured the parietal peritoneum to the skin. Into this 
incision a loop of the displaced transverse colon was pushed by the 
hand within the abdomen and fixed by a number of sutures. When 
this was done I attempted to replace the intestines, but after trying 
all the ordinary devices I had to abandon the attempt. The patient 
was now placed on her side, and one of the most distended loops 
was grasped, held over a basin, and punctured with a large trocar, 
while the remaining intestines remained covered with the warm com- 
presses. As the escape of gas and fluid faeces through the cannula 
was very slow, an incision an inch and a half in length was made in 
the gut. As the intestine did not contract, the escape of contents 
was very slow, and I had to resort to pouring out of the contents, as 
it were, by seizing the gut several feet alx)ve and below the incision 



42 INTESTINAL SURGERY, 

and elevating it; a large quantity of fluid fsBoes was literally poured 
out When no further evacuation could be effected the visceral 
wound was closed by the continued suture, and after thoroughly 
disinfecting the loop, the bowels were returned without difficulty. 

The abdominal incision was closed in the usual way, only that 
I added two tension sutures as a matter of precaution. After the 
abdominal wound was closed and dressed, the colon that had been 
stitched into the inguinal wound was incised and the margins of 
the incision separately stitched to the sides of the external wound. 
A considerable quantity of gas and fluid f SBces escaped. The vomit- 
ing ceased after the operation and the patient rallied under the 
effects of stimulants. The abdominal distention had diminished 
greatly the next day, and disappeared almost completely on the 
second day. The patient's general condition continued to improve 
until the tenth day after the operation, when symptoms of collapse 
set in which persisted until she died on the following day. The 
post-mortem showed that the median incision had healed with the 
exception of the skin, and that the artificial anus had served as a 
perfect outlet to the intestinal contents. Small intestines restored 
to nearly normal size, and incision healed, the fine silk suture being 
completely imbedded. The cause of the recent diffuse septic peri- 
tonitis was traced to perforation of a small abscess behind the 
carcinoma. The constriction caused by the carcinoma had reduced 
the lumen of the bowel so much that it was only permeable to the 
tip of the little finger. 

I shall refer again to the relation which exists between chronic 
causes giving rise to acute obstruction. This case also illustrates 
the importance of establishing the artificial anus, when such a 
procedure cannot be avoided, not in the laparotomy wound, but in 
the right or left inguinal region. When exventration is practiced it 
is essential to furnish the prolapsed and dilated intestine with an 
artificial covering which shall act as nearly as possible as a sub- 
stitute for the abdominal parietes. This is best accomplished with 
warm compresses in the hands of one or two reliable assistants. 
After the surgeon has found the obstruction it becomes necessary to 
demonstrate the permeability of the remaining portion of the 
intestinal canal, as it has happened that after a successful removal of 
an obstruction, patients have died because a second obstruction was 
overlooked. Of course in such cases the search for additional 



INTESTINAL ANASTOMOSIS. 4:8 

obstractions must be extended below the obstraction whicli has been 
fonnd and removed. An infallible test for ascertaining the permea- 
bility of the remaining portion of the intestinal canal is furnished by 
rectal insufflation of hydrogen gas. In cases where after exventra- 
tion it is not possible to find the obstruction by examination of the 
distended portion of the intestine, the contracted empty portion 
below the obstruction can be brought into sight by the same means, 
and a search for the obstruction made from below upwards by 
examining the bowel as it becomes inflated, until the seat of 
obstruction is reached. 

Operative Treatment of the Obstruction. 
1. Intestinal Anastomosis. 

What shall be done if the obstruction cannot be found after all 
diagnostic resources have been exhausted? Shall we establish an 
artificial anus and leave the patient to the inevitable fate of 
remaining a sufferer from*this loathsome condition the balance of his 
lifetime, should he recover from the operation? Under such 
circumstances the surgeon assumes a great responsibility in estab- 
lishing an artificial anus high up in the intestinal canal, even as far 
as the immediate effects of the operation are concerned. The 
paretic bowel below the seat of the artificial outlet, unable to empty 
itself of its contents, constitutes an immediate and remote source of 
danger, as it leaves that portion of the bowel between the new 
opening and the obstruction, in the same condition as before the 
operation, and permanent exclusion of a considerable portion of the 
intestinal canal alone may subsequently destroy life by progressive 
marasmus. In such cases I should advise the following plan of 
treatment: The empty bowel below the seat of obstruction, if not 
already founds should be inflated with hydrogen gas per rectum, and 
the highest portion of the inflated bowel drawn forward into the 
*wound, and two rubber bands passed through its mesentery about 
four inches apart and held in place by an assistant. The surgeon 
now locates as near as he can the lowest portion of the bowel on the 
obstructed side, which is also brought forward into the wound and 
similarly secured. The bowel on the proximal side is incised on the 
convex surface to the extent of an inch and a half; through this 
incision the contents are evacuated as far as possible, after which all 
the four rubber bands are tied and the bowel on the distal side 



44 INTESTINAL SURGERY. 

incised in a similar manner. Into each of these incisions a decalci- 
fied perforated bone plate is inserted and, with the lateral sntore 
armed with a round needle, the margin of the wound on each side is 
transfixed. After the plates and sutures are in place the loops are 
thoroughly disinfected and the serous surfaces to the extent of the 
size of the plates are lightly scarified with the point of a needle, 
when the' wounds are placed vis-a-vis, and the corresponding four 
threads tied together with sufficient firmness to secure perfect 
coaptation of the serous surfaces. The sutures are cut short and their 
ends buried as deeply as possible by pushing them in between the 
approximated bowels with a director or blunt scissors. A few 
superficial stitches of a continued suture will enhance the safety of 
the operation. In this manner an anastomosis is established with 
the exclusion of probably only a small portion of the intestinal 
tract. 

After uniting two intestines by approximation plates in the 
formation of an intestinal anastomosis it appears at first sight as 
though on the slightest distention of the intestines, leakage of gas or 
fluid contents would take place between the serous surfaces. That 
this fear is unfounded I have satisfactorily proved by a number of 
experiments. The intestines of animals recently killed were used 
and an anastomosis made between the lower portion of the ileum 
and the colon. The colon was tied below the new opening and fluid 
forced into the ileum on the proximal side. The pressure was 
measured by a mercury gauge. It was found that no leakage occurred 
under a pressure of two pounds to the square inch, continued for 
thirty seconds. As even in cases of great intestinal distention the 
pressure can never reach this degree, leakage from mechanical or 
physical causes will never take place from the new* opening. The 
margins of the visceral wounds act like valves and when the serous 
surfaces are kept in contact by the plates, prevent the escape of gas 
or fluids into the peritoneal cavity. The safety arid practicability of 
this operation I have abundantly demonstrated by my experiments 
on animals and by a number of operations on the human subject. 
The operative treatment of the obstruction will depend upon the 
location and nature of the obstruction. If it is decided not to 
remove the obstruction, either on account of its intrinsic harmless 
character, aside from its mechanical effect, or on account of its 
extent, in which case the removal would be an imminent source of 



INTESTINAL ANASTOMOSIS, 45 

danger to life, or if after removal a recurrence in the near fntore 
appears inevitable, an anastomosis is established between the intestine 
above and below the obstruction by lateral apposition with decalci- 
fied perforated bone plates. By this* operation the continuity of the 
intestinal canal is restored with permanent exclusion of the seat of 
obstruction. 

In oases of cicatricial stenosis as a cause of obstruction, intesti- 
nal anastomosis, for instance, would be a vastly more safe operation 
than resection and circular enterorrhaphy, and would secure 
equally well restoration of the continuity of the intestinal canal. 
In cases of carcinoma of the intestine with extensive infiltration of 
the lymphatic glands a resection followed by circular enterorrhaphy 
must always constitute a hazardous precedure, and even if it proved 
successful an early recurrence of the disease would be inevitable. 
Under such circumstances it is advisable to establish in preference 
an intestinal anastomosis, which will effectually exclude the cause 
of obstruction, alleviate suffering and prolong life. The opponents 
of laparotomy in cases of acute intestinal obstruction have urged 
as one of the principal reasons for their opposition that the dilated 
inflamed intestine above the obstruction is not in a condition 
to undergo reparative processes when the operation demands a 
solution of continuity in this part of the intestinal tract. Circular 
enterorrhaphy under such circumstances is a very dangerous pro- 
cedure for two reasons: 1. It becomes necessary to unite bowel 
ends of unequal size. 2. The inflamed intestine has undergone 
textural changes illy adapted for suturing, as the sutures readily cut 
through the softened tissues. A number of clinical observations 
have satisfied me that the failures which have attended circular 
enterorrhaphy in such cases, are not due to a lack of healing capacity 
on the part of the inflamed end of the bowel, but to the mechanical 
difiiculties which are encountered in the approximation and retention 
of the bowel ends, and the danger of the cutting through or yielding 
of the sutures. I believe on the contrary that in case septic 
peritonitis does not exist, the vascularity of the bowel above the seat 
of obstruction constitutes a favorable condition for rapid union. To 
demonstrate the correctness of this assertion, I made the following 
experiments: 

Experiment 1, Dog, weight fourteen poiinds. The whole abdomen was 
shaved and thoroughly disinfected, and while the animal was mider the inflnenoe 



46 INTESTINAL 8UROERY. 

of ether a small inoiBion was made in the left iliao region, and a loop of intestine 
drawn forward and ligated with a band of iodoform gauze, the ligatnre being 
tied with sufficient firmness to cause complete occlusion, intestine returned 
and woxmd sutured. Seventy-three hours later, the dog was again etherized 
and median laparotomy performed.* Distended yasoular loops of the intestine 
came into the wound, which were pushed aside and the hand introduced, which 
being passed towards the left inguinal region at once came in contact with 
the ligated portion which had formed adhesions to the parietal peritoneum 
and neighboring intestinal loops. The adhesions were separated and the 
ligated loop drawn out of the wound. Above the ligature the bowel was at 
least one and a half times larger than immediately below the seat of obstruc- 
tion, very vascular and contained gas and fluid faeces. The degree of dilatation 
diminished from below upwards. The seat of obstruction was eight inches 
above the ileo-csBcal valve, and the gauze ligature was covered with a thick 
layer of plastic lymph. The obstruction was left and the continuity of the 
intestinal canal restored by an ileo-colostomy with perforated decalcified bone 
plates. The animal, which was not vigorous before the experiment was made, 
appeared much prostrated and died twenty-four hours after the operation. 
l?he necropsy showed that the bowel above the constriction had to a great 
extent recovered its normal size and color. The two intestines where anasto- 
mosis had been made were firmly adherent, the groove between them, corre- 
sponding to the length of the plates, filled in with plastic lymph. New 
opening permeable; no leakage at point of operation under hydrostatic 
pressure. No peritonitis. 

Experiment 2, Dog, weight twenty-four pounds. Obstruction produced 
in a similar manner as in preceding experiment. Seventy-five hours later, 
operative treatment of obstruction by laparotomy. The seat of obstruction 
was again readily found by manual exploration of the abdomen. Bowel above 
seat of constriction at least twice the normal size and highly congested. 
Peristaltic action sluggish, responding very slowly and imperfectly to 
mechanical irritation. Gauze band buried under a ring of plastic lymph, 
which bridge-like united the gut below and above the constriction. As the 
obstruction was located about the middle of the ileum, an ileo-ileostomy 
by lateral apposition with decalcified perforated bone plates was made, leav- 
ing the gauze band undisturbed. The incision into the bowel above the seat 
of obstruction showed that all the coats were thickened and softened, while 
below the obstruction, only the mucous membrane was in a state of catarrhal 
inflammation. About eight inches of the bowel including the seat of constric- 
tion were excluded by the operation. The animal showed no signs of suffering 
or illness after the operation, and when killed after the expiration of twenty- 
one days was in excellent condition. During this time the appetite was good 
and fsBcal evacuations normal. Gauze band completely encapsuled, and close 
to it an acute flexion of the bowel; excluded portions adherent along convex 
surface to each other; bowel above constriction about one-third larger than 
below. New opening admits the tips of two fingers. 

Experiment 3. Dog, weight twenty-eight pounds. Laparotomy seven 
days after complete obstruction had been caused by ligation of small intestine 



INTESTINAL ANASTOMOSIS. 47 

with gauze band through a small wound in the left ingninal region. Tympan- 
ites moderate. Obstrnotion found sixteen inches above the ileo-oieoal region. 
Peristaltio action almost suspended in bowel above obstruction, normal below. 
Intestine above the constriction dilated to twice its normal size, exceedingly 
vascular, containing solid fsBcal masses, fluid faeces and gas; below, empty, 
contracted and ansBmic. Exclusion of six inches of the intestine at eeat of 
obstruction and restoration of continuity of intestinal canal by ileo-Ueostomy 
with decalcified perforated bone plates. After operation function of intesti- 
nal oanal normal and appetite good. Killed eight days after operation; no 
peritonitis; adhesion of omentum to line of abdominal incision; gauze band 
completely covered by a plastic exudation; a number of adhesions between 
adjacent intestinal loops. Point of operation situated in the center of a 
horse-shoe shaped loop of intestine, which was found to be the excluded por- 
tion. Intestine above obstruction about one-fourth larger in size than below. 
Excluded portion of bowel empty. At seat of anastomosis a mass of straw 
and hair had accumulated on proximal side. New opening large enough to 
admit two fingers. 

Experiment 4. Dog, weight thirty-four pounds. Complete obstruction 
of small intestines by ligation with gauze band through a small wound in the 
left iliac region. Operative treatment by laparotomy one hundred and twenty 
hours later. This animal vomited several times shortly before the operation. 
Bowel at seat of obstruction adherent to adjacent intestines. Obstruction 
readily found and brought into the incision. Intestine above constriction 
twice its normal size, dark purple in color, tissues swollen and very much 
softened. Below constriction bowel empty, collapsed, pale, and only the 
mucous membrane in a state of catarrhal inflammation. The dilated bowel 
contained gas and fluid fadces. Peristaltic action in this part nearly sus- 
pended, the response to mechanical irritation being slow and imperfect. 
Below the obstruction function of bowel unimpaired. > As the occlusion was 
only four inches above the ileo-C8Bcal valve, it was found impossible to limit 
the anastomosis to the ileum, consequently the continuity of the bowel was 
restored by an ileo-colostomy, uniting the ileum just above the obstruction 
with the colon above the cascum, using the perforated approximation plates. 
The gauze band was left in eita. The animal showed no untoward symptoms 
after the operation, and was killed twenty-one days later. During this time 
appetite was good and intestinal functions normal. A number of adhesions 
were found at the site of operation between adjacent intestinal loops. Gkiuze 
band completely encysted. Some crude material, as straw, hair and frag- 
ments of bone, was found on the proximal side of new opening. Anastomotic 
opening large enough to admit tips of two fingers; union between approxi- 
mated portions of intestine so complete that it presented all around the 
appearance as though their peritoneal surfaces were continuous. ^ 

These experiments show conclnsiyely that in acute obstruction 
even after seven days, the bowel above the obstruction is capable of 
undergoing a rapid reparative process and that adhesive union takes 
place as early, if not earlier than in operations upon a normal 



48 INTESTINAL SURGERY. 

inteetine. The experiments likewise prove the greater safety of 
anastomosis by lateral apposition with decalcified perforated bone 
plates thaa of circular enterorrhaphy in restoring the continuity of 
the intestinal canal after resection. Anastomosis, after resection for 
intestinal obstruction, can be made in the same manner between the 
proximal and distal part after the resected ends have been closed by 
invagination and a few stitches of the continued suture, as when the 
obstruction is not resected but excluded. 

In cases of congenital atresia of the small intestines, most fre- 
quently met with in the upper portion, anastomosis should always 
take the place of circular resection, as the operation can be done in 
less than twenty minutes, an exceedingly important matter as far 
as the immediate effects of the operation is concerned in infants, at 
the most only a few days old. In cases where such a congenital 
defect is suspected the abdomen should be opened in the median 
line, being careful not to cut through the umbilicus, when the seat 
of obstruction can be readily and rapidly located by inflation of the 
stomach and rectum with hydrogen gas. It is necessary to inflate 
from both directions, as in some cases the atresia is multiple. In 
cases of cicatricial stenosis of the pylorus a gastro-enterostomy by 
lateral apposition with approximation plates is a safer operation than 
resection, or the procedures recommended by Loretta and Mikulicz, 
while the functional result is equally, if not more, satisfactory. In 
carcinoma of the pylorus, where resection is contra-indicated on 
account of the extent of the disease, or its extension to neighboring 
organs, or because glandular infection has taken place, suffering can 
be diminished and life prolonged by making a gastro-enterostomy, 
substituting for the tedious double suturing as advised by WOlfler 
the perforated approximation plates. During the last year I made 
four such operations and with such satisfactory results as far as the 
operation was concerned that I am induced lo report them in this 
connection with the hope that others may give this method of oper- 
ating a trial in similar cases. I have made it a rule that the patient 
should abstain from taking food by the stomach for at least twenty- 
four hours before the operation, and rely for a few days, at least, 
entirely upon rectal alimentation, allowing only pieces of ice to 
quench thirst 

The operations were performed as follows : The evening 
before the operation the stomach was washed out by the syphon 



INTESTINAL ANASTOMOSIS. 



49 



tube and again Just before the ansBsthetio was administered. For 
the last irrigation a five per cent, solution of salicylate of soda was 
used. In all of these oases the incision was made through the 
median line and extended from near the ensiform cartilage to the 
TimbiliotiB. The opening in the stomach was made parallel to the 
long axis of the organ and at least an inch and a half distant from 
the margin of the tumor. A continued suture of fine silk was applied 
around the whole circumference of the opening both for the purpose 
of arresting haemorrhage and preventing bulging of the mucous 
membrane. In the intestine the opening was made between two 
rubber ligatures, so as to prevent any extravasation of intestinal 
contents and the margins of the wound were sutured in a similar 
manner. The opening in the intestine was made first and the 
plate introduced and sutures adjusted and the loop retained in the 
lower angle of the wound, covered by a warm compress. The large 
curvature of the stomach near the pyloric orifice was then drawn 
sufficiently forward into the wound to make the incision and 
introduce the plate. When everything was ready for adjustment, 
the parts around the visceral wound were carefully disinfected, dried 
and the serous surface lightly scarified with an ordinary needle 
over a surface corresponding to the size of the plate; the new open- 
ings (wounds) were then brought opposite each other and a fine silk 
suture,, embracing only the serous and muscular coats, was applied 
behind the lower middle-plate-suture and tied; the middle lower 
Butore was now tied, while an assistant approximated the two open- 
ings; the lateral sutures were next tied, and lastly the anterior 
middle. The sutures were all cut short and ends buried. During 
the tying of the sutures, it is necessary to exercise daution that the 
margins of the visceral wound are well embraced by the plates all 
around. As in these cases the weight of the intestine exerfcs consid- 
erable tension, I have taken the precaution in my two last cases to 
apply a superficial continuous sutuife anteriorly after tying the four 
sutures, so as to approximate the serous surfaces over the anterior 
margins of the plates. The necessary preparations being made, with 
good assistance the operation can be finished in from twenty to 
thirty minutes. Neither shock nor peritonitis was observed in any 
of the cases. Usually on the third day small quantities of pepton- 
ized milk and beef tea were given at short intervals and solid diet 
during the second week. 






60 INTESTINAL SURGERY, 

Case I. Male, aged sixty-flTe. STrnptoms of pyloric stenoeiB for one 
year. Emaciated to a skeleton; oedema of legs; uiable to retain food of any 
kind for more than a few hoars. The patient was so an»mio and prostrated 
that he was only partially annethetized. During the operation the pulse 
became almost imperceptible, and brandy had to be administered snbcntane- 
onsly, with lowering of head, and hot applications externally. An hour after 
the operation the pnlse was stronger than before it was commenced. Beotal 
feeding; only slight rise in temperature on second day; no pain. On the third 
day small quantities of liquid food by the stomach. The heart's action 
gradually failed and the patient died of marasmus five days after the operation. 
The post-mortem revealed that the plates were still in aitu, adhesions Arm and 
opening patent. No peritonitis. In this case the carcinoma was circular and 
limited to the pylorus. Anastomosis just below the duodenxmi. The intense 
suffering had made the patient desperate, and although the nature of the 
disease and the probable outcome of the operation had been fully explained 
to him, he begged to have it done, with a perfect understanding that at best 
it would afford only temporary relief. I am quite confident that the operation 
did not shorten his life. 

Case II, Male, aged forty-seren. Duration of disease eighteen months; 
obstinate vomiting; great emaciation and oedema of legs. Oontour of tumor 
could be readily mapped out by percussion and palpation. Tumor adherent 
to under surface of liver; enlargement of lymphatic glands. In this case the 
anastomosis was again made just below the duodenum. No untoward symp- 
toms after operation. At the end of the first week solid food was allowed. 
No vomiting. At the end of the third week an abscess formed in the upper 
part of the healed incision, in the contents of which the plate ligatures were 
found. A gastrie fistula formed, through which food escaped almost im- 
mediately after it was swallowed. This closed in less than two weeks; after 
which the patient improved in strength and gained in weight. He retained 
and digested all kinds of food. Improvement continued so that he was able 
to walk short distances and to take long drives. At the end of three months 
after the operation he commenced to fail and died two weeks later of progres- 
sive marasmus. Unfortunately no post-mortem could be obtained. 

Case III, Male, aged thirty-five. Symptoms of pyloric stenosis for six 
months. Tumor discovesed four months ago, rapidly increasing in size. 
Considerable emaciation and cachectic appearance. Tumor involves nearly 
one-third of anterior wall of stomach and the entire pylorus. Glands of 
omentum infiltrated. The first loop of intestine which came within reach was 
united with the anterior wall of stomach in the usual manner. Sutures of 
abdominal wound removed on the eighth day. Until this time no untoward 
symptoms, although the patient had taken liquid food for several days. The 
day following obstinate vomiting occurred; the plates, very much softened 
and greatly reduced in size, were ejected. The stomach was repeatedly 
irrigated, but vomiting continued until the patient died three weeks after the 
operation. Post-mortem: Abdominal incision united throughout; omentum, 
stomach and intestines adherent to abdominal incision. Anastomosis perfect 



,, o t „ 



INTESTINAL ANASTOMOSIS. 51 

at a point eight feet below pyloras. Intestine between pyloma and artificial 
opening enormously distended. As the opening was large enough to admit 
two fingers it was difficult to understand what had caused the obstruction. 
The pyloric orifice was large enough to admit the tip of index finger. Fluid 
could not be forced from the stomach into the bowel below the new opening. 
Injection through the duodenum was made with the same negative result. On 
dose examination it was found that the intestine at the point of anastomosis, 
probably on account of the great length of the part between the stomach and 
the new opening, had become flexed at the point where it was attached to the 
stomach, and the two limbs were adherent to each other for four inches. This 
bending of ihe bowel had formed a spur, opposite to the opening in the 
stomach by the apex of the concave side of the bowel, and this spur acted like 
a valve, closing the opening in the distal part of the bowel when water was 
injected into the stomach or duodenum. ' 

This case taught me that it is tmsaf e to follow the advice given 
by Luecke and others, to seize the first presenting loop for the anas- 
tomosis, as by so doing, it is possible to grasp a loop of intestine 
which corresponds to the lower portion of the small intestines, as in 
this case. If this is done we not only exclude permanently too 
great a portion of the intestinal canal from the processes of digestion 
and absorption, but a similarly unfortunate mechanical difficulty at 
the new opening may be created, as has been described above. 

Lauenstein recently reported a case of gastro* enterostomy where 
the post-mortem revealed that the new opening was made near the 
ileo-csecal region. In making a gastro-enterostomy it is important 
for the reasons just cited to follow the advice of Hahn and search for 
the duodenum, which when f oimd can be readily recognized by its 
short and fixed attachments, and to make the new opening in the 
upper part of the jejunum as near as possible to the duodenum. 

Case IV, Male, aged forty-three. Has complained of stomach difficulties 
for a year. During the last two months obstinate vomiting an hour or two 
after meals. Tumor as large as a child's fist; movable. Emaciation and 
marked aniemia; glandular infection behind the stomach. Anastomosis made 
just below the duodenum. Very little pain, and no other symptoms until the 
tenth day, when he vomited several times. Stomach washed out twice, four 
hours apart, and food by the stomach discontinued. No vomiting after this, 
and after two days a liquid diet ordered. At the end of the second week could 
digest aU kinds of solid food, which caused no distress. On the thirteenth day 
fragments of both plates were foimd in one of the stools.. Patient has gained 
in fiesh, and after four weeks presented a great deal better appearance than 
before the operation. 

These cases have satisfied me that gastro-enterostomy in cases 
of inoperable carcinomatous stenosis of the stomach is a safe and 



52 INTESTINAL SURGERY. 

justifiable operation and shonld be more frequently resorted to, as it 
is the only resource 'which promises substantial relief, prolongs life 
and infoses new hope in a class of patients otherwise doomed to 
certain, speedy death. 

2. Phtsiologioal Exclusion bt Anastomosis. 

In some cases of intestinal obstruction the restoration of the 
continuity of the intestinal canal by resection and circular enteror- 
rhaphy would necessitate the removal of several feet of the intestine 
where the cause of obstraction in itself constitutes no intrinsic 
source of danger, and where recovery would be more likely to take 
place by the substitution of anastomosis for resection. That resec- 
tion of a number of feet of the small intestines is not always com- 
patible with health is well illustrated by a case reported by Baum, 
in which he removed 137 cm. in a woman forty years of age. The 
patient was suffering from strangulated femoral hernia. Taxis was 
only partially successful. On opening the sac an offensive fluid 
escaped, and a portion of the omentum was removed. Peritonitis 
followed and a swelling formed in the abdomen above the crural 
ring, which broke and a fsecal fistula formed; rapid emaciation 
ensued; symptoms of strangulation made a laparotomy necessary. A 
mass of intestine was found twisted into a bunch which could not 
be unravelled, and as it was surrounded by an abscess it was 
resected and the ends united with sutures. Patient recovered from 
operation and improved for several weeks. Six months later pro- 
gressive marasmus resulted in death. The autopsy revealed no 
other cause of death except marasmus from too extensive resection. 
In such a case I would propose that the twisted adherent intestinal 
coils, the cause of the obstruction, if they present no evidences of 
gangrene, should be left and permanently excluded from the fsecal 
circulation by making an anastomosis with approximation plates 
between the bowel leading to and from the obstructing mass. A 
case somewhat similar to Baum's, but under less favorable circum- 
stances, came imder my care during the last year where this plan of 
treatment was adopted. 

Strangulated Hernia; Resection of Oangrenous Portion; Additional Obstruc- 
tion by a Mass of Adherent Intestinal Loops; Restoration of Continuity of 
Intestinal Canal by Anastomosis. — The patient was a brewer, thirty years 
of age, who had an ing^ninal hernia for several years, bnt never wore a truss. 
On lifting a heavy weight the swelling became suddenly enlarged, followed by 



PHYSIOLOGICAL EXCLUSION BY ANASTOMOSIS. 53 

symptoms of aonte strangulation. The attending physician overlooked the 
hernia and treated the patient for gastritis. Eight days after the attack he 
was admitted into the Milwaukee Goxmty Hospital. At this time symptoms of 
acnte diffuse peritonitis were weU marked. Pulse rapid^and feeble; extremities / 
cold; abdomen tympanitic and excessively tender on pressure. Stercoraceons 
vomiting. Hernia as large as a child's fist, skin covering it discolored and 
oedematons. It was plain enough that gangrene had occurred, -and that in 
consequence of this, peritonitis had developed. The patient was given 1-120 
of a grain of atropia hypodermically before chloroform was administered. 
On opening the sac faecal matter escaped and a large mass of discolored 
omentum presented itself. The sac was irrigated with a weak solution of sub- 
limate, and the omentum drawn forward and wrapped in a small compress of 
gauze. The entire loop of intestine was gangrenous and perforated on the 
convex surface at its highest point. The parts were again irrigated before 
the inguinal canal was laid open by incision. The omentum was now drawn 
downward until a healthy portion was reached, when it was ligated in several 
parts and cut off. The intestine was separated from its attachments to the 
inguinal canal and the gangrenous part, about eight inches in Ksngth, excised, 
after having previously guarded against faecal extravasation by applying a 
rubber ligature on each side. Examination of the abdominal cavity at this 
time showed recent peritonitis. 

In drawing down the proximal end of the gut it was found that it was but 
little distended, hence search was made for an additional obstruction higher 
up, which was found in the shape of a mass of intestinal coils twisted in every 
conceivable shape and so firmly adherent that all attempts at tmraveUing had 
to be abandoned. The intestine above this point was enormously distended, 
showing that the bunch of adherent intestines had paused a second obstruc- 
tion. Excision of three to four feet of intestines, under these circumstances, 
was not to be thought of, as the patient would certainly have died on the 
table. Should I leave the cause of obstruction and establish an artificial anus 
on the proximal side? I decided to leave the obstruction and establish a 
communication between the intestine on the distal and proximal sides of th6 
obstruction. Both resected ends were closed by invagination and a few 
stitches of the continued suture. By lateral apposition with decalcified per- 
forated bone plates an anastomosis was established between the distal 
collapsed end and the dilated bowel on the proximal side of the obstruction. 
Before the approximation sutures were tied, the intestinal contents were 
evacuated as far as possible. The whole peritoneal cavity was fiushed with 
sterilized water, carefully dried, drained, and the wound sutured. The toilette 
of the peritoneum was made with a sponge wrung out of a 1-2000 solution of 
sublimate. The hernial sac was excised and the stump fastened in the inguinal 
canal by the deep sutures used in closing the external wound. Duration of 
operation less than an hour. The patient rallied from the operation, but 
succumbed to the peritonitis at the end of twenty four hours. Post-mortem: 
On removing the sutures the sac walls were found agglutinated by plastic 
lymph. Drainage tube surrounded by a thick layer of plastic lymph, and coils 



54 INTESTINAL SURGERY. 

of intestine which completely shut ont the abdominal oaTity. Only about 
half of the omentum remained. The part of intestine where anastomosis was 
madd was found in the pelvis iyin^ against the concave surface of the sacrum, 
surrounded by numerous recent adhesions. The new opening was twelve 
inches above the ileo-cescal valve; adhesion between the serous surfaces, held 
in approximation by the plates, was sufficiently firm to prevent leakage under 
strong hydrostatic pressure. Opening patent. 

My experiments on animals related in the paper previously 
referred to, have demonstrated that physiological exclusion of a cer- 
tain portion of the intestinal tract is a less dangerous operation than 
excision. The appearances of the specimens also tend to prove that 
as long as any of the contents of the intestines reach the excluded 
portion, the peristaltic or anti-peristaltic action in that part is effect- 
ive in forcing it back into the active current of the faecal circulation. 
If the excluded portion again becomes permeable it resumes its 
physiological function and again takes an active part in the processes 
of digestion and absorption; if the obstruction remains permanent it 
undergoes progressive atrophic changes. 

3. Lapabo-Entebotomt. 

Incision of the bowel for the removal of obstruction during 
laparotomy is indicated when the obstruction is due to the presence 
of a foreign body, a concretion, an enterolith, or a pedunculated 
benign polypoid tumor. In the removal of a foreign body, a con- 
cretion, or an enterolith, not amenable to removal by submural 
crushing, or fragmentation with a needle, the incision for extraction 
should not be made over the seat of impaction, as this part of the 
intestine has undergone changes unfavorable to the satisfactory 
healing of the visceral woimd. It is much better in such cases to 
make the incision in a healthy part of the intestine an inch or two 
below the impaction, and then crush the foreign body by instruments 
introduced through the incision. The removal of a non-malignant 
pedunculated polypoid tumor is to be accomplished by making an 
incision on the convex surface of the bowel large enough to admit of 
dragging of the tumor through it, after which the base of the 
pedicle is transfixed by a double ligature and tied, the tumor cut off, 
and the wound closed in the usual manner. 

4. Enteregtomy. 

Enterectomy is indicated when the obstruction is due to a 
malignant tumor if it is possible to remove the disease completely, 



ENTERECTOMY. 55 

also for the removal of benign tumors which cannot be excised by 
enterotomy, and in all cases where gangrene has been caused by 
constriction, compression or over-distention. Carcinomatous stenosis 
is met with most frequently in the large intestine, while the causes 
which result in gangrene are most common above the ileo-csecal 
valve. For malignant disease resection should be done if the entire 
tumor and all infected glands can be removed completely and with 
safety. Even if, on account of loss of substance, circular enteror- 
rhaphy cannot be made in such cases, the continuity of the in- 
testinal canal can be restored by lateral implantation, or by lateral 
apposition with decalcified bone discs. Immediate circular enteror- 
rhaphy after resection for intestinal obstruction has always been 
attended by a great mortality, for reasons mentioned elsewhere. In 
a series of thirty-five resections of the large intestine, which Weir 
collected, when symptoms of obstruction indicated the operation, the 
mortality amounted to one hundred per cent. KeicheP has also 
shown that resection of the small intestines for conditions giving 
rise to obstruction, gave a mortality of 75 per cent., whereas in 
secondary resection for an artificial anus, the mortality is reduced to 
37 per cent., a statement which is supported by Makins^ in his 
report of fifteen deaths in thirty-nine resections for artificial anus. 
If after the resection is made, a primary circular enterorrhaphy is 
not made, Hahn recommends, so as to preserve the advantages of a 
dean wound and yet to allow the escape of faeces, that the intestine 
should be closed tightly around a rubber tube, which is left project- 
ing some distance for this purpose. 

In the removal of a tumor of the caecum with partial resection 
of the intestinal wall, it may be advisable to follow the example of 
Porter' in restoring the continuity of the intestinal canal by suturing. 
In his case a part of the circumference of the caecum including a 
portion of the ileo-caecal valve was resected for the cure of a faecal 
fistula. The wound was closed by slitting up a portion of the ileum 
from the seat of resection and uniting the margins of this wound 

L 

^ Easnistisohe Beitr&ge znr cirkniftren Darmresektion and Darmnaht, 
Dentsohe Zeitschrift f . Ghirnrgie, B. XIX, Heft 2. n. 3. 

^ Med. Chir. Transactions, vol. LX VI. 

^Excision of a Portion of Intestine, including Part of the Ileo-Gsecal 
Valve, for the Cure of Fascal Fistnla in Right Groin. Bost. Med. & Snrg. Journal, 
May 15, 1884. 



56 INTESTINAL SURGERY. 

with the resected surface of the csBCum. The patient recovered. 
In cases where the lumina do not correspond it is advisable to follow 
the suggestion first made by Wehr in performing pylorectomy, 
viz. : to cut the end of the narrower part of the bowel not trans- 
versely, but sufficiently oblique so that the circumference of the 
oblong opening will correspond to the lumen of the larger end of 
the bowel. The obliquity should always be made at the expense 
of the convex portion of the bowel, so as to interfere as little 
as possible with the vascular supply from the mesenteric sida 
Madelung in resecting the bowel makes his incisions somewhat 
obliquely in the same direction, for the purpose of guarding more 
effectively against gangrene on the convex side of the bowel after 
circular enterorrhaphy. In such extensive resection of the colon 
where the possibility of circular suturing is precluded on account 
of the impossibility of approximating the cut ends, an artificial 
anus should never be established, as no subsequent treatment could 
restore the continuity of the intestinal canal. Two such cases were 
recently reported by Hahn. 

It is possible that, in the future, experimental research will 
prove the practicability of restoring such defects by a plastic opera- 
tion, consisting of transplantation of a corresponding portion of 
the small intestines between the separated ends, a procedure which 
would necessitate circular suturing at three different points. Until 
it has been shown that some such plan is feasible, the surgeon 
must content himself with establishing an anastomosis between 
the proximal and distal end by lateral apposition with decalcified 
perforated bone plates. The latter procedure offers all the advan- 
tages to be derived from approximation and keeping in uninter- 
rupted coaptation a large serous surface, with immobilization of 
the parts it is intended to unite during the process of repair. In 
circumscribed gangrene, due to decubitus and involving not more 
than one-half of the circumference of the bowel, affecting its lateral 
or convex surfaces, such as is caused by constriction by a narrow 
band, resection is not necessary. After the constriction has been 
removed, the gangrenous spot is turned inwards and is covered 
by suturing the adjacent healthy margins of the bowel over it. The 
serous surfaces unite rapidly, so that perforation during the sepa- 
ration of the gangrenous part is prevented by union of the serous 
surfaces over it. "When a whole loop or number of loops of the 



DIRECT TREATMENT IN STRANGULATION 57 

intestine present evidences of gangrene from constriction, the 
indications for resection are clear as affording iJie only possible 
chance of preventing death from sepsis or perforation. Unfortu- 
nately in such cases septic peritonitis has usually set in before the 
operation is performed, and it becomes necessary after the resection 
has been made and the continuity of the intestinal canal restored by 
approximation plates, to treat the peritonitis by flushing the abdom- 
inal cavity with sterilized water, and disinfection with some mild 
antiseptic, as a one-third per cent, solution of salicylic acid, as 
advised by Mikulicz. Drainage in such cases is a necessity. 

5. DiBEOT Treatment of Obstruction in Strangulation by a Band 
OR Diverticulum, Flexion, or Adhesion of the Intestines. 

The most favorable cases of intestinal obstruction for laparotomy 
are those where the obstruction is due to constriction from a narrow 
ligamentous band. The history of such cases usually points to an 
antecedent attack of localized peritonitis. One or more of the 
adhesions during the course of time are drawn out into a band under 
which the intestine is caught, and strangulation takes place in the 
same manner as in strangulated hernia. These are the cases of 
intestinal obstruction which if left alone almost without exception 
result in death; if submitted to an early operation they are cured by 
one stroke of the scissors. If the strangulated loop presents no evi- 
dence of gangrene, and no signs of decubitus are found at the point 
of compression the strangulation is relieved by cutting the band. For 
the purpose of preventing a recurrence of the strangulation from the 
same cause, it is necessary to trace the band to its points of fixation 
and resect it between two ligatures. A diverticulum of the small 
intestines, remnants of the vessels of the vitelline duct, or the 
appendix vermiformis have often been found as causes of constric- 
tion when the free extremity of these structures had become adhe- 
rent to some fixed point. It is always necessary to make a close 
examination of a constricting band before resorting to cutting 
instruments, as a mistake in recognizing the true anatomical charac- 
ter of the obstructing cause might lead to serious results. A^ narrow 
appendix may be tied and resected the same as a ligamentous band, 
but when the obstruction is caused by a diverticulum, greater care 
must be exercised in removing the cause of obstruction. Many of 
the divei-ticula which have been met with as a cause of obstruction 



58 INTESTINAL SURGERY. 

were nearly as large at their base as the intestine with which they 
were connected, and in such instances it would be unsafe to rely 
upon a ligature at the resected end in effecting permanent oblitera- 
tion, as cutting through of the ligature might be followed by 
perforation, and death from septic peritonitis a few days after the 
apparent recovery of the patient. The proximal end of such a 
resected diverticulum must be closed with the same care and in the 
same manner as the ends of the intestine after permanent interrup- 
tion of its continuity by resection, and its function by anastomosis. 

If the obstruction is found to be due to flexion, the mechanical 
difficulty must be corrected by separating the adhesions, as the apex 
of the flexion is generally if not always adherent to some fixed point; 
after this has been done the proper shape and contour of the bowel 
should be restored and its permeability tested by pushing the 
contents beyond the flexed part, and if this can be done without 
meeting with resistance, and the condition of the intestinal walls at 
the site of flexion presents no serious textural changes, the intestine 
is returned and the abdominal incision closed. As the concavity of 
the flexion is usually directed towards the mesenteric attachment the 
vascular disturbances are most marked on the convex surface of the 
bowel, and if gangrene or perforation has taken place it is found at 
this point. In either of these events it would become necessary to 
liberate the intestine by separating the adhesions and then resort 
to a " V " shaped excision on the convex side of the intestine. The 
portion to be excised must be of sufficient size to include the 
diseased tissue and to enable the surgeon to rectify the malposition 
after suturing. Immobilization of a considerable portion of the 
intestinal canal by a large blood clot and extensive parietal and 
visceral adhesions may give rise to symptoms of intestinal obstruc- 
tion. When intra-abdominal hsemorrhage is followed by a complexus 
of symptoms indicative of the presence of intestinal obstruction, 
the abdomen should be opened and the coagulated blood removed by 
sponging and flushing of the peritoneal cavity with sterilized water, 
and the recurrence of the same condition prevented by arresting 
further haemorrhage. 

A form of visceral adhesions between coils of intestines massed 
into a bunch has already been described as a cause of intestinal 
obstruction. If this condition has lasted for several days and the 
adhesions have become Arm, it is absolutely impossible to unravel 



DIRECT TREATMENT IN STRANGULATION 59 

the gut withoat ronning the risk of inflicting numberless and per- 
haps irreparable injuries. In such instances excision of the mass, 
followed by circular enterorrhaphy, or anastomosis between the 
intestine above and below the obstruction, as previously described, 
present themselves as the most appropriate methods of treatment. 
Each of these operations is applicable to special cases and adapted 
to meet particular indications. Thus if any of the embedded 
coils should present indications of incipient gangrene resection 
must be done. If no such textural changes are present intestinal 
anastomosis should be preferred, as by it the obstruction is removed 
and the portion temporarily excluded, after subsidence of the inflam- 
mation, and absorption of the adhesions, may again become perme- 
able and resume its physiological function. Circumscribed parietal 
adhesions, as a cause of intestinal obstruction, are most frequently 
met with in the pelvis, and on account of the greater frequency of 
pelvic inflammation in the female occur more frequently in women 
than men. Pelvic intestinal adhesions produce obstruction in two 
distinctly different ways: 1. An adherent intestine becomes flexed 
or twisted by the peristaltic action of the free portions and obstruc- 
tion results from sudden or gradual stenosis of the lumen of the 
boweL 2. A portion of intestine becomes fixed at either end by 
adhesions and a loop is caught under it, when obstruction is 
caused in the same manner as from ligamentous bands. 

The only case of intestinal obstruction after ovariotomy which 
occurred in my practice was produced in this manner. The pedicle 
was tied and its surface cauterized. No untoward symptoms until 
the end of the third week, when symptoms of intestinal obstruction 
appeared suddenly and increased in intensity in spite of irrigation of 
the stomach and high rectal injections. She died two weeks later. 
The post-mortem showed that a loop of the lower portion of the 
ileum had become adherent to the surface of the pedicle, and that 
the mesentery constituted the second fixed point; under this loop 
another loop four inches in length had slipped from above down- 
wards and had become incarcerated in this position. The intestine 
below the obstruction was perfectly empty, while above it was enor- 
mously dilated and exceedingly vascular as far as the duodenum. 

Quite a number of similar cases have been reported by different 
operators. In old cases of pelvic peritonitis and salpingitis the 
cause of a subsequent attack of intestinal obstruction is frequently 



60 INTESTINAL SURGERY. 

iaraceable to intestinal adhesions and the formation of ligamentous 
bands. In the separation of such old adhesions the greatest care 
must be exercised not to tear the bowel, as both the parietal and 
visceral peritoneum may have been transformed into a cicatricial 
mass which it is not safe to separate by tearing. The separation 
must be done by careful dissection, which for the sake of safety is 
done rather at the expense of the parietal than the visceral tissues. 
Defects of the peritoneum thus caused or made during other abdom- 
inal operations, should be covered either by suturing, by laying the 
omentum over it or, if need be, by omental grafts to prevent a 
recurrence of such complication. The parietal peritoneum is so 
loosely attached almost everywhere that it yields sufficiently to cover 
a defect at least two inches in width by suturing, and whenever this 
can be done it should not be neglected, as surfaces denuded of peri- 
toneum are liable to become permanently adherent to adjacent 
abdominal viscera When the omentiun is within reach this should 
be utilized in covering the defect 

During the last year I have made a number of experiments on 
animals, which demonstrate that when a piece of parietal peritoneum 
three to four inches square is removed and not restored in some of 
the above ways, permanent adhesions form between the denuded 
place and the organ that comes in contact with it. Another series 
of experiments which it would be too tedious to describe in full, 
were made to show that peritoneal defects which cannot be restored 
by suturing or covering with the omentum can be treated success- 
fully by transplantation of an omental or peritoneal graft In 
some of the experiments I removed from each side of the abdominal 
wall at corresponding points, a piece of peritoneum four inches 
square, and transplanted the pieces to opposite points and sutured 
them to the margins of the wound with catgut All of these ex- 
periments proved successful. Omental grafts answered the same 
purpose, and in only one instance did the graft fail to unite 
thoroughly, and here one of its margins projected into the median 
abdominal incision which did not unite by primary union. Infection 
of this margin led to gangrene of the graft and septic peritonitis. 

6. Toilette or Peritoneal Cavity. 

If everything that has come in contact with the abdominal 
cavity during a laparotomy for intestinal obstruction, has been 



TOILETTE OF PERITONEAL CAVITY. 61 

lendered aseptic by the most scrupulous antiseptic precautions, and 
the local conditions found have caused no infection and no soiling 
of the peritoneal cavity with intestinal contents has taken place 
during the operation, the abdominal cavity is aseptic after the 
operation and can be closed after the removal by gentle sponging, of 
any blood that may have collected. Unnecessary exposure of the 
intestines should always be most carefully guarded against by com- 
presses around the incision during intra-abdominal exploration, and 
by keeping the intestines constantly covered by warm compresses as 
long as they are outside the peritoneal cavity, for the purpose of 
preventing infection by floating microbes and to guard against loss 
of heat during the operation. The case is, however, entirely 
different when the parts concerned in the obstruction have caused 
intraperitoneal sepsis at the time the operation is imdertaken, or 
when, during its performance, in spite of all care to prevent it, the 
peritoneal cavity has become contaminated by f secal extravasation. 
Under these circumstances the peritoneal cavity should be flushed 
with gallons of sterilized warm water in which one-tenth per cent, of 
salicylic acid has been dissolved. The end of the glass tube or 
rubber tubing of the fountain syringe should be held in different 
parts of the abdominal cavity, especially in the deepest portion of the 
pelvis and the lumbar regions so as to direct the current of the anti- 
septic solution out of and not into the peritoneal cavity. After the 
abdominal cavity has been cleansed by flushing, it is dried by 
sponges wrung out of a 1-5000 solution of sublimate. In such cases 
drainage should never be omitted. The closure of the external 
incision when intra-abdominal pressure is excessive, is greatly facili- 
tated by covering the intestines with a napkin or thin compress of 
gauze which is tucked underneath the margins of the wound all 
around. The sutures should be all introduced before any of them 
are tied. When the sutures are all in place they are tied from 
above downwards. If tension is considerable it is necessary to 
add two or more button sutures, which are passed down only to, but 
not through, the peritoneum, and are removed as soon as the 
tympanites disappears. 

7. ArTER-TREATMKNT. 

Uniform equable support of the abdomen by strapping and 
bandages over the antiseptic absorbent dressing furnishes efficient 



62 INTESTINAL 8UROERY. 

support to the distended abdominal walls and the paretic intestines, 
and is not only grateful to the patient but is an important aid in 
relieying the distress due to distention and peristalsis. I have 
insisted that in all operations for intestinal obstruction, efforts should 
be made to empty the bowel not only at the seat of obstruction, 
but as far as it can be done, as such immediate evacuation consti- 
tutes one of the elements of success. 

J. Greig Smith states distinctly that "No case of operation for 
intestinal obstruction is properly concluded until the distended 
bowels are relieved of their contents." One of the most favorable 
symptoms after a successful operation for intestinal obstruction is a 
spontaneous action of the bowels, as it not only proves the permea- 
bility of the intestinal canal, but is also an evidence that peristaltio 
action has been restored. The retention of fsBcal material in the 
distended paretic intestines after operation for intestinal obstruction 
is a condition which not only retards recovery, but is in itsolf a 
grave source of danger. Through the sympathetic nerves the dis- 
tended intestine exerts a most depressing effect on the cerebro-spinal 
centers, while the putrefactive changes which are constantly going 
on in the stagnant intestinal contents, must be a constant source of 
intoxication, while the migration of septic micro-organisms through 
the paretic walls threatens life from septic peritonitis. 

Mr. Tait has taught us the value of cathartics in the prevention 
of peritonitis after abdominal operations. Would it not be rational 
to follow his example in the after-treatment of operations for intes- 
tinal obstruction ? I have repeatedly made the observation that the 
paretic intestine above the seat of obstruction will respond slowly, 
but surely, to mechanical irritation, and it is only logical to conclude 
that the same effect would be produced by the administration of a 
brisk saline cathartic. Dangerous as the use of cathartics necessa- 
rily miLst be before the obstruction is removed, so beneficial may their 
jvdicious employment be after the continuity of the intestinal canal 
has been restored by operative treatment 

IT. Anatomico-pathological Forms of Obstrnction. 

I. Entero-lithiasis. 

a. Biliary calculi. 

The term intestinal obstruction in the strict sense of the word, 
is applied most appropriately to that form of obstruction where the 



ENTERO'LITHIASIS.— BILIARY CALCULI. 63 

lamen of the bowel is occupied and completely closed by a foreign 
body or an enterolith. A foreign body introduced into a healthy 
bowel, even if it completely fills its lumen, does not necessarily 
produce intestinal obstruction, as the healthy intestine is capable of 
dilatation to a sufficient extent to furnish an outlet to fluid intestinal 
contents between the wall of the bowel and the foreign body. The 
following experiments were made for the purpose of studying the 
effect of the presence of a foreign body of sufficient size to interfere 
with the passage of intestinal contents, and also with a view of 
ascertaining if the exclusion of peristaltic action of a certain segment 
of the intestine could produce intestinal obstruction. The opera- 
tions were performed under strict antiseptic precautions, and the 
abdominal incision was always made through the linea alba. The 
animals were fed on the coarsest kind of food, and as a rule their 
appetites were not impaired by the operation. 

EsBperiment 1. Dog, weight thirty-four pounds. The ileum was drawn 
forward into the abdominal womid, and an incision made abont an inch in 
length, on the convex surface abont twelve inches above the ileo-csBcal valve, 
and throngh this opening a stiff tnbe fonr inches in length, and three-qnar- 
ters of an inch in diameter, was inserted in a downward direction. The 
mbber tnbe distended the bowel so thoroughly as to produce a limited longi- 
tudinal rupture of the peritoneal coat. This tube was pushed forward as far 
as the iLeo-ciBcal valve, when the intestinal wound and the peritoneal rent were 
sutured. The visceral wound was covered with an omental graft which was of 
sufficient length to embrace the entire circumference of the intestine, and was 
Axed in its place by two catgut sutures, which were passed through the mesen- 
tery and both ends of the graft. The intestine was now thoroughly cleansed, 
dried, and returned, and the abdominal wound closed. The tube was passed 
per rectum in sixty hours. No symptoms of obstruction were observed 
during this time, and the animal remained in perfect health until killed twenty 
days after the operation. The intestinal wound was recognizable upon the 
external surface of the bowel by a ridge, which consisted plainly of a portion 
of the omental flap; the remaining portion had evidently disappeared by 
absorption, at least it had become invisible to the naked eye. The interior 
surface of the bowel along which the rubber tube had to pass on its way out 
of the body presented nothing abnormal. 

Experiment 2, Dog, weight twenty-four pounds. In this instance the 
incision of the bowel was made eighteen inches above the ileo-csBcal region, 
and instead of a rubber tube a glass tube three and three-quarters inches in 
length, and half an inch in diameter, was introduced and pushed along the 
bowel until its distal end was within six inches of the ileo-c89cal valve. Omen- 
tal graft over the visceral wound. No symptoms. Tube passed in sixty-eight 



64 INTESTINAL SURGERY. 

hours. Dog killed fifty-seyen days after operation. Intestinal canal throngh- 
out healthy. Omental graft had disappeared completely. 

Experiment 3, Dog, weight sixty-two pomids. Incision of bowel twelve 
inches above ileo-caecal region, and of soffloient size to permit the insertion 
of a glass tube five-eighths of an inch in diameter, and six inches in length, 
which was pushed in a downward direction to within an inch of the ileo-csdcal 
valve. The tnbe filled the Inmen of the gat completely, bnt produced no 
tension in the walls. No symptoms. One month later the abdomen was again 
opened, and the tnbe was found in the descending colon. The abdomen was 
closed and the tube was passed per rectum four days later. 

In these experiments hollow tubes were used, and it might be 
daimed that intestinal obstruction was not produced because the 
fluid intestinal contents could pass through the lumen of the tube. 
The effect of the peristaltic action of the bowel in that portion 
occupied by the tube was certainly eliminated as far as the faecal 
circulation is concerned, and yet no symptoms of obstruction during 
life were observed, and the post-mortem appearances indicated that 
no obstruction had existed during life. It is certainly surprising 
that the peristaltic action of the intestine should be able to force a 
rigid tube of such length and dimensions as were used in the last 
two experiments through the ileo-csecal valve into the colon. 

In the following experiments the foreign body which was intro- 
duced was of such a structure that in case it filled the entire lumen 
of the bowel it would of necessity produce intestinal obstruction, 
unless a space for the passage of intestinal contents would be created 
between the foreign body and the intestinal wall, by dilatation of 
the bowel. 

Experiment 4, Dog, weight thirty-four pounds. Intestine was incised at 
the junction of the ileum with the jejunum and the barrel of a glass female 
syringe six .inches in length, and half an inch in diameter, was inserted with 
the closed end in a downward direction. The animal never showed any 
untoward symptoms, and as the syringe was not found in the f sBcal discharges, 
the animal was killed six weeks later, when it was ascertained that it must 
have passed at some previous time through the normal outlet, as it could not 
be found, and the intestine presented throughout a normal appearance. 

Experiment 5, Dog, weight sixty pounds. In this experiment the incision 
in the bowel was made thirty inches above the ileo-csBcal valve, and through 
it was inserted with considerable force a g^ass female syringe six and a half 
inches long and three-quarters of an inch in diameter, with a metal cap which 
considerably increased its diameter at this point. The piston of the syringe 
projected one inch and a half from the cap. The perforated end of the 
syringe was directed downwards. Visceral wound protected by a circular 
omental graft. For the first few weeks the animal appeared to be in good 



ENTERO-LITHIASIS,— BILIARY CALCULI, 65 

condition, and the fsBoal discharges were*normal. Later the appetite became 
impaired and the last few days obstinate constipation appeared. The dog 
was killed forty days after the insertion of the foreign body. At this time the 
syringe conld be plainly felt through the abdominal wall. The syringe was 
found in the ascending colon, haying passed through the ileo-csBcal valve. 

The ileo-c89cal region was distended and partially obstructed by a mass of 
straw, hair, fragments of bone, etc., for a distance of about ten inches. 
Above this point the bowel was considerably dilated and contained liquid 
fsdcal matter. Several ulcerations were found in the portion of ileum traversed 
by the syringe. The lowest ulcer was about an inch and a half in length and 
half an inch wide, reaching as far as the Ueo-csecal valve, and apparently of 
recent date. The next ulcer, about one inch longer, but of the same width, 
was found six inches higher up. This ulcer presented a granulating surface 
and beginning cicatrization. The third point of ulceration was twelve inches 
above the ileo-csecal valve, in an advanced stage of cicatrization. These ulcers 
were evidently of traumatic origin and were undoubtedly caused by friction of 
the intestinal wall against the projecting point of the piston, in the attempts 
of the bowel to propel the foreign body by increased peristaltic action. In this 
case the intestinal obstruction commenced with the accumulation of solid 
material on the proximal side of the syringe, being in reality not caused by 
the foreign body, but by the coprostasis. Had this latter condition not devel- 
oped, the foreign body would undoubtedly have been expelled spontaneously, 
as in the former experiments. 

These experiments furnish positive proof that a foreign body of 
sufficient size to fill the entire lumen of a healthy intestine above 
the ileo-csecal valve causes no obstruction, and that when obstruc- 
tion takes place in such instances, it is caused by tissue changes in the 
intestinal wall arising from prolonged contact with the foreign body. 
In reference to these points we shall consider the subject of entero- 
lithiasis as a cause of intestinal obstruction. Entero-lithiasis in 
man is due in the great majority of cases to the impaction of a 
gaU-stone or the formation of an enterolith in the lumen of the bowel, 
the nucleus of which is a gall-stone. It has been a disputed ques- 
tion in what way a gall-stone of sufficient size to give rise to obstruc- 
tion could enter the intestinal canal. Bokitansky asserted that a 
calculus the size of a hen's egg may pass through the bile-ducts. 
It is now generally believed that, as a rule, at least, such large con- 
cretions can only escape from the gall-bladder by ulceration through 
its walls, or that a gall-stone of smaller size after it has passed 
through the bile-ducts, subsequently becomes larger by the forma- 
tion of concentric concretions during its retention in the intestinal 
canal. In reference to the frequency of this form of obstruction 



66 INTSSTINAL SURGERY. 

Leiohtdnstem has found that Out of fifteen hundred and f ort^-one 
cases of intestinal obstmction with different causes, tabulated by 
himself, forty-one were produced by gall-stones. 

Wising* collected fifty-one cases of intestinal obstruction caused 
by the presence of biliary calculi, with the result that in only 
twenty-four of them could the anatomical condition of the gall- 
bladder be ascertained. In eighteen of these the post-mortem 
appearances showed that the calculus had entered the intestine from 
the gall-bladder by a process of ulceration, and only in three cases 
it appeared as though the calculus had passed througn the common 
bile-duct. In thirty -three cases the place of obstruction was twelve 
times the jejunum, and twenty-one times the ileum. In the twenty- 
one cases where the calculus was impacted in the ileum, the seat of 
obstruction in two was in the middle, in six in the upper half, and in 
twelve in the lower half of this portion of intestine. Icterus was 
observed only in eight of the fifty one cases. The prognosis is 
always very grave, as of the fifty-one cases thirty-eight died. In 
twenty -five fatal cases, death occurred fourteen times between the 
sixth and the eighth day, while in isolated cases it did not occur 
until from the ninth to the twenty eighth day, and one patient died 
after two months from perforative peritonitis. Taking all cases of 
obstructions from gall-stones together, we can say that the seat 
of obstructions is located in the lower portion of the ileum in fifty 
per cent, of the cases. The upper part of the jejunum is the next 
most frequent site of obstruction, and in a few cases the gall-stone 
becomes impacted in the duodenum at the site where it has ulcerated 
through the walls of the gall-bladder and intestine. In thirty-two 
cases collected by Leichtenstem, the gall-stone occupied the duode- 
num and jejunum in ten cases, middle of ileum in five cases, lower 
part of ileum in seventeen cases. 

Treves is of the opinion that gall-stones causing intestinal 
obstruction ulcerate directly into the intestine. He had oollected 
forty-eight cases of obstruction due to gall-stones. In the majority 
of cases direct evidence of ulceration between the gall-bladder 
and duodenum was to be obtained. The gall-bladder was entirely 
disorganized in a case in which the gall-stone was supposed to 
have traversed the biliary ducts. When impaction takes place high 

^ Ueber Gallenstein ileus. Nord Med. Archiv., B. XVII, No. 18. 



ENTERO'LITHJASIS.— BILIARY CALCULI. 67 

up in the intestinal tube, tympanites may be entirely wanting and 
the symptoms point rather to the existence of pyloric stenosis than 
intestinal obstmction. The higher the location of the impaction 
the greater the probability that the calculus attained its size 
within the biliary passages, and that it entered the intestine by a 
process of ulceration. In some cases the communication between 
the gall bladder and the duodenum remained at the time of death, 
showing that perforation had only recently taken place. Wising 
has reported such a case. The patient was a woman, seventy years 
of age, who had never suffered from biliary colic or jaundice. The 
attack of intestinal obstruction was acute, faecal vomiting being 
an early symptom, slight icterus and little tympanites, death on 
the fifth day. At the necropsy a biliary calculus 7 cm. in length 
and 10 cm. in circumference was found firmly impacted in the 
ileum. The intestine on the proximal side was found greatly 
distended and of a color suggesting incipient gangrene, while the 
bowel belaw the obstruction was pale and contracted Gall-bladder 
ulcerated and contracted by cicatricial tissue communicating with 
the duodenum by a perforation above the common bile-duct. A 
smaller communication was also found between the gall-bladder 
and the transverse colon. Shattock^ mentions a case under the 
care of Dr. Bristowe, in which the remains of the gall-bladder, 
which was very small, communicated directly with the intestine. 

In some cases the pathological conditions within and around the 
gall-bladder show evidences which go to prove that perforation had 
taken place long before the development of the intestinal obstruc- 
tion. In such cases the gall-stone must have occupied the intestinal 
canal for a vtiriable period of time without having given rise to 
obstruction, the intestinal contents passing between it and the intes- 
tinal wall in the same manner as in the experiments detailed above. - 
In some cases the gall-stone becomes encysted and symptoms of 
obstruction are not produced until the size of the stone has increased 
by the addition of concentric layers of concretion. Harley^ reported 
a case where a gall-stone became encysted in the duodenum. 
Woodbury' reports a case that came under the observation of Dr. 
T. H. Andrews, of a woman sixty years of age, who was suddenly 

1 British Medical Jonmal, March 19, 1887. 
^ Path. Soc. Transactions, London, vol. YIH. 
' Amer. Jonr. Med. Sciences, January, 1880. 



68 INTESTINAL SURGERY. 

attacked with symptoms of acute intestinal obstruction wittiout 
having previously suffered from any disorder of the biliary passages. 
She died on the seventh day. A concretion the size of an English 
walnut was found firmly impacted in the upper portion of the 
jejunum. Upon section the concretion was seen to consist of a 
brown, friable, cortical substance, enveloping a, dense, white crystal- 
line body as large as a cherry, which was evidently cholesterine. It 
appears that in this case a small gall-stone which had passed 
through the bile-ducts without producing symptoms, was in some 
way retained high up in the intestine, and served as a nucleus for 
the formation of an enterolith of sufficient size to give rise to intes- 
tinal obstruction. 

Barlow ^ reports the case of a woman fifty-seven years of age 
who had symptoms of gall-stones for a year. She suddenly devel- 
oped an acute intestinal obstruction from which she died. About 
the center of the ileum there was found a biliary calculus of the size 
of a walnut, partially sacculated. In some rare cases the obstruction 
is caused by the retention of numerous calculi in a circumscribed 
portion of the bowel. Metcalfe' presented to the New York Patho- 
logical Society a specimen taken from a man fifty-four years of age, 
where the duodenum was occupied by numerous gall-stones in such a 
way as to give rise to complete obstruction. 

A calculus may attain great size before it becomes impacted. 
Smith ^ observed a case of acute intestinal obstruction which proved 
fatal on the fifth day, where the post-mortem revealed the cause 
to be a biliary calculus measuring four and a half by two and a half 
inches in circumference, which was found impacted in the jejunum 
thirty inches below the pyloric orifice of the stomach. 

Clark ^ relates the case of a woman fifty-eight years of age who 
died of acute intestinal obstruction, where two large gall-stones were 
found impacted immediately above the ileo-csecal valve, each of 
which was one inch in length and four inches in circumference, 
and together weighed one and one-fourth ounces. The stones 
were composed of cholesterine and coloring material of bile. The 

1 Gay's Hospital Reports, 1884. 

^ Transactions New York Pathological Society, vol. n, pp. 2, 8. 
' Pathological Society's Transactions, London, 1854. 
^ A Case of Large Biliary Oonoretion in the Ilenm. Medico-Chimrg. Trans., 
vol. 55, p. 1. 



ENTERO'LITHIASIS,— BILIARY CALCULI. 69 

intestine was perforated at the seat of impaction and a number of 
small gall-stones was found in the peritoneal cavity. The biliary 
passages were dilated and thickened, but the gall-bladder appeared 
to be normal in size and structure and not adherent to the duodenum; 
jaundice had never existed. Eight months previous to the last ill- 
ness she had a similar attack of obstruction and at that time a firm 
tumor could be felt in the right hypochondriac region. This and 
the next case illustrate that the great danger of impaction of a gall- 
stone consists of textural changes of the intestine at the site of 
impaction. Meymott's* patient was a woman forty-seven years old, 
who died after a short illness during which symptoms of intestinal 
obstruction were well marked. At the necropsy a gall-stone com- 
posed of cholesterine, and weighing four hundred grains was found 
impacted in the ileum four inches above the ileo-csecal valve. At 
the seat of impaction circumscribed gangrene and perforation had 
taken place. 

Fagge,'^ in his excellent paper "On Intestinal Obstruction", 
gives an account of a case which he examined where, in a woman 
sixty-nine years of age, who had died with symptoms of intestinal 
obstruction, a gall-stone measuring four and a half inches in its 
largest circumference and two and a half inches in its smallest, was 
found impacted in the jejunum thirty inches below the pyloric orifice 
of the stomach. The stone had passed from the gall-bladder into 
the duodenum through a perforation, firm adhesions having pre- 
vented its escape into the peritoneal cavity. In two other cases to 
which the same author refers, the patients suffered from intestinal 
obstruction, and recovery followed after the evacuation of gall-stones 
of immense size. In cases terminating by spontaneous recovery he 
believes that perforation takes place into the colon. That the danger 
is not always passed when a large biliary calculus enters the colon 
directly through a perforation of the gall-bladder is well illustrated 
by a case reported by Bourdon,^ where the calculus became lodged 
in the sigmoid flexure, where it produced an inflammation which 

^Impaction of a Large Gall-stone in the Ilenm. The Lancet, April 
27, 1872. 

''On Intestinal Obstrnction. Guy's Hospital Beports, vol. XIV. 

^ Oalcnl biliare d'nn volnme considerable, tomb^ dans le tube digestif k 
trayers les parois perfor^es de la vesicnle et dn colon transverse. Gaz. des 
HOpitanx, No. 72, 1859. 



70 INTESTINAL SUROEBY, 

proved fatal. In a uumber of cases reoovery took place by discharge 
of the oalcnlas per viam naturalis even after the symptoms had 
pointed to complete obstruction. The largest stone which has been 
saocessfnlly passed was three and a half inches in circumference. 
Pye-Smith ^ narrates a case which tends to show that in cases 
of intestinal obstruction due to the presence of a biliary calculus, a 
spontaneous cure is possible even after the symptoms have continued 
for a number of days. The patient was a female seventy-eight years 
of age who had never suffered from jaundice, and gave no history of 
biliary colic She had always been very constipated; obstruction 
finally ensued; and after some temporary relief became complete. 
By external palpation no tumor could be felt. On rectal examina- 
tion, however, the finger could just reach a smooth, hard, movable 
tumor, and it seemed probable that there was malignant disease of 
the colon. After thirteen days of complete obstruction, however, a 
large gall-stone was passed, and the patient recovered quickly, and 
subsequently remained free from the trouble. 

Treatment. 

Foreign bodies when impacted in the intestine set up inflam- 
mation, and this may go on to gangrene and perforation, and so it 
can be explained how cathartics under such circumstances are more 
likely to do harm than good. If impaction has taken place near 
the Ueo-csecal valve or in the colon, large injections and massage 
may be tried, provided symptoms of severe inflammation or gangrene- 
at the site of impaction are absent. In the great majority of cases, 
however, the local lesions at the site of impaction are of such a 
nature at the time surgical aid is summoned, that nothing short of a 
laparotomy will promise any hope of success. It will be well for 
the surgeon not to place too much importance upon the presence of 
tympanitic distention of the abdomen in these cases as an indication 
for the necessity of an abdominal section, as ihia sign may be 
.entirely absent if the impaction is located high up in the intestinal 
tract, and if the impaction is in the lower part of the ileum or colon 
an operation should not be postponed until such distention has taken 
place. After the abdomen has been opened in the median line, and 
the seat of obstruction determined, the course to be pursued will 
depend upon the pathological conditions at the seat of impaction. 

^ British Medical Jonrnal, March 19, 1887. 



BILIARY CALCULI,— TREATMENT. 71 

As the mtLGOUd mombrane in contact with the f oregn body is always 
first to snfPer in consequence of the impaction, puncture and incision 
should be avoided at this point. 

As the cases must be few where such a stone, even soon after 
impaction has taken place, can be pushed along the intestinal canal 
and through the ileo-csecal valve into the colon, submural crushing 
of the stone should be practiced where attempts at distant displace- 
ment have failed, and where the condition of the intestinal wall 
is such that no fear need be etitertained that gangrene or perfora- 
tion will take place. The stone should never be attacked at the seat 
of impaction, but shouid be pushed in an upward or downward 
direction, and then removed if possible by breaking it up by manual 
pressure, or, if this fail, the method suggested by Tait^ ^f passing 
in a needle obliquely through the intestinal wall and attacking the 
calculus in this manner may be tried. A stout steel needle, such as 
is used for electrolysis, is best adapted for this purpose. The needle 
should always be introduced obliquely through the intestinal wall an 
inch or two below the impaction in order to secure healthy tissue for 
the seat of puncture. After the stone has been crushed and the 
debris within the gut has been pushed into a healthy segment of 
bowel below, the puncture in the serous coat should be closed by 
drawing the peritoneum over it wtth a fine superficial suture for the 
purpose of guarding against leakage. 

When efforts at submural crushing or fracturing of the entero- 
lith have failed and it is deemed necessary to excise it, it is also 
advisable to push the foreign body within the gut iii an upward or 
downward direction sufficiently far to bring it to a perfectly healthy 
portion of the intestine, as the healing process of the visceral wound 
made for its extraction would proceed more satisfactorily here than 
where the tunics of the intestine had undergone pathological 
changes in consequence of the impaction. If the stone cannot be 
displaced and the incision must be made through an inflamed 
intestinal wall a graft of omentum should be placed around the 
intestine, after suturing the visceral wound so as to cover the 
wound, and its ends fastened together by two sutures passed through 
the mesenteric attachment. Such a procedure will place the visceral 
wound in the very best condition for healing and will furnish an 

1 The Lancet, Beoember 10, 1887. 



72 INTESTINAL SURGERY. 

additional safeguard against subsequent perforation. If the intes- 
tine at the site of impaction shows evidences of gangrene or if 
perforation has already taken place no efforts should be made to 
extract the stone, as under such circumstances the surgeon is 
compelled to resect that portion of intestine in which the stone is 
imprisoned. As patients presenting such conditions are always 
more or less collapsed it becomes of the greatest importance to finish 
the operation as rapidly as possible; consequently after the resection 
has been made in the usual manner, the continuity of the intestinal 
canal should be restored by an operative procedure which can be 
executed without unnecessary loss of time. 

As the bowel above the seat of obstruction is always found 
greatly dilated, circular enterorrhaphy for this reason alone would 
be a difficult if not impracticable task ; hence both ends of the intes- 
tine should be invaginated to the extent of an inch and the invagi- 
nation maintained by three or four superficial stitches of the con- 
tinued suture, and the continuity of the intestinal canal restored by 
making an incision an inch in length in each closed end of the bowel, 
on the convex surface about two inches from the sutured extremity, 
and lateral apposition of the wounds secui^ed by decalcified perfo- 
rated bone plates. This method should always be preferred to circu- 
lar enterorrhaphy in uniting the bowel after resection under such 
circumstances, as the extensive and secure coaptation of serous sur- 
faces greatly enhances the chances of early union between the coap- 
tated bowels, and at the same time establishes a communicating 
opening equally serviceable as that after circular suturing. 

b. Intestinal Ooncretions. 

We have already seen that a small gall-stone when retained for 
a sufficient length of time in the intestinal canal may become the 
nucleus for an intestinal concretion, which by the addition of 
concentric layers gradually increases in size until it fills the lumen 
of the bowel, and after its impaction gives rise to intestinal obstruc- 
tion. Enteroliths causing obstruction have been found in which a 
variety of foreign bodies have been found as nuclei. 

Cloquet^ divides the concretions found in the alimentary canal 
into two classes. The first includes enteroliths in man, and bezoars 
in animals, both being the result of calcareous deposits secreted by 

^ Amer. Jonr. Med. Sciences, Jannary, 1856, p. 216. 



ENTER0-LITHIA8IS,— INTESTINAL CONCRETIONS, 73 

the parieties of the intestines. The second class comprises abnormal 
masses, such as solids, (animal or vegetable hairs which have escaped 
the process of digestion, and agglomerate to form segagropili), 
pulverulent substances, and foreign bodies, such as kernels of fruit, 
biliary calculi, and hardened faeces. He described an enterolith 
which formed around a pin as a nucleus, by deposits of phosphate of 
lime and which had become arrested in the csecum, where it caused 
the death of the patient. In another case he found that the nucleus 
was composed of an ivory pessary which had perforated the bowel on 
one side and the bladder on the other. The perforation of the bowel 
was covered by a concretion of phosphate of lime, while the part in 
the bladder was encrusted with uric acid. 

Aberle^ reported a case where chronic intestinal obstruction was 
caused by the presence of thirty-two enteroliths, each of which was 
composed of a concretion in concentric layers around a cherry stone 
as a nucleus. The concretions had collected in the colon and were 
successfully removed by rectal injections and cathartics. A chemical 
examination of the concretion showed that it was composed of 
phosphate of lime and a considerable quantity of fat, animal glue, 
and traces of cholesterine. 

Schoor^ described an enterolith which for five years had given 
rise to pain, first in the ileo-csecal region and later in the left inguinal 
region, and was finally discharged spontaneously. It measured 
four and one-half inches in length and 2.9 inches in width and 
weighed 44.9 grammes. On making a section of it, it was found 
that the central portion or nucleus was composed of a triangular 
piece of bone around which in concentric layers the concretion was 
arranged. A chemical examination of the concretion showed that 
it was largely composed of phosphate of ammonia and magnesia, 
the remaining part of it consisting of vegetable fibres, coloring 
material of bile, cholesterine, and chloride of sodium. 

Yirchow^ made a careful chemical and microscopical examination 
of an enterolith which had caused symptoms of obstruction in a 
woman, but was finally expelled after a severe attack of colica ster- 
coralis. The stone measured 5 cm. in length and 8.5 cm. in its 

^ Bin Fall von Steinbildnng in Barmkanale. Wtlrt. Hed. Gorresp. blatt, 
No. 23, 1868. 

^ Canstatt's Jahresbericht, B. 2, 1853, p. 64. 
' Virohow's Archiv. B. XX, Heft 3 n. 4. 



74 INTESTINAL SURGERY, 

greatest circumference. On making a secition through the center 
it was seen to be composed of a plum-stone surrounded by a shell 
2 cm. in thickness, made up of concentric layers of crystalline bodies 
held together by a brownish mass. Chemical analysis showed that 
the shell was composed largely of phosphate of ammonia and* 
magnesia. 

In Friedlander's^ case the obstruction was due to the impaction 
of an enterolith in the ileum 80 cm. above the ileo-csecal valve, 
which was composed of shellac. The patient was a cabinet-maker, 
and it is said that the apprentices of this trade not infrequently 
consume the alcoholic solution of shellac used for varnishing; in the 
stomach the alcohol is absorbed, and the shellac is deposited In 
this case the stomach contained a large number of the same kind of 
concretions. 

At the 9ieeting of the Congress of German Surgeons in Berlin, 
in April, 1880, Langenbuch^ showed some large concretions, some 
of which he had removed by enterotomy in a patient who had suffered 
from repeated attacks of intestinal obstruction. As the symptoms 
became more urgent and failed to yield to simpler measures, abdom- 
inal section was performed in the median line, and the operator 
without much difficulty found a swelling in the jejunum, laid open 
the intestine, and removed the mass of concretions which completely 
filled the lumen of the bowel. Vomiting continued and the patient 
died a few hours after the operation. The necropsy revealed a 
secondmass still larger, in the pyloric region of the stomach. Yirchow 
examined the concretions and found that they consisted almost exclu- 
sively of organic substance, and especially of the derivative of the 
biliary acids known as dyslysin. 

The surgical treatment of intestinal concretions is the same as 
in cases of impacted gall-stones. 

o. Parasites as a Cause of Intestinal Obstruction. 

A few cases of intestinal obstruction have been recorded where 
the obstruction was caused by a mass of ascarides which interfered 
with the passage of intestinal contents in the same manner as an 

• 

* Schellack-steine als Ursache von Hods. Berl. Klin. Woohenfiohrift, No. 
1, 1882. 

2 Verh. der deutschen Gesellschaft f . Ohirnrgie, 1880. 



ENTERO'LITHIASIS.— PARASITES AS A CAUSE. 75 

enterolith. Halma-Gnmd^ refers to a patient ten years of age that 
came under his care suffering with the characteristic symptoms of , 
acute intestinal obstruction, followed by hsamorrhage from the 
bowels, collapse and death. The necropsy reyealed as the cause of 
obstruction a mass of ascarides eighteen in number which completely 
filled the lumen of the ileum. At the site of impaction an ulcer was 
found showing an eroded vessel which had been the source of 
haemorrhage. 

Saurel's^ patient was twenty-three years of age, who suffered 
from symptoms which resembled closely an attack of intestinal 
obstruction. A swelling could be felt to the left of the umbilicus. 
Two ascarides were thrown up during a severe attack of vomiting. 
Anthelmintics were administered and injections given without any 
effect, and the patient died in collapse. The necropsy revealed the 
cause of obstruction to have been a mass of ascarides which were 
firmly impacted in the lower part of the ileum. 

Pockels' was called to attend a patient who had suffered for 
some time from an intra-abdominal swelling the size of a hen's egg 
which could be distinctly felt below and to the left of the umbilicus. 
A purge of male fern and jalap expelled one hundred and three 
ascarides, after which the tumor disappeared and the patient's health 
was completely restored. 

Stepp^ has recently recorded an instance in a boy, aged four, 
who died with symptoms of acute intestinal obstruction an hour and 
a half after medical aid was summoned. The post-mortem showed 
that the intestine was completely obstructed by a twisted mass of 
some forty or fifty round worms, lodged just above the ileo-csecal 
valve. The ileum contained about thirty-five more, higher up, and 
there were a few in the stomach and cesophagus. The mother of 
the child had given the patient some worm medicine a few days 
before the acute attack, and Stepp thinks that the worms, weakened 
by the medicine, were dislodged in numbers by the violent peristalsis 

^Enteritis Verminosa. Mit Darmblntnng u. EinklemmnngBerschein- 
xmgen. Schmidt's Jahrbtlcher, B. 99, p. 92. 

2 Darmverstopfnng dnroh Wlirmer. Schmidt's Jahrbflcher, B. 99, p. 92. 

^Briefliche Nachriohten tiber Bnndwtlrmer. Schmidt's Jahrbtloher, B. 
99, p. 92. 

* Centralblatt f . die med. Wissensch, No. 27, 1888. 



76 INTESTINAL SURGERY, 

set up by an injudicious diet afterwards, and so rolled down in 
a tangled mass too large to pass the ileo-csecal valve. 

When the surgeon is called upon to treat a case of intestinal 
obstruction in a child, such a cause should be borne in mind, as in a 
case of this kind, a timely anthelmintic remedy followed by a brisk 
cathartic may prove efficient in removing the cause of obstruction. 
If such treatment should prove unavailing, no time should be lost in 
resorting to operative treatment by abdominal section, which is to be 
conducted in the same manner as in operations for intestinal con- 
cretions. 

d. FsBcal ObBtruotion. 

Fsecal obstruction is almost without exception met with only in 
the large intestine, and here in preference, in the csBcal region or in 
the sigmoid flexure. Gases have been reported where a congenital 
abnormal dilatation of some part of the colon predisposed to this 
affection. The acquired form of dilatation which attends all cases is 
the result of prolonged overdistention resulting in paresis of the 
distended segment of the bowel. 

Boys de Loury ^ has collected a number of cases of retention of 
faeces \a the caecum and colon which Anally gave rise to inflammation 
at the seat of impaction, and intestinal obstruction. Among them 
was one observed by N^laton, where the faecal tumor, occupying the 
caecum and ascending colon, by pressure against the under surface of 
the liver and gall-bladder, caused icterus. The icterus and symptoms 
of obstruction disappeared promptly after the removal of the faecal 
accumulation by cathartics. Retention of faeces after a time pro- 
duces more or less acute enteritis, attended by tympanites, pain, and 
dyspnoea. The patients usually have been constipated for a long time, 
sometimes alternating with diarrhoea. The retained faeces become 
inspissated and hard and form mural concretions, the middle often 
remaining tunneled for the passage of fluid faeces. The masses are 
modelled and when thrown off often describe in accurate outline the 
contour of the bowel. Distention of the bowel often takes place to 
an enormous extent. Cruveilhier found on making a necropsy on an 
old man, the transverse colon so dilated that it measured 35 cml in 
circumference. The caecum was even more dilated and was the size 
of a child's head. In one of my cases of periodical accumulation of 



^ Gaz. hebd., No. 28, 1868. 



ENTEBO'LITHIASIS—FJSCAL OBSTRUCTION, 77 

• 

faeces in the sigmoid flexure, the patient would only return for treat- 
ment at a time when symptoms of obstruction set in, and every time 
he presented himself the swelling woulc^ occupy almost the entire 
space in the abdomen below the umbilicus. Mechanical removal of 
the f 8Bcal accumulation followed by massage and the use of the Far- 
adio current and galvanism had no effect in diminishing the size of 
the bowel, or in preventing the periodical accumulation of faeces. If 
the caecum alone is the seat of impaction it often presents the appear- 
ance of a circumscribed tumor which maybe, and has been mistaken 
for an ovarian tumor, abscess or carcinoma. The retained mass con- 
stitutes an irritant which sooner or later causes a catarrhal enteritis, 
which extends to the remaining tunics and is often the direct cause 
of perforation or diffuse peritonitis. In some instances the inflamma- 
tion extends to the connective tissue around the intestine and an 
abscess forms without an antecedent perforation. The distended 
bowel gradually becomes paretic and the local and general symp- 
toms are aggravated. 

One of the most important diagnostic points is to niake pressure 
over the tumor in chloroform narcosis, when the faecal masses become 
displaced, leaving a permanent depression at the' point of pressura 
If the impaction is within reach the removal should be accomplished 
by the use of a scoop, assisted by copious injections. If the bowel at 
the seat of impaction has lost its contractility the use of cathartics is 
useless, and if it is in a state of inflammation, positively hurtful. In 
such cases massage and high injections are indicated. Perforation 
and suppurative inflammation in the connective tissue surrounding 
the bowel must be met by prompt surgical treatment In cases 
where all ordinary measures fail in removing the faecal accumulation 
and the symptoms of obstruction continue unabated, it would be not 
only justifiable, but good surgery, to cut down upon the distended 
bowel and to break up the mass within the gut and push it along to 
a portion of the intestine where peristaltic action has not been 
impaired. In cases where the intestinal wall presents pathological 
conditions which would contra-indicate such a course of treatment, 
it may become necessary to resort to enterotomy and remove the 
faecal mass through the wound, and according to circumstances either 
close the visceral wound by suturing, or establish a temporary 
artificial anus in one of the inguinal regions. 



78 INTESTINAL SURGERY. 

m 

t 

2. Invagination. 

Treves' asserts that thirty per cent, of all forms of intestinal 
obstruction, exclusive of ^emia and congenital malformations, are 
cases of invagination. The same author recognizes clinically four 
forms. The ultra-acute is very rare, and terminates fatally in twenty- 
four hours ; the acute, lasting from two to seven days, numbered 
about forty-eight per cent, of all cases of invagination; the sub-acute, 
lasting from seven to thirty days, are about thirty- four per cent. ; and 
the chronic, lasting over thirty days, occurred about eighteen times 
out of every one hundred cases. As far as the operative treatment 
is concerned it is exceedingly important to classify all cases into 
acute and chronic, as in the former class the symptoms appear with 
' great violence, and the pathological changes at the seat of invagina- 
tion come on so rapidly that death is inevitable, unless efficient 
surgical treatment is resorted to before the tissues at the seat of 
invagination have -undergone changes incapable of repair. In the 
chronic form the symptoms are never so urgent and the adoption of 
early radical measures is not so urgently indicated. Of the anatom- 
ical forms, in the cases collected by Treves, thirty per cent, were 
enteric; eighteen,. colic; forty-four, ileo-csecal; and eight, ileo-colic. 
The enteric forms are most common at the lower part of the jejunum, 
and are small. The colic forms are mostly to the left of the trans- 
verse colon. The latter as a rule belong to the chronic form of 
invagination. 

Leichtenstern^ calls an invagination ileo-ceecal when the ileo- 
ceecal valve is pushed forward and forms the apex of the intussuscep- 
tum; ileo-colonic when the ileum is pushed through the valve. The 
invagination always increases at the expense of the intussuscipiens. 
In examining four hundred and seventy-nine cases of invagination 
in reference to the anatomical location of the lesion he gives the 
following figures: 

Ileo-c8Bcal 212 

neum 142 

Colon 86 

Ileo-colonic 39 

479 

^ The Lancet, December 13, 1884. 

^Ueber Darm-Invagination. PragerVierteljahrssohrift f. Heilknnde. B. II 
n. Ill, 1873. 



INVAGINATION. 79 

I shaQ not endeayor to elaborate upon the viewp entertained by 
different authors and experimenters concerning the mechanism of the 
ordinary forms of invagination, but from a surgical aspect it is impor- 
tant to allude to some of the pathological conditions which produce 
the invagination, and at the same time complicate the treatment. 
Mr. Bellamy^ has described a case of a very rare form of intestinal 
obstruction, due to invagination of a portion of small intestine in 
the walls of the rectum, successfully treated by abdominal section. 
The obstruction had been complete for nine days. The patient was 
a female who had been subject to obstinate constipation, and on 
three occasions the retention of f secal matter had given rise to serious 
symptoms, which, however, had always yielded to ordinary means. 
On admission into the hospital a hard swelling could be felt in the 
left iliac fossa, in the region of the inguinal canal and sigmoid 
flexure. Manual examination of the rectum disclosed an obstruc- 
tion in the upper part of this portion of the intestine. As the 
symptoms of obstruction became urgent and failed to yield to ordi- 
nary treatment, abdominal section was performed after exploration of 
the left external inguinal ring, which had been the seat of an old 
hernia, by enlarging the incision upwards and obliquely outwards. 
On introducing the hand into the abdomen it was ascertained that 
the swelling in the iliac region was composed of a knuckle of small 
intestine which was obviously invaginated in the anterior aspect of 
the first part of the rectum, and in addition there was felt what 
appeared to the touch to be bands of organized lymph, stretching 
across in the same place, and probably the result of a former circum- 
scribed peritonitis. The operator intrpduced his right hand into the 
rectum and pushed the prolapsed mass upwards and towards his left 
hand, which was in the pelvic cavity, at the same time breaking down 
the adhesions and gently drawing out the knuckle from its imprisoned 
position, and freeing it from the peritoneal fold. The symptoms of 
obstruction subsided promptly and the patient, after having passed 
through a moderate attack of peritonitis, made a complete recovery. 

In examining the literature of the subject the author had been 
unable to find any case where abdominal section had been performed 
for a similar condition, although Lockhart described this form of 
hernia, but he stated that he had never known an operation neces- 

^ British Medical Jonrnal, March 8, 1879. 



80 INTESTINAL SURGERY. 

sary. The cause of a chronic inYagination is often a tumor attached 
to the inner surface of the boweL The tumor by its weight drags 
the portion of intestine to which it is attached, into the segment of 
bowel below, and the descent of the intussusceptum is often very 
slow. In these cases the tumor is always found attached to the 
apex of the intussusceptum. Inyagination caused by tumors is most 
frequent in the large intestine, as this is more frequently the seat 
of inyagination than the intestinal canal above the ileo-csBcal valve. 
Tuffier^ reports a case of invagination operated on by Marchand 
which is of special interest on account of the rare condition found 
which had led to the invagination. 

The patient was a woman forty-three years of age, who had 
suffered from a gradually increasing intestinal obstruction. Bectal 
examination revealed a timior, which had dragged an upper segment 
of the bowel with it into the rectum. Marchand opened the abdo- 
men in the left inguinal region and found an invagination of the 
sigmoid flexure into the rectum. Reduction was found impossible. 
An artificial anus was established after the method of Littr6. Death 
on the fifth day. The necropsy showed diffuse peritonitis, which in 
the BmaU pelvis had assumed a suppurative type. The sigmoid 
flexure was found invaginated to the depth of 6 cm., and the 
serous surfaces adherent, which yielded only to considerable traction 
force. A pedtmculated lipoma was attached to the apex of the 
intussusceptum. 

Kulenkampff^ reports the case of a woman, aged thirty-nine 
years, who had suffered from incomplete obstruction of the bowels 
with bloody discharge from the anus for six months. During the 
progress of the disease a mass could be felt in the rectum, which 
was thought to be a polypus. This proved to be a papilloma (prob- 
ably malignant) that originated in the sigmoid flexure, and had 
been the cause of the invagination of that part of the colon into the 
rectmn. The entire mass, including the intussusceptum, was removed 
through the rectuuL An adherent coil of intestine was accidentally 
wounded and the wound was at once closed by suturing. The 
operation was followed by an aggravation of symptoms of obstruc- 
tion, and on the tenth day laparotomy had to be performed, and an 

^ Invag^ation de V iliaqne dans le rectum. Laparotomie laterale. Anns 
de Littr^. Lipome de 1' intestin. Le Progr^s Medical, 1882, p. 202. 
^Oentralblatt f. Ghirnrgie, No. 47, 1886. 



INVAGINATION, 81 

artificial anus was established in the left groLD* The patient 
recovered, but the faecal fistula remained. 

Bryant* related the case of a lady, aged seventy-four, who had 
been suffering from obstruction, due to invagination, for fourteen 
days. He suspected the existence of a growth, and this, after much 
difficulty, was found, drawn down and removed, the patient making 
a rapid and perfect recovery. • 

Barker,^ in a case of invagination of the rectum, due to adenoid 
epithelioma of that part of the gut, succeeded in drawing down and 
excising the affected part, and reduced the invagination. The patient 
recovered completely. Three similar cases had been treated previ- 
ously in the same manner, two by Vemeuil, and one by Kulen- 
kampff, only one of them recovering. 

The case reported by Nicolaysen* is of special interest as illus- 
trating the course to be pursued when it becomes necessary to resect 
a portion of the intestine with the tumor. The patient was a woman 
forty-nine years old, who had suffered from troublesome constipa- 
tion and painful defecation for a year, due to chronic invagination 
of the sigmoid flexure of the colon* into the rectum, produced by an 
epithelioma. Through the, rectum a tumor could be felt which by 
traction could be drawn down to the anus. The diagnosis made 
was carcinoma of the colon and invagination of colon into rectum. 
The patient could produce the invagination at will. The extirpation 
was made by pulling the tumor downwards beyond the anal orifice. 
The healthy mucous surfaces 2.5 cm. above the base of the tumor 
"were circumscribed by a row of silk sutures, which were carried 
through the entire thickness of both intestinal walls. The tumor 
was excised one cm. below the sutures; only one artery had to be 
tied. Posteriorly and on the left side of the circular wound the 
divided meso-colon could be seen. The wound was accurately united 
by a superficial continued suture. As soon as the bowel was replaced 
it retracted as far as the upper portion of the rectum. The patient 
had recovered after fifteen days and reported herself well at the 
end of two and a half months. The intestinal tube removed meas- 

1 British Medical Journal, April 9, 1887, 
a The Lancet, May 14, 1887. 

' Tumor caroinomatosns intestini S. romani: Besektion af S. romannm; 
Heltredelse. Nord. Med. Arkiv. B. XIY, No. 18. 



82 INTESTINAL SURGERY, 

Tired 6.5 cm. The tumor under the microscope showed the typical 
structure of cylindrical-celled epithelioma. 

Becker ^ has collected a number of cases from the literature, 
where the cause of the invagination was a diverticulum of the small 
intestine, and he believes that some of the reported cases of 
elimination of portions of the intestine with the appendix vermi- 
f ormis were of this kind, and that in« these cases, what appeared as 
the appendix was in reality a diverticulum. 

l^e mechanical disturbances at the seat of invagination are 
sometimes the cause of an additional obstruction. In one of Dent's 
cases in a chil<} six months old, who for three days before admission 
into St. George's Hospital had sufiFered from evident intussusception, 
the abdominal section revealed a two-fold cause for the obstruction, 
invagination and internal strangulation. When the abdomen was 
opened a loop of bowel was found constricted by the sharp edge of a 
piece of mesentery of the ileum which was invaginated into the 
C8BCum. The band was divided and the invagination easily reduced. 
Peritonitis had set in before the operation, and the child died in five 
hours after it. This case should remind us to look for additional 
causes of obstruction around the site of the invagination in all cases 
where the abdomen is opened in the treatment of intussusception. 
Similar care should be exercised under the same circumstances after 
the reduction has been accomplished, to look for an additional 
invagination, as cases have been reported where two or more 
invaginations were present at the same time. 

Claudot^ has given an accurate description of a specimen of 
double invagination in a patient who had died with symptoms of 
intestinal obstruction. The first invagination was 80 cm. below the 
pylorus, the second two metres further down; the latter consisted of 
an invagination of the ileum into the colon, the intussusceptum 
having advanced nearly the entire length of the ascending colon. 
The upper invagination showed evidences of gangrene, of which no 
signs could be seen in the lower, and for this reason it is probable 
that the upper invagination occurred first. Intestinal haemorrhage 
was one of the prominent symptoms during life in this case. 

At a meeting of the Pathological Society of London, Power ^ 

^ Znr Aetiologie der Darmeinschiebnng. Dissertation. Kiel, 1885. 
^ De rocolnsion intestinale. Th^se, Paris, 1884. 
^ Transactions, vol. XX, page 240. 



PATHOLOGY OF ACUTE INVAGINATION, 83 

demonstrated a specimen, obtained from a child five months old, of 
double intussusception, one in the ileo-csecal region two inches in 
length, the other in the transverse colon, one inch in length. The 
latter was an ascending invagination. Both invaginations showed 
adhesions between the serous surfaces, and consequently must have 
been ante-mortem conditions. 

In regard to the age of patients suffering from invagination, it 
can be said that fifty per cent, of all cases occurred in persons under 
ten years of age. Invagination in children, according to Heusner, 
is the cause of obstruction in three-fourths of all cases of intestinal 
obstruction. If all cases of invagination were tabulated it would be 
seen that one-fourth of the whole number would be children under 
one year of age. The acute form is most frequent in the young, and 
the chronic variety between the ages of twenty and forty. 

Leichtenstem^ has studied the mortality which attends invagi- 
nation, and in five hundred and fifty-seven cases in which the termi- 
nation was known the result was as follows: 



Mortality of Oasee 
Without Elimination 
Age. Total Mortality. of Gangrenous Portion. 

1 Year ^ 88) „« 

2 Years 82 3 °^ 

2-10 *• 72 80 

11-20 " 63 86 

21-40 " 63 82 

41-60 " 63, „^ 

61-60 " 71^ ®" 



\ 

More than 60 years 77 

From this table it can be seen that the mortality up to the age 
of forty increases with the diminution of the age of the patients, 
being greatest in infants and children, in whom the invagination 
usually pursues an acute course. 

Pathologry of Acute Invasrination. 

The pathological changes in the acute form of invagination are 
chiefly of two kinds: 1. Obstruction of the bowel; 2. Strangulation 
of the intussusceptum. Both of these results may be absent in the 
chronic form. The obstruction is due not only to the narrowing 
of the lumen of the bowel by the invagination, but also* to the 
swelling of the invaginated portion, caused by the constriction of 
the blood vessels supplying the intussusceptum at the neck of the 

^ Ueber Darminy agination, III, Theil. Prager Vierteljahrssohrift f. Heil- 
knnde, B. CXX, p. 17. 



84 INTESTINAL 8URGKHY. 

intussuscipiens. In cases of chronic invagination where no such 
vascular engorgement is present the lumen of the intussusceptiun 
remains sufficiently large for a free passage of the intestinal contents, 
and no symptoms of obstruction are observed- In a number of my 
experiments on animals where I produced invagination artificially, no 
symptoms of obstruction were observed, and when the animals were 
killed weeks or months after the invagination had been made, the 
lumen of the intussusceptum was not larger than an ordinary lead 
pencil, and yet the bowel on the proximal side was not dilated, but 
somewhat hypertrophic. The greatest danger after invagination has 
taken place arises from the constriction of the intussusceptum at the 
neck of the intussuscipiens. The acuity of the symptoms are always 
proportionate to the severity of the strangulation at this point. The 
circular constriction interferes with the return of venous blood from 
the intussusceptum, which is followed by oedema, complete stasis and 
gangrene of the constricted portion. An acute invagination becomes 
irreducible by ordinary means within a few hours, on account of the 
appearance of oedema in the intussusceptum. If the strangulation 
is less intense the passive congestion precedes a plastic inflammation 
of the serous surfaces held in apposition, and adhesions form which 
again oppose or render a reduction impossible. In cases where 
gangrene of the invaginated portion follows a few hours or days 
after the invagination, no adhesions form between the serous surfaces. 
Adhesions at the neck of the intussuscipiens and throughout the 
extent of the invagination may form soon and they may be absent 
after six weeks, in the chronic variety. Adhesions are met with in 
about eighty per cent, of chronic cases, and forty per cent, of acute 
ones. In acute cases a fatal termination usually takes place from 
perforation at the neck of the intussuscipiens followed by septic 
peritonitis. 

Numerous cases have been reported where a spontaneous cure 
was effected by sloughing and elimination of the intussusceptum. 
This favorable termination is only possible if the continuity of the 
intestine is restored at the neck of the intussuscipiens by firm unyield- 
ing adhesions, before the proximal end of the intussusceptum has 
become gangrenous, or if the line of demarcation is below the neck. 
Gangrene usually commences at the apex of the intussusceptum and 
travels in the direction of the neck. That sloughing and elimination 
of the intussusceptum are not always followed by recovery becomes 



PATHOLOGY OF ACUTE INVAGINATION. 85 

evident from a study of one hundred and forty-nine such cases col- 
lected by Leichtenstem. Out of this number sixty-one died and 
eighty-eight recovered, a mortality of forty-one per cent. Separa- 
tion of the gangrenous intussusceptum usually takes place in acute 
cases from the eleventh to the twenty-first day, and in children 
somewhat earlier than in adults. The length of the slough corre- 
sponds with the length of the invaginated portion, and cases are on 
record where recovery followed after the elimination of five or six 
feet of intestine. According to Treves, spontaneous elimination takes 
place in about forty per cent, of all cases. The frequency with 
which it takes place in the different anatomical forms varies, being 
twenty per cent, in the ileo-caecal form, twenty-eight per cent, in 
the colic form, and sixty-one per cent, in the enteric form, so that it 
is most rare in the most common form. Frequency of elimination 
also increases with the age of the patient, being least common in 
infants on account of the rapidly fatal course of the disease in them, 
and most frequent in patients advanced in life. 

Birch-Hirschfeld^ gives an accurate post-mortem description of 
a child two years of age, which had recovered from a double invagi- 
nation by sloughing and elimination of the intussuscepta, and died 
four months later of measles. At the necropsy it was found that 
the lower portion of the ileum, the caecum and appendix vermif ormis 
were absent. A circular cicatrix in the lumen of the gut showed 
where separation had taken place ; upon the serous surface at the 
same point, a circular depression indicated the site where separation 
had occurred. The second invagination had evidently been in the 
colon at the junction of the ascending with the transverse portion, 
as a similar cicatrix was also found in this locality. The cures 
after spontaneous elimination of the intussusceptum are often more 
apparent than real, as such an ideal restoration of the intestinal 
canal as that described by Birch-Hirschfeld is but rarely effected. 

Kuettner^ has followed up the history of several of these cases 
and has found that not an inconsiderable number of them die later 
from perforation and peritonitis. Stricture of the intestine has also 
been observed as a sequela in some of these cases. . 

^ Fall TOn Geheilten Invaginationen des Darmes. Arohiv. der Heilknnde, 
Heft 1, 1869, p. 108. 

' Drei F&Ue von Intnasasoeption nnd deren praBSnmptiye. Heilimg. Yir- 
chow's Arohiv., B. 63, p. 274. 



86 INTESTINAL SURGERY. 

Gerry ^ reports such a case. The invagination was acute, and 
after three weeks a portion of the small intestine, seventeen and a 
half inches in length, passed per anum, followed later by a number 
of smaller fragments. Soon after the apparent recovery had taken 
place, symptoms of obstruction again set in, due to the formation of 
a stricture at the point where spontaneous resection had taken place, 
from the effects of which the patient died, seven months after the 
invagination. At the necropsy a circular stricture was found in the 
upper part of the small intestine with loss of several feet of the 
intestine by sloughing, a fistulous communication between the small 
intestine and the descending colon, and chronic peritonitis. 

Pathologry of Ohronio Invaerination. 

In cases of chronic invagination the symptoms are identical with 
those of intestinal stenosis from other causes. The constriction at 
the neck of the intussuscipiens is not sufficient in degree to arrest 
the circulation in the invaginated portr^n, consequently gangrene 
does not take place. The seat of the invagination and the bowel on 
the proximal side become the seat of hyperplastic changes, from the 
chronic congestion which attends the lesion, and from the increased 
peristalsis which is maintained by the chronic obstruction. 

Pohl'^ has described an interesting specimen of chronic invagi- 
nation taken from a man sixty -two years of age, who suffered from 
two attacks of intestinal obstruction eleven years apart. The second 
attack proved fatal after an illness of eleven days. The post-mortem 
appearances indicated that the invagination which was found had 
existed for eleven years, and that the second attack was due to an 
aggravation of the mechanical difficulties at the seat of invagination, 
which had given rise to ulcerative inflammation of the mucous mem- 
brane lining the intussusceptum, perforation and suppurative peri- 
tonitis. The intussusception was located in the lower portion of 
the ileum. The intussuscipiens was 30 cm. in length, its muscular 
coat hypertrophic, mucous membrane thickened and very vascular, 
and some of its folds adherent to the enclosed intestine ; on the 
posterior wall near the mesenteric attachment two perforations were 
found. The intussusceptum was 24 cm. in length, and its mucous 

^ A Case of Intussusception. Boston Medical Journal, No. 25, 1877. 
^ Ueber den Befund einer dnrch viele Jahre getragene Darm-Intossnsoep- 
tion, Prager Med. Wochenschrift, No. 21, 1884. 



CHRONIC INVAQINATION.—TREATMENT. 87 

membrane extensively ulcerated; old and £rm adhesions at the neck 
of the intussuscipiens. The mesentery of the ileum, throughout, 
but especially at the seat of invagination, much thickened. Ileum 
above obstruction dilated and its walls thickened. 

Leichtenstem^ reports a case of chronic invagination which 
presents a number of interesting points. The attack was brought on 
by indiscreet diet and was attended by well-marked symptoms, 
tenesmus, liquid stools mixed with mucus and blood. The patient 
lived for eleven weeks. After the first few days the stools were 
normal in size and consistence. Recurring colicky pains, often very 
severe, constituted the most troublesome and important symptom. 
A swelling in the region of the transverse colon could always be felt, 
but became firmer and more circumscribed during the attacks of 
colic or after a prolonged examination by palpation. The necropsy 
revealed an ileo-csecal invagination, the lowest portion of which con- 
sisted of the point of entrance of the ileum into the colon, the inner 
cylinder of the csecum and ascending colon, and the outer cylinder 
or sheath of the transverse colon. All of the parts involved in the 
invagination were the seat of hypertrophic changes. 

' Treatment. 

Early recognition of the existence of invagination is of the 
greatest importance for successful treatment, as the prospects for 
successful reduction by ordinary surgical means diminish with the 
development of secondary pathological conditions at the seat of 
invagination. Many of the artificial invaginations which I made in 
animals were reduced spontaneously within a few hours, and in 
order to study the effects of invagination I had finally to resort to 
suturing at the neck of the intussuscipiens in order to permanently 
retain the invaginated portion. Reduction was resisted after a time 
either by the swollen, oedematous intussusceptum or by the adhesions 
at the neck of the intussuscipiens, or between the serous surfaces 
througbiout the invaginated portion of the bowel. From these 
observations I have come to the conclusion that reduction by gentle 
but efficjient distention of the bowel below the invagination would 
succeed in the majority of cases, if this procedure were practiced 
before either of the two principal conditions which cause irreduci- 

^ Darm-Invagination von monatlicher Dauer. Dentsches Archiv. f . Elin. 
Medioin, B. XII, p. 381. 



88 iirrBSTiNAL suroery. 

bility have had time to make their appearance. As soon as the 
existence of an invagination is suspected the large intestines should 
be emptied of their contents hj the administration of a large enema, 
the patient being kept in Hegar's position. After this has been 
done the patient should be placed thoroughly under the influence of 
an anaesthetic so as to facilitate the next step in the treatment: 

Bectal Insufflation of Htdbooen Gas. 

As gas can be readily forced beyond the ileo-ceecal valve, this 
method of treatment is applicable in the treatment of invagination 
in any portion of the intestinal canal, and as distention of the intes- 
tine below the seat of obstruction may prove successful in correcting 
the mechanical difficulties due to other causes, it should be resorted 
to both as a diagnostic and therapeutic measure in the beginning 
of all cases of intestinal obstruction, in which a positive diagnosis of 
other forms of obstruction cannot be made without it. The modus 
operandi of this surgical resource I witnessed in an animal, on 
the third day after the invagination had been made, by opening the . 
abdomen and exposing to sight the seat of invagination before the 
insufflation was made. In this instance two inches of the ileum 
were invaginated into the colon and fixed by two fine silk sutures at 
the neck of the intussuscipiens. On the third day the abdominal 
cavity was re-opened by an incision along the outer border of the 
right rectus muscle, and the invaginated bowel drawn forward into 
the wound. The bowel at point of operation was very vascular, and 
the neck of the intussuscipiens covered with plastic exudation. The 
sutures were removed and the rectum and colon distended with gas 
for the purpose of effecting reduction. As soon as the colon had 
become thoroughly distended, the adhesions which had formed gave 
way with an audible noise, and complete reduction followed in such 
a manner that the part last invaginated was first released. As the 
force necessary to rupture the adhesions and to reduce the bowel 
produced no injury of any kind to the intestine below or at the seat 
of invagination, this experiment would tend to prove that insufflation 
can be practiced successfully in cases of invagination of several 
days' duration. 

The rectal insufflation of hydrogen gas in the reduction of an 
invagination should always be made under the influence of an ansBs- 
tlietic administered to the extent of complete muscular relaxation. 



RECTAL INSUFFLATION.—COLOTOMY, ' 89 

The pressure upon the rubber balloon should be uninterrupted and 
should never exceed two pounds to the square inch. Disinvagina- 
tion is effected by inflation by two distinct forces. In the first place, 
the steady elastic pressure of the gas distends the bowel between the 
sheath and the returning cylinder, which makes traction upon the 
neck of the intussuscipiens, while the column of gas by its pressu];p 
against the apex of the intussusceptum acts as a direct reduction 
force. In order to accomplish the desired mechanical effect the infla- 
tion must be made slowly and continuously, as when this is done, 
there is less danger of rupturing the bowel than when rapid inflation 
is made under the same pressure but with interruptions, and the 
object of the inflation is more surely realized. The return of the 
gas is prevented most effectually by an assistant pressing the mar- 
gins of the anus against the rectal tube. A small gutta-percha female 
syringe makes the best rectal tube. A sudden diminution of pressure 
indicates either that disinvagination has been effected or that a rup- 
ture of the intestine has occurred. It is exceedingly important that 
the surgeon should satisfy himself of the existence of a rupture if 
this accident has occurred. The best way to recognize the accident 
is to continue the inflation under a pressure of not more than a quar- 
ter to half a pound to the square inch. If the invagination has been 
reduced the intestine above it will become gradually distended by the 
gas, and the distention takes place first over the middle of the abdo- 
men and above the pubes, ascending gradually as the inflation is 
continued in an upward direction. If the intestine has been ruptured 
the gas escapes into the peritoneal cavity, and the existence of the 
accident is proved by the appearance of a uniform free tympanites 
with disappearance of liver dullness. In a recent case there is no 
danger of rupturing .the bowel under a pressure of two pounds to the 
square inch, and in cases where the tissue of the intestine yields 
under this pressure, a laparotomy is the only proper remedy, and the 
occurrence of the accident renders the indication for the performance 
of the operation imperative, without adding to its danger. 

COLOTOMY. 

Two indications for colotomy might arise in the treatment of 
cohc invagination: 1. In acute cases, when the general symptoms 
are so grave as to contra-indicate a laparotomy. 2. In irreducible 
chronic cases, when the lower portion of the colon is invaginated into 



/ 



90 INTESTINAL SURGERY. 

the upper part of the rectum, where it is impossible to make a 
resection or anastomosis by lateral apposition. According to the 
location of the invagination the operation is made either in the right 
or the left iliac region, in the former instance the opening being 
made in the caecum, and in the latter in the descending colon. 

Dubois* reports a case of intussusception where the invaginated 
portion could be felt in the region of the sigmoid flexure, through the 
abdominal wall. Colotomy was performed afeove the seat of obstruc- 
tion, and the patient not only recovered, but four months later the 
permeability of the intestinal canal was restored spontaneously, 
although the artificial opening had not closed 

Entebotomt. 

In irreducible iliac and ileo-ceecal invagination, an enterotomy 
should only be made when the patient is in such a collapsed 
condition that more radical measures are inadmissible. As in the 
majority of cases the invagination is below the ileo-csecal valve, the 
artificial opening should be made in the right iliac region. Should 
the invagination be located higher up in the intestinal canal, and an 
empty collapsed coil of intestine present itself in the opening, it 
should be pushed aside and search made for a distended loop. An 
enterotomy is justifiable even when the patient is in an almost 
pulseless condition, as this operation is attended by little if any 
shock, as it can be done in a few minutes, and, if necessary, without 
an anaesthetic. Emptying the bowel above the seat of obstruction 
will bring relief by removing the abdominal distention, and by 
favorably influencing the invaginated part by diminishing the hydro- 
static pressure above the obstruction, which in itself is a potent cause 
in maintaining vascular engorgement, 

Langenbeck^ saved the life of a patient suffering from invagina- 
tion of the colon, by an enterotomy. The invagination had advanced 
so far that the apex of the intussusceptum could be felt in the 
rectum. He performed N^laton's operation and the patient recov- 
ered. Nine months after the operation both the invagination and 
the artificial anus remained. 



^ Ent^rotomie pratiqu^e in extremis. Journ. de M4d. de BrnxeUes, 
December, 1878. 

2 Vorstellung eines Falles von geheilter Enterotomie. Verh. der dentschen 
Gesellschaft f . Chirurgie,. 1878. 



LAPAROTOMY. 91 

Lapabotomt. 

Bemembering that the general mortality Of invagination is 
seventy per cent, and in children less than eleven years of age 
spontaneous cure by elimination of intussusceptum does not exceed 
twelve per cent., it becomes plain that in cases where reduction ig 
not accomplished by rectal inflation, a laparotomy is indicated in all 
instances where the general condition of the patient is such as to 
justify such a procedure. It is true that the experience of the past 
in the operative treatment of invagination is not such as to inspire 
confidence, but it must not be forgotten that almost without excep- 
tion the abdomen was only opened as a last'resort, after the patient 
had been completely prostrated by the disease, or after the invagina- 
tion had given rise to irreparable local conditions. Instead of 
discouraging operative interference, the statistics collected so far 
are the best possible arguments in favor of early operation where 
simpler measures have failed. 

Ashhurst^ brought together, with more or less detail, the 
histories of thirteen cases in which laparotomy has been undertaken 
for the relief of intussusception. Of this number five recovered, and 
eight died. As the result of a study of his cases he has come to 
the conclusion that the operation is not admissible in patients 
less than one year of age, as all operations up to that time done in 
children less than a year of age proved fatal He also advises 
against an operation when the symptoms present, and particularly 
the existence of intestinal haemorrhage, render it probable that the 
tightness of the intussusception will lead to sloughing of the invagi- 
nated portion, as he claims that under these circumstances an 
operation would almost surely fail, while there is a fair hopQ that 
separation of the invaginated mass might lead to spontaneous recov- 
ery. Experience has shown that cure by spontaneous elimination of 
the intussusception seldom, if ever, takes place in very young children 
and infants; consequently the hopelessness of the situation in such 
cases, where legitimate efforts at reduction have failed, can be 
advanced as the nlost logical reason in favor of operative treatment, 
as the patient and surgeon have nothing to lose and everything to 
gain. 

^ Laparotomy for Intussusception. Amer. Joum. Med. Sciences, July, 
1874, p. 48. 



92 INTESTINAL SURGERY. 

• 

Enaggs,^ after reporting an unsaccessfnl case of abdominal 
section for invagination that occurred in his own practice, gives the 
results of thirty-seven operations including his own. Of this number 
eight recovered, and twenty-nine died. In many of these cases 
peritonitis had set in before the operation was performed, and this 
condition and not the operation, was answerable for the subsequent 
fatal issue. 

Sands' has tabulated the records of twenty-one cases of lapar- 
otomy for intussusception, eight of which have occurred since the 
publication of Ashhurst's paper. Of twenty cases in which the 
result of the operation is given, seven recovered, and thirteen proved 
fatal, thus showing a mortality of sixty-five per cent. After a study 
of these cases he came to the conclusion that the prognosis after 
operation is also influenced by the age of the patient; thus, of twelve 
cases of two years old or imder, three recovered^ and nine died; of 
seven cases sixteen years old or over, four recovered, and three died, 
showing that the mortality is greater in infants than in adults. Sands 
remarks very properly that the mortality depends more on the con- 
dition of the intestine than the age of the patient. In taking all 
cases together, he has found that the mortality of the operation is 
fourteen per cent, in the easy, and ninety-one per cent, in the difficult 
cases. The largest number of operations for invagination has been 
collected by Braun.^ He tabulated fifty-one operations performed 
since 1870; that is, operations done under antiseptic precautions. 
Of this number, eleven patients were cured, and forty died. In 
twenty-seven of these cases disinvagination was effected, and in 
twenty-four it was not; of the former eighteen were children, and 
nine adults. Four children recovered, while fourteen died. Seven 
adults lived and two died. Besection of the invaginated portion was 
practiced twelve times with only one recovery. An artificial anus was 
established in nine cases, followed by death in every instance. 

Treves* gives the general mortality in one hundred and thirty- 
three recorded cases as seventy-two per cent. ; where reduction was 
easy it was thirty per cent., and when difficult ninety-one per cent. 
No one can look over these tables without noticing that the mortality 

^ The Lancet, June 4, 11, 1887. 

2 New York Medical Jonmal, Jnne, 1887. 

^ Verb, der dentschen Oesellschaft f. Chirnrgie, 1885. 

* The Lancet, December 13, 1884. 



LAPAROTOMY. 98 

was greatly influenced by the local conditions, as when the reduction 
was easy it was greatly reduced. This fact alone should convince 
us that laparotomy should be resorted to without delay as soon as a 
faithful attempt at reduction by rectal insufflation has demonstrated 
that reduction cannot be accomplished in any other way. The oper- 
ation should be done as a first, and not as a last resort. As in cases 
of strangulated hernia, the obstacles to reduction become more 
persistent as time advances, and the danger is augmented in propor- 
tion to the time which elapses until reduction is attempted. In 
reference to the time when the operation should be done, I can only 
caution against delay and make the positive statement that it should 
be done as soon as it has been shown that reduction cannot be 
effected by rectal insufflation. The age of the patient should not 
enter into consideration in deciding upon the propriety of an opera- 
tion. Sands operated successfully upon an infant only six months 
old, where the ordinary treatment by injection and inflation had 
been only partially effective in accomplishing disinvagination. The 
csBCum and appendix vermiformis and a small portion of ileum 
remained firmly fixed in the sheath, and it required considerable 
traction force to release them. 

Godlee* performed abdominal section successfully for invagin- 
ation in a child nine months old, four days after the commencement 
of acute symptoms. In this case the invagination had progressed 
so far that the apex of the intussusceptum protruded at the anus. 

Mr. Hutchinson^ narrates the particulars of a successful abdom- 
inal section for intussusception in a child two years of age. The 
invagination had commenced in the ileo-csBcal region and during the 
course of one month had advanced to such an extent that the intus- 
susceptum was extruded several inches at the child's anus. As 
rectal injections failed in reducing the bowel, the abdomen. was 
opened by an incision through the linea alba below the umbilicus, 
and the intussusceptum was then easily found, and as easily reduced. 
The child made a rapid recovery. 

As a rule, to which there should be no exception, the incision 
should be made in the median line, as it furnishes the most ready 
access to the invagination, and enables the operator to apply the 
various surgical resources with the greatest facility. For special 

'The Lancet, December 16, 1882. 
Medical Times and Gazette, Nov. 29, 1883. 



94 INTESTINAL SURGERY. 

indications a lateral incision can be made later. If the swelling has 
not been preyiously located by palpation or insufflation, it is nsuallj 
not difficult to find the seat of obstruction. As soon as the invag- 
inated part has been found it should be brought into, or as near to 
the wound as possible for careful examination, as the future action 
of the surgeon will be guided by the local conditions of the invag- 
inated bowel. If on examination no evidences of gangrene are found 
efforts should be made to effect reduction. 

a. Diainvagination. 

In recent and especially acute cases, I am satisfied that the 
difficulties which resist reduction should not be sought in the presence 
of adhesions as often as in the swollen oedematous intussusceptum. 
The same measures should be resorted to to eliable reduction as in 
the preliminary treatment of a phimosis or paraphimosis. The 
oedema and inflammatory swelling should he removed before any 
efforts at reduction are made. This can he readily a^ccomplished by 
steady and uninterrupted manual compression of the invaginated 
portion. As soon as the swelling has been reduced in this manner, 
reduction is attempted by making gentle traction upqq. the bowel 
above the neck of the intussuscipiens. Should this fail, inflation is 
practiced, and as soon as the bowel between the returning cylinder 
and the sheath has become expanded, traction is again made upon 
the upper and lower ends. If this maneuver fails to effect reduction, 
Rydygier's* device of making traction above and pushing from 
below can be tried. Bydygier also directs that reduction should be 
facilitated by inserting the finger between the intussusceptum and 
the intussuscipiens, for the purpose of breaking up adhesions. Any 
one who has had much experience with such cases must have 
observed that the neck of the instussuscipiens grasps the bowel very 
tightly, and that any such efforts as tha introduction of a finger 
would be almost certain to result in a rupture of the bowel. If the 
treatment as above directed does not effect reduction the presence of 
adhesions must be suspected. These should be broken up, not by 
the introduction of the finger, but by inserting and passing around 
the bowel a Kocher's director or a small probe. When the adhesions 
have been severed, the efforts at reduction by traction and inflation 
are repeated. 

1 Beilage, Gentralblatt f. Ghirnrgie, 1887, p. 81. 



INTESTINAL ANASTOMOSIS. 95 

Boser has suggested that after reduction has been effected, the 
inyaginated portion should be sutured to the abdominal wall for 
the purpose of preventing re-invagination. Under proper treatment 
it is not very likely that re-invagination will take place, and such fixa- 
tion might subsequently result in another form of intestinal obstruc- 
tion. Re-invagination can positively be prevented by shortening 
the mesentery at the point of invagination, by folding it upon itself 
in a direction parallel to the bowel, and maintaining it in this position 
by a few catgut sutures. 

Should repeated attempts at reduction fail, one of two courses 
of treatment may be pursued : 1. The establishment of an intesti- 
nal anastomosis. 2. Resection of the invaginated portion with or 
without circular enterorrhaphy. Resection of the invaginated por- 
tion, especially if the invagination is extensive, is a very grave 
undertaking, as it requires a long time for its execution, a matter of 
vital importance in these cases, and involves the removal of impor- 
tant parts, and on these accounts should never be resorted to unless 
the invaginated parts show evidences of gangrene. 

b. Intestinal Anastomosis. 

An intestinal anastomosis between the bowel above and below 
the invagination by decalcified.perforated bone discs can be made in 
fifteen minutes, and at once restores the continuity of the intestinal 
canal. As soon as the hydrostatic pressure above the obstruction has 
been removed by this operation, the danger of gangrene is diminished, 
and the bowel may again become permeable by a subsequent spon- 
taneous reduction or by elimination of the intussusceptum. If the 
invagination remains permtoently it does no particular harm, as the 
obstructed portion has been excluded by the anastomosis and subse- 
quently undergoes atrophic Changes. In cases where the intussus- 
ceptum has advanced beyond the sigmoid flexure, it would become 
necessary after ligation to remove a part of it through the lower 
incision, in order to render the bowel permeable below this point. I 
have in my possession a number of beautiful specimens of intestinal 
anastomosis obtained from animals in which I had made an artificial 
invagination, and subsequently treated them by making an intestinal 
anastomosis,. and I am firmly convinced that the same treatmei\t will 
prove useful in practice. 



96 INTESTINAL 8UROERY, 

Korcjnski^ reports an exceedingly interesting case where intes- 
tinal anastomosis was established spontaneously in a case of invagi- 
nation, followed by cure. The patient was forty-one years of age, 
and the symptoms of obstruction had lasted for six weeks but 
were completely relieved by the new opening. The existence of such 
an opening could be readily verified by digital exploration of the 
rectum. After the symptoms of obstruction had subsided, the exclu- 
sion of a part of the intestinal tract could be ascertained by insuffla- 
tion of the rectum, which at once produced a tympanitic distention 
of the middle of the abdomen without distention of the colon. A 
similar but small communication was found on post-mortem exami- 
nation, as in the case reported by Gerry, previously referred to. 

c. Resection, 

The only indication for resection is furnished by gangrene of 
the invaginated portion. The extent of the gangrene is immaterial 
in reference to the advisability of making a resection, as a small 
gangrenous spot necessarily would lead to perforation and death 
from septic peritonitis, unless this radical measure were adopted. 
The resection must always include the entire intussusceptum, but 
not necessarily the entire sheath. The first evidences of gangrene 
upon the external surface of the bowel appear about the neck of 
the intussuscipiens. When the invagination is extensive and the lower 
portion of the sheath presents a healthy appearance, it is only neces- 
sary to resect the neck of the intussuscipiens and the intussusceptum, 
which after division and isolation about the neck, can be drawn out 
and removed. The bowel above and below the proposed points of 
section should be tied with a rubber band to prevent f secal extrava- 
sation during the operation. The mesenteric attachments must be 
tied in small sections with fine silk ligatures, as tying in large 
sections or with catgut is liable to be followed by haemorrhage. 

After the resection has been made it becomes a serious question 
how to proceed further. Shall the continuity of the intestinal canal 
be restored at once by suturing, or shall an artificial anus be estab- 
lished ? When the resection involves the ileum above and the colon 
below, it is exceedingly dijfficult to restore the CQntinuity of the intes- 
tinal canal by circular enterorrhaphy, on account of the difference in 

^ Zwei Fftlle von Darminyagination langer Dauer. Yirchow n. Hirsoh^s 
Jahresbericht, B. 11, 1881. p. 193. 



RESECTION, 97 

the Imnina of the bowel to be united. As ileo-caecal inyagination is 
the most common form, it is evident that, as a rule, some other plan 
must be followed. Under these circumstances one of two methods 
of procedure can be chosen. The colon at the point of division is 
inverted to the extent of an inch or more, and closed by making a 
few stitches of the continued suture, which should embrace only the 
serous and muscular coats, and the iliac end is implanted into a slit, 
corresponding in size to the circumference of the bowel, made in the 
colon on the side opposite to the meso-colon, at a point just below 
the closed end. Fixation is most efficiently secured by a rubber 
ring and two inversion sutures, to which should be added as a 
matter of precaution a superficial continued suture. If lateral 
implantation cannot be readily done, an equally efficient method 
consists in closing both ends and establishing the continuity of the 
intestinal canal by lateral apposition with decalcified perforated bone 
plates in the same manner as has been described under the head of 
intestinal anastomosis. Bestoration of the continuity of the intesti- 
nal canal after resection of an invaginated bowel by lateral implan- 
tation or lateral apposition, requires much less time than a circular 
enterorrhaphy, while both operations secure better conditions for 
definitive healing than circular enterorrhaphy, and on these accounts 
should, under these and similar circumstances, be preferred to the 
latter procedure. 

In cases of colic invagination requiring an extensive resection, 
approximation of the two ends is not possible on account of their 
distance from each other and the comparatively slight immobility 
of this part of the intestine. In such a case lateral implantation 
is impracticable for the same reasons. The choice lies between 
the establishment of an artificial anus and lateral apposition; the 
former should never be made, as in case of recovery of the patient, 
the f secal fistula would remain as a permanent condition without any 
prospects of an ultimate cure The continuity of the intestinal canal 
can be restored at once in these cases by making an ileo-colostomy, 
or a colo-colostomy by lateral apposition with perforated decalcified 
bone plates, according to the location or extent of the resection. 

Wassiljew* reports a very interesting case of resection for in- 

^ Inyaginatio ileo-osBoalis. Laparotomia, Beseotio intestini. Heilnng. 
Centralblatt f. Ghirnrgie, No. 12, 1888. 
1 



98 INTESTINAL SURGERY. 

Tagination which ultimately terminated in recovery. The patient 
was a man, aged twenty-five years, who was seized with abdominal 
pain and vomiting. As the symptoms of obstruction did not yield 
to ordinary treatment laparotomy was performed on the second day. 
On opening the abdominal cavity a swelling was readily detected in 
the right hypogastric region. This swelling was drawn forwards, 
and found to be an extensive invagination of the ileum into the 
colon. As reduction could not be accomplished an elastic ligature 
was tied around the gut in two places and the ileum and mesentery 
were divided. Then the invaginated portion was readily withdrawn 
and about seventeen inches were resected. The abdominal cavity 
was washed out with a solution of sublimate, and the cut ends of the 
gut were fixed by sutures to the abdominal wound. Much gas and 
faecal matter escaped, when the ligatures were united. During the 
sixth week an operation was performed for the cure of the artificial 
anus. About six inches more of the intestine were resected and the 
cut ends united by Czemy's suture. On the third day the bowels 
moved, but on the fifth day the f SBcal discharges again escaped 
through the wound. The diJf erent attempts to close the fistulous 
opening failed. Digital exploration showed that a spur was begin- 
ning to form. To this spur a pressure forceps was applied; it fell 
off on the third day; ultimately the fistula closed. 

3. Volvulus. 

Volvulus or twisting of a loop of intestine around its axis con- 
stitutes a well-defined form of intestinal obstruction. This patho- 
logical condition can only occur where the mesentery of the bowel is 
of considerable length, and is therefore most frequently met with in 
the lower portion of the ileum and at the sigmoid flexure of the 
colon. This condition as compared with some other forms of intes- 
tinal obstruction is quite rare. In fifteen hundred and forty-one 
cases of obstruction from different causes, collected by Leichtenstem^ 
and analyzed with special reference to the anatomical cause of the ^ 
obstruction, after deducting one hundred and seventy-eight due to 
carcinoma, thirty-three cases only were due to twisting of the bowel, 
this including twists of both the sigmoid flexure and the ileum. 

^ Ziemssen's Cyclopaedia of the Practice of Medicine. Amer. Translation, 
Vol. ni. 



VOLVULUS, 99 

Upon another page the same author gives the result of his examina- 
tion of seventy-six cases of volvulus which he has collected, and of 
this number the lesion was found in forty-five cases in the sigmoid 
flexure, in twenty-three cases in the ileum, and in eight cases in the 
jejunum and ileum combined. 

A simple twist of a long loop of intestine one-half to once 
around its axis does not necessarily lead to intestinal obstruction. 
I made a number of experiments on animals by rotating a loop of 
intestine from one-half to twice around its axis and keeping it fixed 
in this position by suturing at the base of the loop. These experi- 
ments are interesting, inasmuch as they show that the primary con- 
striction produced in making and maintaining the volvulus which 
was sufficient to cause venous engorgement in the twisted loop, 
must have been only of short duration, the disappearance of the 
constriction being undoubtedly due to the gradual yielding of the 
sutured parts; while the faulty axis of the twisted loop was main- 
tained by the sutures, the circulation improved and remained in a 
sufficiently vigorous condition to adequately nourish the most distant 
portions of the volvulus. In most cases where I made a volvulus 
artificially, the animals did not suffer from intestinal obstruction, 
and yet the examination of the specimens showed that the twist had 
remained. The shortness of the mesentery had undoubtedly a 
great deal to do with the restoration of the circulation in the twisted 
loop, as this portion of the bowel immediately after fixation always 
presented a cyanosed appearance. While it was found difficult to 
force £uid through a specimen of volvulus, during life, propul- 
sion of the intestinal contents by peristaltic action was carried on in 
a satisfactory manner, as the bowel above the volvulus was not 
dilated, and contained no abnormal amount of fluid, and the animals 
manifested no symptoms indicative of intestinal obstruction. In 
cases where death has been produced by volvulus the post-mortepi 
appearances will show that the obstruction was caused not so much 
from mechanical causes as from the secondary pathological condi- 
tions in the twisted loop. The abnormal length of the mesentery 
found in these cases precludes the possibility of partial or complete 
spontaneous reposition, and the consequence is that the parts in- 
volved in the volvulus become the seat of serious vascular disturb- 
ances which lead to oedema and paresis. These secondary conditions 
are followed by distention of the intestine and accumulation of 



100 INTESTINAL SURGERY. 

intestinal contents, wliich cannot fail in aggravating the mechanical 
difficulties which initiated the obstruction. 

A number of these points are well illustrated by a case of volvu- 
lus reported by Wilson.^ A boy, nineteen years of age, without any 
premonitory symptoms, was suddenly seized with symptoms of acute 
intestinal obstruction. Colicky pains and persistent vomiting were the 
most conspicuous symptoms. Tenderness over the umbilicus and 
slight fullness between pubic arch and umbilictLs. Whole abdomen 
tympanitic. Pulse rapid and small. Skin pale and cold. The patient 
died thirty-two hours after the commencement of the attack. The 
necropsy showed moderate distention of the intestines, which were 
also found congested. Four or five loops of the small intestines 
occupying the hypogastrium were of a deep purplish-black color, 
and gangrenous. They were also considerably more distended than 
the surrounding gut, and taken together, they compared exactly with 
the outline of the circumscribed tympanitic distention observed 
during life in this region of the abdomen. On careful examination, 
these blackened coils of intestine were found to constitute a port^.on 
of the ileum, five feet in length, tightly twisted upon itself in its 
mesenteric axis. The lower point of crossing was five inches 
above the ileo-C8Bcal valve. At the point of crossing of the upper 
and lower end of the volvulus the intestines were flattened, and with 
the corresponding mesentery tightly twisted upon itself, formed a 
firm, hard, cord-like pedicle about an inch and a half in length, and 
a little more than one-third of an inch in diameter. The twist was 
from left to right, and amounted to a complete turn upon the 
vertebro-enteric axis of the mesentery. The gangrene and rapidly 
fatal termination in this case were due to the compression of veins at 
the base of the volvulus and not to the obstruction. In reference to 
the causation of volvulus a number of theories have been advanced. 
All authors are agreed upon one point, that the mesentery must be 
of abnormal length. 

Grawitz^ asserts that the immediate cause of a volvulus is to 
be found in an accumulation of intestinal contents above a con- 
stricted portion of bowel; that the distended portion of intestine 
above the seat of constriction undergoes elongation, and that this 

^ Amer. Journal of Med. Soienoes, July, 1878, p. 78. 
^ Yirohow n. Hirsch's Jahresberioht, B. 1, 1876, p. 284. 



VOLVULUS. 101 

elongated portion then rotates around its axis. Henning ^ studied the 
aetiology of volvulus experimentally. He firmly ligated the intes- 
tine in animals and then injected water c^bove the seat of obstruc- 
tion. In the small intestines the distended and elongated coils 
above the ligature always showed a tendency to rotate upon their 
vertebro-mesenteric axis, and thus a volvulus was produced. In 
the large intestines, on account of the shortness of the mesenteric 
attachment, the .^ame experiment caused rupture of the bowel before 
a volvulus could be produced. He collected a number of c&ses of 
volvulus scattered through the literature, where, in the post-mortem 
description of the twisted bowel, it was distinctly stated that the 
lumen of the intestine was narrowed by some form of acquired or con- 
genital stenosis. While it cannot be denied that chronic obstruction 
may be a direct or indirect caus^ of volvulus by producing not only 
elongation of the intestine, but also of the mesentery above the seat 
of obstruction, many cases have been reported where no such con- 
dition was found, and where, therefore, the lesion was due to other 
causes. 

Nieberding' has recently called attention to another cause of 
volvulus. He has reported a case which occurred in Bumm's 
practice, where, after an ovariotomy, a volvulus of the small intes- 
tine occurred which proved fatal after a few days. During the 
operation, the omentum, which was adherent to the cyst, was sepa- 
rated and a portion was excised. The necropsy showed that the raw 
surface of the omental stump had formed an adhesion to a loop of 
the small intestine, and above the fixed point a volvulus was found. 
He reported another and somewhat similar case which came under 
his own observation. A large cysto-sarcoma of the left ovary was 
removed, in a girl twenty-nine years of age. Before closing the 
wound it was noticed that the omentum was so short that the intes- 
tines could not be covered by it in the region of the incision. At 
the end of the second day symptoms of acute obstruction set in, the 
temperature remaining normal. As the symptoms increased in 
gravity, and the ordinary treatment proved fruitless, the wound was 
opened and a loop of intestine was found adherent to the left margin 

^ Beitrftge znr Eenntniss der Pathogenese des YoIyhItis. Dissertation. 
Berlin, 1888. 

' Beitrftge znr Darmoodnsion naoh ovariotomie. Gentralblatt f . Gynftkol- 
ogie, No. 12, 1888. 



102 INTESTINAL SURGERY. 

of the peritoneal wound, and after this was separated a yoIvtiIus was 
detected. The bowel was untwisted and its contents forced into 
the segment further down, beyond the seat of obstruction, the 
detached loop pushed beyond the reach of the abdominal wound, 
and the abdomen closed. The day after the operation the intestinal 
canal appeared to be permeable, as gas escaped per rectun% but 
evidences of peritonitis set in and the patient died with symptoms 
of collapse. He believes that the peritonitis was produced by the 
obstruction. 

G. Braun^ reports a case of volvulus in a woman occurring 
at the end of pregnancy, and believes that the pressure of the gravid 
uterus upon the sigmoid flexure produced the obstinate constipation 
which preceded the attack, and gave rise to elongation of the mesen- 
tery and bowel above the seat of campression, to a sufficient extent 
to cause volvulus. At the time she was admitted to the hospital 
the abdomen was enormously distended, nausea but no vomiting. On 
the next day labor pains set in and she was delivered of a dead 
child. On the same day vomiting commenced and a tendency to 
collapse was observed. The day after delivery she complained of 
intense pain in the abdomen, difficulty in breathing, and great pros- 
tration, and in a few days she died, the symptoms pointing to an 
intestinal obstruction remaining constant. At the necropsy the sig- 
moid flexure and its mesentery were found greatly elongated and 
rotated twice around its axis. That volvulus is not a frequent com- 
plication of pregnancy becomes apparent from the statement of 
Braun, that this was the flrst case in sixty thousand deliveries which 
had come under his own observation. 

Kuettner'* had unusual opportunities to study this form of 
intestinal obstruction, as four cases came under his own treatment in 
the short space of two and a half years. As predisposing causes he 
mentions advanced age and emaciation, as the latter is attended by an 
absence of fat in the omentum and mesentery, which renders the 
peritioneal cavity more spacious. Abnormal length of mesentery and 
intestinal tract is also enumerated as an important element in the 
causation of volvulus. Among the exciting causes he mentions as 

^ Enterostenosen in ihrer Beziehung znr Gravidit&t und Gebnrt. Wiener 
Med. Wochenschrift, No. 24, 1885. 

2 Ueber innere Incarcerationen. Virchow's Archiv., B. 43, p. 478. 



VOLVULUS. 103 

the most important, unequal distribution of intestinal contents and 
exaggerated peristalsis. He never observed peritonitis in any of his 
cases, even if life was prolonged for five to six days. He believes 
that in these cases the rapid fatal termination is due to pressure upon 
the sympathetic nerves, which causes paralysis and destroys life in 
the same manner as in peritonitis. He asserts that the complicated 
forms of knotting of the intestine which are still described in the 
text-books as rare but distinct forms of obstruction, are only varieties 
of volvulus. 

Treatment. 

Treves in his paper on " The Operative Treatment of Intestinal 
Obstruction"* claims that this form of obstruction is only aggra- 
vated by forcible rectal injections, as such a procedure will tend 
to tighten rather than to relax the twist. Of the operative 
treatment he says that simple laparotomy is an unpromising pro- 
cedure, but that in the future he will make the incision in the 
median line, ptmcture the gut, and attempt its reduction; if this 
fail, or the result appear unsatisfactory, he will evacuate the involved 
gut through an opening in the summit of the flexure, unfold the 
volvulus, and establish an artificial anus, using the opening just 
mentioned for that purpose. In some cases of volvulus the rotation 
around the v^ebro-mesenteric axis is often less than one complete 
circle, and before the involved bowel has become considerably 
changed by the twist, a reduction might be effected by dilating and 
elongating the bowel below the seat of obstruction, thus bringing the 
same causes to bear which have produced the displacement, but in 
an opposite direction. Careful inflation with hydrogen gas soon 
after the obstruction has occurred will be a harmless procedure, and 
ia favorable cases might lead to the desired result. Why this 
method of reduction should not be tried after the twisted loop has 
become softened and greatly distended by intestinal contents, requires 
no explanation. 

Of all forms of intestinal obstruction volvulus leads most rapidly 
to a fatal termination. This fact alone is a sufficient warning to lose 
but little time by temporizing measures. If life is to be saved 
prompt operative treatment must be adopted. After the symptoms 
have become sufficiently well marked, if insufflation proves unavail- 

^ The British Medical Jonrna], Angnst 29, 1886. 



104 INTESTINAL 8URQERY, 

ing, laparotomy shonld be resorted to at once without reference to 
the time which has elapsed If the abdomen is opened before the 
bowel has undergone serious pathological changes reduction will not 
be difficult, and as the intestine is otherwise in a healthy condition 
the prospects of a favorable termination are good. In such a favor- 
able case it would not only be prudent, but imperative to resort to 
means to prevent a recurrence of the volvulus. As an elongated 
mesentery plays the most important rdle in its production the best 
prophylactic means against a recurrence would be to shorten the 
mesentery. Besection of the mesentery is out of question, as such 
a procedure might result in gangrene of a corresponding portion of 
the gut. Shortening of the mesentery, however, can be effected by 
folding and suturing the mesentery in the same manner as has been 
described in treating of the operative treatment of invagination. 
Such an expedient would shorten the mesenteric attachment without 
interfering with the intestinal circulation. If the twisted portion of 
the intestine presents evidences of gangrene, resection becomes neces- 
sary, and after it has been done the continuity of the intestinal canal 
should be restored by circular enterorrhaphy or by lateral approxi- 
mation with decalcified perforated bone plates. If reduction cannot 
be accomplished without evacuating the distended bowel, an incision 
should be made on its convex surface at the summit o%the loop, and 
its contents removed by pouring out, taking, of course, all the neces- 
sary precautions not to soil the peritoneal cavity. After this has been 
done the visceral wound should be sutured and another attempt 
made at reduction. If this does not succeed and the symptoms are 
such that the necessary time required for resection would prove an 
element of danger, the volvulus should be left and the obstruction 
rendered harmless by establishing a communication between the 
bowel above and below the volvulus, by lateral apposition with decal- 
cified perforated bone plates. 

4. Obstruction by Flexions and Adhesions. 

Every pathologist who has carefully examined the intestinal 
canal of persons who have acute peritonitis, must have noticed the 
presence of numerous flexions caused by visceral and parietal adhe- 
sions, and yet such patients seldom exhibited well-marked symptoms 
of intestinal obstruction during life. I have observed the same con- 
ditions in animals during my experimental work on the intestinal 



OBSTRUCTION BY FLEXIONS AND ADHESIONS. 105 

canal and seldom found that simple flexion gave rise to intestinal 
obstmotion. I have made numerous flexions when performing 
operations for establishing intestinal anastomosis, and in most 
instances satisfied myself by examination of the specimens that fluids 
passed them without great difficulty. If the bowel at the point of 
flexion remains free, certain portions of its walls will yield to pressure 
from within of the fluid intestinal contents, and gradually the lumen 
of the bowel will become restored. If, on the other hand, the entire 
circumference of the bowel at the point of flexion has become flxed 
and immovable by inflammatory adhesions or other pathological 
products, a compensating dilatation becomes impossible and flexion 
becomes a direct and serious cause of obstruction. In recent cases 
of flexion, of course the circumference of the lumen of the bowel at 
the point of flexion is equal in size to that above or below the 
obstruction. The obstruction in such cases is not caused by stenosis, 
but by compression of the distal limb of the flexion by the intestinal 
contents in the proximal portion, thus causing a valvular closure not 
at, but just beyond the seat of flexion. This is more likely to take 
place if the apex of the flexed portion of the bowel is adherent to 
some flxed point, as in this case a compensatory dilatation of the intes- 
tinal wall at a point corresponding to the apex of the flexion, cannot 
take place. When a flexion has existed for a long time without 
having given rise to symptoms of obstruction, it finally may cause 
occlusion by a cicatricial stenosis at the seat of flexion, due to a 
circumscribed plastic inflammation and cicatricial contraction of the 
inflammatory product. 

Such a case came under the observation of Obalinski.^ A boy, 
eighteen years old, had suffered from typhoid fever eight months 
before the attack of intestinal obstruction set in. Some time before 
the acute symptoms appeared he suffered from pain in the abdomen 
which gradually increased in intensity until the clinical picture of 
obstruction was well marked. On the eighth day after the attack, 
the abdomen was opened by a median incision. Distended and col- 
lapsed intestinal coils came within easy reach. The obstruction 
consisted of a rectangular flexion of the small intestine caused by a 
pseudo-ligament the size of a lead pencil. After division of this band 

— ^ 1 

^ Weitere Beitrftge znr Laparotomie bei inneren Darmooolnsionen. Wiener 
Med. Preese, Nos. 4-12, 1886. 



106 INTESTINAL SURQBBT. 

and straighiening the bowel, it was seen that it was oonsiderably 
oontracted at the point of flexion by a circular cicatrix, but as it was 
permeable nothing further was dona The boy was dischargtxl cured 
fooi; weeks after the operation. That the pressure of intestinal con- 
tents in the proximal bar is exerted mainly upon the spur which 
forms in acute flexions between the two bars, is well shown by a 
specimen described by Birkett^^ where an intestinal anastomosiB was 
established spontaneously by ulceration between the approximated 
adherent tubes at the point of compression, so that the intestinal con- 
tents passed directly from one intestine to the other through this 
<< fistula bimucosa," instead of traversing the loop. The patient was 
a man, aged fifty-eight, who six months before his death had pre- 
sented a strangulated hernia thai had beoi reduced by taxis. 

When the flexion is yeiy acute, the spur formed by the apex of 
the approximated walls of both bars acts like a valve in closing the 
lumen of the distal bar, under the influence of the hydrostatic 
pressure from the accumulation of intestinal contents above the seat 
of flexion. Nicaise' has reported a typical case of this kind. A man, 
aged twenty-five years, was operated upon for strangulated hernia 
1^\e years before the attack of intestinal obstruction. Since the 
herniotomy he had suffered frequently from attacks of vomiting and 
ocmstipation with abdominal pain. The last attack was so severe 
that enterotomy was performed. He died the next day. The 
necropsy revealed an acute flexion idiich had become permanent by 
old adhesions^ The flexion was so acute thai the mucous membrane 
at its apex constituted a kind of valve across the lumen of the boweL 
After liberation of a flexed bowel the seat of an intestinal obstruc- 
tion, it becomes a step in the operation to resort to such prophylactic 
measures as may appear necessanr to prevent a return of the mal- 
poisition, and to cover as fxc as possible the peritoneal defects which 
have been made during the separation of the loop. Winslow' reports 
a case in point. In this case a loop of the small intestines was found 
firmly adherent in the pelvis over an an^ of six inches and sharply 
flexed. After it was carefnllv detached it vras found denuded of 
peritonenm over a small space. The coi:itinuitT of the peritoneal 
surface was restored by applying a number of sutures transversely 

^ Pathological Soe. Tnnsacuoiis. t\^ X« 15^>i^ 

^BoU^tui •« Menu a« 1a Soc, a« Cbinugie* Puis« l^i5a p^ 583L 

' Am«r. Journal Med» SemDM«s» tqL 'U» p. 411. 



ADHESIONS. 107 

to the long axis of the bowel. It is distinctly stated that this portion 
of the bowel was deeply congested, hence the seat of the textural 
changes consequent upon the obstruction. In most cases of flexion 
which have been described in connection with intestinal obstruction, 
the flexed bowel was found either in the pelvis near the internal 
inguinal rings, or in the ileo-csecal region, localities where localized 
peritonitis is most frequently met with. 

If, after the reduction of a strangulated hernia, the replaced 
loop of intestine is or becomes the seat of a plastic peritonitis, it 
forms an attachment to the abdominal parietes or viscera with which 
it comes in contact. In case the adhesion thus formed remains firm 
and is not drawn out in the form of a band, a flexion may form by 
the free portion of the bowel changing its relative position, and the 
two bars of the flexion thus formed, when in close contact and 
the seat of the same plastic inflammation, become adherent and the 
flexion becomes permanent. If the continuity of the bowel cannot 
be restored by separation of the adhesions in the operative treatment 
of obstruction caused by flexion, and the tissues at the seat of obstruc- 
tion present no evidences of gangrene, an anastomosis between the 
two bars of the flexion should be made in preference to resection and 
circular suturing. Circumscribed spots of gangrene can be excised 
and the wound sutured transversely to the long axis of fhe bowel, 
as this will cause no stenosis and will tend to correct the faulty posi- 
tion of the bowel. As in cases of constriction by bands, if it is found 
difficult to separate the adhesions, no attempt should be made to 
liberate the gut until a rubber ligature has been applied to each 
bar of the flexion, to prevent feecal extravasation should the bowel 
be ruptured during the separation. 

Adhesions. 

Quite recently a number of abdominal surgeons have published 
their experience in reference to the occurrence of intestinal obstruc- 
tion after laparotomy. A number of cases of intestinal obstruction 
which occurred soon after ovariotomy were found to have been caused 
by extensive parietal adhesions of the intestines ; hence the question 
has been discussed how such adhesions are to be prevented. 

P. Mueller^ has advised that in difficult ovariotomies adhesions 

^ Znr Nachbehandlung schwerer Laparotomien. Arohiv. f . Gyn&kologie, 
B. 28, Heft 3. 



108 INTESTINAL SURGERY. 

of the intestines amongst themselves, and with the abdominal walls 
should be prevented by avoiding external compression by bandages, 
and by filling the abdominal cavity with a physiological solution of 
common salt (0.7 per cent.) For the purpose of limiting peritoneal 
absorption, he suggests that the solution should be introduced from 
time to time and finally should be withdrawn through the drainage 
tube. 

Olshausen^ has found in all the cases of intestinal obstruction 
after ovariotomy that occurred in his practice, that the obstruction 
was caused by adhesion of an intestinal loop to the surface of 
the stump. Mueller's prophylactic treatment he considers rational, 
especially in cases where the operation is attended by consider- 
able haemorrhage. Schatz holds that visceral and parietal adhe- 
sions of the intestines after ovariotomy are a much more frequent 
condition than is generally believed. He is of the opinion that 
serious consequences do not necessarily follow such a condition. 
Gusserow asserts that adhesions are frequently found on making a 
second laparotomy in the same patient, which had not produced any 
untoward symptoms. 

Kaltenbach now uses a 1-6000 solution of sublimate in place of 
carbolic acid solution, and since he has made this change he has not 
observed a case of intestinal obstruction in fifty-four consecutive 
laparotomies, while of twenty-four cases where carbolic acid was 
used he lost two cases from this cause. Kruckenberg attributes to 
the use of sublimate an influence in causing plastic adhesions and 
asserts thaib since he has abandoned this agent he has had no cases 
of internal obstruction after ovariotomy. Sanger's experiments 
appear to prove that for the formation of a firm and permanent adhe- 
sion only one wounded surface is necessary. Schwarz believes that 
parietal adhesions along the internal surface of the abdominal 
wound are of frequent occurrence, because intestinal loops are caught 
in the furrow of peritoneum along the line of suturing, where addi- 
tional irritation is caused by the sutures. 

Martin^ as early as 1865 reported two cases which illustrate one 
of the dangers which follow puerperal pelvic peritonitis. In one 
case the peritonitis followed a manual separation of the placenta. 



^ Yerh. der Dentschen Qesellsohaf t fdr Gyn&kologie, 1886. 
^ Zwei Fftlle von Darmeinklemmnng dnrch Exsndatf ftden naoh Woohen- 
betten. Monatsschrift ftlr Qebnrtskimde, Jnly, 1865. 



ADHESIONS. 109 

The patient made a rapid recovery, but six weeks later symptoms of 
acute intestinal obstruction developed, from which the patient died 
on the fourth day. On post-mortem the cause of obstruction was 
found to be a firm pseudo-membranous band which connected the 
anterior surface of the csecum with a coil of the small intestine. In 
the second case a metro-peritonitis followed a normal delivery, which, 
however, yielded to proper treatment on the fifth day. During the 
seventh week after delivery symptoms of acute intestinal obstruction 
set in and the disease proved fatal after a few days. A condition 
similar to that in the first case was found at the post-mortem. 

Hirsch^ presents at length the results of his observations and 
researches on intestinal obstruction after ovariotomy. He attributes 
intestinal obstruction after ovariotomy to one of three causes: 
1. Adhesions of an intestinal loop to abdominal incision, and occlu- 
sion from the traction of the cicatrix. 2. Aseptic plastic peri- 
tonitis, which by causing extensive adhesions results in immobiliza- 
tion of a considerable portion of the intestinal canal, which leads to 
coprostasis and complete obstruction. 3. Impaction of an intestinal 
loop between a pedicle, treated by the extra-peritoneal method, and 
the abdominal wall. Sir Spencer Wells reported eleven deaths from 
this cause in one thousand cases of ovariotomy. Usually the 
obstruction occurs soon after the operation, but several years may 
elapse before the accident takes place. The symptoms are the same 
as in obstruction from other causes. 

The prognosis in cases of obstruction from intestinal adhesions 
is extremely unfavorable. Of the fourteen cases collected by the 
writer, only one recovered after secondary laparotomy. In view of 
the great mortality which attends this, the most serious complication 
after laparotomy, it is exceedingly important to resort to proper 
prophylactic measures in all cases of intra-abdominal operations. In 
the first place, when the operation is done in an aseptic peritoneal 
cavity, all irritating antiseptic solutions should be kept from coming 
in contact with the peritoneum, as their local irritant action might 
produce a plastic peritonitis. The peritoneum should not be unnec- 
essarily bruised or sponged, as a slight traumatic irritation might 
be productive of a circumscribed adhesive inflammation. Finally, it 
should be the aim of the surgeon to restore, if possible, the 

^ A^chiY. f. Gyn&kologie, B. XXXU, Heft 2. 



110 INTESTINAL SUROEHY. 

oontinnitj of the peritoneal snrface, should any defects be found 
during, or caused by the operation, before ^he abdomen is closed. 
Adhesion of the intestines to the abdominal incision can be prevented 
by spreading the omentum carefully over the intestines the whole 
length of the incision. Limited defects can be readily closed by 
suturing. The cut surface of the pedicle after ovariotomy should be 
covered by stitching the peritoneiun over it The stump, after supra- 
vaginal amputation, is treated in a similar manner. Parietal and 
visceral defects not amenable to suturing can be covered with an 
omental graft, which is stitched to the margins of the defect with 
catgut sutures. In cases of intestinal obstruction due to extensive 
adhesions after operations, or attacks of circumscribed peritonitis, it 
is essential to resort to early operative treatment, which consists in 
separating the adhesions and in restoring peritoneal defects as far as 
possible, for the purpose of guarding against similar attacks in the 
future. After the intestine has been liberated, it is advisable to place 
the detached portion in some part of the abdominal cavity where a 
similar condition is less likely to occur. 

5. Strangulation by Ligamentous Bands or Diverticula. 

Ligamentous bands resulting from old adhesions are usually 
found in parts of the abdominal cavity most frequently the seat of 
peritonitis, viz.: in the pelvis and the ileo-csBcal region. Their 
formation can generally be traced to a broad parietal adhesion, 
which by the peristaltic action of the free portion of the intestine, 
has become elongated and often narrowed to a delicate cord. It 
becomes a cause of obstruction when the migrating or free end forms 
an attachment to some fixed point, which then renders the band tense 
and unyielding. In case a loop of intestine becomes ensnared 
underneath it strangulation takes place in the same manner as in 
strangulated hernia, the constricting cord by its pressure causing 
venous engorgement below the constriction, and by the increased 
peristaltic action of the proximal limb of the loop forcing intestinal 
contents into, but not through, the constricted loop. As in hernia, 
an intestine may have become adherent and fixed underneath such a 
band for an indefinite period of time without strangulation taking 
place, as long as the immediate causes of strangulation are absent 
Any causes which disturb the mechanical relations still further in 
such a case, as a fall, lifting, coughing, the administration of an active 



LIGAMENTOUS BANDS OR DIVERTICULA. HI 

cathartic, etc., may bring on an acute attack of intestinal obstraction. 
The history of cases of obstruction due to the presence of a 
ligamentous band frequently refers to an attack of peritonitis 
through which the patient passed perhaps years before, and as 
frequently alludes to one of the above-mentioned proximate causes 
as preceding the attack of intestinal obstruction. 

A displaced neck of hernial sac may cause obstruction in the 
same manner as a ligamentous band. Kurz^ treated such a case 
successfully by laparotomy. The patient, a man thirty-three years 
of age, had been the subject of a small inguinal hernia for several 
years without causing much inconvenience. When symptoms of 
acute intestinal obstruction set in, the inguinal canal was carefully 
examined and was found empty. The symptoms of obstruction 
were very grave, including a' subnormal temperature and faecal 
vomiting at the time the operation was performed. Digital explora- 
tion of the ileo-csecal region through a median abdominal incision, 
led to the discovery of a ring in which the colon had become 
ensnared. Beduction by moderate traction was found impossible, 
and it was found necessary to incise the ring at two points, when 
the bowel, which was deeply congested, was readily withdrawn. 
The ring was found displaced four iiMihes from the internal ring. 
The patient made a rapid and satisfactory recovery. In other 
instances the contents of a hernia, either the omentum or the intes- 
tinal loop, when in a condition of plastic inflammation, may lead to 
the formation of a ligamentous band when either of these structures 
becomes attached near to the internal ring, the adhesion which 
forms lengthening out until it is attached to some other fixed point. 
Obre'* described the post-mortem appearances of such A case. The 
strangulated loop had wandered nearly to the xiphoid cartilage; 
while between it and the inguinal ring a cord seventeen inches long 
was found. 

A band of constriction can also be formed by the margins of 
an opening in the mesentery or omentum in which a loop of intes- 
tine can become strangulated. In such cases it becomes necessary 
after reduction has been effected, to close the opening by sutures to 
prevent a possible relapse of the obstruction from the same cause. 

1 Deutsche Med. Wochenschrift, March 26, 1885. 
^ Pathological Society Transactions, 1851, p. 95. 



112 INTESTINAL SURGERY. 

An adherent portion of omentum in the conrse of time may become 
drawn out into a narrow twisted cord which may become a cause 
of internal strangulation. In operating for intestinal obstruction 
caused by constricting bands, it is always necessary, after relieving 
the point of constriction first found, to search for additional bands, 
as it is not unusual to find more than one. Obalinski^ made a 
laparotomy for intestinal obstruction on the third day after the 
appearance of acute symptoms. On introducing his hand through 
a median incision he felt in the right iliac region distended and 
empty coils, and by tracing the latter in an upward direction found 
as the cause of obstruction two bands, each the size of a goose-quill, 
extending from the csecum to the abdominal wall, between which a 
loop of intestine 30 cm. in length had become strangulated. Both 
bands were ligated and divided. Qowels moved on the fourth day 
and patient was discharged cured in two weeks. Fowler' has met 
with two cases where, at the autopsy, a second band was found close 
to the divided one. 

Another frequent location for bands is in the umbilical region, 
where the remains of the umbilical artery may become a cause of 
constriction. Polaillon' opened the abdomen, in a young man, by 
lateral incision on right side for intestinal obstruction, one week 
after the appearance of the first symptoms. As the patient was the 
subject of an inguinal hernia, both inguinal canals were examined 
by digital exploration through this incision, but nothing was found 
to explain the obstruction. The incision was enlarged and the 
whole hand introduced, and after careful exploration a falciform 
fold was found to the left of the median line, which extended from 
the left inguinal ring toward the umbilicus. Between the band and 
the abdominal wall a sac was found which contained numerous coils 
of intestine. The whole intestine was carefully examined, and 
finally an empty loop about ten inches in length was foimd. The 
cause of strangulation was the peritoneal band, reduction having 
taken place by the introduction of the hand. The band was not 
divided for fear of haemorrhage. The patient recovered after a 
slight attack of peritonitis. 

Intestinal obstruction by a constricting band furnishes the 

1 Wiener Med. Presse, No. 4-12, 1886. 
3 The Lancet, June 80, 1888, p. 1120. 
' Gazette M^dioale de Paris, April 25, 1885. 



UOAMENTOUS BANDS OB DIVERTICULA. 113 

simplest and most favorable conditions for early operative treatment 
by abdominal section. Without prompt surgical treatment a fatal 
termination is almost inevitable, as death results either from the 
mechanical effects of the obstruction, or the constriction produces 
gangrene of the entire loop, or circumscribed gangrene under the 
sharp margin of the band, followed by perforation, and death from 
septic peritonitis. An operation undertaken before the strangula- 
tion has caused great abdominal distension and serious textural 
changes by pressure or constriction would be almost sure to be 
rewarded by success. Two cases of intestinal obstruction caused by 
ligamentous bands, recently reported by Bull \ illustrate in a most 
striking manner the importance of early operative interference. 
Both cases were treated by laparotomy, and the difference in the 
resxdtp obtained was plainly traceable to the length of time which 
had intervened between the onset of the disease and the operation. 
In the first case the operation was delayed until the eleventh day, 
and during the separation of the band a gangrenous spot in the 
bowel gave way, followed by fsecal extravasation. The circum- 
scribed gangrenous patch was excised, making a wound an inch in 
length, and parallel to the long axis of the bowel, which was closed 
with twelve Lembert sutures. Death twelve hours after operation. 
In the second case laparotomy was performed almost under identical 
circumstances, but the strangulation had existed only six days. In 
this case the operation was limited to the removal of the cause of 
obstruction, as the constricted bowel had not undergone irreparable 
damage, and the patient recovered. 

The operative treatment of the obstruction in this form of 
intestinal strangulation is usually not attended by any difficulties. 
The band of constriction, whatever its location or mode of origin 
may be, is traced to both the fixed points of attachment and excised 
between two ligatures. This not only relieves the strangulation, 
but prevents a possible recurrence of a similar attack from the same 
cause. In some instances, however, the local conditions may be 
more complicated. Beali met with a case where it was found im- 
possible to liberate the intestine from a constricting band, and where 
he divided the intestine at the point of constriction and united the 
ends again by circular suturing, and his patient recovered. If on 

^ Report of Cases of Intestinal Obstmotion treated by Laparotomy. Qail- 

lard's Medical Journal, March, 1888. 
8 



114 INTESTINAL 8URQERY. 

careful examination the oonditions at the seat of constriction are 
snch as make it probable that the got is the seat of gangrene from 
compression underneath the band, or that the separation of the band 
from the intestine is not readily accomplished, no attempts shonld be 
made to liberate the intestine nntil measnreB have been employed to 
gnard against fsecal extravasation in case the gnt shonld be mptnred. 
This precaution consists in emptying the intestine on each side of 
the constriction to a distance of from two to four inches, by displac- 
ing the contents in its interior between the thumb and index finger 
and applying a rubber ligature, which is passed through the mes- 
entery with a pair of hsemostatic forceps. The ligatures are not 
removed until the bowel has been liberated, and if it* is injured or 
presents evidences of gangrene, not until its continuity has been 
restored by suturing or excision, or by establishing an anastomosis 
after resection. 

From a surgical standpoint in the causation and treatment of 
intestinal obstruction, the appendix vermiformis must be looked 
upon as a diverticulum. The appendix vermiformis may become a 
cause of obstruction when it is of abnormal length and supplied by 
a long mesentery, and when it is transformed into an unyielding 
band by fixation of its free extremity to some firm point, by adhesive 
infiammation. Greves ' reports such a case. A boy, six years of age, 
who had suffered frequently from attacks of constipation lasting 
from a few days to a week or fortnight, was seized with a violent 
pain in the bladder and other symptoms of acute internal strangula- 
tion. On the fourth day the pain was referred to the iliac region, 
where a resonant swelling could be located. As the usual means 
prov^ of no avail laparotomy was performed on the fifth day. 
About twelve inches of the small intestines were found to be tightly 
strangtQated by an abnormal appendix vermiformis, whose free end 
had become fixed to the iliac fossa, forming a complete ring, through 
which the small intestine had slipped and become strangulated. 
Strangulation was relieved by division of the ring. Patient had not 
a single bad symptom after the operation. Excision of the appendix 
vermiformis, when the cause of obstruction, should always be prac- 
ticed with a view of preventing a similar attack from the same cause. 
As in such cases the process has undergone elongation by traction, 



1 The Lancet, December 6, 1884. 



LIGAMENTOUS BANDS OR DIVERTICULA. 115 

it is sufficient to apply a ligature near its base and then remoTe it 
by excision. 

Quite a number of cases of intestinal obstruction are on record 
where the obstruction was caused by a diverticulum, and in a number 
of these cases thp strangulation was successfully treated by lapar- 
otomy. To the same class belong bands, the remains of obliterated 
omphalo-mesenteric vessels. 

In 1851 Parise^ published his paper on a new cause of strangu- 
lation, in which he claimed that he was the first one to show that 
strangulation may take place from constriction by a diverticulum. 
The same year Bonvier^ described a case where a diverticulum of 
unusual length, springing from the ileum three feet above the ileo- 
csecal valve, encircled a loop of the small intestine so firmly as to 
give rise to complete obstruction. Where the diverticulum joined 
the ileum the lumina of both were equal in diameter, but the 
diverticulum tapered towards its end, ending in a bifid extremity, 
adherent to intestinal coils. Omentum and abdominal wall furnished 
the xmyielding points. The constriction was not very firm and 
reduction could have been readily effected had an abdominal section 
been made. 

Fitz,' in an exhaustive article on " Persistent Omphalo-mesen- 
teric Remains ", has collected all material facts pertaining to 
Meckel's diverticulum, with especial reference to the causation of 
internal strangulation. As the result of a careful study of this sub- 
ject he has come to the following conclusions: 

1. Bands and cords as a cause of acute intestinal obstructioi^ 
are second in importance to intussusception alone. 

2. Their seat, structure, and relation are such as frequently 
admit their origin from obliterated or patent omphalo-mesenteric 
vessels, either alone or in connection with Meckel's diverticulum, and 
oppose their origin from peritonitis. 

3. Recorded cases of intestinal obstruction from Meckel's 
diverticulum, in most instances at least, belong in the above series. 

^ M^moire snr le m^oanisme de 1' ^tranglement intestinal par nn noend 
diyeiticulair. Bull, de V Acad, de M6d., 1851, p. 373. 

^ Note snr un Gas de V ^tranglement interne de V intestin grdle par un 
diyertionle de 1' ileon. Gaz. des HOpitanx, No. 87, 1851. 

' Amer. Journal Med. Sciences. 



116 INTESTINAL SURGERY. 

4. In the region where these congenital causes are most fre- 
qnently met with, an occasional cause of intestinal strangulation, 
▼iz. : the vermiform appendix, is also found 

5. It would seem, therefore, that in the operation of abdominal 
section for the relief of a^^te intestinal obstruction, not due to 
intussusception, and in the absence of local symptoms calling for 
the preferable exploration of other parts of the abdominal cavity, 
the lower right quadrant should be selected as the seat of incision. 
The vicinity of the navel and the lower three feet of the ileum 
should then receive the earliest attention. If a band is discov- 
ered it is most likely to be a persistent vitelline duct, L e. : 
Meckel's diverticulum, or an omphalo-mesenteric vessel either patent 
or obliterated, or both these structures in continuity. The section 
of the band may thus necessitate opening the intestinal canal or a 
blood-vessel of large size. Each of these alternatives is to be 
guarded against, and the removal of the entire band is to be sought 
for, lest subsequent adherence prove a fresh source of strangulation. 

According to Schroder* a diverticulum is only supplied with a 
mesentery when it springs from the lateral aspect of the intestine, 
or near the mesenteric attachment. * Diverticula on the convex sur- 
face of the bowel are free and supplied with vessels from the intes- 
tinal wall. Meckel found in several specimens a valve at the junction 
of the diverticulum with the bo^el, and in one instance Phoebus 
found the opening of the diverticulum into the bowel crossed by 
a bridge of tissue connecting its margins. The so-called false 
diverticula always form on the concave side of the bowel, and are 
hernial protrusions, their walls being composed of peritoneum and 
mucous membrane. 

Greenhow'* observed a case where a coil of the ileum had slipped 
through a slit in the mesentery of a diverticulxmi, which in this case 
contained omphalo-mesenteric vessels, and had become strangulated 
in this position. Sometimes a number of congenital diverticula are 
found in close proximity and at times associated with other congen- 
ital defects of the intestine. 

Moore ^ exhibited to .the Pathological Society of London the 
intestines of a man aged forty, showing three diverticula in the first 

1 Ueber Diyertikel-Bildnng im Darmkanale. Dissertation, Erlangen, 1854. 

2 The Lancet, May 17, 1884. 

* The Lancet, Nov. 10, 1883, p. 816. 





LIGAMENTOUS BANDS OR DIVERTICULA. 117 

thvee feet of the small intestine, and a congenital stricture at the 
commencement of the jejunum. The diverticula were each an inch 
long and about as much in diameter, and were on the mesenteric 
side of the intestine. Their walls consisted of all intestinal coats, 
and were not mere hernial protrusions. As long as the free end of 
a diverticulum remains unattached, strangulation from this cause 
cannot take place. Strangulation can only occur when both extremi- 
ties are fixed, either as a congenital condition, or when later, the free 
end becomes adherent to some fixed point. Harris^ showed a speci- 
men to the Pathological Society of Manchester of internal strangu- 
lation from a man aged twenty. There was a whipcord-like adhe- 
sion about an inch and a half long, stretching from the tip of 
Meckel's diverticulum to the mesentery of the lower part of the 
ileum, and through the aperture so formed a loop of the lower part 
of the bowel had become strangulated. There had also been a twist 
of Meckel's diverticulum which had ruptured near its base, and 
death ensued from acute peritonitis consequent upon fsecal extrava- 
sation. 

That the danger of perforation and peritonitis from strangula- 
tion by a Meckel's diverticulum is greater than when the obstruction 
is caused by a ligamentous band, is shown by another case reported 
by Heiberg.^ The patient was a woman, forty years of age, who 
died in a few days from an acute attack of intestinal obstructicm. 
At the necropsy he found a diverticulum seven inches in length, 
thirty inches above the ileo-csecal region, which constricted a loop of 
the ileum twenty-one inches in length. The free end of the divertic- 
ulum had passed between its base and the intestine, and was found 
here with its terminal end somewhat dilated. The softened wall of 
the diverticulum was found perforated at one point, which had given 
rise to fsdcal extravasation and septic peritonitis. A somewhat 
similar mechanism of strangulation by a diverticulum was described 
by Concato.' A man, otherwise in perfect health, was attacked by 
acute intestinal obstruction and died on the fourth day. A loop of 
the small intestine was found constricted by a diverticulum located 
several feet above the ileo-csecal valve, the free end of which had 
insinuated itself between the junction of the diverticulum with the 

^ British Medical Jonrnal, May 28, 1887. 

^ Ueber innere Inoaroerationen. Virchow's Arohiv, B. 54, p. 80. 

' Virchow u. Hirsoh's Jahresbericht, B. 11, 1871, p. 155. 



I 



118 INTESTINAL SURGERY. 

intestine and constricted bowel, thns forming a firm knot aroi;uid 
the bowel. 

That in most cases where a diverticulmn causes an obstruction 
the free end has found a firm point of attachment is well shown by 
the cases tabulated by Cazin.^ He collected thirty cases of intestinal 
obstruction caused by diverticula, and of this number, in twenty-five 
the free end was found adherent. A diverticulum may give rise 
to symptoms of intestinal obstruction without directly interfering 
with the fsBcal circulation. Such a case has been reported by 
Doran.^ A boy, four years old, died on the fourth day after an 
attack of what resembled acute intestinal obstruction. At the 
necropsy a diverticulum the size of a pear was found at the junction 
of the ileum with the jejunum, which contained a pea. The foreign 
body had caused ulcerative inflammation and perforation of the 
diverticulum and death from perforative peritonitis. The divertic- 
ulum was supplied with a mesentery and its walls were composed of 
all the tunics of the bowel. 

Southey' alludes to another variety of obstruction caused by a 
diverticulum, viz. : contraction of the intestine at a point where the 
diverticulum is given off. He gives a description of two such 
specimens. In one the diverticulum formed a band the size of a 
goose-quill, and extended from a point two feet above the ileo-csecal 
valve to the abdominal wall two inches below the umbilicus. The 
ileum just above the diverticulum was so constricted as only to admit 
the tip of the little finger, and at the point of constriction the coats 
of the intestine, both muscular and mucous, were ulcerated through, 
the continuity of the intestine being preserved only by the thickened 
peritoneum. In the second case the bowel, at a point about eighteen 
inches above the ileo-csecal valve, was abruptly constricted to a 
diameter of about half an inch, and a diverticulum five inches long, 
having a calibre, at first large enough to admit the little finger, passed 
from the intestine and was attached at its extremity to the umbilicus. 
In this case death was hastened by acute diffuse peritonitis. That 
not all constricting bands are the remains of the vitelline duct, 

^ Etude anatomique et pathologiqne snr lea diyerticnles de V intestin. 
Th^se. Paris, 1862. 

^Gase of Acute Intestinal Obstruction; perforation of a diyerticuluxiL 
Transactions of the Pathological Society, Vol. XXlY, p. 122. 

* Transactions of the Clinical Society of London. Vol. V, 1872. 



UOAMENTOUS BANDS OR DIVERTICULA, 119 

requires no argument in speaking of the operative treatment of 
obstruction from constriction by bands; but the possibility of mistak- 
ing a peritoneal fold enclosing unobliterated umbilical vessels for an 
ordinary cicatricial band must be remembered and the necessary 
sections of the band made between ligatures. If a Meckel's 
diverticulum is found to be the cause of obstruction, this appendage 
should always be resected by ligating it at its base with a rubber 
ligature, and after the incision, the end invaginated and the invagi- 
nation maintained by a few stitches of the continued suture. Weir 
recommends in the excision of a constricting diverticulum to apply 
a ligature and after cutting it off, to stitch the peritoneal surface 
over the divided muscular and mucous coat; but when the divertic- 
ulum is nearly of the same diameter as the intestine from which it 
springs, such a course would not afford ample protection against 
perforation. 

Glutton^ related a case to the Clinical Society of London, of 
intestinal obstruction caused by a diverticulum, successfully treated 
by operation. The patient was a boy aged ten years, who had 
suffered on several occasions from colicky pains lasting for two or 
three days and always terminating with a copious evacuation from 
the bowels. This attack commenced with vomiting and great pain 
m the abdomen, which persisted in spite of opium treatment for 
four days, when he was brought into the hospital and at once 
submitted to an operation. On opening the abdomen through the 
linea alba a collapsed portion of bowel was soon found, and, on 
bringing it to the surface, a tight ring-like cord could be felt and 
seen to be the cause of strangulation. The cord was divided 
between .two pairs of forceps and each end tied with a catgut 
ligature. This step of the operation relieved the bowel from 
strangulation. On making an investigation as to the nature of the 
band divided it was found that one of the ligatures was situated at 
the extreme end of a diverticulum two inches in length, and the 
other was placed upon the wall of the same loop of intestine at a 
distance of about six inches. A portion of bowel of about three 
inches in length between these two points of ^attachment was the 
part strangulated, and was of an extremely dark color witii a deep 
sulcus at each side. The boy made an uninterrupted and rapid 
recovery. 

^ The Lancet, May 17, 1884. 



120 INTESTINAL SURGERY. 

Glntton explained the condition as follows: '^The yitelline 
duct had obliterated at the mnbilicns, and set free from the abdominal 
wall, but remaining patent towards the ileum the lower end had 
become a pouch-like diverticulum from the intestine. This divertic- 
ulum terminating in a pointed extremity or cord part also of the 
vitelline duct which had been obliterated had remained floating 
about among the intestines till it became attached to the bowel in 
contact with it. The gut between the two points of attachment liad 
slipped beneath the cord which united them, and being unable to 
extricate itself had become strangulated." 

Another interesting case of intestinal strangulation caused by a 
Meckel's diverticulum and successfully treated by laparotomy is 
reported by McGill.^ The patient was a man, aged thirty years, 
who had suffered from acute intestinal obstruction for nine days. 
The abdomen was very much distended at the time of operation. As 
the seat of obstruction could not be readily found by intra-abdom- 
inal palpation, partial extrusion of intestines was allowed to take 
place, but as soon as three feet of the small intestines had escaped 
the junction of the distended with the empty intestine came into 
view. At this point a Meckel's diverticulum, much dilated and 
about six inches in length, was seen, passing downwards and 
forwards, to be attached to the fundus of the bladder. A loop of 
collapsed intestine passed under the diverticulum, the obstruction 
being caused by the twisting of the bowel at the point where the 
diverticulum was attached. Slight traction proved efficient in 
releasing the bowel from the grasp of the diverticulum, and as soon 
as this was accomplished, the empty portion of the bowel became 
filled with the intestinal contents. Nothing was done to the 
diverticulum. On the tenth day a small faecal fistula formed at 
the lower angle of the wound; this continued two weeks, when the 
discharge ceased and the patient recovered without any further 
untoward symptoms. The author believes that this is the first 
recorded case where the free end of the diverticulum had its attach- 
ment to the fundus of the bladder. There can be but little doubt 
that the faecal fistulft in this case was caused by a perforation of the 
diverticulum, an accident which might have proved fatal if extrava- 



^ Remarks on a Case of Acnte Intestinal Obstrnotion dne to the Presence 
of a Meckers Diverticulum Successfully Treated by Laparotomy. British 
Medical Journal, January 14, 1888. 



NON-MALIGNANT STENOSIS. 121 

sation had taken place into t^e peritoneal cavity, and which might 
have been avoided had the diverticulum been removed, which would 
also have protected the patient with certainty against a possible 
recurrence in tiie future, of obstruction from the same cause. 

6. Non-malignant Stenosis. 

1. Oon&renital. 

Congenital narrowing of the bowel varies in degree from a 
slight contraction to complete atresia. In my experiments on 
animals I have shown that when the lumen of the small intestines 
is diminished one-half in size by partial enterectomy and suturing 
of the wound in a direction parallel to the long axis of the bowel, 
the function of the bowel is not impaired, and obstruction does not 
occur, but if the stenosis is carried beyond this point there is great 
danger of obstruction arising from accumulation of solid intestinal 
contents on the proximal side of the stenosis. The same holds true 
of congenital stenosis of the small intestines. Even if the narrow- 
ing is considerable no serious symptoms are produced until some 
foreign bodies collect above the seat of constriction and cause 
obstruction from coprostasis. 

Legg^ reports an exceedingly interesting case where a congeni- 
tal stenosis of the ileo-csBcal opening led to chrbnic obstruction, 
dilatation of ileum, and finally to perforation into the ascending colon. 
A female twenty-six years of age was admitted into the hospital 
April, 1858. She stated that since she was five years of age she had 
suffered from occasional attacks of colic, perhaps five times during 
a year, attended by constipation and vomiting. After such an attack 
eight years ago a number of cherry-stones passed with the fseces. 
Becently the attacks became more frequent, and the last was so 
severe that she found it necessary to seek admission into the hospital. 
When admitted she presented many symptoms of obstruction. In 
the right iliac fossa on percussion a dry crackling sound could be 
heard and felt. In a few days she again passed a few cherry and 
plum stones and felt relieved. She was given five gutta-percha 
pills, which never passed through. She left the hospital improved, 
and was not seen again until six years later. At this time she again 

^ Congenital Constriction of the Ileo-csacal Orifice and Dilatation of the 
Bemn; Retention of Fmit-stoneR in Jejunum and Ilenm. Trans. Pathological 
Society, Vol. XXI, p. 171. 



122 INTESTINAL SURGERY. 

suffered from well-marked symptoms ^of intestinal obstruction, and 
during the first few days vomited a number of cherry and plum 
stones, and a black round mass which, on cutting, was belieyed to be 
one of the gutta-percha pills which she had taken six years before. 
Below the umbilicus the same crackling sound could be heard and 
felt as before. The symptoms of obstruction gradually became 
worse, and a few weeks after admission she died. At the necropsy 
the entire colon was found empty and contracted, the ileum very 
much dilated, so much so that the lower portion measured seven 
inches in circumference. On opening it fluid faeces and a few fruit- 
stones escaped. Ileo-csBcal orifice contracted so that it would admit 
only a number nine catheter. Above the ileo-csecal valve a communi- 
cating bimucous fistulous opening the size of a quarter of a dollar 
had formed between the colon and ileum, and a little distance above 
this point, another but smaller opening had formed in the same man- 
ner by adhesion and perforation. In the small intestines a pint of 
cherry-stones were found, all of them covered with a black crust, 
which on examination proved to contain iron. The author could 
find in the literature only six cases of non-malignant stenosis of the 
ileo-csBcal opening. In Schroeder van der Kolk's case the opening 
was even smaller, and in the lower portion of the ileum, which was 
enormously dilated, a large mass of cherry-stones and fragments of 
bone we'lre found. 

Bourdon^ observed another case of congenital stenosis of the 
ileo-csBcal orifice like that narrated by Dor.^ The patient, a man 
thirty-two years of age, had suffered for a month from pain in 
the abdomen, nausea and vomiting. The bowels were moved with 
difficulty by cathartics. On examination nothing could be found 
except a doughy condition of the middle portion of the abdomen^ 
where percussion revealed also a certain degree of dullness. He 
remained two weeks in the hospital without any improvement being 
noticeable, when he left, but returned three days later. At this time 
an irregular, uneven swelling could be distinctly felt in the right 
groin. The swelling rapidly increased in size and the patient died 
in a few days of peritonitis. At the necropsy the small intestines 
were found very much distended, colon and rectum contracted and 
empty. Just above the ileo-csecal valve the ileum was. distended to 

> L'Union M^dioale 57, 1856. Schmidt's Jahrbticher, B. 96, p. 204. 
2 Gaz. M6d. de Paris, No. 9, 1836. 



NON-MALIGNANT STENOSIS. 123 

the size of a foetal head adherent to the posterior abdominal wall, 
mesentery and intestinal coils. The walls of this pouch were thick- 
. ened and of a brown color. When opened it was found to contain 
one hundred and twenty plum-stones and ninety-two lead bullets. 
The ileo-csecal valve was nearly closed and was permeable only to 
fluids. The patient had probably swallowed the bullets to overcome 
obstinate constipation. 

In all of these cases of congenital stenosis no symptoms were 
caused by the congenital defect until the foreign bodies which 
collected above it, finally produced death from intestinal obstruction 
or perforative peritonitis. The clinical history in each case distinctly 
points to aggravation of the obstruction by the occurrence of copros- 
tatis above the seat of stenosis. The surgical treatment in such 
cases consists in removing the impacted substances through an 
incision above the stenosis, and after clearing the bowel of its con- 
tents uniting it with a similar incision in the bowel below the obstruc- 
tion, by lateral apposition with decalcified perforated bone plates, 
thus establishing a free anastomosis between the bowel above and 
below the obstruction, and excluding at the same time permanently 
from the intestinal circulation, the contracted portion of the intestine. 
Excision and restoration of the continuity of the intestinal canal by 
circular enterorrhaphy can only be thought of in case perforation 
has taken place. 

2. Acquired or Cicatricial. 

Cicatricial stenosis of the intestines is one of the remote conse- 
quences of deep ulcerative lesions, such as are caused by dysentery, 
typhlitis stercoralis, tuberculosis, and ileo-typhus. The cicatrix 
which forms during the reparative stage of the ulceration contracts 
slowly and gives rise to stenosis and chronic intestinal obstruction. 
As in cases of congenital stenosis, the obstruction often becomes 
complete and gives rise to acute symptoms when foreign bodies or 
solid faeces become impacted above the seat of constriction. Not 
infrequently the causes which have led to cicatricial stenosis are 
located at the same time .or appear successively in different parts of 
the intestine, producing consequently also multiple strictures. 

Sharkey' presented to the Pathological Society of London a 
specimen of multiple strictures of the ileum, taken from a woman 

1 The Lanoet» May 24, 1884. 



124 INTESTINAL SURGERY, 

thirty-three years of age, who had snfifered freqnently from indi- 
gestion and vomiting. The immediate cause of death was facial 
erysipelas. The lower two-thirds of the small intestines exhibited 
nnmerous ulcers apparently healed. They were so hear together 
and produced snch marked constriction that the appearance of a 
succession of poaches was simulated. There were no distinct evi- 
dences of tuberculosis in the intestine or any of the other organs. 
In the discussion which followed the demonstration of this speci- 
men Treves spoke of other, somewhat similar, recorded cases in which 
typhoid fever and tuberculosis seemed to be excluded. Treves^ has 
described another cause of cicatricial stenosis. He has met with 
such cases in patients who suffered from strangulated hernia, when 
the prolonged compression during the strangulation had produced a 
circumscribed gangrene of the mucous coat. In all of the recorded 
cases the patients appear to have recovered well from the hernial 
trouble, and after a varying time to have gradually developed symp- 
toms of cicatricial stenosis of the small intestines. 

Another form of cicatricial stenosis of the intestines is caused 
by the formation of a cicatrix in the peritoneal coat, as the result of 
a circumscribed plastic peritonitis. In this form the mucous and 
muscular coats are intact, but the bowel is narrowed and puckered 
by a band of cicatricial tissue. Cicatricial stenosis of the colon is 
caused most frequently by dysentery, while the same condition in 
the rectum often appears as a syphilitic lesion. In the treatment of 
cicatricial stricture of the intestine the question of resection again 
confronts us. Maydl^ reports two successful cases of circular resec- 
tion and suturing for cicatricial stricture of the ileo-csecal valve. In 
the first case he relieved the obstruction by an enterotomy, and a 
year later excised the constricted portion of the caecum and united 
the ileum with the ascending colon. In the second case the general 
condition of the patient warranted a radical operation^ which con- 
sisted in the excision of the caecum and immediate restoration of the 
continuity of the intestinal canal by suturing, The conditions in 
these cases for circular enterorrhaphy were unusually favorable, as 
the colon must have been in a contracted state, while the lower por- 

^ Intestinal Obstruction that May Follow after Hernia. The Lancet. 

^ Ueber einen zweiten Fall von narbiger Striktni der Ileo-C8Bcal Klappe 
durch cirknlftre Darmresektion und Naht gebeilt. AUgem. Wiener Med. 
Zeitun/ar. No. 17, 1881. 



NON'MAUQNANT STENOSIS. 125 

tion of the ileum, from the prolonged obstraction, was much dilated, 
so that the lumina of the resected ends must have been neiarly equal 
in size. Both patients recovered. In the first case, .where the 
patient suffered all the inconveniences of an artificial anus for one 
year, a radical operation by an ileo-colostomy could have been made 
with no more risk than was incident to the enterotomy, and would 
have thus avoided the necessity of establishing an artificial anus and 
of performing a second operation. Where no gangrene or perfora- 
tion is present, I should strongly recommend the substitution of 
intestinal anastomosis for resection and circular enterorrhaphy. In 
cases of multiple stricture where they involve a limited area of the 
intestine an anastomosis should be made between the intestines at a 
point above the first and below the last stricture, excluding perma- 
nently the intervening portion from the f sBcal circulation. 

Eddowes^ operated on a case of intestinal obstruction due to a 
cicatrical stricture where the symptoms were promptly relieved by* 
the formation of an artificial anus, and the patient recovered with a 
permanent fistula. A woman forty-six years old, was seized nineteen 
days before the operation with abdominal pain, which had persisted 
ever since. For twelve days there had been no action of the bowels 
without enemata; complete constipation had existed for five days. 
There was no history of syphilis, tuberculosis or cancer. The 
abdomen was distended, but soft and free from tenderness; the walls 
were very thin, and moving coils of small intestine were plainly 
seen. The abdomen was opened by an incision four inches long in 
the median line between umbilicus and pubes. A small quantity of 
peritoneal fluid mixed with lymph escaped, and the abdominal con- 
tents appeared congested. A stricture of the small intestine was 
soon found, forming a complete obstruction, impermeable even to 
flatus. An artificial anus was formed at the lower extremity of the 
wound, about two inches from the pubes. The operation was 
followed by a great sense of relief. The lower portion of the wound 
suppurated on account of escape of faeces, otherwise the recovery 
progressed favorably. Seven months after the operation the patient 
was in perfect health, had gained considerably in weight, and was 
able to go about her household work as before. The bowels acted 
very regularly every morning, the motion was gradually formed, and 

.-■-■-■ ', 111 ^M, 

1 British Medical Journal, July 24, 1886. 



126 INTESTINAL SURGERY, 

in this case she had very good control, but she was unable to con- 
trol liquid motions and flatus. On introducing the flnger, it was 
felt to be distinctly grasped by a sphincter. 

Although the symptoms of obstruction were successfully re- 
moved by establishing an artificial anus in the median line, this 
course of practice is open to serious objections. An artificial anus 
should never be established in the median incision, as the contact of 
faeces with the wound necessarily prevents healing by first intention. 
If such a course is contemplated after the abdomen has been ex- 
plored through a median incision, a small incision for the enterotomy 
should be made in one of the inguinal regions, and the median 
incision closed and dressed separately. In following such a course 
the large incision will heal by primary union and the abdomen can 
subsequently be opened again to better advantage through the 
median line for the performance o^ a radical operation. This, like 
all similar cases, would have been a proper subject for intestinal 
anastomosis. 

In non-malignant stricture of the colon, colectomy and circular 
enterorrhaphy should be done in all cases where approximation of 
the bowel ends is possible. In multiple strictures of this portion 
of the intestinal canal resection is inapplicable, and the, obstruction 
can only be rendered harmless and the continuity of the intestinal 
canal restored by lateral implantation or by establishing an intesti- 
nal anastomosis. 

Goupland and Morris ^ have collected a number of cases of stric- 
ture of the intestine, and in commenting on the material, assert that 
in three-fourths of all the cases, the disease affected the lower part 
of the bowel, being about equally divided between the rectum and 
the sigmoid flexure. With few exceptions strictures are located 
below the csecum. In many of the fatal cases death occurred from 
perforation either above the stricture or in the caecum. From 
Bryant's investigations it appears that one-third of the cases of 
stricture of the rectum or lower bowel are not malignant, a most 
important practical point with regard to treatment. He lays down 
the following general rule for performing lumbar colptomy in cases 
of stricture of the rectum: "In all cases of cancerous stricture of the 
rectum or colon, including the annular, which are not amenable to 

^ On Striotures of the Intestine; with Remarks upon Statistics as a Ghiide 
to Diagnosis and Treatment, 1878. 



TUMORS. 127 

Inmbar colectomy or anal excision, right or left lumbar colotomy is 
strongly to be advocated, with the well-gromided hope of relieving 
suffering, retarding the progress of the disease, and prolonging life 
even for five or six years. To secure these advantages it is neces- 
sary for the operation to be performed bef (fire the pernicious effects 
of obstruction occur." 

* Against lumbar colotomy I have already, in another part of the 
paper, entered my protest, and in cases of inoperable carcinoma of 
the rectum producing evidences of obstruction, I wish to call atten- 
tion to the method of operating devised by Madelung.* In cases of 
malignant stricture of the rectum, where it is desirable to exclude 
the part at and below the seat of obstruction completely and per- 
manently from the faecal circulation, he opens the abdomen by a 
lateral incision and divides the colon completely in a transverse 
direction, and as low down as possible. The distal end is closed by 
invagination and two rows of sutures, and dropped into the peri- 
toneal cavity, while the proximal end is sutured into the wound. 
This operation secures absolute physiological rest for the diseased 
portion of the bowel and is less likely to be followed by prolapse, as 
is the case when the bowel is simply stitched into the wound and 
opened. Anal extirpation of the rectum, both for cicatricial and 
carcinomatous stenosis, should always be practiced when the obstruc- 
tion and the local conditions which have caused it, can be removed 

by this method. 

7. Tumors. 

A tumor can give rise to intestinal obstruction in different ways, 
according to its location and anatomico-pathological character. A 
tumor or swelling outside of the intestinal tube may cause obstruc- 
tion by compression. A polypoid growth springing from the mucous 
or sub-mucous tissue interrupts the fsecal circulation either by 
blocking the lumen of the bowel by its size, or by causing an 
invagination or flexion. A circular carcinoma produces a stenosis 
which leads to chronic obstruction, but which is frequently the 
indirect cause of acute intestinal obstruction when either by addi- 
tional pathological changes at the seat of the malignaut disease, or 
by the accumulation of foreign bodies or solid f secal masses above 
the seat of constriction the faecal circulation is completely arrested. 

1 Modification der Oolotomie wegen Garoinoma Beoti. Yerh. der Deutsohen 
Gesellsohaf t f . Ohiinrgie, 1884. 



128 INTESTINAL SURGERY. * 

1. Non-Mali^rnant Tuxnors. 

Benign polypoid tumors seldom attain a sufficient size to give 
rise to intestinal obstruction, unless they cause additional mechanical 
distorbance, such as invagination or flexion, conditions which have 
already been alluded to. If the tumor alone is the cause of obstruc- 
tion it is removed by laparo-enterotomy. A few cases have recently 
been reported where the obstruction was caused by cysts. In Bnch- 
wald's' case the symptoms of obstruction were acute, and laparotomy 
was performed on the third day. The patient was a boy who had 
previously been in good health. As soon as the peritoneal cavity 
was opened, two cysts attached to the small intestine presented 
themselves in the wound. As the cysts had produced a sharp flexion, 
9 cm. of the bowel, including the cysts, were resected and the ends 
united by circular suturing. Twenty-seven hours after the operatioa 
the patient died. The necropsy showed that the resected piece was 
taken from the jejunum one-half metre below the duodenum. One 
cyst measured 17 and the other 10 cm. in diameter. The walls of 
the cysts were white and very thin. The microscopical examination 
showed that they were composed of the same tunics as the bowel, 
but the mucous membrane was atrophied and contained no glands. 
The cysts communicated with each other and the limien of the 
bowel. The latter was not diminished in size. The oysts contained 
a yellowish fluid, with a strong odor of acetone. Under the micro- 
scope the contents showed cylindrical cells in a state of fatty 
degeneration, cholesterine crystals, granules of leucin, fat globules, 
and rod- shaped bacteria, but no intestinal contents. He believes 
that the cysts had no connection whatever with the vitelline duct. 

Kulenkampff ' reports the case of a child three years old that 
had suffered occasionally from colic and constipation, and was 
attacked suddenly with symptoms indicative of acute intestinal 
obstruction. Abdomen somewhat tympanitic, but no swelling could 
be made out by percussion and palpation. Tenderness and slight 
dullness in the right inguinal region. The boy died on the second 
day. The autopsy revealed as the cause of death a cyst in the region 
of the caecum. The cyst was as large as a man's fist, and had thin, 

^Ueber Darmoysten als Ursache eines kompleten Darxnversohliisses. 
Deatsohe Med. Wochensohrif t, No. 40, 1887. 

Ein Fall von Entero-kystom. Tod dnroh Darmversohlingimg. Central- 
blatt f . die gesammte Medicin, No. 42, 1888. 



TUMOBS. 129 

almost transparent walls. It showed several depressions which 
gave it the appearance of being composed of three or four parts. 
It was located in the mesentery of the ileimi, about 40 cm. above 
the ileo-cascal valve. It did not commmiicate with the lumen of the 
bowel, and contained a thin chocolate-colored fluid. The mesentery 
at this point was drawn out like a string and encircled a loop of the 
ileum. Above this point the bowel was greatly distended. He 
believed with Both ^ that the cyst was congenital and had developed 
from a diverticulum of the ileum. As a rule such cysts are located 
on the convex side of the bowel, but in this instance it occupied a 
position opposite. At first sight the cyst appeared like a greatly 
distended loop of intestine. As in both these cases the cyst had 
produced intestinal obstruction by secondary mechanical conditions, 
the operative treatment of the obstruction would include the removal 
of the primary cause and the correction of the secondary mechanical 
difficulties. This would include resection of the bowel at the seat 
of obstruction including the tumor, and restoration of the continuity 
of the intestinal canal by circular suturing. 

2. Malifirnant Tumors. 

Malignant stenosis of the intestines may be caused either by a 
sarcoma or carcinoma, of which the former is more frequent above 
and the latter below the ileo-csBcal valve. A sarcoma in the intestine, 
as in any other organ, primarily starts from an embryonal matrix 
of connective tissue, and hence it always has its starting-point in the 
wall beneath the mucous membrane; while carcinoma, being an 
atypical proliferation of epithelial cells, either commences in the 
mucous membrane or its glandular appendages. 

a. Sabooma. 

Nicolaysen' reports an exceedingly interesting case of entereo- 
tomy for a sarcomatous stenosis of the small intestine. The 
patient was twenty-eight years of age. A firm nodulated, kidney- 
shaped tumor could be felt in the abdomen below the umbilicus. 
The tumor was first noticed six months before, when it was as largo 
as a hen's egg. In the morning the tumor usually could be felt 

> Virohow'8 Arohiv. B. LXXXVI, p. 811. 

' Myosarkom des Ddnndarmes. Extiipation mit DarmreseoHction. Oen- 

iralblatt f . die ges. Medioin, No. 28, 1886. 
9 



180 INTESTINAL SURGERY. 

under the costal ardi, while dtiring the day it descended into the 
hypogastric region where it always caused more pain. As the symp- 
toms of obstruction gradually increased in severity and did not yield 
to ordinary treament laparotomy was performed. Median incision 
14 cm. long. It was found somewhat difficult to bring the tumor 
forward into the wound. The tumor occupied the mesenteric side of 
the bowel and behind it a number of enlarged lymphatic glands 
could be felt. Eighteen centimetres of intestine, including the tumor 
and a triangular piece of mesentery were excised, and the ends of the 
intestine united with sutures, embracing only serous and muscular 
coats, whereupon the proximal end was invaginated to the extent of 
2 cm. and the invagination retained with five Lembert sutures, over 
which the peritoneum was once more stitched with a continued 
suture of fine catgut. The mesenteric wound was also closed by 
suturing. The tumor consisted of several nodules the size of a goose- 
egg, which had perforated the intestine. Microscopical examination 
of the tumor and lymphatic glands showed sarcomatous tissue. The 
patient recovered 

Bessel-Hagen^ described a somewhat similar specimen which he 
found in a child. A boy seven years old, after a trauma, suffered 
from a rapidly growing tumor in the abdomen, which resulted in 
death from marasmus in four months. At the autopsy a large 
sarcoma of the jejunum was found which had perforated into the gut 
by necrotic destruction of the interior of the tumor. Microscopic 
examination proved it to be a small-celled, round-celled sarcoma 
which had originated in iiie submucosa of the jejunum. Multiple 
metastasis in kidneys, on back and in the lymphatic glands. Peri- 
tonitic adhesions had caused flexion of the intestine below the tumor, 
and dilatation of the proximal portion from obstruction thus pro- 
duced. As a sarcoma of the intestine only gives rise to symptoms 
of obstruction, and consequently comes under surgical treatment, 
usually after extensive infiltration of the mesentery and retro- 
peritoneal tissues has taken place, it is questionable if it is pradent 
to attempt a radical operation, as in case the patient recovers from 
the operation, an early recurrence is almost inevitable. If a suffi- 
ciently early diagnosis were possible, resection could be made with a 
fair prospect of a permanent result; but if the infection has extended 

^UloerOses Saroom des Jejnnnm bei einem Kinde. Yirohow's Arohiv. 
B. XGIX, Heft 1. 



TUMORS. 181 

to the tissues aroTind the bowel, it is more judicious to leave the 
sarcoma and to explude the obstruction by an intestinal anastomosis. 

b. Gaboinoma. 

In most cases of carcinoma of the intestine the disease com- 
mences in the mucous membrane, in which case the parenchyma of 
the tumor is composed of cells which resemble the columnar epithe- 
lium which lines the intestinal canal. Carcinoma is found most 
frequently in the region of the sigmoid flexure, the caecum and 
rectum. A malignant stenosis may have existed for months with- 
out symptoms, when suddenly symptoms of acute intestinal obstruc- 
tion are developed, as in a case here related. In cases of acute 
intestinal obstruction in elderly people, where no cause for it can be 
found in the abdomen, a thorough rectal examination should never 
be neglected. 

During my visit in Zurich last year I was present at a very 
interesting autopsy made by Klebs upon one of KrOnlein's patients. 
A few days before a woman forty years of age was brought into the 
hospital, presenting well-marked symptoms of intestinal obstruction, 
which had lasted for two weeks. On examination no cause for the 
obstruction could be found. The abdomen was very tympanitic, 
rendering palpation difficult and unsatisfactory. Laparotomy was 
made, but as nothing could be found and the small intestines 
were enormously distended throughout, inguinal colotomy was per- 
formed. The operation was followed by decided relief, the abdomen 
collapsed and a large quantity of faeces was discharged through the 
artificial anus; but the patient died of exhaustion the next day. At 
the post-mortem examination the cause of the obstruction was found 
20 cm. below the artificial anus, in the shape of a narrow, annular, 
carcinomatous stricture of the colon. In his remarks on the case 
KrOnlein stated that he had observed four similar cases during the 
time he had been in Zurich. It would be well in the future, when a 
similar condition is suspected, to explore, if need be, the upper por- 
tion of the rectum and lower extremity of the colon as far as accessible 
by Simon's method, as in case the lesion is recognized and accurately 
located, some of these oases might be amenable for a radical opera- 
tion by excision. 

Schede^ made a resection of the small intestine for carcinoma 

^ Yerh. der Deutschen G^ellsohaft fdr Ohirargie, 1884. 



182 INTESTINAL SURGERY. 

in a case where the tumor had extended to the abdominal walL The 
intestine was excised with the tumor and the ends united by circular 
suturing. The patient recovered. A few weeks later he returned 
to the hospital with symptoms of complete intestinal obstruction. 
The abdomen was again opened and an artificial anus was estab- 
lished. The patient died on the fifth day. The cause of obstruction 
was a constricting band which was divided during the operation. 
Schede is of the opinion that in cases of complete obstruction of the 
bowels by a malignant tumor, excision is contra-indicated, as in eigh- 
teen cases of intestinal resection for malignant disease, of six cases 
in which the occlusion was complete all died, while of the remaining 
twelve, where the occlusion was only partial, only three died. These 
statistics should only induce us to endeavor to make a correct 
diagnosis before urgent symptoms have set in, and to resort to opera- 
tive treatment at a time when the general condition of the patient 
is such as to warrant a radical operation, and the local conditions at 
the seat of obstruction are favorable to a speedy process of repair. 

If, after resection of the lower portion of the colon, it is found 
impossible to approximate the two ends of the bowel, and the distal 
end is not sufficiently accessible to make an intestinal anastomosis 
or lateral implantation, then the course adopted by Oussenbauer^ in 
a case of this kind should be chosen. The patient was a man forty- 
six years of age, who had suffered for years from obstinate consti- 
pation. On examination a tumor was discovered the size of a hen's 
egg in the left hypogastric region, two fingers' breadth below a line 
drawn from one anterior superior spinous process of the ilium to the 
other. The tumor could also be felt high up in the rectum by press- 
ing it downwards into the pelvis. The abdomen was opened by an 
incision over the tumor parallel with the course of the descending 
colon. The tumor was found to occupy the most prominent portion 
of the sigmoid fiexure, freely movable, and not attached to any of 
the surrounding organs. A few glands behind the affected portion 
of the colon were enlarged. Circular resection was made, including 
a corresponding portion of the meso-colon and the enlarged lym- 
phatic glands. On account of too great loss of substance, circular 
enterorrhaphy could not be made, consequently the distal end was 
closed by invagination and suturing and dropped into the abdominal 

^ Znr operativen Behandlimg der Oaroinome des S. Bomanimi. Prsger 
Zeitschrif t f . Heilknnde, 1881. 



TUMOBS. 188 

cavity, while the piozimal end was sntnred into the external wonnd. 
The patient made a good recovery, and at the end of ten months the 
disease had not retained. 

Bnll^ reports two oases of carcinoma of the sigmoid flexnre 
where, in each instance, he opened the abdomen through the median 
line and stitched the descending colon into the wound without incis- 
ing it, reserving this step of the operation until adhesions had taken 
place. Both patients recovered. In one of these cases he resected 
six inches of the colon, including the artificial anus, and the tumor 
twelve months later, and the patient again recovered from the opera- 
tion. At the time the report was made the operator had in view a 
third operation for the closure of the second artificial anus, which 
was made at the close of the second operation. In all cases where 
the seat of obstruction can be located in the csBCum or colon before 
the operation, lateral incision should be selected, as it will afford 
better access to the seat of obstruction than median incision. 

If it is found impossible to remove the obstruction, one of two 
things must be done. If the bowel below the obstruction can be 
reached, an intestinal anastomosis is made, or the ileum is divided 
just above the ileo-esecal valve, the distal end closed, and the prox- 
imal implanted into the bowel below the seat of obstruction. If 
resection can be done with a prospect of removing all the diseased 
tissues it should be invariably practiced as a primary radical opera- 
tion, and if, on account of its extent, circular enterorrhaphy cannot 
be done, the distal end is permanently closed, and the proximal 
stitched into the wound. If the distal portion can be reached the 
continuity of the intestinal canal is restored by intestinal anasto- 
mosis or lateral implantation. If the seat of obstruction cannot be 
ascertained before the operation and exploration through a median 
incision locates it in the caecum, colon, or rectum, it may become 
necessary to make a lateral incision if a radical operation is decided 
upon, and when this appears impossible or unjustifiable, an intestinal 
anastomosis or lateral implantation can be made through the median 
incision. If on account of the location of the obstruction, either of 
these operations are also inapplicable, an artificial anus should be 
established in the right or left inguinal region, and the median 
incision closed and dressed separately. 

1 OaiUard'8 Medical Joomal, March, 1888. 



184 INTESTINAL 8UR0EBY. 

T. Dynamic Intestinal Obstruction Caused by Suspension 

of Peristalsis. 

A nmnber of pathological conditions are known to produce 
symptoms which so closely resemble intestinal obstmction that the 
abdomen has been repeatedly opened in such oases, with the expec- 
tation of removing the cause of the obstruction, but no occlusion 
of any kind could be found. These are the cases that have caused 
the greatest difficulty in diagnosis, and have often brought disap- 
pointment and reproach upon the surgeon. The obstruction in these 
cases is not caused by a narrowing of the lumen of the intestine, 
but by suspension of the dynamic forces which propel the intestinal 
contents, and which results in accumulation of f eeces and gases in 
the paralyzed portion of the bowel; which is followed by distention 
of the intestines, constipation and obstinate vomiting, which in rare 
oases may become f SBcal. Circumscribed or diffuse paresis of the 
intestines is caused either by an inflammatory affection, such as peri- 
tonitis or enteritis, which produces suspension of muscular contrac- 
tions in the same manner as when an inflammatory process in any 
other organ affects directly the muscular tissue, or the tunics of the 
intestines are in an intact condition, but a paralysis has resulted from 
reflex causes. 

Pitts ^ narrates two cases in which, after reduction of a strangu- 
lated hernia, he performed laparotomy on account of persisting 
symptoms, and found no cause for these symptoms save that pre- 
sented by the free but lifeless coil that had been liberated too late. 

The contents in a paretic bowel are liable to undergo fermenta- 
tive and putrefactive changes, and the gases which are developed 
during such changes accumulate and cause such an extensive tympan- 
ites that the latter may become a mechanical cause of obstruction. 

I. Tympanites. 

Cases of sudden death from over-distention of the intestines 
and stomach by rapid accumulation of gas have been reported by 
Dechambre, Mercier, L'Pereyra, and others. The patients were 
generally aged persons, or young persons during convalesence from 
protracted diseases. 

^ St. Thomas' Hospital Reports. Vol. 11, 1882, p. 75. 



TYMPANITES. 135 

Ghi^neau de Mossy/ in a clinical lecture, treats of the mechani- 
cal conditions which canse acctunulation of gas in the intestines. 
Where no mechanical obstruction is present the gaseous distention 
is due to paralysis of the sympathetic nerves. The failure of the 
expulsion of the gas is owing to the formation of numerous flexions 
from the over-distention, and later, to compression of some parts of 
the intestines by the distended loops. The lowest portion of the 
ileum may be compressed against the ascending colon so flrmly as 
to become a cause of complete mechanical obstruction. Proof of 
the existence of such a mechanical condition is furnished in cases of 
extensive tympanites where the introduction of a rectal tube affords 
no relief. In such case? the distention increases even after death. 

The author has also furnished experimental proof. The cadaver 
of a child was inflated moderately through the oesophagus, after 
which the oesophagus was tied, and a tube was introduced into the 
rectum and its distal end immersed under water. Pressure upon 
the abdomen expelled the air through the rectal tube. When he 
repeated the experiment, but carried the distention further, no air 
could be made to escape through the rectal tube by compressing the 
abdomen. On opening the abdomen with great care, it was seen that 
the lower portion of the distended ileum was pressed against the 
ascending colon so firmly as to completely interrupt the communi- 
cation between them. From these observations it can be readily 
seen how the formation of an intestinal anastomosis would frequently 
prove the means not only of relieving the obstruction, but also of the 
removal of its cause. 

If gas is present in the peritoneal cavity as the result of putre- 
factive changes of the products of peritoneal inflaiomation, it presses 
the liver away from the diaphragm, and the percussion dullness dis- 
appears completely when the patient lies on his back. In distention 
of the abdomen from the presence of gas in the intestines, the dia- 
phragm and liver are crowded upwards, but the latter remains in 
contact with the chest wall, and the area of liver dullness remains 
the same, but is displaced in an upward direction. Where life is 
threatened by tympanitic distention of the abdomen during the con- 
valescence from acute diseases, the symptoms appear very rapidly 
and death restilts from mechanical compression of important organs. 

■ - ' — 

1 Des conditions M^oaniques de la tympanite. Gaz. hebd., No. 31, 1867. 



186 INTESTINAL SURGERY. 

Panctnre of the distended intestines followed by aspiration, if need 
be, repeated at short intervals, is positively indicated in snch cases. 
There can be no doubt that in many cases of peritonitis attended by 
difhise and excessive tympanites the symptoms which point to intes- 
tinal obstruction are due to the same causes, viz. : flexions and com- 
pression, and such cases would also be greatly benefited and some- 
times cured by the same treatment. 

2. Peritonitis. 

Peritonitis may lead to symptoms resembling intestinal ocoln- 
sion in different ways, according to the extent and type of the diseasa 
In extensive plastic peritonitis the immobilization of a considerable 
portion of the small intestines may give rise to persistent vomiting, 
and absolute constipation. Again, as we have just seen, arrest of the 
fsBcal circulation may be caused by the tympanites alone, while per- 
forative peritonitis is attended by a local and general shock, which 
causes intestinal paresis through the sympathetic nerves. Heusner^ 
has observed that perforative peritonitis gives rise to disturbances 
simulating intestinal obstruction, by arresting intestinal movementa 
He narrates the histories of two cases of this kind where the symp- 
toms of intestinal obstruction were so prominent that laparotomy 
was performed. In both cases perforative peritonitis, but no occlu- 
sion, was found. 

Henrot,' in his classical monograph on pseudo-strangulation, 
describes a number of cases of perforation of the gall-bladder and the 
processus vermiformis, where the symptoms during life had pointed 
so strongly to the existence of intestinal obstruction that a wrong 
diagnosis was made by able clinicians. He also calls attention to 
those cases of paralytic obstruction which are often observed after 
herniotomy, and in cases of strangulation of the appendix vermi- 
formis and testicle. The intestinal paresis, where it is not the 
result of inflammation, must be looked upon as a reflex symptom. 

Physical signs and symptoms are sometimes utterly inadequate 
to distinguish between acute intestinal obstruction and diffuse peri- 
tonitis. In differentiating between these two conditions^ it must be 
remembered that in the absence of a tumor, absolute constipation and 
f SBcal vomiting are the most characteristic symptoms of obstruction, 

^ I>eatBohe Med. Woohensohrift, 1877. 

' Des Pseado-^tranglements, eto., Th^se, Paris, 1865. 



CATARRHAL AND ULCERATIVE ENTERITIS. 187 

and that in peritonitis the pain is severe and continuous, with diffuse 
tenderness, tympanites, and absence of visible intestinal coils. In 
mechanical obstruction of the bowels the temperature as a rule is not 
above normal unless complications have set in, while in peritonitis 
a rise in temperature is the rule, although in some of the gravest 
oases it is sub-normaL Many cases of supposed recovery from 
intestinal obstruction without operation undoubtedly were cases of 
dynamic obstruction, and the recovery was either entirely spontane- 
ous, or facilitated by means which assisted in the restoration of 
peristaltic action. In 1851 a' patient was admitted into Dupuytren's 
ward with well-marked symptoms of acute intestinal obstruction. 
This eminent surgeon gave it as his opinion that without an opera- 
tion a fatal termination was inevitable, but the patient objected to 
the operation and was transferred to another ward, where he re- 
covered in three days under the use of simple cathartics. Numerous 
similar cases could be cited in illustration of the difficulty of differ- 
entiating in all cases between mechanical occlusion and dynamic 
obstruction. 

3. Catarrhal and Ulcerative Enteritis. 

For some reasons which at present it is difficult to explain, 
simple catarrhal enteritis and circumscribed ulcerations of the small 
intestines have occasionally been the cause of rapid accumulations 
of gas, followed by symptoms of intestinal obstruction. Mercier^ 
has recorded a case where a patient died after a brief illness, during 
which all symptoms pointed to the existence of intestinal obstruction, 
including complete constipation and fsBcal vomiting. The necropsy 
showed no stenosis or any other form of mechanical obstruction, but 
several large ulcers in the middle of the ileum. 

Mosler^ reports a case of acute intestinal obstruction which 
followed a catarrhal enteritis, where on post-mortem no primary 
mechanical obstruction could be found. The small intestines were 
so enormously distended that they filled the entire abdominal cavity, 
compressing the ascending colon so firmly as to render it completely 
impermeable; the transverse colon was also compressed, but to a 
lesser extent. 

^ Note BTir denz oas d ileus. Gazette M6d. de Paris, 1867, p. ^51. 
' Ueber den nens. Arohiv der Heilknnde, No. 2, 1864. 



188 INTESTINAL aUHGKHY. 

Zimmermann^ described a case of acnte intestinal obstmciionf 
where daring life the collapse came on so rapidly as to resemble 
cholera. The bowels remained completely constipated, and the 
vomiting was so severe and persistent that on the seventh day it 
became stercoraceons. The patient lived six weeks. At the necropsy 
the small intestines were found enormously distended and their 
walls very much attenuated; the colon was also distended. In the 
ileum a number of small ulcers were found, which had destroyed the 
entire thickness of the mucous membrana In a case of this kind 
Obalinski made a laparotomy, and as he foimd the external surface 
of the lower portion of the ileum only congested, but no mechanical 
obstruction, he closed the external incision and the patient recovered* 
He believed that in this case there were typhoid ulcers which caused 
a functional stricture of the gut and the symptoms which induced 
him to open the abdomen. 

4. Exventration. 

At a recent meeting of the Berlin Obstetrical Society, Olshausen 
reported several cases of laparatomy, in which more or less exven- 
tration became unavoidable during the operation. A few days 
after the operation the patients presented all the appearances of an 
attack of acute intestinal obstruction, and death followed five to ten 
days after the operation. Olshausen explained the symptoms during 
life and the fatal termination, by aRWiming the existence of intestinal 
paralysis, distention of the bowel and absorption of toxic agents from 
the intestinal canaL During the exventration the intestines became 
engorged by venous'hypersemia, which in turn again was followed by 
exudation into the tissues of the boweL 

Sebileau' re-opened the abdomen in two cases of acute intestinal 
obstruction after laparotomy, and no mechanical ocdusiOn or 
exudation of any kind, but enormous meteorism was found. He 
attributes this condition to intestinal paresis and rapid accumulation 
of gas. The prophylactic treatment of such cases is more important 
than the curative. The administration of a brisk cathartic on the 
second or third day after the operation, will usually prevent iympan- 

1 Ein Beitrag zor Lehre vom dynamisohen Hens. Oanstatt's JahreBbericht, 
B. 8, 1860, p. 245 

*De qnelqnes aooidents intestananx sTuryeiiant aprte les operations 
abdominales. Annal. de Gyn^oologie, T. XXV, p. 118. 



EXVENTRATION. 189 

itio distention pf the abdomen by stimulating the paretic walls to 
active muscular contractions, and by removing the intestinal contents, 
the source of putrefactive changes. This treatment should never be 
postponed until the paralysis has been aggravated by over-disten- 
tion, but should be resorted to either before, or upon the first 
appearance of intestinal distention. 

Uniform compression of the abdbmen with strips of adhesive 
plaster and bandage applied over the antiseptic absorbent dressing 
immediately after the operation should be kept up imtil all danger 
from the occurrence of tympanites has passed. When the distention 
has become so great as to threaten life, the treatment should consist 
of the employment of such prompt mechanical measures as will 
diminish the intra-abdominal pressure. As the stomach may also be 
dilated, its contents should be removed through a flexible stomach 
tube, followed by an irrigation with a harmless antiseptic solution. 
Tubage of the colon followed by a turpentine enema is used for the 
same purpose. If these measures fail in relieving the distention, a 
prompt resort to intestinal puncture with a flne hollow needle becomes 
imperative. This surgical resource may be repeated as often as it 
may become necessary to avert danger from an increasing intra- 
abdominal pressure. 



AN EXPEEIMENTAL OONTEIBUTION TO INTES- 
TINAL 8TJEGEET WITH SPECIAL EEFEE- 
ENCE TO THE TEEATMENT OF 
INTESTINAL OBSTEUOTION/ 



The most important, and, at the same time, the most popular 
topic for disGnssion among surgeons of the present day is intestinal 
surgery. The current medical literature is teeming with reports of 
cases, and at the meetings of almost every medical and surgical soci- 
ety, large or small, this subject comes up for discussion and occupies 
a liberal space and conspicuous place in their printed transactions. 
The unusual activity which has been manifested in all parts of the 
civilized world in the development of this, one of the most modem 
and aggressive departments of abdominal surgery, is sufficient 
evidence that the subject is comparatively new, and as yet imper- 
fectly understood. A study of the literature of intestinal surgery 
must convince every xmprejudiced mind that here, as in many other 
difficult problems in surgery, the positive knowledge which we have 
acquired rests almost exclusively on the jresults obtained by experi- 
mental research. Ghmshot woxmds of the abdominal cavity have 
been made the object of careful and patient experimentation by a 
number of enthusiastic sui^eons, and the results obtained have laid 
the foundation for a rational method of treatment of these injuries, 
-which has been eagerly accepted by all modem aggressive and pro- 
gressive surgeons. The practical results which have been obtained 
thus far in the hands.of a number of surgeons have been the means 
of saving a number of lives, which by the old conservative method of 
treatment .would have been doomed to inevitable death from hflomor- 
rhage or septic, peritonitis. The numerous valuable practical sugges- 
tions for treatment of gunshot injuries of the intestines are the 
direct outcome of experiments on animals, and this, as w^ as 

^ Bead in the Surgical Section of the Ninth International Medical Congress, 

Washington, September 6, 1887. 

141 



142 INTESTINAL 8UBGSBY. 

the remarkable reooveries following ganshot wottnds of the abdomen 
treated by laparotomy, have so firmly oonvinced the profession of 
the necessity of resorting to operative measures in snch oases, that 
few surgeons could be found at the present day who would be willing 
to trust to conservatiye treatment any case where positive, or only 
probable, evidences pointed towards the existence of a visceral injury 
of any portion of the intestine. 

While a decided advance has been made in the treatment of 
injuries of the intestinal tract, the operative treatment of intestinal 
obstruction still constitutes one of the darkest and most unsatisfactory 
chapters in the wide domain of intestinal surgery. The obscurity 
and uncertainty which cling to this subject are due to the difficulties 
which often surround an accurate diagnosis. At the same time we 
have every reason to believe that the appalling mortality which has 
so far attended the surgical treatment of intestinal obstruction is 
mainly due to late operations, and not infrequently to a faulty 
technique in the removal of the cause of the obstruction, and in 
the restoration of the continuity of the intestinal canal. An accurate 
anatomical or pathological diagnosis in such cases during life is often 
•difficult, if not impossible, and when, as a dernier ressort, laparot- 
omy is performed, and the surgeon is confronted by an unexpected 
condition of things, he is often in doubt as to what course to pursue, 
and frequently ends the operation by establishing an artificial anus. 
No one who has been forced to resort to this measure has left his 
patient with a feeling of Satisfaction, as he must have been sadly 
impressed with the fact, that, at best, he has only been instrumental 
in relieving the urgent symptoms of the obstruction, while he has 
failed to remove its cause, anch consequently also in restoring the 
continuity of the intestinal canal. A patient with an artificial anus 
is indeed an object of conmuseration, as experience has sufficiently 
demonstrated how difficult it is in many instances to close the abnor- 
mal outlet, even after the cause of obstruction is subsequently 
removed or corrected spontaneously, without exposing him a second 
time to the risks of life incident to another abdominal section. If 
the causes which have led to the obstruction are of a permanent 
character, all attempts at closing the fistulous opening will, of course, 
prove worse than useless, and the patient is condemned to suffeir from 
this loathsome condition the balance of his pr her lifetime, without a 
hope of ultimate relief. I believe I can safely make the statement 



TREATMENT OF INTESTINAL OBSTRUCTION. 148 

without fear of contradiction that most of these unfortunate patients 
would prefer death itself to such a life of misery. The ideal of an 
operation for intestinal obstruction embraces the fulfillment of two 
principal indications: 

1. The removal or rendering harmless of the cause of obstruc- 
tion. 

2. The immediate restoration of the continuity of the intestinal 
canaL 

To meet the first indication the cause of obstruction must be 
found, its nature determined, and whenever advisable or practicable, 
it is removed, a step in the operation which may be very easy, or 
may demand a most formidable and serious undertaking, more 
especially in cases where the pathological conditions which have 
given rise to the obstruction are of such a nature as to constitute in 
themselves an imminent or remote source of danger, as, for instance, 
malignant disease or gangrene of the bowel from constriction. In 
all cases of inoperable conditions the cause of obstruction is rendered 
harmless as far as obstruction is concerned by establishing an 
anastomosis between the bowel above and below the obstruction by 
an operation which will be described further on. 

Immediate restoration of the continuity of the intestinal canal 
should be secured in the operative treatment of all cases of intesti- 
nal obstruction, with the exception of inoperable cases of carcinoma 
of the rectum, but is most urgently indicated in cases of obstruction 
in the upper portion of the small intestines and the colon, as the 
formation of an artificial anus in the former locality would prove 
a direct source of danger from marasmus, by excluding too large a 
surface for intestinal digestion and absorption, while in the latter 
situation the cure of a fsecal fistula only too often proves an oppro- 
brium of surgery. A careful perusal of the literature on the 
treatment of intestinal obstruction proves only too plainly the im- 
perfection of this branch of surgery. The rules laid down in our 
text-books are often given with so much hesitation that it becomes 
impossible to apply them in practica Opinions are so widely at 
variance that every surgeon finally acts upon the impulse of the 
moment and adopts a method which he deems appropriate for his 
case. It can be said that no uniformity of action exists, consequently 
the statistics which have been produced so far are of but little value 
from a practical standpoint A rational and successful surgical 



144 INTESTINAL 8UROERY. 

treatment of intestinal obstraotion, like other abdominal operations, 
can only be established upon a basis founded upon the resiQts 
obtained hj experimental investigation. In view of this fact it is 
astonishing that so little has been accomplished in this direction. I 
am convinced that accurate work of this kind will render essential 
information in the diagnosis of the obscure causes of obstruction, 
and will point out more clearly the indications for operative inter- 
ference, while improved methods of operation will have to be studied 
exclusively in this manner. 

During the last eighteen months I have made one hxmdred and 
fifty operations on animals for the purpose of studying the effects 
of the principal varieties of intestinal obstruction, which were pro- 
duced artificially ; at the same time I have attempted to estabhsh 
a number of new operations for the relief of certain forms of intes- 
tinal obstruction where it is impossible or inadvisable to remove the 

• 

local conditions which gave rise to the obstruction. One of the 
greatest dangers in all operations for intestinal obstruction is the 
length of time required to perform the ordinary operations ; hence 
it has been my object to simplify the operations, and thus by short- 
ening the time diminish the danger from shock All patients - 
requiring an operation for intestinal obstruction are invariably in 
a condition not well adapted for prolonged operations, which neces- 
sitate the opening of the peritoneal cavity and exposure of its 
contents to the cooling influences of the atmospheric air. An opera- 
tion which can be completed in twenty minutes must certainly prove 
less disastrous to the patient than one requiring from one to two 
hours. A prolonged operation on the intestines is attended by two 
great risks : 1. Lnmediate, due to shock. 2. Bemote, prolonged 
exposure to infection. Both of these dangers are diminished in 
proportion to the shortening of the time consumed in the operation, 
which is made possible by resorting to simpler measures, provided 
they are equally safe and efficient 

General Remarks on Experiments. 

With few exceptions the experiments detailed in this paper 
were made at the Milwaukee Coxmty Hospital, located at Wauwatosa, 
six miles from Milwaukee; and here I desire to return my thanks 
to Dr. M. E. Connel, superintendent of the hospital, and his 
assistants, as well as to Dr. William Mackie, of Milwaukee, for 



REMARKS ON EXPERIMENTS. 145 

Yalnable services rendered in my experimental work As the main 
object of these experiments was not to show favorable statistics, but 
more for the purpose of studying the effect of different forms of 
intestinal obstruction and to establish new principles of treatment, 
the animals were not submitted to any special treatment before or 
after the operation; the diet was not restricted and no internal 
medicines were given. I pursued this course in order to bring the 
intestinal canal in the most unfavorable conditions for operative 
interference, so as to expose the operations to the severest test. 
Ether was used exclusively as an anaesthetic. The abdomen was 
shaved, thoroughly washed with soap and warm water, and disin- 
fected with a 1-1000 solution of corrosive sublimate or a two and a 
half per cent, solution of carbolic acid. For the sponges the same 
solution of carbolic acid or a weaker solution of corrosive sublimate 
was Used. The abdomen was covered by several layers of aseptic 
gauze, with a slit in the centre. 

Whenever division or incision of the bowel was made, fsecal 
extravasation was guarded against by compressing the bowel on each 
side by compressors made for this special purpose, or by constriction 
with an elastic rubber band. Experience showed that the latter 
method was preferable, as it proved less injurious to the tissues of 
the bowel, and afforded greater security against extravasation, while 
fit the same time it proved less disastrous to the circulation between 
the points of compression. The rubber bands for this purpose should 
be about an eighth of an inch in width, rendered properly aseptic by 
prolonged immersion in a five per cent, solution of carbolic acid, and 
can be readily applied by perforating the mesentery with an ordinary 
hsemostatic forceps at a point not supplied with visible blood vessels, 
and tied in a loop with sufficient firmness to obstruct the lumen of 
the bowel. Elastic constriction practiced in this manner prevents all 
possibility of extravasation, and does not interfere with the free 
manipulations of the operator, as is the case with clamps or the 
hands of an assistant, while the degree of compression that is 
necessary exerts no injurious effects on the vessels and tissues at 
the seat of constriction. Drainage was never resorted to, and the 
abdominal wound was always closed by deep interrupted sutures 
including the peritonetum. In all cases where partial or complete 
exventration was made necessary, the bowels were kept covered with 
warm gauze compresses. In all cases where complete exventration 

10 



146 INTESTINAL SURGERY. 

became necessary, and where the bowels remained ont of the 
abdomen for half an hour or more, a certain degree of shock was 
always noticed, and a nnmber of animals died within a few hours 
after the operation, death being referable directly to this causa For 
an external dressing we nsed iodoform ointment applied directly 
over the wound, and a compress of cotton, retained by a bandage, 
and a jacket made of coarse doth. As a rule the sutures were 
removed at the end of six days, when the wound was usually found 
healed by primary union. 

I. Artificial Intestinal Obstruction. 

In imitation of the more common forms of intestinal obstruction 
in the human subject, due to congenital malformation or pathologi- 
cal conditions, the following kinds of obstruction were produced on 
animals: (1) stenosis, (2) flexion, (3) volvulus, (4) invagination. It 
is a noteworthy fact that even in cases where the obstruction was 
complete from the beginning, vomiting was moderate, and in some 
instances entirely absent. As vomiting constitutes one of the earliest 
and most conspicuous and persistent symptoms in most cases of 
intestinal obstruction in man, we can only explain its lesser intensity 
or complete absence in animals from the circumstance that animals 
suffering from this condition, as a rule, refuse all food and drink. 
As a rule, the tympanitis was also less marked than in the human 
subject 

z. Stenosis. 

Circular narrowing of the lumen of the bowel was produced by 
excision of a semi-lunar piece of the intestinal wall and double 
suturing of the wound in a direction parallel to the intestine; and by 
circular constriction with bands of aseptic gauze. 

a. Partial Enterectomy. 

EoBperim&nJt 1, Dog, weight thirty-nine ponndB. A semi-lunar portion 
embracing half the oircnmferenoe of the bowel removed from the oonyez 
surface, two inches above the ileo-c8Bcal yalve. Womid closed in a longitudinal 
direction by Gzemy-Iiembert suture. The first two weeks the discharges 
from the bowels were fluid and dark in color, subsequently normal in color and 
consistence. Animal killed thirty-six days after operation. Body well nour- 
ished; abdominal wound indicated by a firm linear cicatrix. Omentum 
adherent at point of operation; lumen of bowel at point of operation reduced 
one-half in size; lumen of bowel above and below the contraction equal in size, 
showing that the stenosis had not furnished an obstacle to the passage of 



STENOSIS. 147 

intestinal contents. A few of the sntnres remained attached, their free ends 
floating in the bowel. 

Experiment 2. Large, f nil-grown oat. The same operation was performed 
on the concave side of the bowel about the middle of the ileum, a semi-lnnar 
piece of the wall of the intestine with the corresponding mesentery being 
removed and the wound closed in a similar manner, which diminished the 
diameter of the lumen of the bowel to about one-eighth of an inch. It was 
noticed during the operation that the convex surface of the bowel over an 
area corresponding to the partial excision presented a cyanosed appearance. 
The animal died od the fourth day after operation, and the whole segment of 
the sutured bowel was found gangrenous, but no fluid in the abdominal 
cavity. 

Experiment 3. Large, adult cat. Ixl this case a segment of the ileum was 
emptied of its contents, and before cutting away a semi-lunar piece from the 
•convex surface, a back-stitch, continuous suture was applied on the inner 
margin of the proposed line of incision, which left about one-third of 
the lumen of the bowel. After excision of the semi-lunar piece the margins 
of the cut surface were turned inwards and covered with serous surface by a 
continuous catgut suture. Several small passages occurred after the operation, 
but the animal died on the fourth day with symptoms of intestinal obstruction. 
The visceral wound was found healed, but the lumen had become so narrow 
from the inflammatory swelling of the tunics of the bowel that it was entirely 
inadequate for the passage of intestinal contents, and as a result of this 
obstruction the bowel had become considerably dilated above the point 
-of operation. 

Bemabes. — These experiments illustrate conclusively that in 
wounds of the convex side of the intestine, where from the nature of 
the injury transverse suturing is impossible, longitudinal approxima- 
tion and suturing can be safely done, provided at least one-half of 
the lumen of the bowel can be preserved. If the stenosis is carried 
beyond this point there is great danger that the inflammatory swell- 
ing following the operation will still further narrow the tube and 
lead to the most serious consequences due to intestinal obstruction, 
and place the visceral wound in the most unfavorable condition for 
the healing process. 

Experiment No. 2 shows the great danger of interference with 
the blood supply from the mesentery in longitudinal suturing of 
wounds on the concave side of the bowel, as such a procedure is 
invariably followed by gangrene of the corresponding segment of 
bowel on the convex side. ' 

b. Oircular Oonstriction. 
The following experiments were made to study the effect of 
•circular constriction upon the circulation of the isolated constricted 



148 INTESTINAL SURGERY. 

loop of bowel In all cases where the constriction was made with a; 
gauze band, this was tied with the same degree of firmness, so as to 
determine whether the same degree of strangulation would produce 
identical results. 

Eosperiment 4. Adult oat. A loop of bowel abont the middle of the 
ileaxn, six inches in length, was tied with a band of aseptio ganze with soffi- 
oient firmness to oanse slight congestion, bnt without interfering with a free 
arterial supply, as the arteries in the ligated portion continued to pulsate 
freely. The day after operation a few small f»cal discharges stained with 
blood. The cat died forty-eight hours after the operation. No rise in temper- 
ature was obserred, and death was evidently caused by collapse from perfora- 
tion. The loop of bowel showed gangrene on convex side equidistant from 
the point of strangulation, and a smaU perforation which had given rise to 
diffuse septic peritonitis. The whole visceral and parietal peritoneum was 
uniformly affected and the peritoneal cavity contained a considerable quan- 
tity of sero-sanguinolent fluid. 

Experiment 5. Large, adult cat. A loop of the ileum of the same length 
was tied in a similar manner and with same degree of firmness. The animal 
absolutely refused food until the eighth day. Rise in temperature second and 
third day. Only one fsBcal discharge on the second day. Killed eight days 
after operation. Abdominal wound completely united; no peritonitis. Four 
inches of bowel below the point of constriction showed that partial reduc- 
tion had taken place. The gauze band was found completely covered with 
adherent omentum, and a thick -layer of plastic lymph which formed a com- 
plete bridge connecting the intestine above and below the ligature. The 
ligated portion showed no evidence of defective circulation, and no ulceration! 
underneath the ligature. The obstruction was complete, as no fluid could be 
forced through the bowel, and in proof that the same condition existed during 
life, it was found that the bowel above the constriction was considerably 
dilated, while below the strangulation it was empty and contracted. 

Experiment 6. Large, Maltese cat. A loop of the ileum, six inches in 
length, tied in a similar manner. On the third day fsBces stained with blood. 
On the same day the temperature, which had remained nearly normal until 
this time, rose to 105° F., and on the following day the animal died, having 
manifested symptoms of perforative peritonitis for twenty-four hours. 
Abdominal wound united; recent diffuse peritonitis. The abdominal cavity 
contained several ounces of sero-purulent fluid. Bowel above constriction 
distended with fluid contents, below the obstruction empty and slightly con- 
tracted. The greater portion of strangulated loop was found gangrenous and 
adherent to adjacent loops of bowel. Perforation had taken place in the 
middle of the loop on the convex surface, showing that gangrene had taken 
place first at this point and had extended from here towards the ligature. 

Experim,ent 7. Adult dog, weight twenty-six pounds. In this case an 
opening was made in the mesentery through which a loop of the smaU intes- 
tine, six inches in length, was pushed. With sutures this opening was made 



FLEXION. 149 

Bnffioiently small so that its marginB produced Blight strangnlation. The dog 
remained perfectly well after the operation, and was killed on the twenty- 
second day. Abdominal womid completely healed. No signs of peritonitis. 
On searching for the seat of obstmction it was fomid that spontaneous redac- 
tion had taken place, the site of perforation in the mesentery being indicated 
by a recent cicatrix. 

Bbmabes. — The post-mortem appearances in these cases demon- 
strate clearly that the gangrene was not produced by the primary 
mechanical strangnlation, but that it depended upon consecutive 
pathological changes in the loop or its vessels. In experiment No. 5 
the primary strangulation was fully as great as in the preceding 
experiment, and yet gangrene did not take place, and we have posi- 
tive proof that va&cular engorgement in the ligated portion was less 
intense from the fact that partial reduction took placa In all cases 
where gangrene resulted, it must not have been from deficient arte- 
rial blood supply, but from an obstruction to the return of blood 
through the veins. If defective arterial blood supply had been 
the immediate cause of the gangrene, we would have found more 
constantly gangrene of the entire loop, while every specimen illus- 
trated that gangrene always commenced at a point where the return 
of venous blood met with the greatest resistance, viz., on the convex 
surface in the middle portion of the loop. As in cases of hernia, 
or in any other form of intestinal strangulation, where a firm con- 
stricting band surrotmds the loop of bowel, the danger of complete 
strangulation is increased if by the peristaltic action additional 
portions of the intestine are forced through the ring; and the imme- 
diate cause of the gangrene is always referable to obstruction to the 
zetum of venous blood, which leads rapidly to oedema, complete 
stasis, and moist gangrene in that portion where the venous circula- 
tion is most seriously impaired. Violent peristalsis imder such 
circumstances always aggravates the existing conditions, and is often 
the precursor of symptoms of complete strangulation. In such 
cases opiates act favorably by arresting peristaltic action, and in so 
doing may avert gangrene by preventing the causes which otherwise 
would have led to complete venous stasis. 

2. Flexion. 

As many instances are on record where flexion of the bowel 
constituted the cause of intestinal obstruction, this condition was 
artificially produced in animals either by making a partial entereo- 



160 INTESTINAL 8URGEBY. 

tomy by remoTing a wedge-shaped piece from one side of the l>oweI, 
or by bending the bowel upon itself acutely, and fixing it in this 
position with catgut sutures. 

Experiment 8. Dog, weight sixty ponnds. A wedge-shaped piece of the 
waU of the ilenm was remoyed from the ooncave side with a oorresponding 
portion of the mesenteric attachment, and after arresting the bleeddxig by 
tying several vessels with catgut, the wonnd was closed transversely l>7 two 
rows of sntnres. The excised piece measured one inch at its base, ckud the 
apex reached as far as the median line of the boweL Immediately after 
excision, the convex portion of the bowel which had become acutely flosed by 
uniting the wound, presented a livid, congested appearance, and af tef tying 
the sutures the cyanosis increased. The area of disturbance of the cironlation 
corresponded to the width of the base of the excised portion. About fourteen 
inches from this place a similar piece was excised from the convex sido of the 
bowel, and the wound closed in the same manner. At this point the £exion 
was only slight, the mesenteric portion forming the prominence of th^ ourre. 
On the third day the temperature rose to 105.6° F., and the following <3ay the 
animal died with symptoms indicative of perforative peritonitis. On ox^ning 
the abdomen, diffuse general peritonitis was found with numerous adls-^sions. 
Oangrene and perforation were found on the convex side directly opposite the 
place of first operation. Second visceral wound closed, and lumen ot bowel 
at this point somewhat contracted, but permeable to fluids. 

Experiment 9, Large, adult cat. Removed from convex side of Ueum a 
triangular piece measuring one inch at its base, the apex reaching a little 
beyond the middle line of the bowel. Wound closed transversely by Ozeniy- 
licmbert sutures. After closure of the wound the bowel presented at point of 
partial resection an obtuse angle, the apex being formed by the mesenteric 
portion. The stools were bloody the second day after operation. The animal 
remained in excellent condition until it was killed, forty-three days after 
operation. Adhesions of loops of small intestines to abdominal wound, and 
of omentum and adjacent intestines at point of operation. The extent of 
flexion was found somewhat diminished, yet the concavity on convex side 
of bowel was well marked. Size of bowel above and below the operation wa» 
equal, showing that the flexion had not acted as a cause of obstruction. On 
opening the bowel a pouch-like bulging was found on the mesenteric side, 
which appeared to compensate for the narro^mig caused by the artificial 
stenosis. Two of the deep sutures still remained attached to the inner surface 
of the bowel. 

Experiment 10. Large, adult cat. In this case a loop of the middle por- 
tion of the ileum, four inches in length, was acutely flexed in such a manner 
that the peritoneal surfaces of the convex side were brought in contact, and 
in this position the bowel was fixed by a number of fine catgut sutures. Ko 
symptoms pointing towards intestinal obstruction were observed, and the 
animal was killed sixteen days after the operation. Wound was found com- 
pletely united, and no signs of peritonitis. The angle of flexion had some- 
what diminished, but otherwise the bowel was adherent in position left after 



VOLVULUS. 151 

operation. The bowel presented no dilatation above nor contraction below the 
flexion, showing that complete permeability of the canal at the point of 
flexion was qniokly restored. 

Bemabks. — The partial excision on conoaye side of bowel in 
experiment No. 8, illustrates the danger of suturing wounds in this 
locality where the blood supply from the mesentery is likewise 
impaired, as gangrene of the remaining portion of the bowel is 
almost certain to take place. In all wounds on this side of the 
bowel more than half an inch in length, there is also another great 
danger which attends transverse suturing, viz., stenosis, which may 
become the cause of intestinal obstruction. As the small intestines 
naturally describe quite a strong curve with the concavity on the 
mesenteric side, closure of a woxmd involving this portion of the 
bc>wel gives rise to acute flexion which, at least during the process 
of healing, must cause more or less obstruction, until by yielding of 
the opposite portion of the intestinal wall an adequate dilatation 
of the calibre of the tube has taken place. A considerable portion of 
the wall on the convex side of the bowel can be removed and sutured 
transversely imtil the bowel has been transformed into a straight 
tube, and a wound an inch in length will make only a slight flexion 
which furnishes no serious mechanical obstacle to the passage of the 
intestinal contents. In this connection the question arises: Does 
simple flexion, even if acute, without diminution of the lumen of the 
bowel, give rise to symptoms of obstruction ? I have made numer- 
ous flexions when performing operations for establishing intestinal 
anastomosis, and in most instances satisfied myself by examination 
of the specimens that fluids passed them without great difficulty. If 
the bowel at the point of flexion remains free, certain portions of its 
wall will yield t6 pressure of the fluid intestinal contents, and grad- 
ually the lumen of the bowel will become restored. If, on the other 
hand, the entire circumference of the bowel at the point of flexion 
has become fixed and immovable by inflammatory adhesions or other 
pathological products, a compensating dilatation becomes impossible, 
and the flexion becomes a direct and serious cause of obstruction. 

3. Volvulus. 

This condition, only another form of flexion, was experimentally 
produced by rotating a loop of intestine one and a half or two times 
around its axis, and retaining it in this position by a number of fine 



152 INTESTINAL SURGERY. 

sntares, which were applied in places at the base of the yoIyhIiis, 
where fixation was most required. 

Experiment 11. Dog, weight twelve ponnds. A loop of the ilenm, eight 
inches in length, was brought ont through a small incision and the tubes 
turned around their axis twice and the twist maintained by two catgut 
sutures. The constriction was sufficiently firm to cause considerable venous 
engorgement in the twisted loop. The dog manifested no unpleasant symptoms 
after the operation. The specimen was not obtained, as after a few days the 
dog ran away. 

Experiment 12. Medium-sized adult cat. In this case the yolyulus was 
made by twisting a loop of the ileum, about four inches in length, twice 
around its axis, and retaining it in this position by a number of fine silk 
sutures. Vomited several times during the first day. The first three days in 
taking the temperature in the rectum, the thermometer when taken out was 
bloody. The first two days the temperature was normal, followed by an 
increase to 104.6° and 108.2° F. the two succeeding days; then it became 
normal. No constipation; appetite good throughout the whole time. Animal 
killed twenty- two days after operation. Abdominal wound completely united; 
no peritonitis. Volvulus remains as after operation, with the exception that 
where the bowel had been fiattened by the twisting it had, at least partially, 
resumed its tubular form. Serous surfaces where approximated had become 
firmly adherent at point of constriction, size of bowel considerably diminished. 
The twisted loop contained liquid f»ces. Connecting the specimen with the 
faucet of a hydrant, water could be forced through, but on increasing the 
force of the current the peritoneum ruptured extensively in a longitudinal 
direction to point of partial obstruction. 

Bemabks. — These experiments are interesting, inasmuch as the 
primary constriction produced in making and maintaining the toIyu* 
lus, which was sufficient to cause venous engorgement in the twisted 
loop, must have been only of short duration, the disappear- 
ance of the effects of constriction being undoubtedly due to the 
gradual yielding of the sutured parts. While the faulty axis of the 
twisted loop was maintained by the sutures, the circulation improved 
and remained in a sufficiently vigorous condition to adequately 
nourish the most distant portions of the volvulus. While it was 
found difficult to force fluid through a specimen of volvulus during 
life, propulsion of the intestinal contents by peristaltic action was 
carried on in a satisfactory manner, as the bowel above the volvulus 
was not dilated, and contained no abnormal amount of fluid, and the 
animal manifested no symptoms indicative of intestinal obstruction. 

4. Invagination. 
The most frequent and, from a surgical standpoint, the most 
important form of intestinal obstruction is invagination. Leichten- 



INVAGINATION. 158 

stem and Leubuscher haye made careful experimental studies to 
explain the mechanism and pathological conditions which give rise 
to this kind of intestinal obstraction; but in the following experi- 
ments this part of the subject was ignored, and the inyaginations 
were made hj direct manipulation. It was found impossible to 
make an invagination at any point, as long as the bowel was in a 
condition of contraction, consequently it was always found necessary 
to wait until the peristaltic wave had passed by, or to cause relax- 
ation by firm pressure continued for several minutes. Usually, it 
was found easy to produce an invagination of the bowel, when in a 
state of relaxation, by indenting one side of the bowel, and pushing 
the pouch forward with a blunt instrument until the entire lumen of 
the intestine had passed into the section of the bowel below. After 
this was accomplished, further invagination was readily effected by 
manipulation, consisting in pushing gently the intussusceptum and 
intussuscipiens in opposite directions. After I had learned by 
experience that disinvagination frequently takes place spontaneously, 
I resorted sometimes to suturing of the intussusceptum to the neck 
of the intussuscipiens for the purpose of maintaining the invagina- 
tion. But even this expedient did not always succeed in retaining 
the malposition, as spontaneous reduction was observed in several of 
these cases. 

Experiment 13. Adult cat. The lower portion of the ileum and the 
osBonm and upper portion of the colon were drawn forward into an incision 
through the linea alba, and five inches of the ileum were pushed into the colon 
through the ileo-osBoal valye, when the parts were replaced and the abdominal 
wound dosed. For six days the animal had a temperature from 102.6° to 
105" F., and suffered from tenesmus. The stools contained mucus and blood. 
After the sixth day the symptoms due to invagination subsided, and were 
replaced by symptoms of peritonitis. The animal was killed twenty-two days 
after operanon. Great emaciation ; abdominal wound completely united ; 
diffuse purulent peritonitis. The disease had evidently commenced in the 
ileo-csBcal region, as at this point the pathological changes were found most 
advanced. Complete spontaneous reduction of the invagination ; colon 
greatly distended, and intensely congested. 

Experiment 14. Large, adult cat. Invagination was made in the lower 
part of the ileum. Length of intussusceptum three inches. For nine days 
the scanty fescal discharges contained mucus and at times blood. On the 
ninth day the temperature registered 105 '^ F. ; absolute refusal of food, and 
only occasional vomiting ; death on the thirty-third day after invagination. 
Abdominal wound healed ; small ventral hernia ; no peritonitis. Apparently, 
the greater portion of the intussusceptum had disappeared by sloughing, and 



154 INTESTINAL SURGERY. 

the Bubsequent healing process had produced an acute flexion at the neck of the 
intnssuBcipiens. Firm adhesions between peritoneal surfaces in the concavity 
of the flexion, nearly an inch in length. Above this point the intestine was 
enormously dilated and distended with fluid contents. Below the obstruction 
the bowel was found contracted and empty. Water could not be forced 
through the obstruction from either direction. On slitting open the bowel in a 
longitudinal direction, it was found that the lumen at the point of flexion was 
contracted to such an extent that only a fine probe could be passed. On the 
concave side of the flexion the mucous membrane presented a prominence 
marked by a number of longitudinal ridges. These folds had undoubtedly 
acted like valves in completely preventing the passage of intestinal contents, 
and later, the injection of water. Death in this case resulted from intestinal 
obstruction caused by cicatricial contraction after the sloughing of the invagi- 
nated portion of the bowel. 

Experiment 15, Adult cat. Two inches of the ileum were invag^ated 
into the colon and fixed by two fine silk sutures at the neck of the intussus- 
cipiens. For two days after the invagination the stools were scanty and 
contained mucous and blood. On the third day the abdominal cavity was 
re-opened by an incision along the outer border of the right rectus muscle, and 
the invaginated bowel drawn forward into the wound. No peritonitis. The 
bowel at point of operation was very vascular, and the neck of the intussus- 
cipiens covered with plastic exudation. The sutures were removed and the 
rectum and colon distended with water for the purpose of effecting reduction. 
As soon as the colon had become thoroughly distended the adhesions gave 
way with an audible noise, and complete reduction followed in such a manner 
that the portion last invaginated was first reduced. After reduction had been 
accomplished the injection was continued to test the competency of the ileo- 
ctecal valve. As soon as the caecum was well distended the fluid passed readily 
through the valve into the small intestines, showing that the valve had been 
rendered incompetent by the invagination. The force required to overcome 
the adhesions in the reduction of the invagination was sufficient to rupture 
the peritoneal covering of the large intestines in three different places, the 
rents always taking place parallel to the bowel. The animal died on the 
following day with symptoms of diffuse peritonitis. 

Eoeperiment 16, Ascending invagination in a cat. A few inches above 
the ileo-ciecal region the ileum was invaginated in an upward direction to the 
extent of two inches. At the time the invagination was made the intussus- 
cipiens contracted firmly. In consequence of this, a tear occurred in its peri- 
toneal covering in a direction parallel to the bowel. The stools were few and 
scanty. On the fourth day the animal died of perforative peritonitis. Abdom- 
inal wound not united, but the peritoneal wound closed by omental adhesions. 
Spontaneous reduction of half an inch of the invagination had taken place. 
Reduction by traction was found impossible on account of firm adhesions 
about the neck of the invagination. Recent diffuse peritonitis caused by two 
perforations, one at the neck of the intussusceptum on mesenteric side, and 
the other a little to one side of this one and on proximal side of the boweL 



INVAOINATION. 155 

The perforation resulted from beginning sloughing of the invaginated portion 
of the bowel. Abont two inches above the invagination the bowel was acutely 
flexed towards the mesenteric side by recent firm adhesions. Flexion was 
undoubtedly caused by circumscribed plastic peritonitis and increased peri- 
stalsis. 

Experiment 17, Large, adult cat. Descending invagination of ileum to 
the extent of two inches in the upper portion of this part of the boweL 
Second and third days the scanty discharges from the bowel bloody. Temper- 
ature from second day after operation varied between 103.4° and 105.4° F. 
Death from perforative peritonitis on the seventh d.ay after invagination. 
Abdominal wound united. Recent diffuse peritonitis from a perforation at 
the neck of the invagination on the mesenteric side. Gangrene of intussus- 
ceptum and partial separation which had again caused a sharp flexion of the 
bowel at the neck of the invagination. Above the seat of obstruction the 
bowel dilated and distended with fluid contents; below empty and contracted. 

Easperiment 18, Young cat. Invagination of ileum into ascending colon 
to the extent of three inches. For a week after operation frequent tenesmus, 
followed by mucous discharges mixed with blood. The temperature during 
this time varied from 102.6° to 105° F. After this the animal improved and 
was in good condition when killed fourteen days after operation. Abdominal 
wound united. No omental adhesions or peritonitis. Firm union between the 
serous surfaces. No dilatation of bowel above seat of obstruction. Intussus- 
ceptum not gangrenous, its lumen about the size of an ordinary lead-penciL 
It was found impossible to reduce the invagination by traction or by forcible 
injection of fluid from below. When the traction was increased, the peritoneal 
surface of the neck of the intussuscipiens ruptured in a longitudinal direction. 

Eocperiment 19, Large, adult cat. Six inches of the ileum were invagi- 
nated into the colon. Frequent bloody discharges until the third day, when 
the abdomen was reopened and the neck of the intussuscipiens exposed to 
sight, so as to observe directly the mechanism of disinvagination by rectal 
injection of water. As soon as the colon was well distended the adhesions at 
the neck of the intussuscipiens began to give way, and complete reduction 
followed, as the adhesions gave way under the pressure from below. The 
abdominal wound was again closed and dressed in the usual manner. The 
animal recovered completely from the operation, and was killed twenty-four 
days after the first operation. Abdominal wound well united. In the ileo- 
osBoal region, numerous adhesions around the portion of bowel which had been 
invaginated and subsequently reduced. 

Experimeni 20, Invagination of colon into colon was commenced about 
the middle of the bowel, and advanced as far as the caecum. Second day bloody 
discharges from the bowels. Animal killed five days after operation. External 
wound united only on peritoneal side. Invagination completely reduced, 
liocalized plastic peritonitis limited to the portion of the bowel which had 
been invaginated ; otherwise peritoneum and intestines in a healthy condition. 

EoDperimeviJt 21, Invag^ation of colon into colon to the extent of four 
Inches, in a cat. The subsequent symptoms only for a short time indicated 



1S6 INTESTINAL 8UBOERY. 

the existenoe of inyagination, which after they had snbeided, were followed b^ 
eridenoe of peritonitis. Death oooorred oa the nineteenth day after the 
invagination. Abdominal wound well united; diffnae purulent peritonitiui; 
under snrf aoe of diaphragm covered with plastic lymph. Although Bought 
for, no perforation could be found in the diainyaginated bowel, but as the 
peritonitis appeared to have started at the site of operation, it is probable 
that infection took place through the paretic waUs of the disiny aginated boweL 
ExperimefU 22. Same kind of inyagination made in a cat as in the 
preceding case. For two days the stools were frequent, scanty, and contained 
mucus and blood. After this the animal remained in good condition until it 
was killed thirty-flye days after the inyagination. Abdominal cavity showed 
no trace of inflammation. The invagination was completely reduced and the 
entire colon presented a normal appearance. 

Bbmabks. — ^With the exception of experiment No. 16, the in- 
vagination was always made in a downward direction. In the case 
of ascending invagination, gangrene of the intnssasoeptnm and 
perforation resulted in death from diffuse peritonitis on the f onrth 
day after partial spontaneous reduction had taken placa In experi- 
ments Nos. 15 and 19, both cases of ileo-c9Bcal invagination, 
complete reduction was effected by distention of the colon with 
water ; in the first case the force required to accomplish this result 
was sufficient to produce multiple longitudinal lacerations of the 
peritoneal surface of the distended bowel, which undoubtedly were 
responsible for the death on the following day from diffuse perito- 
nitis ; while in the second case no such accident occurred, and the 
animal recovered, although the abdominal wound was re-opened for 
the purpose of observing the mechanism of reduction by this method 
of procedure. In one case of ileo-csecal invagination, experiment 
No. 18, the intussusceptum remained in situ after the invagination, 
and became so firmly adherent to the intussuscipiens that even in 
the specimen, reduction by traction was found impossibla In this 
case, although the lumen of the invaginated portion barely permitted 
the introduction of an ordinary lead pencil, no symptoms of obstruc- 
tion were manifested during life, and the bowel above the invagina- 
tion was not found dilated after death. In experiment Na 14, the 
sloughing of the intussusceptum led to cicatricial contraction of the 
bowel and flexion at site of invagination, conditions which resulted 
in death from obstruction twenty-three days after invagination. 

The great danger which attends sloughing of the invaginated 
portion is circumscribed gangrene and perforation of the intussus- 
cipiens at the neck, and death from perforative peritonitiB, as 



PERMEABILITY OF ILEO-CMCAL VALVE. 15? 

illtistrated by experiments Nos. 16 and 17. Experiment No. 16 
illustrates that ascending invagination, should it occur, is not more 
likely to be reduced spontaneously than the more common form of 
descending inyagination. These experiments also demonstrate 
conclusiTely that the danger attending the invagination increases the 
higher it is located in the intestinal canal, being greatest when it is 
situated high up in the tract of the small intestines, and gradually 
less as the ileo-csecal region is approached. The ileo-csecal form is 
less dangerous, as spontaneous reduction is more likely to take 
place; and gangrene of the intussusceptum, when it occurs, does so 
after a longer time, after firm adhesions about the neck of the intus- 
susoipiens have formed, a condition which is well adapted to prevent 
perforation. Of the three invaginations of the colon, experiments 
Nos. 20, 21 and 22, complete spontaneous reduction took place in 
all of them from the first to the fourth day, and in only one of them 
was the result fatal, in experiment No. 21, where purulent perito- 
nitis, either from infection through the operation wound or, what is 
more probable, through the damaged wall of the colon occurred, 
and was the cause of death on the nineteenth day after the invagi- 
nation. Experiments Nos. 15 and 19 prove both the danger and 
the utility of distention of the colon in cases of ileo-csBcal and 
colonic invaginations. As a rule, the longer the invagination has 
existed the firmer the adhesions, and consequently the greater the 
danger of relying too persistently on this measure in reducing the 
invagination. In resorting to this expedient in the reduction of an 
ileo-c8Bcal invagination, it is of the greatest importance to relax the 
abdominal wall completely by placing the patient fully under the 
influence of an anaesthetic; and to add to the distending force as 
much as possible by gravitation, the patient should be inverted and 
the injection should always be made very slowly and with requisite 
care to prevent rupture of the peritoneal coat by rapid over-disten- 
tion. When the obstruction is located beyond the ileo-csBoal valve, 
no reliance can be placed upon this measure, as can be seen from 
the following experiments made to determine the 

Permeability of the Ileo-OsBcal Valve. 

Experiment 23, While completely ander the inflnence of ether an incision 
WB8 made through the linea alba of a oat, Boffloiently long to render the 
ileo-08Bcal region readily accessible to sight. An incision was made into 
the ileum jnst above the valve, and by gently retracting the margins of the 



158 INTESTINAL 8UBQERY. 

wound, the valye oonld be distinotly seen; water was then injected per reotum, 
and as the oieonm became well distended, it could be readily seen that the yalve 
became tense and appeared like a circular curtain preventing effectually the 
escape of even a drop of fluid into the ileum. The competency of the valYe 
was only overcome by cnoer-distenlUon of the ciecum which mechanically 
separated its margins, which allowed a fine stream of water to escape into the 
ileum. The insufficiency of the valve was clearly caused by great distention 
of the csBcum. That such a degree of distention is attended by no incon- 
siderable danger was proved by this experiment, as the cat was immediately 
killed, and on examination of the colon and rectum a number of longitudinal 
rents of the peritoneal coat were found. 

Experiment 24. In this experiment, a cat was fully narcotized with ether 
and while the body was inverted water was injected per rectum in snfGUsient 
quantity, and adequate force by means of an elastic syringe, to ascertain the 
force required to overcome the resistance offered by the ileo-csocal valve. 
Great distention of the.csacum could be clearly mapped out by percussion and 
palpation before any fluid passed into the ileum. As soon as the competency 
of the valve was overcome, the water rushed through the small intestines, 
and having traversed the entire alimentary canal issued from the mouth. 
About a quart of water was forced through in this manner. The animal was 
killed and the gastro-intestinal canal carefully examined for injuries. Two 
longitudinal lacerations of the peritoneal surface of the rectum, over an inch 
in length, were found on opposite sides of the boweL 

ExperimetU 25. This experiment was conducted in the same way as the 
foregoing, only that the cat was not etherized. More than a quart of water 
was forced through the entire alimentary canal from anus to mouth. The 
animal was not killed, and lived for eight days, but suffered the whole time 
with symptoms of ileo-colitis. A poet-mortem examination was not made in 
this case, although the symptoms manifested during life leave no doubt that 
they resulted from injuries inflicted by the injection. It will thus be seen 
that in the three cases where fluid was forced beyond the ileo-c»cal valve, in 
two of them the post-mortem examination revealed multiple lacerations of 
the peritoneal coat of the large intestines, while the third animal sickened 
immediately after the experiment was made, and died from tho effects of the 
injuries inflicted eight days later. The injection of water beyond the ileo- 
CBBcal valve in the treatment of intestinal obstruction must therefore be looked 
upon in the Ught of a dangerous expedient and should never be resorted to. 

II. Enterectomy. 

It still remains an open question to what extent resection of the 
small intestines can be performed with impnniiy. It is tme that 
Koeberl^, Kocher and Banm have snccessfolly removed respectivelj 
205 cm., 160 cm., and 137 cm. of the small intestine in the human 
subject; bnt while two of the patients do not appear to haye suffered 
any ill effects in consequence of the remoyal of such a large surface 



ENTEBECTOMY. 159 

tor digestion and absorption, in Baum's case death, which super- 
vened six months after the operation, was attributable clearly to 
marasmus, brought about by the extensive intestinal resection. As 
in a number of pathological conditions of the mtestinal canal, where 
the wounds are large and in close proximity, such as multiple strict- 
ures, gangrene, and multiple gunshot wounds, it may be necessary 
to resort to extensive resection, it becomes an important matter for 
the surgeon to know how much of the intestinal tract can be removed 
without any immediate or remote ill consequences. 

The immediate danger attending such an operation is the 
traumatism, which of course, will be proportionate to the length of 
the piece of intestine removed; while the remote consequences are 
due to impairment of the functions of digestion and absorption 
caused by the shorteiiing of the intestinal canaL With the view of 
obtaining additional light on these important questions the following 
experiments were undertaken : 

Experiment 26. Dog, weight twenty-two ponnds. Mesentery divided into 
fonr portions and tied with oatgnt, and thirty inches of the ilenm from near 
the ileo-cs9cal region upwards excised, and ends sntnred together by Czerny- 
Lembert sntnres. Abdominal wound failed to nnite, and a copious sero- 
sanguinolent discharge escaped from it the last day. Death on fifth day from 
peritonitis. Peritoneal adhesions in abdominal wound only partial; omentum 
adherent to wound. Intestines firmly adherent to omental stxmip. Giroum- 
soribed gangrene of bowel on convex side at site of operation. Recent diffuse 
peritonitis caused by perforation. 

Experiment 27. In a cat, twelve inches were removed from the middle of 
the ileum, and the ends united by a double row of sutures; mesenteric vessels 
tied en mxtsse with one catgut suture. The animal never rallied from the 
operation, and died of the shook the same night. 

Experiment 28. Dog, weight thirty-six pounds. Mesentery tied in several 
sections with catgut ligatures; ileum divided just above the ileo-c8dcal valve 
and six feet of the smaU intestines excised, and the ends united by Gzemy- 
Lembert sutures. On the third day the fsecal discharges were bloody. Although 
the appetite remained good, and the dog was aUowed to eat as much as he 
desired, he lost several pounds in weight during the first week. On the third 
day the abdominal wound opened as the sutur«s had cut through and required 
re-suturing. After this time the wound healed kindly. Three or four fluid 
focal discharges during twenty -four hours. The character of the discharges 
remained the same, and seyeral microscopic examinations made at different 
times revealed the presence of free undigested fat. The dog was kept busy eat- 
ing most of the time, and although the most nourishing food was furnished, he 
emaciated to a skeleton. He was killed one hundred and sixty-one days after 
the operation. Marasmus extreme, hardly a trace of fat could be found any- 



160 INTESTINAL SUROERY. 

where in the tiBsnes. Stomach enlarged to three or four times its normal size, 
and distended with food. A slight thickening of the wall of the gut indicated 
externally the site of sntnring, and the lumen of the bowel at this point was 
slightly diminished in size. At point of operation a loop of intestine was 
fonnd adherent and somewhat contracted. The remaining portions of the 
small intestines, only forty-flve inches in length, seemed to have undergone 
compensatory hypertrophy, as the coats were much thickened and exceedingly 
yascular. At the seat of suturing, the mucous membrane presented a slight 
circular prominence. Pancreas, liyer and spleen were normal in size and 
appearance. 

Eaopenment 29, Medium-sized, adult dog. Mesentery tied in several 
sections, and eight feet and two inches of the small intestines from ileo-csecal 
region upwards excised and ends sutured in the usual manner. On the follow- 
ing day the dog vomited, and blood was seen to escape from the abdominal 
wound. Death three days after operation. The abdominal cavity was filled 
with fluid and coagulated blood, which on closer inspection was found to have 
escaped from one of the stumps of the mesentery, where the catgut ligature 
had slipped off. 

Experiment 30. Scotch terrier, weight ten pounds. Mesentery ligated in 
part with catgut ligatures, the ileum divided four inches above the ileo- 
csBcal region, and fifty inches of the small intestines excised, and the continu- 
ity of the intestinal canal restored by the usual method of suturing. Some 
difficulty was experienced in suturing, as the lumen of the upper end was 
considerably larger than that of the lower. Until four weeks after the opera- 
tion the dog, although eating well, seemed to become more and more emaci- 
ated. After this time he gained somewhat in weight until killed forty-seven 
days after the resection. During the whole time the faeces were either fluid 
or only semi-solid, and at different times contained free, undigested fat. 
Appetite most of the time voracious. No adhesions to abdominal wound. 
Omentum adherent to visceral wound and to bowel. The site of operation was 
indicated by a slight depression on the surface of the bowel. On palpation a 
ring-like thickening was felt corresponding to the united ends of the boweL 
Bowel above seat of resection somewhat enlarged. On cutting into the bowel 
the point of union was indicated by a circular prominence of mucous mem- 
brane. Nine of the deep sutures were found still attached to the mucous 
membrane. The entire tract of the small intestines which remained measured 
only two feet and ten inches in length. 

Experiment 31, Adult Maltese cat. The mesentery was tied in Ave 
sections with catgut ligatures corresponding to twenty-nine inches of the 
ileum which was excised. Previous experience in circular enterorthaphy had 
satisfied me that perforation is most likely to take place on the mesenterio 
side of the bowel, where, on account of the triangular place made by the 
reflections of the peritoneum, the muscular coat is not covered by serous 
membrane. To obviate this difficulty I secured a continuity of the serous 
covering of the ends of the bowel before suturing, by drawing the peritoneum 
over this raw surface by a flne catgut suture. The mesentery was detached 



EXCISION OF COLON. 161 

only to a snffioient extent to apply the second row of sntnres. The fine catgut 
Butnre to approximate the edges of the peritonenm was applied near the 
margin of the divided end of the bowel, so that the knot did not interfere 
with the accurate coaptation of the serons surface between the deep and 
superficial row of sutures. This modification of circular suturing was adopted 
for the first time in this case. Although the animal manifested no untoward 
symptoms, and the appetite remained good, the marasmus was progressive 
until the time of killing, twelve days after the excision. Abdominal wound 
not completely united. Intestinal wound, which was two inches above the 
ileo-C8Bcal region, completely healed. The sutured surface was adherent to a 
loop of bowel which caused a sharp flexion. Intestine above this point some- 
what dilated and partially distended with fsecal accumulation. Slight contrac- 
tion of the lumen of bowel by circular bulging of mucous membrane, in 
which most of the deep sutures remained fixed. The post-mortem appear- 
ance pointed to partial obstruction at point of flexion; remaining portion of 
small intestines measured only twenty-one inches in length. 

Experiment 32, Medium-sized Maltese cat. Mesentery tied in sections, 
and thirty-four inches of the small intestines excised and the divided ends 
united in the same manner as in the last case, special care being taken to 
secure an uninterrupted peritoneal surface for divided ends before suturing. 
Appetite remained good, but progressive marasmus, which appeared at once, 
continued and proved the direct cause of death twenty-one days after the 
excision. Abdominal wound firmly united. No peritonitis. Visceral wound 
completely united; intestine at site of operation covered with adherent 
omentum. 

I. Excision of Colon. 

Easperiment 33. Large, black cat. The meso-colon was divided in numer- 
ous sections, and each part separately tied with a catgut ligature. As the 
meso-colon was very short, a number of the ligatures slipped off and had to be 
replaced by fine silk ligatures. The entire colon and about two inches of the 
lower end of the ileum were excised. As it was found impossible to unite the 
bowel on account of the deep location of the rectal end, it became necessary 
to dose the distal or rectal end by inverting its margins and applying a 
continuous suture. An artificial anus was established by stretching the iliac 
or proximal end into the abdominal wound. Death from shock a few hours 
after the operation. 

Experiment 34. Medium-sized dog. Resection of entire colon and three 
inohes of ileum. Meso-colon divided into sections and ligated with silk 
ligatures. In order to enablo circular enterorrhaphy it was found necessary to 
excise a triangular piece from large distal end, so as to make its lumen corres- 
pond to that of the divided ileum. After this was done and the lateral wound 
doeed by two rows of sutures, the ends of the bowel were united in the usual 
nuAner. Death from shock six hours after operation. 

Experiment 35, Excision of entire colon and two inches of ileum in a 
cat* Excision of triangular piece from distal end, to narrow the bowel suffi- 
u 



162 INTESTINAL 8URQERY. 

oiently bo that its lamen should correspond to that of the ileum. The ileum 
and rectum were then united by Czemy-Lembert 'sutures. The animal never 
rallied from the prolonged operation, and died of shock two hours later. 

Bemabks. — The resnlts of these experiments speak for them- 
selves. In all oases of extensive resection of the small intestines 
where the resected portion exceeded one-half of the length of this 
portion of the intestinal tract, where the animals survived the 
operation, marasmus followed as a constant result, although the 
animals consumed large quantities of food. In all of these cases 
defective digestion and absorption could be directly attributed to a 
degree of shortening of the digestive canal imcompatible ¥dth 
normal digestion and absorption. Only one of these animals 
(experiment No. 27) died from shock a few hours after operation. 
Another death resulted from the trauma, in experiment No. 29, 
where fatal haemorrhage occurred from one of the mesenteric vessels, 
where the catgut ligature became displaced from shrinkage of the 
included mesenteric tissues. When the vessels of the omentum or 
mesentery are tied en masse there is always danger from this source, 
and to prevent this accident it becomes necessary not to include too 
much tissue, and to tie firmly with fine threads of aseptic silk. 
After I commenced to tie in this manner, I encountered no further 
difficulty in arresting and preventing haemorrhage in operations 
requiring incision of these tissues. Although tho largd artery 
running parallel with the bowel where the mesentery is attached was 
excised in every case with the intestine, gangrene and perforation 
occurred only in experiment No. 26. The post-mortem appearances 
after extensive enterectomies indicated that the portion of bowel 
which remained underwent compensatory hypertrophy, but that as a 
rule the increased functional activity was not adequate to make up for 
the great anatomical loss. In all instances where the animal recovered 
from the operation, the discharges from the bowels were frequent, 
fiuid or semi-fluid, and contained undigested food, among other 
substances, free undigested fat, showing that the intestinal secretions 
play an important role in the digestion of fat. As an approximate 
estimate the statement can be ventured that in dogs and cats, the 
excision of more than one-third of the length of the small intestines 
is dangerous to life, as it is followed by marasmus, which sooner^ or 
later results in death. As all three cases of excision of the colon 
proved fatal from shock in from two to six hours, it can be safely 



PHYSIOLOGICAL EXCLUSION, 163 

asserted that this operation is impracticable, and is invariably 
followed by death from the immediate results of the trauma. 

2. Physiologici^l Exclusion. 

As extensive resections of the intestines are always attended by 
great risks to life from the trauma, I concluded to study the subject 
of sudden deprivation of the system of a great surface for digestion 
and absorption, by eliminating or diminishing the cause of death from 
this source by leaving the intestine, but by excluding permanently 
a certain portion from participating in the functions of digestion and 
absorption; in other words, by resorting to physiological exclusion. 
These experiments were also made to determine the tissue changes 
which would take place in the bowel thus excluded, and to learn if 
under such circumstances accumulation of intestinal contents would 
become a source of danger, as had been feared by the older surgeons. 
The complete interruption of passage of intestinal contents either by 
section and closure of the bowel, or by making an intestinal obstruc- 
tion of some kind, and the restoration of the continuity of the 
physiologically active portion of the intestinal canal, was established 
by suturing the proximal end of the high section with the distal 
end of the lower section, or by implanting the proximal end into the 
bowel lower down, the intervening portion of the intestinal tract isx 
either case thus becoming the excluded portion. 

EoeperimeTU 36. Large oat, weight nine pounds. Double division of small 
Intestines, npper section made about eight inches below the pylorus, and 
the lower three feet lower down; the portion of bowel between these circular 
sections was closed at both ends, and the continuity of the intestinal canal 
restored by suturing the open ends in the usual manner. In this way three 
feet of the smaU intestines were isolated and completely excluded from the 
digestive canal. The intervening portion was emptied of its contents as 
completely as possible beforo its ends were closed by suturing. The animal 
died on the fourth day after the operation. A small perforation of the sutured 
bowel on the mesenteric side was found, otherwise the visceral wound was 
found well united. The perforation had given rise to diffuse peritonitis which 
was the immediate cause of death. 

Experiment 37. Dog, weight thirty-two pounds. The jejunum was divided 
four feet above the ileo-cascal region, and the distal end closed. Jejuno-colos- 
tomy was made by implanting the proximal end into a slit made in the 
convex side of the ascending colon, large enough to correspond to the 
circumference of the jejunum. The implanted end was fixed in its position 
by two rows of sutures. The animal never appeared to rally from the effects 
of the operation, and died at the end of the next day. The abdominal cavity 



164 INTESTINAL SURGERY. 

was fomid filled with blood, which most, have escaped from a mesenterio 
▼easel, from which probably the oatgnt ligature had slipped. The ezdoded 
portion, that is, that portion intervening between the circular section and the 
point of implantation, was fonnd quite empty of intestinal contents, but 
slightly distended with gas. Implanted end perfectly retained by sntares, and 
slight adhesions between serons surfaces had already taken place. Death in 
this case was the result of secondary hasmorrhage. 

Experiment 38, Dog, weight thirty-five pounds. Divided the ileum just 
abcfve the ileo-ciecal region, and closed both ends of the bowel. Ileo-colostomy 
was done by making an incision about an inch and a half in length on concave 
side of ileum, forty-four inches above the division, and a similar slit on convex 
side of ascending colon, and uniting these wounds by Gzerny-Lembert sutures, 
thus excluding from the intestinal circulation forty four inches of the bowel 
The day after the operation the f leces contained blood. During the progress 
of the case it was frequently noted that the stools were thin, sometimes liquid. 
Appetite remained good, and the animal was well nourished at the time 
of killing, twenty-five days after operation. Abdominal wall well united. The 
omentum and a few intestinal loops adherent to inner surface of wound. 
The excluded portion contracted to more than one-half of its usual size, 
atrophic, and not nearly as vascular as remaining portion of intestinal canal, 
the two blind ends adherent to each other and to adjacent loops. The excluded 
portion contained in its blind end a few sharp fragments of bone. The new 
opening between the ileum and colon, about the capacity of the lumen of the 
ileum, surrounded by a prominent margin of ihucous membrane, which some- 
what resembled the ileo-C8Bcal valve to which still remained attached about ten 
of the deep sutures. The coats of both bowels at points of approximation 
thickened by inflammatory exudation. 

Experiment 39, Young cat. The ileum was divided about thirty inches 
above the ileo-cfecal region; the distal end closed and proximal end laterally 
implanted into the convex side of the transverse colon, where it was fixed by 
a double row of sutures. Before implantation, the continuity of the peritoneal 
surface was procured by drawing the peritoneum with a fine catgut suture 
over the denuded space left after detachment of the mesentery. Although the 
animal partook freely of food, progressive marasmus set in, to which the oat 
succumbed eleven days after the operation. Abdominal wound completely 
healed. Union of implanted ileum with colon perfect. No peritonitis. 
Excluded portion empty. Bowel above implantation somewhat dilated. 

Experiment 40, Young, but full-grown cat. Physiological exclusion of 
two-thirds of the small intestines and the entire colon, by division of the 
small intestines at the junction of the upper with the middle third. Closure 
of distal end, and restoration of continuity of the shortened intestinal tract 
by making a jejuno-rectostomy. The implantation was made into the upper 
portion of the rectum at a point opposite the meso-rectum. Previous to 
section and suturing, the portion of bowel to be excluded was emptied of its 
contents. Animal died two days after operation. No peritonitis. Slight 
adhesions between the serous surfaces of rectum and implanted jejunum; 
excluded portion empty. 



PHYSIOLOGICAL EXCLUSION. 165 

Experiment 41, The entire ilenm was excluded, in a oat, by dividing the 
intestine at its jnnotion with the jejnnom, closnre of distal end and making 
a Jejnno-oolostomy by implantation of the proximal end into a slit of the 
transverse colon at a point opposite the meso-colon. The cat remained in 
good condition until killed fifteen days after operation. No vomiting, and 
movements from bowels normal. Abdominal wonnd completely closed ; no 
peritonitis ; jejmiam at point of implantation firmly nnited ; new opening 
in colon the size of the lumen of the ileum. Excluded portion empty, con- 
tracted and ansBmio. 

Experiment 42, Large mastiff. The small intestine was divided six and 
a half feet above the ileo-08Bcal region, the distal end closed, and the proximal 
end implanted into an incision of the transverse colon large enough to receive 
it at a point opposite the meso-colon. Suturing was done exclusively with 
fine silk. For three weeks the dog appeared quite well, ate well, and the 
discharges from the bowels were normal. From this time the emaciation, 
which commenced soon after the operation was done, began to increase 
rapidly, the animal began to refuse food, and died of marasmus thirty-two 
days after operation. No peritonitis. Excluded portion empty, and reduced 
' one-half in size; the coats of the bowels very much attenuated, and the 
vessels hardly half the normal size. Only three feet and five inches of the 
small intestine remained for physiological action. New opening In colon 
sufficiently large to permit the introduction of the index finger as far as the 
first point. On slitting open the colon, the point of juncture with the jejunum 
upon the inner surface was marked by a slight ridge of mucous membrane, 
which bore a faint resemblance to the ileo-cocal valve. 

Bemabks. — ^For some reason which I am unable to explain 
satiBfactorily, in animalfl where the same length of intestine was 
physiologically exclnded, as in the resection experiments, the 
appetite never became so Toracions, and the remaining portion of 
intestine did not undergo the same degree of compensatory hyper- 
trophy as in the excision experiments. Theoretically, two explana- 
tions might be advanced : first, in shortening the intestinal canal 
by resection, an extensive vascular district is cut off by ligation of 
the mesentery, and it is only reasonable to assume that the circula- 
tion in the remaining branches of the mesenteric artery would be 
increased, and consequently the functional activity of the organs 
supplied by them augmented ; second, in cases of physiological 
exclusion by lateral apposition, it is possible that at least some of 
the fluid contents reached the excluded portion from which a certain 
amount might still have become absorbed. The exclusion was com- 
plete or nearly so, hence we must conclude from the post-mortem 
appearances, that in nearly every instance, the excluded portion 
presented an atrophic, contracted condition, and was only sparingly 



166 INTESTINAL SUBQEBY. 

snpplled with blood-vessels. From a practical standpoint these 
experiments teach ns that a limited portion of the intestinal canal 
can be permanently excluded from the processes of digestion and 
absorption in proper cases, hj operative measures without incurring 
any risk of f secal accumulation in the excluded part. These experi- 
ments demonstrate also that physiological exclusion of a certain 
portion of the intestinal tract is a less dangerous operation than 
excision, and that in certain cases of intestinal obstruction, where 
excision has been heretofore practiced, it can be resorted to as a 
substitute for this operation in cases where excision is impracticable, 
or where the pathological conditions which have caused the obstruc- 
tion do not in themselves constitute an intrinsic source of immediate 
or remote danger to life. The post-mortem appearances of the 
specimens of these experiments tend to prove that as long as any 
of the contents of the intestines reach the excluded portion, the 
peristaltic or anti-peristaltic action in that part is effective in forcing 
it back into the active current of the intestinal circulation. 

III. Circular Enterorrhaphy. 

During my experimental work I became convinced that circular 
enterorrhaphy as it is now commonly performed is attended by 
three great sources of danger: 1. Perforation at the junction not 
covered with peritoneum ; 2. Length of time required in perform- 
ing the operation; 3. The number of sutures required. 

To obviate the danger of perforation at the junction of the 
bowel not covered by serous membrane, I resorted to peritoneal 
suturing before uniting the bowel, by drawing the peritoneum over 
the denuded space caused by the limited detachment of the mesentery, 
by a fine catgut suture applied near the free margin of the bowel as 
described before. This requires but little time, and secures for the 
whole circumference of the bowel a peritoneal covering, so that after 
the bowel has been sutured the great rule inaugurated by Lembert 
(serosa against serosa) has been carried out to perfection. The 
results showed that this little modification of the ordinary method 
of suturing yielded more satisfactory results, and sl^ould therefore 
be adopted in all cases where circular enterorrhaphy is done with 
Czemy-Lembert or Lembert's sutures. Time plays an important 
part in determining the results of all operations requiring abdom- 
inal section; and this is especially true in all operations for intestinal 



CIRCULAR ENTERORRHAPHY. 167 

obstraction, as this class of patients is usually greatly exhausted 
before consent to an operation can be obtained. With a patient 
exhausted from an acute attack of obstruction of the bowels, it 
becomes exceedingly important to consume as little time as possible 
in the operation, as the shock incident to a long operation may itself 
determine a fatal result. Even after I had acquired a fair degree 
of manual dexterity in suturing the bowel, I seldom spent less than 
an hour in making a circular enterorrhaphy with a double row of 
sutures. In opening the abdomen for intestinal obstruction, a consid- 
erable length of time is usually spent in finding the obstruction; and 
when this is found and the patient manifests symptoms of collapse, 
a radical operation, which for its performance requires an hour or 
more, is often abandoned and the operation finished by making an 
artificial anus, which at the present time must be looked upon as a 
reproach upon good surgery. 

The last objection to the Czerny-Lembert method of suturing 
requires no argument. Any surgeon who hastily transfixes the bowel 
with a needle from thirty to forty times in applying the Lembert 
suture is liable to perforate the whole thickness of its walls once or 
more; and if silk is used as suturing material, the puncture may 
become the seat of a perforation, and the direct cause of a fatal peri- 
tonitis. This is more particularly the case in operating on the bowel 
in cases of intestinal obstruction, as under such circumstances the 
walls of the bowel have become greatly attenuated from overdisten- 
tion, and consequently more liable to become perforated by the 
needla But the use of so many sutures, from thirty to forty as 
recommended, brings with it another source of danger— gangrene 
of the inverted margin of the bowel. The second row of sutures 
applied in such close proximity must materially affect the blood 
supply to the inverted margin of the bowel, which in some instances 
must terminate in gangrene. Such a result is the more likely to 
ensue as the inner surface of the bowel is exposed to all dangers 
incident to infection from the intestinal canal; in other words, an 
aseptic condition for one side of the wound cannot be secured, con- 
sequently the gangrene is of a septic character, which is prone to 
extend beyond the primary cause which produced it. 

To obviate some of these dangers I experimented with a modifi- 
cation of Jobert's invagination suture. According to Madelung, the 
ingenious method of circular suturing devised by Jobert was practiced 



168 INTESTINAL 8UBQERY. 

• 

only in four oases, and two of the patients are known to have recov- 
ered. A number of years ago, I was forced to resort to resection of 
a part of the small intestine in a very complicated case of ovariotomy 
and resorted to this method, and although the patient died forty-eight 
hours after the operation from causes outside of this complication, 
the bowel was found permeable and quite firmly united, and had the 
patient lived I have no doubt the result of the resection and sutur- 
ing would have been satisfactory. In Jobert's method the invacnna- 
tion sutures most be looked upon as a source of danger, as they 
were made to traverse the entire thickness of the wall of the bowel, 
and the material used was silk. It has been claimed that in this 
method the invaginated portion of the bowel becomes gangrenous as 
in cases of invagination from pathological causes. This claim has 
arisen from a theoretical, and not from an experimental standpoint 
In cases of invagination the intussusceptum carries with it the 
mesenteric vessels intact in the form of an arch, which by constriction 
at the neck of the intussuscipiens is prone to become strangulated, 
an event which is followed by oedema and inflammatory swelling of 
the invaginated portion, which rapidly tends to complete venous 
stasis and gangrene. In circular suturing by Jobert's method the 
intussusceptum has no vascular connection with the intussuscipiens. 
The vascular arch is interrupted and consequently the danger arising 
from venous obstruction is almost completely obviated. My experi- 
ments will show that gangrene of the invaginated portion as a rule 
does not occur. My modification of Jobert's method consists 
essentially in the use of a thin elastic rubber ring for lining the 
intussusceptum to prevent ectropium of the mucous membrane, to 
protect the mucous membrane of the bowel against injurious pressure 
from the suture, to keep the lumen of the bowel patent during th^ 
inflammatory stage, and to assist in maintaining coaptation of the 
serous surfaces, and finally the substitution of catgut for silk as 
invagination sutures. 

My method of proceeding is as follows: The upper end of 
the bowel which is to become the intussusceptum is lined with a 
soft pliable rubber ring made of a rubber band, transformed into 
a ring by fastening the ends together with two catgut sutures. 
This ring must be the length of the intussusceptum, from one-third 
to half an inch; the lower margin is stitched by a continuous catgut 
suture to the lower end of the bowel which effectually prevents the 



CIRCULAR ENTERORRHAPHY. 169 

bnlging of the mncons membrane, a condition which is always 
difficult to overcome in circular suturing. After the ring is fastened 
in its place the end of the bowel presents a tapering appearance 
which materially facilitates the process of invagination. Two well- 
prepared fine juniper catgut sutures are threaded each with two 
needles. The needles are passed from within outwards, transfix;? 
ing the upper portion of the rubber ring and the entire thickness 
of the wall of the bowel and always equidistant from each other; 
the first suture being passed in such a manner that each needle is 
brought out a short distance from the mesenteric attachment, and 
the second suture on the opposite convex side of the boweL During 
this time an assistant keeps the opposite end of the bowel compressed 
to prevent contraction and bulging of the mucous membrana The 
needles next are passed through the peritoneal, muscular and con- 
nective tissue coats at corresponding points about one-third of an 
inch from the margins of the opposite end of the bowel, and when 
all the needles have been passed, an assistant makes equal traction 
on the four strings, and the operator assists the invagination by 
turning in the margins of the lower end evenly with a director, and 
by gently pushmg the rubber ring completely into the intussus- 
oipiens. The invagination accurately made, the two catgut sutures 
are tied only with sufficient firmness to prevent disinvagination 
should violent peristalsis follow the operation. This is their only 
function. 

The invagination itself effects accurate, almost hermetical seal- 
ing of the visceral wound. The intestinal contents pass freely 
through the lumen of the rubber ring from above downwards, and 
escape from below is impossible, as the free end of the intussuscipiens 
secures accurate valvular closure. After a few days the rubber ring 
becomes detached, and by giving way of the catgut sutures is again 
transformed into a flat^band, which readily passes off with the dis- 
charges through the bowela The invagination sutures of catgut are 
gradually removed by substitution on the part of the tissues, hence the 
punctures in the bowel remain closed either by the catgut or by the 
products of local tissue-proliferation; and thus extravasation is pre- 
vented. In my first experiments I used three invagination sutures, 
but found by experience that two are just as efficient in making and 
retaining the invagination. No superficial or peritoneal sutures were 
used in any of the cases, sole reliance being placed upon the invagi- 



170 INTESTINAL SURGERY. 

nation to maintain approximation and coaptation. The mesenteric 
attachment, both of the intnssnsceptnm and intussnscipiens, was 
separated only a few lines to enable invagination without too much 
narrowing of the Inmen of the intussuscipiens. 

Eocperiment 43. Dog, weight fifteen pounds. Three invagination sntures 
were need. The ileum was ont completely across at a point abont three feet 
above the ileo-cascal region. Depth of invagination one inch. For two days 
after operation a slight rise in temperatnre; no symptoms of obstruction 
during the whole time. Animal in good condition when killed two weeks after 
operation. Omentxmi adherent at point of operation as well as on adjacent 
loop of intestine. Union between intussosceptnm and intnssnscipiens firm, 
no signs of gangrene. Narrowest portion of Inmen of bowel was large enongh 
to pass the little finger to second joint. An enterolith composed of fragments 
of wood, bone, etc., in the centre of which the straight rubber band which had 
been the rubber ring, was found just above the seat of operation. No disten- 
tion of the bowel above this point. Bowel considerably flexed at seat of 
invagination, this condition being evidently brought about by inflammatory 
adhesions. 

Experiment 44. Dog, weight twenty pounds. Section of bowel and 
invagination with rubber ring the same as in the foregoing experiment. In 
subsequent history no mention is made of any symptom of obstruction, but 
for the last few weeks it was noticed that the dog began to emaciate. He died 
suddenly eighty-one days after the operation. Diarrhoea was a prominent 
symptom toward the last. No adhesions and no peritonitis. An enormous 
enterolith composed of all kinds of crude material, and again holding in its 
centre the rubber band, -was found just above the invagination. Bowel at this 
place considerably dilated. Intussusceptum firmly adherent, a false passage 
admitting the tip of the little finger had been made on one side between it and 
the intussuscipiens. Death in this case was evidently produced by the entero- 
lith. In this, as in the last case, the invagination was made at least an inch 
in length, and the collection around the detached rubber ring of the crude, 
indigestible material, which the dog must have eaten in large quantities, gave 
rise to the enterolith. The wall of the bowel surrounding the foreign body 
was not only dilated, but also greatly thickened. It is a well known fact that 
even a moderate degree of stenosis of the bowel i^ dogs is liable to give rise 
to the formation of an enterolith, as the crude material which these animals 
swallow becomes arrested, and by constant accretions of the same kind of 
material, the enterolith forms and continues to increase in size, until its pres- 
ence causes catarrhal inflammation and finally intestinal obstruction. 

It is quite possible that the lower end of the intussusceptum became 
impermeable during the inflammatory, stage, and that the false passage was 
formed on this account by perforation on one side of the intussusceptum, an 
accident which was plainly traceable to too deep invagination. 

Experiment 45. Dog, weight forty pounds. This experiment is mterest- 
ing only from the fact that it shows that it is possible to make a mistake in 



NOTHNAQEUa TEST. 171 

the diieotion of the inyagination, even after the operation has determined 
with aoonracy which is the ascending and descending end of the gnt, and to 
show the disastrous consequences which mnst necessarily follow such a techni- 
cal mistake. The invagination was made in the nsnal manner with rnbber 
ring and three oatgnt sntnres. The animal appeared to be quite ill the day 
following the operation, and on the next day the thermometer showed a rise 
in temperature to 104.2 °F. On the third day the dog died with well marked 
symptomd of perforative peritonitis. Recent peritonitis with some aggluti- 
nations of intestines. Considerable quantity of sero-sanguinolent fluid in the 
peritoneal cavity. To my utter astonishment, I found that an ascending 
invagination had been made. Circular gangrene of intussusceptum and com- 
plete separation of ends was found. The rubber ring remained in situ still 
attached to the intussuscipiens by the catgut sutures, which had become some- 
what softened. The invagination had decreased considerably by the traction 
caused by the peristalsis and by the pressure of the intestinal contents from 
above the obstruction, and the extensive gangrene of the bowel was undoubt- 
edly determined to a great axtent by these causes. 

Experiment 46. This experiment illustrates another source of danger 
due to faulty technique. Medium-sized dog. Circxdar enterorrhaphy was done 
with the rubber ring two feet above the ileo-C89cal valve. In making the invagi- 
nation it was noticed that the ring was too large, as it was seen that it caused 
too much pressure. I'hinking that the parts might adapt fchemselves to this 
pressure, the bowel was replaced and the abdominal wound closed. The dog 
died thirty-six hours after the operation. Abdominal wound not united; 
omentum and intestines adherent to each other, and at point of operation. 
The circumscribed gangrene of the intussuscipiens was evidently entirely due 
to pressure on the part of the rubber ring. The intussuscipiens was much 
swollen, a condition which materially aggravated the pressure caused by the 
rubber ring. With the following experiment two new departures were inaugu- 
rated, viz.: Instead of three invagination sutures only two were used, a qhange 
which still further shortened the time for performing the operation, and Noth- 
nagel's test was employed to determine the direction in which the invagination 
should be done. In all of the remaining experiments of circular enterorrhaphy 
which were made, only two catgut sutures were used. Until this time it was 
necessary to find one of the extremities of the small intestines for the pur- 
pose of determining which was the afferent and which the efferent end of the 
tube, so as to make the invagination in the right direction; a procedure which 
often required considerable time, and brought additional risk by increasing 
the shock of the operation and the danger of traumatic infection. 

I; NothnageFs Test. 

In experimenting npon animals for the purpose of studying the 
functions of the intestinal canal in health and diseai^d, Nothnagel 
made the discovery that when the salts of potash are brought in 
contact with the serous surface of the bowel, circular constriction 



172 INTESTINAL SURGERY. 

takes place, and when the peritoneal surface is tonohed with a 
crystal of common salt, ascending peristalsis is produced. The sodic 
chloride test I applied in sixteen cases, and found Nothnagel's 
observations corroborated in fifteen cases, by subsequent anatomical 
examination. In the remaining case where a wrong conclusion was 
drawn, the error might have been due to a faulty observation, or else 
the observation was not continued for a sufficient length of £ime. If, 
in the human subject, these observations could be verified, it would 
be of great practical importance to surgeons in operations on the 
intestinal canal whenever it becomes necessary to determine which 
is the ascending or descending part of the bowel. 

Experiment 47. Dog, weight thirty pounds. Gironlar seotion of ileam 
and immediate enterorrhaphy by invagination with mbber ring and two 
oatgnt sntnres. Intnasnaoeptam invaginated not more that a quarter of an 
inch. A few days after the operation stools mixed with blood, no other 
unfavorable symptoms. Animal kiUed fourteen days after operation. Wound 
united firmly. A number of omental and intestinal adhesions. A small 
abscess in mesentery at point of operation. No obstruction of any kind. On 
opening the bowel the walls at site of operation were yery thick, correspond- 
ing to the three intestinal coats, which had become considerably attenuated. 
The inner surface showed the point of junction of the intussusceptumwith the 
intussuscipiens in the shape of a circular ring of mucous membrane. The 
most contracted portion was large enough to admit the little finger. 

Experiment 48. Dog, weight fifteen pounds. Section of ileum and 
circular enterorrhaphy with rubber ring and two catgut sutures. Depth of 
invagination one-third of an inch. No unfavorable symptoms after operation. 
Animal killed after seven days. Wound completely united. Firm union of 
viscefal wound; no gangrene of intussusceptum. Rubber ring retained in situ 
by catgut sutures, which were easily torn. Upper end of rubber ring matted 
with hair. No obstruction. Lumen of bowel somewhat contracted b^ a 
circular ridge of mucous membrane, which indicated the junction of the two 
invaginated ends of the bowel. 

2. Transplantation of Omental Flap. 

In almost all post-mortem examinations of specimens from oper- 
ations on the intestines, I observed that the omemtnm was adherent 
over a greater or less surface at the seat of sutnring. I also observed 
that perforations never occurred where this additional protection 
to the peritoneal cavity had formed. To anticipate nature in 
protecting the peritoneal cavity in this manner, I conmienced to 
transplant an omental flap about an inch in width and sufficiently 
long to reach around the bowel, over the neck of the intussuscipiens. 



TRANSPLANTATION OF OMENTAL FLAP. 178 

where it was fastened on the mesenteric side by two oatgat sutures. 
The flap was taken either from the margin of the omentum or from 
its middle, care being taken to take some portions supplied with a 
vessel of considerable size. Its base was left attached to the 
omentum; all bleeding points were carefully tied with catgut liga- 
tures. The two catgut stitches used for its fixation were passed twice 
through the flap, its base and free end and the mesentery, in such a 
way that when tied the direction of the suture corresponded to the 
course of the mesenteric vessel, so that after tying they would not 
interfere with the vascular supply of the bowel. When the flap was 
taken from the middle of the omentum, the lateral halves were united 
Trith one or two oat^ sutures before closing the abdominal wound. 

EoBperiment 49, Dog, weight forty pounds. Ilenm diyided eighteen 
inches above ileo-osscal region, and the ends united by invagination with 
rubber ring, and two oatgut sutures. Transplantation of omental flap one 
inch in width around the whole circumference of the bowel over neck of intus- 
suscipiens, fixation with two catgut sutures on mesenteric side. Invagination 
one-third of an inch in depth. Animal killed two weeks after operation. 
Abdominal wound perfectly healed. Omental flap firmly adherent to bowel 
over neck of intussuscipiens. Bowel at seat of operation much thickened; 
rubber ring gone; lumen of bowel at its most contracted point large enough 
for the passage of the little finger. 

Experiment 50, Dog, weight twenty pounds. Complete division of ileum 
and immediate union of divided ends by invagination with rubber ring and 
two catgut sutures. Transplantation of omental flap two inches in width 
over the neck of the intussuscipiens. On third day stools mixed with blood. 
Died on the fifth day. Wound not united; omental fiap firmly adherent except 
. at a small point on the mesenteric side where a minute perforation had taken 
place from circumscribed gangrene of the intussusceptum. Rubber ring only 
loosely held by one of the sutures. Limien in invaginated portion quite 
narrow, but permeable. 

Experiment 51, Dog, weight fifteen pounds. Oomplete section of ileum 
and union of divided ends by invagination. The rubber ring was only one- 
third of an inch wide, while formerly none were used less than half an inch 
in width. Neck of intussuscipiens protected by an omental fiap two inches 
wide. The dog remained perfectly well, and was kiUed twenty-five days after 
operation. Abdominal wound completely healed, covered on the inner side 
by adherent omentum. Rubber ring gone. Lumen of bowel at most con- 
tracted point readily admits the little finger. No signs of obstruction. 
Omental flap adherent throughout. 

Experimiemt 52, Dog, weight twenty-two pounds. Division of ilenm and 
suturing in usual manner by invagination with rubber ring and two catgut 
sutures; transplantation of omental flap. The dog remained perfectly well 
and was killed twenty-three days after operation. A number of intestinal 



174 INTESTINAL SXTROERY. 

adhesions had produced several flexions. Point of operation four feet above 
the ileo-08doal region. Omental flap firmly adherent to bowel throughout. 
Rnbber ring gone. Lmnen of bowel in invaginated portion qnite large. 
The invaginated portion so atrophic and retracted that it appeared in the 
shape of a firm ring and was indicated in the interior by a oircnlar promi- 
nence of the mncoos membrane. No evidence of obstr action. 

Experiment S3. Dog, weight fifteen ponnds. Oomplete division of the 
ileum and reunion of ends by invagination. Transplantation of omental 
flap two inches in width over neck of intussusclpiens, two catgut fixation 
sutures. Second day after operation stools bloody. After this time all func- 
tions normaL Animal killed forty-four days after operation. Point of opera- 
tion four feet below the pylorus. The invaginated portion atrophied and 
retracted to such an extent that the bowel at this point onlp presented a thick- 
ened ring with its lumen but slightly narrowed by a circular ridge of mucous 
membrane. Omental flap firmly adherent a.11 around /md greatly atrophied. 

Bemabks. — ^In circular enterorrhaphy, as in cases of intestinal 
wounds of any kind, the ideal of any operation should be to bring; 
in continuous, uninterrupted apposition a large surface of serous 
membrane, without, at the same time, interfering with the yascular 
supply of the parts which it is intended to bring together for perma- 
nent union by cicatrization. If in employing the Czemy-Lemberfc 
sutures more than a few lines of the margins of the bowel are 
inverted and included between the two rows of sutures, there is 
great danger of causing primary traumatic stenosis by the project- 
ing circular ring in the lumen of the bowel The narrowing of the 
lumen of the bowel must be as great, if not greater, than after 
invagination. That the second row of sutures has often been the 
cause of gangrene of the inverted margin of the bowel would not 
be difficult to prove by many post-mortem records and specimens. 
By invaginating to the depth of a quarter or third of an inch, accu- 
rate coaptation is secured of the corresponding serous surfaces 
between the intussusceptum and intussuscipiens, which is made 
more secure and effective by the elastic pressure exerted by the rub- 
ber ring. This method of coaptation furnishes a large peritoneal 
surface of peritoneum for immediate union by cicatrization. 

With perhaps one exception, all of my experiments have shown 
that when catgut was used for invagination sutures none of the fail- 
ures were attributable to their presence. On the inner side of the 
bowel the rubber ring is drawn against the puncture, and would thus 
furnish a mechanical protection against the escape of fluids along 
these minute canals ; besides, the swelling of the catgut where it 



CIRCULAR ENTERORRHAPHY. 175 

becomes softened bj the fluids of the tissues, would most effectually 
plug the punctures until a permanent plug is furnished by the gran- 
ulations, which in time completely remove the catgut by substitution 
and close the punctures permanently by a minute cicatrix. One great 
advantage of the rubber ring consists in its furnishing absolute 
protection to the bowel against pressure by the invagination sutures 
during the invagination, and subsequent traction from peristaltic 
contraction should the latter cause tension of the sutures, an occur- 
rence which is not likely to arise if the invagination has been 
properly done. A circular enterorrhaphy as described above can be 
done in fifteen minutes, which certainly compares very favorably 
with any other procedure, as far as time is concerned. In the 
description of a number of the specimens, it has been distinctly 
stated that the injurious results followed the stenosis caused by the 
invagination, and this mi^ht be urged as an argument against the 
safety and applicability of the operation. 

As compared with the human subject the dog is an unfavorable 
animal for circular enterorrhaphy by invagination. In the first place, 
the walls of the bowel are much thicker in proportion to its lumen 
than in man, a condition which of necessity seriously affects the 
lumen of the intussusceptum. Again, the dogs were allowed to eat 
what they desired before and after the operation, and the quantity 
was not limited; consequently a great deal of indigestible substances, 
often of the coarsest kind, as straw, fragments of wood, or bone, 
hair, etc., found their way into the intestinal canal, and in a number 
of cases were arrested at the point of narrowing in the bowel, where 
they gave rise to the formation of an enterolith. In one instance 
death resulted clearly from intestinal obstruction from such a cause. 
In men the coats of the bowel being thinner, and the lumen corre- 
spondingly larger, invagination is done with greater ease, and the 
danger from stenosis could hardly come into question, as the fluid 
contents of the small intestines would pass readily through the 
rubber tube. Some of the older specimens prove that the traumatic 
stenosis caused by the invagination gradually diminishes by atrophy 
of the invaginated portions, which finally only appear as a promi- 
nent ridge of. mucous membrane on the inner surface of the bowel, 
the remaining coats having completely or nearly disappeared by 
retrograde metamorphosis and absorption. In the healing of all 
wounds one important condition for an ideal result is rest. The 



176 ' INTESTINAL 8URGEBY. 

rubber ring in the intnssnscepttim secures this important condition 
for the invaginated portion, as the elastic pressure must overcome 
peristaltic action and secure for this segment of the bowel, as near 
as possible, absolute physiological rest. « The danger of stenosis 
after invagination is greatest as soon as inflammatory swelling 
makes its appearance, a day or two after the operation, and the rub- 
ber ring is again in the right place to prevent any undue swelling 
by affording a gentle support for the invaginated portion, which 
cannot fail in preventing undue venous engorgement and oedema, 
which would otherwise follow the invagination. It serves both the 
purpose of a splint and an elastic bandage. After union of the 
bowel by invagination with a rubber ring peritoneal sutures are 
superfluous, as the invagination itself most effectually prevents any 
escape of intestinal contents by the valvular action of the invaginated 
portion ; at the same time the serous surfaces are kept in perma- 
nent and uninterrupted contact by the elastic pressure on the part 
of the rubber ring. 

Although the experiments have demonstrated the safety of the 
catgut invagination sutures in operating upon dogs, the same 
innocuity might not attend operations after intestinal resections for 
obstruction, as in such cases the coats of the bowel are almost with- 
out exception very much attenuated, and consequently the danger 
of extravasation along the needle punctures would be increased. 
Very recent trials have satisfied me that invagination after circular 
resection can be done with the rubber ring with facility, and probably 
greater safety, by dispensing with the invagination sutures and 
adopting the following plan: The lower end of the intussusceptum 
is lined with a soft rubber ring about one-quarter to one-third of an 
inch in width, and its lumen of sufficient size to afford free transit 
to the intestinal contents. The lower margin of the ring is stitched 
to the end of the intussusceptimi by a continued fine catgut suture. 
The ends of the bowel are how brought in contact and fastened 
together with four catgut sutures which are placed equidistant from 
each other. Invagination is now made by gently pushing the ends 
of the bowel in opposite directions, being careful to push the ring 
sufficiently deep so that its upper margin is grasped by the neck of 
the intussuscipiens. A few superficial sutures are applied simply 
for the purpose of preventing disinvagination ; the four catgut 
sutures act as invagination sutures, and at the same time prevent 



INTESTINAL ANASTOMOSIS, 177 

ectropinm of the mucous membrane of the lower end of the bowel 
during and after invagination. With proper facilities and good 
assistance, a circular enteirorrhaphy can be made in this manner 
without using invagination sutures, in ten minutes; and by using not 
more than four retention sutures, the blood supply to the inverted 
portions is not impaired, and at the same time the two ends of the 
bowel have been joined together by a large surface of peritoneum, 
which is held in accurate contact for rapid union by granulation 
and cicatrization. 

The advantages that are derived from covering a sutured intes- 
tinal wound by an conental flap are self-evident. The procedure is 
simply an imitation of nature's process ^in protecting the perito- 
neal cavity against perforation, and in hastening the healing of the 
visceral wound. AxL adherent omentum secures rest for the part to 
which it has become attached. As the omental flap becomes flrmly 
adherent before definitive healing of the visceral wound has taken 
place, it furnishes additional protection, and in the event of a small 
perforation it guards against perforative peritonitis by mechanically 
preventing the entrance of pus into the peritoneal cavity. Should 
pus reach the omental flap after it has become flrmly adherent it is 
not very probable that perforation would take place through the 
two layers of peritoneum furnished by the adherent omental flap, and 
the subsequent healing of the perforation of the bowel would be 
most likely to take place. I shall again refer to this subject under 
the head of " Omental Grafting." 

IT. Intestinal Anastomosis. 

By an intestinal anastomosis we understand a condition of the 
intestinal canal where on account of an obstruction or complete 
occlusion, the intestinal contents are directed into a segment of the 
bowel below the seat of obstruction or occlusion, through a fistulous 
opening between the bowel above and below the seat of partial or 
complete occlusion. The idea of establishing such a communication 
between the bowel above and below the seat of obstruction originated 
with Maisonneuve, who, without testing the new procedure first on 
animals, operated on two cases, but as the result in each case was 
fatal, he seems to have become discouraged and abandoned the 
operation, and never published the communication on this subject 
which he had in preparation. In the Surgical Society of Paris, his 

13 



178 INTESTINAL SURGERY, 

proposition met with yiolent opposition from bis contemporaries, who 
argued that the excluded portion of the intestine would become the 
seat of fsQcal accumulation, which, even if the operation were a 
success, would subsequently destroy the life of the patient. The 
subject was revived in 1863 by Hacken, who under the directions of 
Adelmann made some experiments on dogsi For a long time the 
operation was completely forgotten until E. Hahn, of Berlin, very 
recently alluded to it again in commenting on his two cases of 
excision of the colon where circular enterorrhaphy could not be 
performed, and where an artificial anus was established. Both 
patients recovered from the operation, but all attempts to dose the 
preternatural opening proved futile. 

The results of my experiments have shown conclusively that the 
fear of accumulation of f seces in the excluded portion of the intestine, 
that is, the intervening portion containing the seat of obstruction 
and extending on each side as far as the new opening by which the 
anastomosis has been established, is unfounded. If this objection 
can be laid aside, it becomes evident that the operation of establish- 
ing intestinal anastomosis has a great future, and will soon become 
an established procedure in the treatment of intestinal obstruction, 
and as a substitute for circular suturing in some forms of injuries of 
the intestines, which require excision. When I first made my experi- 
ments for establishing intestinal anastomosis, I made the operation 
by making an incision an inch and a half to two inches in length 
through the convex surface of each bowel, and sutured the wounds 
together by Czemy-Lembert sutures the same as in making a circular 
enterorrhaphy. The results soon showed that the operation was 
attended by the same dangers as suturing after circular resection, 
that is, gangrene of the margins of the bowel, and perforation. 

Dr. M. E. Connel, Superintendent of the Milwaukee County 
Hospital, suggested the use of perforated plates for making the 
« lateral apposition, in place of suturing. A few crude experiments 
were made with perforated discs of lead, wood, gutta-percha, and 
leather, and the results soon satisfied us of the expediency and greater 
safety of uniting the intestines in this manner. Although the first 
experiments were very imperfect, and faulty in technique, almost 
every animal recovered. In the first experiments no needles were 
used. Around the oval perforation four catgut or silk sutures were 
tied; a slit was made in the bowel on the convex side parallel with its 



DIRECTIONS FOR PREPARING BONE PLATES. 179 

axis and large enough to permit the passage of a plate about an inch 
in width and about two and a half inches in length. After making 
the incision, and introducing the plate above and below the seat of 
obstruction, the two wounds were brought into apposition, and the 
corresponding strings tied together with sufficient firmness to bring 
the flattened surfaces into accurate coaptation. The threads were 
cut short and the ends pushed inward out of sight. Experience 
showed that although the apposition was good, a tendency was 
observed on the part of the margins of the wound to evert on account 
of the bulging of the mucous membrane. I consequently modified 
the operation by arming the lateral threads with a needle with which 
the margin of the incision about the middle of the wound was trans- 
fixed. This proved a step in the right direction, as the lateral 
sutures completely prevented eversions of the margins of the wound, 
at the same time they fixed the plates in their position, and lastly, at 
once transformed the longitudinal slit into an oval foramen of suffi- 
cient size for the free passage of intestinal contents. After many 
trials with different kinds of materials for the plates, I came to the 
conclusion that decalcified or partially decalcified bone plates, pre- 
served after the decalcification in pure alcohol, served the best 
purpose. 

bireotions for Preparingr Bone Plates. 

The compact layer of an ox's femur or tibia is cut with a fine 
saw into oval plates, one-fourth of an inch in thickness, two and one- 
half to three inches in length, and an inch in width. The plates are 
then decalcified in a ten per cent, solution of hydrochloric acid, 
changed every twenty-four hours until they have become sufficiently 
soft so that they can be bent in any direction without fracturing. 
After decalcification they are washed by letting water flow over them 
from three to six hours so as to remove the acid. The plates are then 
covered with porous paper and compressed between two pieces of* 
tin until they are perfectly dry. If during the process of drying the 
plates are not compressed between two smooth surfaces they become 
distorted by warping. The hardened plates are next dolled several 
times in a straight line in the centre, and the openings enlarged 
and connected with a flle, until the perforation is flve-eighths of 
an inch in length and about one-eighth to one-sixth of an inch in 
widtL The sharp margins of the plate and perforations are 



180 INTESTINAL 8UROERY, 

removed with a file. With a fine drill the four perforations for the 
sutures are made near the margin of the oblong perforation, one at 
each end and one at each side. For preservation the plates are kept 
in absolute alcohol. When the plates are to be used they are 
washed in a two per cent, carbolic acid solution, and the threads or 
sutures attached hj threading two fine sewing needles, each with a 
piece of aseptic silk, twenty-four inches in length, which are tied 
together. The threads are then fastened to the surface of the plate 
by another thread passing through the perforations in the shape of 
a loop and fastened at the back. 

Instead of describing the experiments in their chronological 
order, I will enumerate them according to the part of the intes- 
tine operated upon, commencing with the upper portion of the 
intestinal tract. 

I. Gastro-Enterostomy. 

As gastro-enterostomy is an operation which establishes an 
anastomosis between the stomach and the upper portion of the 
intestinal canal, with exclusion of the duodenum, and sometimes a 
portion of the jejunum, and is performed in cases of obstruction in 
the pylorus or duodenum, it comes within the legitimate sphere of 
this article. Gastro-enterostomy, as heretofore described and per- 
formed, is an operation attended by many difficulties, and requires 
eVen in the hands of an expert an hour or more for its execution. 
As this operation is only done in cases greatly debilitated by disease 
and long suffering, anything which will simplify the technique and 
shorten the time must be looked upon as an improvement An 
operation that can be done in ten minutes instead of an hour or two, 
and which furnishes even better conditions for the healing of the 
visceral wounds, must take the place of the more complicated pro- 
cedures which so far have only been practiced in the hands of the 
most experienced surgeons. 

Eperiment 54, Dog, weight twenty-fiye pounds. Incision made through 
linea alba from xiphoid cartilage to near ombilicns. Omentum pnshed to one 
side, and the stomach drawn forward into the wound; near the middle of its 
anterior surface a longitudinal incision was made, two inches in length, and a 
perforated gutta-percha plate, to which four medium-sized juniper catgut 
sutures were attached, was introduced. The lateral sutures, armed with 
needles, were passed through the entire thickness of the waUs of the stomach, 
half way between the angles of the wound. A similar incision was made into 



GASTRO'ENTEROSTOMY, 181 

the intestine at the junction of the dnodennm with the jejunum; the same 
kind of plate introduced, and the margins of the wound punctured by the 
lateral armed sutures, when the two wounds were brought ms-a^is and the 
corresponding sutures tied. In tying the sutures, the lower lateral suture was 
tied first and the threads cut short; next the sutures corresponding to each 
angle of the wound were tied, and lastly the upper lateral. The serous surfaces 
of the stomach and intestine over an area corresponding to the size of the 
plates were brought into accurate permanent contact by the tying of 
the sutures. The stomach was replaced and the abdominal wound closed. 
The animal was allowed to eat immediately after the operation, manifested 
no signs of illness or pain, and was killed seven days after operation. 
Abdominal wound healed. Omentum adherent to its inner surface. Union 
between stomach and bowel firm over the entire surface of approximation. 
Plates detached, the one in the bowel had passed, while the other was found 
loose in the stomach. The new opening large enough to admit the index 
finger. 

Experiment 55, Dog, weight fifty pounds. The operation was performed 
in the same manner as in the previous experiment, but great difficulty was 
experienced in bringing the stomach forward, as this organ was distended to 
its utmost with an enormous quantity of solid food. Evacuation was effected 
through the incision, aided by attempts of the animal to vomit, the violent 
contractions of the stomach forcing the food toward the opening, from which 
it was removed with fingers and spoon. After the stomach was emptied it was 
washed out with warm water. For the stomach a bone plate, only partially 
decalcified, was used, while the approximation plate in the bowel was fully 
decalcified. The four approximation sutures were of catgut. Several portions 
of omentum, which were soiled during the emptying of the stomach, were 
excised. The abdominal cavity was thoroughly irrigated with warm water 
before the wound was closed. The animal died the next day, and on opening 
the abdomen it was ascertained that the immediate cause of death was 
hssmorrhage, as the peritoneal cavity was filled with blood. The bleeding 
undoubtedly took place from the omentum, by slipping or loosening of one 
of the catgut ligatures. 

Experiment 56. Medium-sized dog. Operation performed in the same 
manner with decalcified bone plates and catgut sutures. The first two days 
the animal had several attacks of vomiting, subsequently showed no signs of 
Buffering. Appetite good and stools regular. Killed thirty-four days after 
operation. Omentum adherent to inner surface of abdominal wound. At 
point of operation stomach was contracted, so that the organ presented an 
hour-glass appearance. Interior of the organ contained a large mass of hay 
and fragments of bone. New opening large enough to pass index finger. 
Union between stomach and bowel over entire surface of approximation. 
Water passed into the stomach flowed through the pyloric orifice and the new 
opening, in a stream of equal size. 

Experiment 57, Large bull-dog. Approximation of anterior surface of 
stomach with bowel by perforated gutta-percha plates, and four catgut sutures. 



182 INTESTINAL SURGERY. 

Length of Tisoeral inoiBioziB, two inches. The day after operation animal 
Tomited his dinner, subsequently no Tinfavorable symptoms. Animal killed 
fourteen days after operation. Abdominal wound well united. Omentmn 
adherent to wound, duodenum, liver and at point of operation. Firm adhe- 
sions between stomach and bowel. Water passed into the stomach only 
passed through the pyloric orifice. On opening the stomach, it was foxmd 
that the wound in the stomach and intestine had completely healed, the site of 
incisions being marked by a natrow firm cicatrix. The failure of obtaining 
an anastomotic opening between the eftomach and intestine could only be 
attributed to one of two causes, viz.: either the perforations in the plates were 
too narrow, or the needles of the lateral sutures included too much tissue. 
Either cause would bring about approximation of the margin of the wounds 
and permanent closure of the opening by granulation and cicatrization. 

Kemabks. — All of the animals recoyered, except in case of 
experiment 55, without any untoward symptoms, although they 
were allowed to eat immediately after the operation, and the diet 
was not selected or restricted at any time. In the fatal case death 
was caused from complications which had no connection with the 
gastro-intestinal opening. In all of the specimens examined, the 
mucous membrane of the stomach and intestine which had been 
interposed between the approximation plates, presented a healthy 
appearance, showing that the pressure of the plates had exercised 
no injurious effect on this structure. More recent experience with 
this operation on animals has revealed the fact that in the stomach 
a completely decalcified bone plate is almost entirely digested in 
thirty-six to forty-eight hours. It would therefore, appear advisable 
to use only partially decalcified bone which remains for a longer 
time, so that in case of delayed union the approximation would 
be maintained for a sufficient length of time. As the animals 
subjected to the operation recovered promptly, and under the most 
unfavorable conditions, we have every reason to believe that this 
operation will be attended by the same favorable results when done 
for pyloric or duodenal stenosis in man, where a careful preparatory 
and after treatment cannot fail to facilitate the operation and to 
improve the conditions for the formation of early adhesions and a 
speedy definitive healing of the wound. I have no hesitation in 
recommending it as a substitute for the more time-consuming and 
less certain operation by the tedious and difficult method of doable 
suturing which is now generally practiced. 



JEJUNO'ILEOSTOMY. 183 

2. Jejuno-Ileostomy. 

In this operation some form of intestinal obstniction was made; 
either complete, by division of the bowel and closure of both ends, 
or partial, by making a volvulus, invagination or flexion in the vicinity 
of the juncture of the jejunum with the ileum, followed by estab- 
lishing a communication between the bowel above and below the 
obstruction. Before I made use of the perforated approximation 
discs, this was accomplished by making an incision an inch and a half 
or two inches in length through the convex surface of the bowel 
above and below the obstruction, and uniting the wounds by a double 
row of sutures. An operation of this kind usually lasted over an 
hour, while the rapid operation of coaptation by perforated discs 
seldom took more than fifteen minutes. 

a. Jejuno-Ileostoniy by Suturing^. 

Experiment 68, Large oat. Inyagination of ilenm into ileum in a down- 
ward direction, and fixation of intussusoeptmn to neck of intnsBnscipiens by 
two fine catgnt sntnres to prevent spontaneons redaction. Intestinal anasto- 
mosis by establishing an opening an inch in length, sntnring by Czerny- 
Lembert method. The animal never recovered from the shock of the 
operation, and died in less than twenty-f onr honrs. Length of intn^snsceptnm 
two inches, which, after the removal of the sntnres, conld not be reached by 
traction, as the bowel was firmly constricted by the neck of the intnssuscipiens, 
and recent adhesions had formed. No peritonitis; sntnring fonnd perfect. 

Experiment 59. Dog, weight sixty-five poTmds. Intestinal obstruction by 
making acnte fiexions in upper portion of ileum; fixation of loops of intestine 
by fine catgut sutures. Intestinal anastomosis between jejunum and ileum 
by incision and double suturing. The animal died on third day with symp- 
toms of perforative peritonitis. On close examination, one of the superficial 
approximation sutures had been passed through the whole thickness of the 
waU of the bowel, and it was here that perforation had taken place. Becent 
di£Fu8e general peritonitis. 

Experiment 60, Dog, weight seventeen pounds. Descending invagination 
of ileum into ileum, length of intussusceptum three inches, fixation by two 
catgut sutures. Formation of intestinal anastomosis between the bowel 
above and below the invagination by incision and double suturing. Animal 
died on third day with symptoms of perforative peritonitis. Abdominal 
womnd not united. Adhesions at point of operation quite firm. Diffuse 
general peritonitis from a perforation which had been made by a sharp 
fragment of bone above the new opening. Intussusceptum not gangrenous. 

Experiment 61, Dog, weight twenty- three pounds. Intestinal obstruction 
was made by producing a volvulus in the upper part of the ileum. Restora- 
tion of continuity of intestinal canal by making a jejuno-ileostomy by lateral 



184 INTESTINAL SURGERY. 

apposition and doable satnring. Day after operation intestinal disoharges 
were bloody; after this time normal. Animal in perfect health when killed 
sixty -seven days after operation. The volynlns was fonnd in same condition 
as after operation; the intestinal loop empty, atrophied and adherent to 
adjacent loops of intestine. Bowel above seat of obstruction and as far as 
the new opening empty. Intestinal tract above and below the obstruction 
presented no indication of the presence of an obstruction. New opening oval 
in shape and as large as the Inmen of the bowel at that point. 

Eoeperiment 62, Large Maltese cat. Intestinal obstruction by making 
two flexions in ileum, about eighteen inches apart, after this portion had been 
cleared of its contents. Flexions made by doubling the bowel toward its 
convex side, and fixing it in this position by fine catgut sutures. J&juno- 
ileostomy by lateral apposition and suturing. Vomiting day after operation; 
stools scanty the first few days, and later complete obstruction. Died nineteen 
days after operation. Wound completely Tmited; no general peritonitis; 
flexions remained; bowel between them contained a slight amount of fsBcal 
matter. Bowel some distance above the new opening very much dilated, 
pointing to obstruction above new opening. On tracing the intestinal canal 
from above downward, this obstruction was seen to consist in acute flexion of 
the bowel by firm and extensive adhesions. New opening sufficiently large to 
admit the tip of the index finger, aroTmd the margins of which most of the 
deep sutures remained attached. 

Experiment 63, Large cat. Obstruction made by two flexions in the 
ileum, the apices of which were united by catgut sutures. Intestinal anasto- 
mosis made by a jejuno-ileostomy. For eleven days the animal remained in 
good condition, when symptoms of perforative peritonitis manifested them- 
selves, and death ensued two days later. External portion of wound not 
united. Numerous omental and intestinal adhesions. Flexions retained and 
their apices adherent to each other by firm band of adhesion. Excluded 
portions above and below the obstruction empty. Two small perforations at 
point of suturing on anterior surface of bowel; remaining portion of wound 
firmly united. New opening sufficiently large to admit tip of index finger. 
Death from perforative peritonitis. 

Experiment 64, Large, Newfoundland dog. Descending invagination of 
ileum into ileum to the extent of six inches; fixation of intussusceptum by two 
catgut sutures. Permeability of intestinal canal restored by making a jeJTmo- 
ileostomy; wounds united by a double row of sutures. Intestinal discharges 
normal throughout. No rise in temperature. General condition as good as 
before operation, when killed on the twentieth day. Abdominal wound com- 
pletely united; no peritonitis; omentum adherent at site of operation. 
Invagination had reduced itself, and its location was marked by an aeute 
flexion caused by extensive adhesions. No accumulation of intestinal contents 
in excluded portions. The new opening at least two inches in length; a few 
of the deep sutures remained attached to its margins. This opening was 
partially obstructed by a mass of hair and fragments of bone. On passing a 
stream of water from above downward, the fluid passed through an opening in 






JEJUNO'ILEOSTOMY. 185 

the centre of this mass into the lower portion of the ilenm, but not through the 
portion that was inyaginated. After this mass was remoTed, the flnid was 
f oand to pass through the portion that was invaginated, as well as through the 
new opening. 

The many failures which attended jejtmo-ileostomy and ileo- 
ileostomy by lateral apposition and suturing, led to the use of 
perforated approximation discs. A great contrast was observed in 
the animals operated upon by these two methods. The operation by 
suturing required usually niore than an hour, and almost all of the 
animals showed more or less symptoms of shock after its completion, 
and not a few succumbed to its immediate effects; while the opera- 
tion by approximation plates could always be finished within twenty 
minutes, consequently the animals never suffered seriously from the 
immediate effects of the operation. The first experiments were 
made somewhat carelessly and with crude material, and yet it was 
observed that the healing process progressed more favorably and 
was accomplished in a shorter time than after suturing. The 
approximation discs brought into uninterrupted contact large serous 
surfaces without impairing the vascular supply; at the same time 
they secured for the parts destined to become united an essential 
condition for rapid wound healing — rest — ^by serving the useful 

purpose of splints. 

Experiment 65, Dog, weight fifteen pounds. Ileum was completely 
divided at its junction with the jejunum and both ends of the bowel closed by 
invagination, and three stitches of the continued suture. An incision was 
made on convex side of bowel about two inches from the closed ends, and a 
heavy perforated lead plate to which six catgut sutures were fastened around 
the oval perforation, was introduced into the lumen of the bowel of each closed 
end, all of the catgut sutures being brought out through the incision. The 
two wounds were brought opposite each other and the six sutures tied. The 
serous surfaces of the two intestines over a surface corresponding to the size 
of the lead discs were thus brought into accurate apposition. The sutures 
were cut short and the ends buried as deeply as possible. The condition of 
the animal remained excellent until the time of killing, seventy-five days after 
operation. Omentum adherent to wound; large intestines distended with 
normal fsaoes. Bowel above and below point of operation normal in size and 
structure, ^ew opening between ileum and jejunum large enough to admit 
the little finger to second joint. Bowels firmly united by a broad surface. 
Above the communicating opening a double flexion of the bowel was found 
which apparently had done no harm. 

Eocperiment 66, Dog, weight eighteen pounds. Operation done in the 
same manner as in the last experiment, only that instead of lead the discs 
were made of sole leather, and the sutures used were linen in place of catgut. 



186 INTESTINAL SURGERY, 

For a few days the temperature was higher than normal and appetite dimin- 
ished. After fonrth day the animal appeared to be in excellent condition and 
remained so for three weeks, when the appetite failed and occasional attacks 
of vomiting set in. The symptoms remained more or less prominent until 
the time of killing, thirty-nine days after operation. Omentum adherent to 
abdominal wound ; extensive intestinal adhesions at site of operation ; union 
between intestines perfect. On incising the bowel it was found that the plates 
had sloughed through, and had passed along the distal portion of the bowel, 
leaving an opening the size of the plates, the margins of which had almost 
completely cicatrized. The two leather plates, still held together by the linen 
sutures, were found three feet lower down in the ileum, where they had become 
embedded in a mass of hair, straw and faecal matter, and quite firmly impacted, 
causing complete obstruction of the bowel. The intestine above the seat of 
obstruction was enormously dilated, while below the seat of impaction it was 
empty and contracted. Large intestines likewise empty and contracted. The 
cause of the illness was evidently due to intestinal obstruction produced by 
the impaction of the large enterolith, in the center of which the leather discs 
were found. 

Experiment 67, Dog, weight ten pounds. In this instance the bowel was 
divided near the junction of the jejunum with the ileum, both ends closed, 
and its continuity established by incising the convex surface of both ends, 
and approximating the wounds by two perforated bone plates tied together 
by silk ligatures. The animal died fourteen days after operation. During 
the last few days symptoms of intestinal obstruction were present. Abdominal 
wound completely united. Numerous intestinal adhesions at site of operation. 
Bone plates still in situ and firmly fixed. On proximal side, perforation of 
bone plates completely closed by hair and fragments of bone, giving rise to 
complete intestinal obstruction. The bowel above this point was greatly 
dilated, while on distal side it was empty and contracted. Firm adhesions 
between the two intestinal surfaces included by the bone plates. Intestinal 
obstruction by a mechanical arrest of portion of the intestinal contents above 
the proximal plate had caused death before a more efficient commTmication 
could be established by sloughing through of the bone plates. 

Experiment 68, Dog, weight thirty pounds. Ileo-ileostomy by dividing 
the ileum near its centre, closing both sides, and after incising both ends 
on convex surface, bringing wounds in apposition by perforated plates of 
cross-grained walnut wood, which were tied together with silk sutures. The 
dog remained in perfect health and was killed eighteen days after operation. 
External wound completely united. Plates had become detached, leaving a 
communicating opening two inches in length. Blind ends of bowel empty; 
no trace of plates could be found. 

Experiment 69, Dog, weight twenty-four pounds. Double ileo-ileostomy. 
Ileum divided transversely five inches above ileo-csBcal region, and both ends 
closed by invagination and three stitches of the continued suture. Lower 
and upper end of bowel were again brought into communication by incision 
on convex side, and lateral apposition of wounds by means of perforated 



JEJUNO'ILEOSTOMY. 187 

approximation plates of decalcified bone, hardened in alcohol. The plates 
were fastened together by f onr silk sutures, all of the threads being brought 
out of the incision, tied and cut short. Above this point a loop of the ileum 
was made by bringing the convex surfaces into apposition after incision at 
two points, and introducing perforated gutta-percha plates, which were 
retained in place by four silk sutures. No fever or symptoms of obstruction 
followed the operation. Animal killed thirteen days later. External wound 
firmly united. No evidences of peritonitis or intestinal obstruction. First 
operation left a communicating opening large enough to admit the little 
finger in one of its margins. The silk ligatures which had become detached 
from the plates had embedded themselves. The decalcified bone plates had 
disappeared and no trace of them could be found in any portion of the intes- 
tinal canal lower down. The second operation was thirty inches higher up. 
Gutta-percha plates remained in situ, although somewhat loosened by the 
gradual disappearance of the intervening tissues by pressure atrophy. 
Adhesions between the two surfaces of the bowel firm, and extending a little 
beyond the line of approximation. The perforation in the proximal plate 
almost completely closed by an accumulation of hair. The entire ileum 
normal in size and appearance. 

Experiment 70. Dog, weight fifty-four poTmds. Transverse section of 
ileum thirty inches above ileo-08Boal region and closure of both ends in the 
usual manner. The two closed ends were overlapped four inches and brought 
into communication by two longitudinal openings, which were approximated 
by being buttoned together with a shuttle-shaped button, nearly one and a 
half inches in length, the sides being lead plates and the shaft a rubber tube 
through which the anastomosis was established at once. As the margins of 
the intestinal wounds showed a tendency to evert, a fine catgut suture was 
inserted on each side embracing only the peritoneal coat. Only for two or 
three days after the operation did the dog not appear to be well. Killed 
twenty-three days after operation. Omentum adherent to abdominal wound 
which was firmly united. Omental adhesions to intestine at site of operation. 
Intestinal anastomosis thirty inches above the ileo-csBcal valve. Proximal 
blind end of bowel five inches in length adherent to distal end, considerably 
dilated and contained fragments of bone and other crude substances. Approx- 
imation button in situ and quite firmly fixed. A fragment of bone partly filled 
the lumen of the rubber tube. Coaptated peritoneal surfaces firmly adherent. 
The obstruction of the communicating tube had given rise to dilatation of the 
bowel above the point to twice its natural size, while below the seat of partial 
obstruction the intestine appeared empty and contracted. 

Experiment 71. Small dog. In this experiment the ileo-ileostomy was 
made by lateral apposition by perforated approximation plates of partially 
decalcified bone tied together by four catgut sutures. The lateral sutures were 
passed through the margins of the wound near its border, a modification of 
the usual procedure, which not only fixed the plates firmly in their places, but 
also prevented ectropium of the mucous membrane, and ensured free patency 
of the new opening by retracting the margins of the wound, so that the longi- 



188 INTESTINAL SURGERY. 

tndinal slit was at onoe traneformed into an OTal shape. The animal showed 
no nnfaTorable sTmptoms and was killed twenty-nine days after operation. 
Dog well nourished. External wound Tinited. Omentum adherent to wound 
and intestines. The proximal blind end of bowel contained one of the bone 
plates which showed signs of softening and disintegration. The bone plate 
in the distal end had been passed with fadoes preyiously. The new opening 
perfect and sufficiently large to equal in size the lumen of the boweL 

Eocperiment 72, Dog, weight twelve pounds. Made ileo-ileostomy the 
same as in the last experiment, using decalcified perforated bone plates, 
which were tied together with four catgut sutures, the lateral ones being 
passed through the margins of the wound. An omental flap was used to cover 
the sides of the bowel where approximation had been made. This flap was 
retained by two fine catgut sutures. No unfavorable symptoms. Animal 
killed twenty-three days after operation. Omentum adherent to distal blind 
end. Omental flap in position and firmly adherent. Site of operation four- 
teen inches above ileo-c»cal region. Both bone plates had disappeared and 
no trace of them could be found. Some hair had collected in the blind proxi- 
mal end. New opening large enough to admit the index finger. 

Kemabks. — Jejuno- ileostomy or ileo-ileostomy by internal 
apposition with decalcified perforated bone plates in cases of com- 
plete obstruction of the bowel artificially produced, is an operation 
almost devoid of danger. Partially or completely decalcified bone 
plates hardened in alcohol remain firm for a sufficient length of time 
to answer the purpose of retentive measures, nntil firm adhesions 
have formed between the serous surfaces held by them in approxi- 
mation. Until it was ascertained by experiment that the plates 
would undergo softening and disintegration in the course of a few 
days, catgut sutures were used to hold them in place with the 
expectation that the plates would become detached and escape with 
the intestinal contents as soon as the sutures would give way. 
Experience, however, has shown that aseptic silk threads are prefer- 
able to catgut, as they can be tied with greater accuracy and the 
knots will never become loosened, while the approximation discs 
disppear completely by softening and disintegration in a few days. 
Approximation plates of inabsorbable material as lead, wood, leather, 
bone, and gutta-percha, fastened together by silk or linen sutures, 
remain in situ until the interposed tissues disappear by pressure 
atrophy, and the opening that results corresponds in size to the 
dimensions of the plates. In the first experiments the plates were 
tied together by six sutures, but it was found that four sutures 
answered the same purpose. As a rule the plates were about two 



ILEO'COLOSTOMY. 189 

and a half inches in length, and their width corresponded to one- 
third of the circumference of the bowel. The greatest advantage to 
be found in the method of restoring the continuity of the intestinal 
canal by lateral apposition by approximation discs, consists in the 
fact that the point of contact is always made on the convex surface 
of the intestines, so that the means employed to secure coaptation 
do not interfere with the blood supply from the mesenteric vessels. 
As this method requires much less time than any form of circular 
enterorrhaphy, and has been followed almost without exception by 
recovery, it recommends itself strongly as a substitute for the latter 
procedure in many cases where loss of time constitutes an important 
factor in the issue of the case, or where from other causes circular 
suturing appears impossible or impracticable. 

3. Ileo-Colostomy. 

As the ileo-csecal region is frequently the seat of intestinal 
obstruction, it becomes desirable to devise some definite plan of 
operative treatment in cases where the cause of obstruction is not 
amenable to removal, with a view of establishing the continuity of 
the intestinal canal, thus avoiding the necessity of resorting to the 
formation of an artificial anus. To accomplish this object two 
distinct methods were followed : 1. Division of the ileum with 
closure of distal and implantation of proximal end into colon. 2. 
Division of ileum, closure of both ends and lateral apposition of 
proximal end with colon, and the formation of an intestinal anasto- 
mosis by suturing or approximation discs. 

a. Ileo-Oolostoxny by Implantation. 

Experiment 73, Dog, weight thirty-eight pounds. Intestinal anastomosis 
by implantation of ileum into colon. The ilenm was divided transversely 
jost above the ileo-o»cal region, and the distal end closed by invagination and 
three stitches of the continued suture, and dropped back into the abdominal 
cavity. A longitudinal incision, in size corresponding to the lumen of the 
ileum, was made in the ascending colon at a point directly opposite the 
mesentrio attachment, and the proximal end of the ileum was then fixed in 
this opening by Czemy-Lembert sutures. Only slight febrile reaction followed 
the operation. The appetite remained good and the discharges from the 
bowels were normal. The animal was in exceUent condition when killed, 
thirty-three days after operation. Few circumscribed omental adhesions to 
abdominal wound, which was completely closed. Peripheral portion of ileum 
presented a conical appearance, and was found adherent to, and of the same 
length as the appendix vermiformis. Implantation had been done about the 



190 INTESTINAL SURGERY. 

middle of the colon. Union at point of sutnring perfect, apparently no 
intermption of continuity of peritoneal surface. The new opening into 
colon a little smaller than the Inmen of the Uenm. Around the margins of 
this opening, which somewhat resembled the ileo-csBcal Talve, six of the deep 
silk sutures remained attached. Above the new opening the colon and csBCum 
were found empty and somewhat atrophic. Lower portion of the ilenm and 
colon below the new opening appeared normal in size and structure. 

Kemabks. — In the remaining experiments the implantation was 
made by lining the proximal end of the ileum with a narrow flexible 
rubber ring, which was retained in place by a continued catgut 
suture, embracing the free margin of the bowel and the lower margin 
of the rubber ring. The implantation was made by two catgut 
sutures, threaded each by two needles and passed at opposite points 
from within outwards through the upper margin of the ring and the 
entire thickness of the bowel, while the needles were only passed 
through the serous and muscular coats of the colon. After both 
sutures were in place gentle traction upon all of the ends brought 
the end of the ileum into the incision in the colon, and the walls of 
the colon were drawn over the end of the ileum to the points where the 
needles emerged from the ileum, making really a limited invagination. 
When in proper position, the serous surfaces of the colon and ileum 
over a surface corresponding to the width of the rubber ring were in 
accurate coaptation, after the two sutures were tied. Only in excep- 
tional cases was it found necessary to apply one or two additional 
superficial coaptation sutures. As in circular enterorrhaphy, so in 
these cases> the elastic pressure on the part of the rubber ring ren- 
dered material assistance in ftiaintaining accurate coaptation, while 
at the same time it secured' rest for the sutured parts, and kept the 
new opening freely patent for the escape of intestinal contents into 
the colon. This operation did not require one-fourth of the time 
consumed in making an implantation by Czemy-Lembert sutures. 

Experiment 74. Dog, weight fifty pounds. Division of ileum eight 
inches above ileo-C8Boal region, distal end closed by invagination, and three 
stitches of the continued suture. Proximal end lined with rubber ring and 
implanted into incision of ascending colon by two catgut invagination sutures. 
The dog did not appear to do well after the operation, and died on the fifth 
day. Abdominal wound not united. Partial separation of implanted bowel 
and diffuse septic peritonitis from perforation. 

Experiment 75, Dog, weight thirty-five pounds. Ileum divided twelve 
inches above ileo-cascal region, distal end closed and proximal end lined with 
flexible rubber ring and implanted into an incision in the transverse colon, 



ILEO-COLOSTOMY. 191 

and retained by two inTagination sntnres of oatgnt. An omental flap an inch 
and a half in width was placed oyer the junction of the two intestines and fixed 
in its place by two oatgnt sntnres. No nnfaTorable symptoms after operation. 
Animal when killed eighteen days later, in excellent condition. Omentum 
adherent to abdominal wound which was firmly united. Omental fiap adherent 
all round. Colon abOTC new opening ten inches in length, completely empty, 
contracted and atrophic. New opening oval in outline and as large as the 
lumen of the ileum. 

Experiment 76. Dog, weight sixteen pounds. Division of ileum, closure 
of distal end and implantation of proximal into an incision of the colon by 
rubber ring and two invagination sutures of catgut. As the inverted portions 
of the colon showed a tendency to evert, two additional retaining sutures of 
fine catgut were used, which secured perfect coaptation throughout. An 
omental flap was laid over the junction of the intestines and fixed in its 
place by one catgut suture. The dog remained in good condition, appetite 
unimpaired, and discharges from bowels normal. Killed thirteen days after 
operation. Abdominal wound firmly united. Omentum adherent to wound. 
A number of adhesions between coils of intestine. Deum somewhat dilated 
above the new opening. Omental flap in place and adherent. Union between 
ileum and colon perfect. A long, sharp fragment of bone was found lodged 
just above the new openmg, the lower end partially occluding its lumen. The 
dilatation of the lower portion of the ileum was evidently du*) to partial 
obstruction from the presence of the foreign body in the new opening. 

Experiment 77, Dog, medium size. Section of ileum two feet above the 
ileo-c8Boal region, closure of distal end in the usual manner, implantation of 
proximal end into colon by rubber ring and two invagination sutures of cat- 
gut. No omental flap. Animal remained well and was killed forty-three 
days after operation. Omentum adherent to abdominal wound. Distal end 
of ileum conical in shape, the extremity presenting a cup-shaped depression, 
which was filled with cicatricial material. Omentum adherent at ileo-c»cal 
region and at site of operation. Union between the bowels perfect and their 
serous surfaces appeared to be continuous over the line of junction. The new 
opening from the colon admitted the little finger, and was surrounded by a 
prominent ridge of mucous membrane, which resembled the ileo-cascal valve. 

Experiment 78, Dog, weight fourteen pounds. Division of ileum a few 
inches above ileo-csecal valve, distal end closed by invagination, and three 
stitches of continued suture. Implantation of proximal end into colon by 
rubber ring and two catgut invagination sutures. Over the junction of the 
two intestines an omental flap was placed which was retained by a catgut 
suture. The animal showed no unfavorable symptoms and was killed twenty- 
three days after operation. Omental flap retained and flrmly adherent 
throughout. Point of implantation three inches above cssoum; union between 
the two intestines firm throughout. New opening corresponded in size to the 
lumen of the ileum, and was surrounded by a prominent ridge of mucous 
membrane which appeared to be derived from the invaginated portion of the 
ileum. 



192 INTESTINAL SURGERY. 

Eoeperiment 79, Benm diyided a few inches aboTe ileo«08doal region, and 
after doenre of the distal, the proximal end was implanted into the colon in 
the nsnal manner by a mbber ring and two invagination sutures of oatgnt. 
Animal died on third day after operation. Wound partially united; a con- 
siderable quantity of sero-sanguinolent fluid in the abdominal cavity. Ileum 
almost completely separated from colon, and the portion which had been 
invaginated showed signs of gangrene. Rubber ring had disappeared; death 
from perforative peritonitis. In this case we have reason to believe that the 
rubber ring which was used was too large, and that the gangrene and separa- 
tion was due to injurious pressure. 

b. Ileo-Oolostomy by Lateral Apposition. 

Anastomosis by this method was made after producing an 
intestinal obstraction of some kind at or near the ileo-csBcal region, 
and then by bringing the ilenm above the seat of obstraction in 
communication with the colon below the pomt of obstruction, by 
making an incision an inch and a half to two inches in length in both 
intestines at a point opposite the mesenteric attachments, and unit- 
ing the wounds either by a double row of sutures or perforated 
decalcified bone discs. The first experiments were all made by 
suturing but, as in circular enterorrhaphy, it was found by experi- 
ence that perforation not infrequently occurred along the track of 
one of the sutures, in some instances several days after the operation, 
at a time when union had taken place by firm adhesions. These 
unfavorable results led to the use of the approximation discs. 

Eoeperiment 80, Dog, weight twenty-five pounds. The ileum was with- 
drawn from the abdomen through an incision in the linea alba, and having 
emptied a loop of its contents, acute flexion was made just above the ileo-C8Bcai 
region by approximating the serous surfaces of the convex side for a inch and 
a half by five catgut sutures. Two longitudinal incisions of equal size were 
made, one in the ileum six inches above the flexion, and the other in the 
ascending colon three inches above the csBCum. The visceral woTmds were 
carefully united by Czemy-Lembert sutures, using silk for the deep interrupted 
sutures, and fine catgut for the superficial continued sutures. No untoward 
symptoms were observed after the operation ; appetite remained unimpaired, 
and f adoal discharges were normal. The dog was killed thirty-seven days after 
operation. Animal weU nourished. No evidences of peritonitis. Bowel above 
point of obstruction nearly empty, and somewhat contracted as far as the new 
opening. Flexion permeable to a stream of water. Slight omental adhesions 
to bowel at site of operation; union firm throughout. Lumina of non-exduded 
portion of bowel normal in size above and below the flexion. Serous surfaces 
at point of junction appeared perfect and continuous. On slitting open the 
colon opposite the new opening, its outlines were seen to be marked by a 
prominent ridge of mucous membrane to which a number of the deep sntiures 



ILE0-C0L08T0MY. 193 

remained attached. The opening was large enough to admit the tip of the 
middle finger. The excluded portion of the colon and the caBcmn were some- 
what contracted and atrophic, and contained only a very small quantity of 
fsBcal matter. 

Experiment 81, Medium-sized oat. About two inches of the ileum were 
inyaginated into the colon through the ileo-c8Bcal valTe, and theintussusceptum 
stitched to the neck of the intussuscipiens by two fine catgut sutures. 
Continuity of the intestinal canal restored by incising the ileum above the 
obstruction, and the ascending colon below the free extremity of the intussus- 
oeptum, and uniting the wounds by a double row of sutures. The invagination 
caused no serious disturbance, and the animal remained in good health and 
was in excellent condition at the time of killing, one-hundred and sixty-two 
days after operation. A number of adhesions between the folds of the intes- 
tines near the site of operation. At point of juncture of the two intestines the 
peritoneal surface presented a glistening and continuous surface. New open- 
ing an inch and a half in length, oval in outline and located five inches above 
the ileo-oiBcal region. Two inches below the opening the invagination remained 
in the shape of a circular thickening of the bowel with a narrowing of its 
lumen to more than one-half of its normal size. A close inspection of the 
specimen showed that no gangrene had occurred, but that the intnssuscepttmi 
had undergone atrophy. A stream of water passing along the ileum in a 
downward direction escaped through the invaginated portion and through the 
new opening, the stream from the latter being at least three times larger 
than the one through the intussusceptum. Excluded portion of ileum and 
colon empty and very much atrophied and contracted. Below the new open- 
ing the colon and rectum contained normal fasces in considerable quantity. 

EoepeHment 82. Young cat. Ileo-08Bcal invagination; length of intussus- 
ceptum four inches. In order to prevent spontaneous disinvagination the 
bowel was fixed in its position by two fine catgut sutures. Beo-colostomy 
below the lower end of the intussusceptum by lateral apposition and suturing. 
AniTnni died on the fourth day after operation. Abdominal wound united. 
Diffuse peritonitis from perforation at site of suturing. Length of intussus- 
ceptum reduced from four inches to two inches and a half. It was found 
impossible to effect reduction by traction on account of firm adhesions at neck 
of intussuscipiens. No gangrene. 

Experiment 83. Adult, large dog. Intestinal obstruction was produced 
by making two sharp flexions near the ileo-csacal region by folding the bowel 
on its side and fixing it in this position by fine catgut sutures; the apices of 
the flexions were sutured together so as to render the obstruction more com- 
plete. Intestinal anastomosis was established by lateral apposition and 
suturing. Physical condition of dog remained good throughout; appetite and 
evacuations normal. Killed thirty-one days after operation. No peritonitis; 
a number of omental adhesions at point of operation. Flexions quite sharp, 
rendering the bowel nearly, if not completely, impermeable at this point. 
Perfect union between bowels, with some thickening of their walls by inflam- 
matory exudation. New opening oval in shape, an inch and a half in length, 
18 



194 INTESTINAL SURGERY. 

a few of the deep antares still remaining attached to its margins. Excdaded 
portion of bowel empty and somewhat atrophio. 

Experiment 84, Dog, weight thirteen pounds. Obstmotion of the bowels 
made by an aonte flexion four inches abOTe the ileo-cascal region, retained by 
four catgut sutures. Intestinal anastomosis by an opening an inch and a 
half in length, which brought into communication the ileum aboTC the obstruc- 
tion and the descending colon. The animal showed no untoward symptoms, and 
was killed forty-one days after operation. A number of intestinal folds 
agglutinated by adhesions; no eyidences of diffuse peritonitis. Where the 
flexion had been made the loop of intestine was connected by a broad band of 
adhesion which gave to the bowel a horse-shoe shaped appearance. Intestine 
below the seat of flexion contained a small amount of hardened fasces. Colon, 
and C8Bcum aboTO the new opening nearly empty and greatly contracted. 
Line of suturing somewhat thickened. New opening oval in outline and 
about an inch in length, surrounded by a corrugated eleyation of mucous 
membrane. A stream of water passed through the bowel from aboTC down- 
ward readily escaped through the new opening, while only a small stream could 
be forced through the flexion. 

Experiment 85. Dog, weight twenty-seven pounds. A toIyuIus was made 
six inches above the ileo-cascal region by rotating an empty loop of the 
intestine once aroTmd its axis, and fixing it in this position by three catgut 
sutures. Intestinal anastomosis between the ileum above the volvulus and the 

• 

descending colon by lateral apposition and suturing. For four days after the 
operation the evacuations from the bowels contained blood; after this time 
the stools were normal. Dog in excellent condition when killed thirty-one 
days after operation. No signs of diffuse peritonitis. The portion of bowel 
which constituted the volvulus adherent, contracted and empty. Water could 
be readily forced through this part of the bowel. OsBcum and colon above 
new opening empty and contracted. Size of new opening larger than the 
lumen of the ileum, its margins surrounded by a prominent ridge of mucous 
membrane to which a few of the deep sutures still remained attached. In this 
experiment nearly the entire colon was excluded, consequently the f sscal dis- 
charges were quite frequent and fluid or semi-fluid in consistence. 

Experim,ent 86. Dog, weight seventeen pounds. Two inches of the ileum 
were invaginated into the csBcum. Beo-oolostomy by uniting the ileum with 
the transverse colon by suturing. The animal appeared quite ill after the 
operation and died on the flfth day after having manifested well-marked 
symptoms of perforative peritonitis. Abdominal wound not united. Only 
partial union between the intestines at point of junction. Diffuse septic 
peritonitis from perforation. 

Kemabes. — In at least two experiments which are not here 
reported, the animals died of shock a few hours after operation. In 
a number of other experiments the operation was followed by more 
or less shock, but the animals, without receiving any special treat- 
ment, rallied after six to twelve hours. The symptoms referable to 



ILEO'COLOSTOMY. 195 

the immediate effects of the operation were due to the length of 
time required in applying a double row of sutures in uniting the 
visceral wounds, a step in the operation which always required from 
thirty minutes to an hour. These experiments only corroborate the 
statement previously made that the excluded portion of the intestinal 
canal, including the obstruction, does not become the seat of faecal 
accumulation, but undergoes atrophy after free intestinal anastomosis 
has been established between the intestine above and below the seat 
of obstruction. Experiments Nos. 70 and 71 furnish most striking 
proof that the danger of gangrene in cases of invagination is greatly 
diminished by establishing an early intestinal anastomosis, as when 
this is done the violent peristalsis is promptly arrested by furnishing 
a new outlet to the intestinal contents ; at the same time, the serious 
consequences resulting from pressure and distention above the 
obstruction are likewise promptly averted. In cases of intestinal 
anastomosis wliere nearly the entire colon has been excluded, the 
fluid contents of the small intestines reach the rectum at once, and 
cause frequent fluid faecal discharges, an occurrence which does not 
appear to impair the general health of the animal. The new open- 
ing should be made of adequate size, so that its lumen will at least 
correspond to the lumen of the bowel above the obstruction. 

o. neo-Oolostoiny by Perforated Approxixnation Discs. 

Eosperiment 87. Dog, weight twenty ponnds. The ilenm was completely 
diyided three inches above the ileo-o8Boal region, both ends closed by invagi- 
nation and three stitches of the continued suture. A communication was 
established between the proximal extremity and the colon, by making an 
incision into the ileum on convex side near the closed end and introducing 
through this opening a perforated decalcified bone plate. A similar opening 
was made into the ascending colon opposite its mesenteric attachment, 
through which a perforated plate of wood was introduced. To each plate 
were tied four catgut sutures. The lateral sutures were passed through the 
margins of the wound. After the plates and sutures were in place the wounds 
were brought in contact and the four sutures tied, which coaptated the serous 
surfaces of both bowels over an area corresponding to the size of the plates. 
The animal remained apparently weU for two days, when symptoms of 
peritonitis set in and death occurred five days after operation. Diffuse 
peritonitis. Union at point of operation incomplete, which resulted in a 
perforation. Discs had disappeared. As the catgut sutures were quite fine it 
is more than probable that partial separation of the plates occurred before 
adhesions had taken place between the serous surfaces of the coaptated bow- 
els, which resulted in perforation and death from diffuse septic peritonitis. 



196 INTESTINAL SURGERY. 

m 

Experiment 88, Dog, weight fifteen pounds. Inyagination of colon into 
colon to the extent of two inches. Intestinal anastomosis by making an ileo- 
colostomy by lateral apposition of the ilenm to colon below invagination, 
using perforated hard rubber plates which were tied together by four catgnt 
sntnres, the lateral sntnreB being passed through the margins of the wound. 
After tying the sutures it was found that at one point the margins of the 
wound dhowed a tendency to evert, consequently a fine catgut suture was 
passed through the peritoneum only and tied. The animal did not appear 
bright the day after the operation, but subsequently showed no signs of 
suffering; killed twenty-four days after operation. Abdominal wound firmly 
united. Omentum adherent to wound and at point of operation. The in- 
vagination was partially reduced. The bowel at this point was curved in the 
shape of a horse-shoe, but permeable to a stream of water. Excluded portion 
of colon tortuous and atrophic. Oaacum contained a small quantity of fluid 
fadces. Plates could not be foTmd. New opening sufficiently large for free 
passage of intestinal contents. 

Experiment 89. Dog, weight fifteen pounds. Ileum divided transversely 
fifteen inches above the ileo-c89cal region; both ends closed in the usual 
manner. Ileum and colon approximated by decalcified perforated bone 
plates which were tied together by four catgut sutures, the lateral ones 
transfixing the margins of the wound. On the second day the evacuation from 
the bowels contained traces of blood. Animal killed eighteen days after opera- 
tion. Abdominal wound completely healed. Omentum adherent to wound* 
Numerous adhesions between the intestinal folds. Proximal blind end of 
ileum had been changed into a pouch-like form and contained a mass of hair 
and fragments of bone. One very sharp spiculum of bone had nearly perfo- 
rated the intestine. New opening corresponded in size to the lumen of the 
ileum. 

Bemabks. — The operations of lateral apposition of ileum to colon 
by perforated approximation discs, have shown that it is unsafe to 
rely upon catgut as a suturing material, as when fine catgut is used 
coaptation is not maintained for a suj£cient length of time for 
adhesions to take place, and coarse catgut when tied interferes 
with accurate approximation, as the knots after tying mechanically 
separate the serous surfaces. It is advisable to use removable plates 
and to tie with silk. The results of ileo-colostomy made by approxi- 
mation discs have not been as favorable as after jejuno-ileostomy or 
ileo-ileostomy, and in repeating the operation on man it would be 
indicated, after bringing the intestines in apposition by tying the 
four sutures, to apply a number of superficial sutures for the pur- 
pose of still further guarding against the escape of gas or fluid 
contents into the peritoneal cavity. The plates when properly fixed 
in their places and tied together with sufficient firmness, not only 



ILEO'RECTOSTOMY. 197 

coaptate an extensive area of serous surfaces, bat they at the same 
tune secure perfect rest for the parts which it is intended to unite, 
until firm adhesions' have formed. 

4. Ileo-Rectostomy. 

In cases of intestinal obstruction due to inoperable conditions 
low down in the colon, it becomes necessary to establish an intestinal 
anastomosis between the ileum and the rectum, in order to avert the 
necessity of making an artificial anus; in other words, to make an 
ileo-rectostomy. The operation can be made in the same way as 
establishing a communication between the ileum and the colon by 
lateral implantation, by lateral apposition and double suturing, or 
by lateral apposition by perforated decalcified bone plates. The 
operation is, however, more difficult because the rectum is not as 
accessible as the colon, and from the greater vascularity of the gut, 
the incision is more liable to give rise to troublesome hsemorrhaga 
While the slight haemorrhage from an incision into the small intes- 
tines and the colon is usually promptly arrested by suturing, or 
compression by the approximation discs, the bleeding from a wound 
of the upper portion of the rectum not infrequently requires the 
application of one or more catgut ligatures before it is safe to unite 
the wounds. During the operation traction must be made upon the 
rectum in an upward direction so as to lift the upper portion of 
ihe bowel out of the pelvis. In both of the experiments described 
below, the wounds were united by Czemy-Lembert sutures. 

Experifnent 90. Dog, weight ninety pounds. Invagination of colon into 
eolon for two inches and suturing of intussusceptum to neck of intussuscipiens 
by four fine silk sutures to prevent spontaneous disinvagination. Ileum 
incised in a parallel direction for an inch and a half on convex side, and this 
wound united with a similar incision in the rectum on its anterior surface by 
a double row of sutures. For the purpose of immobilizing the sutured intes- 
tines an additional fine catgut suture was applied above and below the place 
of suturing, embracing only tbb peritoneal and muscular coats of the inte8^ 
tines. On the third, fourth, and fifth days the fsBcal discharges contained 
blood and mucus. On the sixth day the abdominal wound partially opened, 
and a considerable quantity of sero-purulent fluid escaped. Death seven days 
after operation. Abdominal wound not united. Diffuse purulent peritonitis. 
Numerous intestinal adhesions. Invagination retained; adhesions between 
the intussusceptum and intussuscipiens; no gangrene; perforation at point of 
operation. 

ExperimeTU 91, Oat, weight seven pounds. Ileo-rectostomy by lateral 
implantation. The ileum was cut across transversely an inch above the ileo- 



198 INTESTINAL SURGERY. 

m 

oiBoal yalve, and the distal end closed by invagination and three stitches of 
the continued sntore. The proximal end was transplanted into a longitudinal 
incision on the anterior surface of the upper portion of the rectum by Czemy- 
Lembert sutures. With the exception of an occasional slight rise in tempera- 
ture no serious disturbances were obseryed during the progress of the case. 
The eyacuation of the small intestines directly into the rectum appeared to 
increase the peristaltic action of the rectum, as the f aBcal discharges were fluid 
and frequent. Animal killed twenty days after operation. Abdominal wound 
completely united. No peritonitis. A few folds of the small intestines and 
the omentum adherent to the wound. Insertion of ileum into rectum in an 
oblique direction; union at point of Junction complete throughout; intestinal 
coats at this point somewhat thickened. Peritoneal surface smooth and con- 
tinuous from one bowel to the other. New ileo-rectal opening corresponded in 
size to the lumen of the ileum; margins of this opening consisted of a ridge of 
mucous membrane to which a row of the deep sutures remained attached. 
Excluded portion of large intestine empty and contracted. Rectum contained 
a small quantity of fluid fasces. 

5. Colo-Rectostomy. 

Among tho many possibilities in the operative treatment of 
intestinal obstruction, a condition might be met with where the seat 
of obstruction is located low down in the colon, perhaps in the sig- 
moid flexure, and where it might be impossible or impracticable to 
remove the cause of obstruction, and where it becomes necessary 
to restore the continuity of the intestinal canal by establishing a 
communication between the permeable portion of the colon and the 
rectum. Such an anastomosis can be made, as in ileo-colostomy, by 
lateral implantation, lateral apposition by perforated approximation 
plates, or by double suturing. For want of time only one experiment 
was made, and although the animal died from the immediate effects 
of the operation, the local conditions at the site of operation found 
after death showed that colo-rectostomy in selected cases is not only 
a justifiable and feasible operation, but whenever it can be done, that 
it is always preferable to the formation of an artificial anus. As the 
operation by lateral apposition requires much less time than lateral 
implantation, it should be preferred to the latter procedure, and 
should be done by perforated approximation discs and a few super- 
ficial sutures. 

Experiment 92, Medium-sized cat. Incision through thelinea alba; colon 
cut transversely in the middle third and the distal portion, and the rectum 
cleared of its contents by injecting a stream of warm water from the cut end 
downward, a procedure which could only be well accomplished after forcible 



ADHESION EXPERIMENTS. 199 

dilatation of the sphinoter ani mnsoles. The distal end was closed in the 
nsnal manner. The leotnm was drown npward and an incision made into its 
anterior wall large enongh to correspond with the Inmen of the colon. Into 
this opening the proximal end of the colon was implanted by two rows of 
sntnres. During the latter part of the operation, which lasted over an hour, 
the animal was seized by convulsions which continued for several hours, and 
finally subsided under the administration of whisky given hypodermically. 
The symptoms of shock, however, continued and death occurred thirty*six 
hours after operation. Numerous omental adhesions; closed end of bowel 
congested; peritoneal surfaces adherent; colon and rectum at point of 
implantation adherent. 

Bemabes. — In cases where the obstraction is located some dis- 
tance from the rectum, where it would be impossible to approximate 
the permeable portion of the colon with the rectum, the entire colon 
must be excluded and the continuity of the intestinal canal restored 
by ileo-colostomy or ileo-rectostomy. In all cases of intestinal 
anastomosis where the communication is made in the lower portion 
of the colon or the rectum, the sphincters of the anus should be 
rendered temporarily incompetent by stretching, for the purpose of 
guarding against over-distention of this part of the bowel during 
the time required for the healing process between the united 
intestines. 

Y. Adhesion Experiments. 

In works on abdominal surgery we invariably meet with the 
assertion that serous surfaces brought into apposition by suturing 
unite after a few hours. Isolated experiments and the results of 
post-mortem examinations ha^e given rise to the general belief that 
serous surfaces so united will become firmly adherent in a very short 
time; but the question concerning the exact time for adhesion to 
take place, and for the definitive healing to be complete, can only be 
determined by experiments made for this special purpose. The 
f oUowing experiments were made with a view of ascertaining the 
exact time which is requisite for adhesions and definitive healing 
between approximated serous surfaces to take place, and likewise to 
study the effects of local conditions which would hasten or retard 
these processes. It is quite important to make a distinction between 
the terms "adhesion" and "healing." Adhesion precedes the pro- 
cess of definitive healing, but implies simply the presence of an 
adhesive or cement substance between the serous surfaces, which 
mechanically agglutinates the parts; while definitive healing includes 



/ 



200 INTESTINAL SURGERY. 

all the processes which take place during cicatrization. In intestinal 
surgery this distinction has an important practical bearing, as per- 
foration may take place as long as the serous surfaces are simply 
held together by adhesions, while such an occurrence is beyond the 
reach of all possibilities after the approximated surfaces have 
become united by living organized tissue. Adhesions between 
serous surfaces take place by the exudation of plastic lymph, which 
acts the part of a cement material; while on the other hand, the 
process of definitive healing is initiated by cell-proliferation from 
the pre-existing endothelial and connective tissue cells, and the for- 
mation of a network of new blood-vessels springing from each of the 
coaptated granulating surfaces. The processes are the same as we 
observe within blood-vessels during cicatrization after ligatura In 
suturing an intestinal wound, or in making a circular enterorrhaphy, 
it has always heretofore been deemed necessary not to injure the 
peritoneum unnecessarily, for fear that such injuries would result 
deleteriously by interfering with the prompt union between the 
sutured surfaces. 

It is a well known fact in surgery that approximation of intact 
serous surfaces does not result in the formation of adhesions. 
When the surgeon desires to secure union between serous surfaces 
he resorts to mechanical irritation for the purpose of inducing a 
circumscribed plastic peritonitis, which invariably results in adhe- 
sions and the obliteration of the serous space. Beasoning from 
this analogy, I was induced to study the effects of traumatic and 
chemical irritation in hastening adhesions and cicatrization between 
apposed serous surfaces. In most of these experiments the serous 
surfaces in the different operations were held in contact by perfor- 
ated approximation plates, and in case artificial means were 
employed to expedite the healing process, the fact is mentioned, 
and the result of such modification noted. The animals operated 
on were all dogs. 

I. Traumatic Irritation of Serous Surfaces. 

TiMB, Six Houbs. 

Experiment 93. The ileum was divided near the middle, and both ends 
closed by invagination and the continued sntnre. Ileo-ileostomy was made 
at two points, making two openings of communication. No suturing. Parts 
kept in apposition by perforated decalcified bone plates. To compare the 
effect of traumatic irritation of the peritoneum in the reparative process 



TRAUMATIC IRRITATION OF SEROUS SURFACES. 201 

with the intact serons snrfaoe, the peritoneal sorfaoes at one point of opera- 
tion designated as the upper, were scarified with the point of a needle oyer an 
area corresponding to the size of the bone discs, the scratches being made 
sufficiently deep to penetrate the entire thickness of the peritoneum. The 
scarifications were made in a longitudinal and transyerse direction, mapping 
out the serous surfaces into small squares. Only slight oozing followed this 
procedure. The serous surfaces between the plates at No. 1, where no scarifi- 
cation was made, was found slightly adherent by a scanty deposit of plastic 
lymph. At No. 2, where scarifications had been done, the amount of plastic 
lymph was greater and stained by blood, and the adhesions much firmer. 

Tims, TwEiiys Houbs. 

Experiment 94. In this experiment the bowel was not interrupted by 
diyision, but two adjacent coils of the ileum were united by making an ileo- 
ileostomy by perforated decalcified bone plates, the plates holding the parts 
perfectly in apposition; a slight tumefaction of the intestinal walls made the 
coaptation more secure. Goaptated serous surfaces yery yascular, coyered 
with a thin layer of plastic lymph which had agglutinated the folds of the 
intestine brought in contact. 

Experiment 95. Bowel not diyided, but two adjoining loops of the ileum 
united by making a double ileo-ileostomy by perforated approximation discs, 
the two communicating openings about six inches apart. At one point of 
operation, designated as No. 2, serous surfaces freely scarified. At both 
points the adhesions were perfect throughout, but where scarification was 
made they were notably firmer. 

Experim£7d 96. In this experiment a gastro-enterostomy and an ileo- 

ileostomy were made at the same time and on the same animal. In both 

operations the parts were coaptated by perforated decalcified bone plates. 

Scarification of peritoneal surfaces at both places. The adhesions between 

the anterior surface of the stomach and upper portion of jejunum were 

uniform throughout, oyer the whole surface, kept in contact by the plates. 

There was no leakage on distending the stomach and intestine forcibly by 

water. The adhesions between the folds of the ileum at point of approxima- ' 

tion were, if anything, firmer than between stomach and jejunum. The 

decalcified bone plate in the interior of the stomach was softened more than 

those in the intestine. 

Time, Eighteen Houbs. 

Experiment 97, Gastro-enterostomy by perforated decalcified bone 
plates; communication made between stomach and upper portion of jejunum; 
no scarification. Agglutination quite firm, so that forcible distention of 
stomach and bowel caused no leakage. New opening sufficiently large to 
admit middle finger, and apparently lined throughout by mucous membrane. 
Plate in stomach yery much softened and on the yerge of becoming detached. 
On forcibly separating the adhesions the serojis surfaces were f oimd to be 
cemented together by a thin layer of plastic lymph, and after scraping this 
away they appeared yascular and rough, as though completely depriyed of the 
endothelial coyering. 



202 INTESTINAL SURGERY. 

Tub, TwaMTx-^uB Houbs. 

EocperiiMnt 98. Triple ileo-ileostomy without diTision of the bowel ; the 
operations were numbered 1, 2, 8, reBpeotively. Coaptation by approxima- 
tion discs of deoaloified bone. Oommnnicating openings abont six inches 
apart. In No. 1 no scarification. No. 2, scarification of one loop only. No. 
8, scarification of both serous surfaces. After twenty-four hours the result 
was as follows : 

No. 1. Lymph scanty; adhesions not yery firm. 

No. 2. Lymph more plentiful ; adhesions firmer. 

No. 8. Lymph more abundant than in No. 2, and mixed with a fine 
stratum of coagulated blood ; adhesions also firmer. The adhesions increase 
in firmness in the order 1, 2, 8. 

Experiment 99. Double gastro-enterostomy by perforated decalcified 
bone plates. The communicating openings, one near the pyloric, and the other 
near the cardiac extremity of the stomach, were made between the anterior 
surface of the stomach, and the upper portion of the jejunum. In operation 
No. 1, the intact serous surfaces near the pylorus were brought in contact, 
while in the second operation both the stomach and bowel were scarified. At 
the post-mortem, it was found that the adhesions at both places were of 
sufficient firmness to prevent leakage under pressure. In No. 2, adhesions 
firmer and the inflammatory infiltration more marked than in No. 1. Plates 
in stomach much softened, but remain in situ. Openings lined throughout 
by mucous membrane and sufficiently large to admit the index finger. 

Experiment 100. Beo-colostomy by lateral apposition and fixation by 
perforated approximation discs. Lower portion of ileum united with the 
ascending colon. No scarification ; bowels lightly agglutinated throughout 
by a very thin layer of plastic lymph ; adhesions, however, could be easily 
separated, and where this is done the peritoneal surface appeared denuded of 
endothelial cells, and very vascular with new vessels along the outer margin 
of the surface of approximation. 

Time, Fobty-eioht Houbs. 

Eocperim£fnt 101. Double gastro-einterostomy. The communicating open- 
ings were between the anterior surface of the stomach and the duodenum, and 
the posterior surface of the stomach and the upper portion of the jejunum. 
In the posterior operation the intact serous surfaces were brought in contact, 
while in the anterior, the peritoneal surfaces of the stomach and duodenum 
were scarified. In both operations perforated decalcified bone plates were 
used. Adhesions between posterior surface of stomach and bowel uniform 
throughout, but easily broken down; the peritoneal surfaces injected and 
apparently deprived of their endothelial covering. The anterior operation 
resulted in the formation of firm adhesions, the products of exudation and 
tissue proliferation being supplied with new vessels, the circumscribed plastic 
peritonitis being much more advanced than at the site of the posterior 
operation. 



CHEMICAL IRRITATION OF SEROUS SURFACES, 208 

Experiment 102. Double ileo-oolostomy by perforated approximation 
plates. The anastomosis between the lower portion of the ilenm and the 
colon jnst above the c»cam was made without soarifioation, while in the second 
operation about six inches higher up in the colon and ileum, both serous 
surfaces were freely scarified. Omentum adherent at point of operation. 
Plates swollen, softened and pliable, but still efficient in maintaining coapta- 
tion and fixation. Adhesions at both places quite firm, but more so in the 
upper portion where scarification had been done. 

Experiment 103. Beo-colostomy by approximation discs. The ileum was 
divided a few inches above the ileo-caBcal region, and both ends closed by 
invagination and three stitches of the continued suture. An anastomosis was 
made between the proximal end and the ascending colon by lateral apposition. 
No scarification. Intestines agglutinated at point of operation, but the 
adhesions gave way when the bowel was forcibly distended under hydrant 
pressure. 

2. Chemical Irritation of Serous Surfaces. 

In these experiments it was aimed to study the effect of 
chemical irritation of the peritoneum in the reparative process after 
intestinal operations. Iodine has been used for a long time in pro- 
ducing plastic inflammation of serous surfaces for the purpose of 
obliterating serous cavities, consequently this substance was used in 
the first experiments. To study the effects of the diffuse application 
of tincture of iron to the intact peritoneal cayity, the following 
experiments were made: 

Experiment 104. Medium-sized dog. The needle of a hypodermic syringe 
was thoroughly disinfected, and a drachm of the tincture of iodine injected 
into the peritoneal cavity. Immediately after the injection the animal 
evinced great pain, which, however, appeared to subside after a short time, 
and subsequently no unfavorable symptoms were observed. Three days after 
the injection the urine was examined and showed the presence of iodine. 
Dog killed nine days after the injection. Oircumpcribed plastic peritonitis 
over a space four inches square, corresponding to the point where Ihe 
puncture was made. At this place the omentum was much thickened, very 
vascular and adherent to the parietal peritoneum and the adjoining folds of 
the intestines. 

Experiment 105. Medium-sized dog. A fluid drachm of the tincture of 
muriate of iron was thrown into the peritoneal cavity by means of a weU- 
disinfected hypodermic syringe. The pain immediately after the injection was 
intense, and the animal appeared to be very ill two days after the injection, 
and died with well-marked symptoms of peritonitis on the sixth day. DifiFuse 
plastic peritonitis was found to be the cause of death. The omentum was 
adherent everywhere, and the intestines were matted together by numerous 
adhesions. The Abdominal cavity contained a considerable quantity of serous 
fluid. 



204 INTESTINAL SURGERY. 

Bemabe& — ^Both experiments prove that when tinotare of iodine 
and tincture of iron are brought in contact with the peritoneum, a 
plastic inflammation ensues; and it was reasonable to expect that if 
either of these substances could be applied to the serous surfaces 
which it was intended to unite, the reparative process would be 
hastened. 

Experiment 106, Triple ileo-ileostomy by perforated deoaloified bone 
plates. Three internal fietnlao were made between the adjacent loops of the 
ileum, abont six inches apart. In operation No. 1, approximation of intact 
serous surfaces; in operation No. 2, the serous surfaces were painted with 
tincture of iron over an area corresponding to the size of the plates; in oper- 
ation No. 8, the serous surfaces over the same extent were brushed with pure 
tincture of iodine. The animal was kiUed forty-eight hours after operation, 
and the following conditions were noted: No general peritonitis. All the plates 
firmly in place coaptating the serous surfaces accurately, the swelling of the 
tunics of the bowel only serving to enhance their efficiency. At No. 1, adhe- 
sions quite firm, flexion of bowel and marked injection of serous surfaces. At 
No. 2, no adhesions between serous surfaces. The peritoneal surfaces to which 
the tincture of iron had been applied appeared stained, almost black, and at 
some points the serous coat was destroyed. At No. 8, peritoneal surfaces 
stained dark brown; adhesions firm, and an abundance of plastic lymph even 
beyond the margin of the plates. 

Experiment 107, Double ileo-ileostomy by approximation plates and 
omental grafting. Operation No. 1, approximation of ileum to ileum by per- 
forated decalcified bone plates; serous surfaces intact. Operation No. 2, 
similar operation six inches higher up uniting the same loops, but painting 
the serous surfaces with pure tincture of iodine. Operation 8, cutting off a 
piece of omentum two inches wide and sufficiently long to encircle the entire 
bowel. After scarifying the bowel and the omental graft on one side, the 
scarified surfaces were brought in contact, and the graft fixed in its place by 
two fine catgpt sutures passed through the mesentery and both ends of the 
graft. Animal killed forty-eight hours after operation. All plates firmly in 
place. At No. 1, adhesions firm. At No. 2, dark-brown discoloration of surface 
to which the iodine had been applied; agglutination oyer the whole surface. 
Under hydrostatic pressure the adhesions first gave way between the two 
plates where the iodine had been applied; showing condusiyely that chemical 
irritation of serous surfaces does not hasten the adheeiye process, while it may, 
and probably does, expedite the definitive healing. At No. 8, omental graft 
firmly adherent to the entire circumference of the bowel, and beginning 
vascularization of the graft around its margins. 

Bemarks. — ^In all of these experiments the post-mortem exami- 
nations showed no evidences of diffuse peritonitis. In most of the 
cases the inflammatory process was limited to the portion of 
the bowel interposed between the plates. Without exception the 



OMENTAL QRAFTINQ. 205 

adhesions formed were firmest and the definitive healing was 
initiated first where scarification was performed; results which dearly 
demonstrate the fact that the reparative process between serous sur- 
faces which it is intended to unite, is hastened by traumatic irritation. 
Traumatic irritation by scarification of the peritoneal surface with 
the point of an aseptic needle, is the most potent means to provoke 
a circumscribed plastic peritonitis, and is followed within a few 
hours by a copious exudation of plastic lymph, which, like a cement 
substance, mechanically agglutinates the coaptated serous surfaces. 
The same measure, by destroying the continuity of the non- vascular 
layer of the peritoneum, brings at once in contact the vascular net- 
work of both sides of the bowel, and opens up a direct route for the 
new vessels, an important element in the rapid healing of the visceral 
wounds. Chemical irritants by destroying the endothelial layer of 
the peritoneum rather retard, than favor, early adhesion and union 
between the coaptated bowels, and should therefore not be resorted 
to in intestinal surgery, to hasten the reparative process. 

3. Omental Grafting. 

Under the head of circular enterorrhaphy, mention is made of 
transplantation of omental fiaps after uniting the two ends of the 
bowel by suturing or invagination, with a view of securing an addi- 
tional safeguard against perforation during the process of repair. A 
number of experiments are described where the procedure was prac- 
ticed with satisfactory results. After a few days the omental flaps 
were found firmly adherent and vascular around the whole circum- 
ference of the bowel, constituting a ring of living tissue outside the 
line of suturing. In all these cases the proximal end of the flap 
remained in connection with the omentum, and care was taken to cut 
the flap in such a manner that some vessel of considerable size should 
famish the necessary vascular supply. I was well aware that plaus- 
ible objections could be entered against this method, in that the 
connecting bridge between the bowel and the omentum might become 
subsequently a cause of intestinal obstruction by making traction 
upon the bowel, thus causing a flexion, or, by becoming a band of 
constriction for some loop of intestina 

For the purpose of obviating such remote consequences I 
resorted to another procedure which I have designated as omental 
grafting. I was familiar with the fact that implantations of aseptic 



206 INTESTINAL SURGERY. 

snbstanoes into the peritoneal cavity had frequently been done 
without any immediate or remote ill-effects, and I had every reason 
to expect that a large, completely detached, aseptic, omental graft, 
in an aseptic abdominal cavity, would be well tolerated, and would 
soon become adherent to the subjacent peritoneal surface, and thus 
afford an additional safeguard against perforation and the disastrous 
consecutive result, namely: perforative peritonitis during the time 
required for the healing of the intestinal wound. In the following 
experiments the grafts used were from one and a half to two inches 
in width, and of sufficient length to completely encircle the bowel. 
The free ends were made to project a few lines beyond the mesen- 
teric attachment, and were fixed by two fine catgut sutures, each of 
which embraced the corresponding angles of the graft and the 
mesentery. The stitches were made in the direction of the mesen- 
teric vessels, so that in tying, no vessels should be included in the 
suture. In these experiments dogs were used exclusively. 

Experiment 108, Three pieces of omentum, two inches wide and suffi- 
ciently long to encircle the bowel, were completely detached and grafted as 
follows: 

1. Graft simply laid over the bowel corresponding to the lower portion 
of the ileum, and fastened in its place on mesenteric side by two fine oatgrnt 
sutures. 

2. Serous surface of bowel about six inches higher up scarified, and graft 
applied to this surface and fixed in the same manner. 

8. Bowel treated in the same way about six inches still higher up, and 
one of the serous surfaces of the graft also freely scarified. 

The graft was scarified on the side which was to be brought in contact 
with the bowel. Fixation of graft by two catgut sutures on mesenteric side. 
Animal killed thirty-six hours after operation. AU the grafts adherent, 
slightly contracting the bowel at the three different places. On separating 
the adhesions the subjacent serous surface very vascular and denuded of its 
endothelial layer. Firmness of adhesions increased in proportion to the 
extent of scarification done, being least firm at No. 1, firmer at No. 2, and 
firmest at No. 3, where both coaptated serous surfaces had been scarified. At 
Nos. 2 and 3, the plastic lymph was freely supplied with new blood-vesselB. 
The vascularization was most conspicuous on the mesenteric side. 

Experiment 109, Two omental grafts planted around the ileum in the 
same manner as described above. At No. 1, both the bowel and the inner side 
of the graft were scarified; at No. 2, only the serous surface of the boweL 
Animal killed forty-three hours after operation. Stump of omentum adherent 
to .abdominal wound and intestines. No peritonitis. At No. 1, graft firmly 
adherent over the entire extent. A slight extravasation of blood between the 
graft and the bowel. Beginning vascularization of interposed plastic lymph. 



OMENTAL ORAFTINO. 207 

At No. 2, also firm adhesions and beginning yascnlarization of the plastic 
exudation. Both of the grafts appear to be stained with the coloring material 
of the blood. 

Experiment 110. Planting of two omental grafts aronnd the ileum about 
eight inches apart. At No. 1, both the bowel and one side of the omental 
graft were scarified. At No. 2, only the serous surface of the bowel was treated 
in this manner. Animal killed six days after the operation. Both grafts 
firmly adherent throughout and freely supplied with blood-vessels, the largest 
of the new vessels being on the mesenteric side. The omental stump adherent 
to the portion of bowel between the grafts where a flexion had been made from 
this cause. 

Experiment 111, In this experiment omental grafting was done at two 
points around the lower portion of the ileum. At one point the serous 
surfaces were left intact, at the other, both the peritoneal surface of the bowel 
and the omental graft were freely scarified. Animal remained perfectly well 
and was killed eight days after operation. No signs of peritonitis. Both 
grafts formed a thin vascular layer around the entire circumference of 
the bowel, and firmly and evenly united throughout. Vascularization was 
more marked where scarification had been done. On attempting to separate 
the grafts it was difficult to find and define the line of union between the 
omentum and the underlying ■ bowel, as the union was very intimate and firm. 

Bemabes. — ^In all of these experiments the grafts retained their 
vitality, and in a few hours became firmly adherent to the intestinal 
surface with which they had been brought in contact. Scarification 
of the serous surface has also been found in these experiments, an 
exceedingly valuable measure in hastening the processes of adhesion, 
granulation and vascularization. By planting grafts side by side, 
with and without scarification, I was enabled to determine with 
ax5curacy the beneficial influence exerted by this procedure in favor- 
ing the reparative process, and without a single exception, observed 
that where scarification was done the adhesions were firmer and 
vascularization more advanced. The post-mortem examinations 
appeared to demonstrate that the firmness of the adhesions and the 
degree of vascularization were in direct proportion to the extent of 
traumatic irritation of the peritoneum, being always most marked in 
cases where both the bowel and the under surface of the graft were 
scarified, and least where intact peritoneal surfaces weve brought into 
apposition. 

As soon as the omental grafts were cut off from the omentum 
they were placed in a 1-2000 solution of corrosive sublimate, kept 
at the temperature of the body, in order to secure for the graft a 
perfectly aseptic condition until everything was in readiness for 



208 INTESTINAL 8URQERY. 

the transfer of the graft to its new location. Before planting the 
graft it was carefolly dried by pressing it between gauze or sponges 
wrung out of the same solution. The scarifications of the serous 
surfaces should only be i&ade sufficiently deep to give rise to a very 
slight oozing, as when haemorrhage is more profuse, there is danger 
of the formation of a dot between the graft and the bowel, which, if 
it does not ultimately prevent union between the coaptated surfaces, 
must necessarily interfere with the formation of early and firm 
adhesions. 

Omental grafting cannot fail to become an established proced- 
ure in many abdominal operations. After suturing a large wound 
of the stomach or intestines, a strip of omentum should be laid 
over the wound and fastened in its place by a few catgut sutures. 
After circular enterorrhaphy, the operation should be finished by 
covering the circular wound by an omental graft about two inches 
wide, which should be fixed in its place by two catgut sutures passed 
through both ends of the graft and the mesentery. Omental graft- 
ing should also be resorted to in repairing peritoneal defects in 
visceral injuries of the abdominal organs, and in covering large 
stumps after ovariotomy or hysterectomy, where the pedicle is 
treated by the intra-abdominal method. 

YI. Conclusions. 

In conclusion I beg leave to submit the following propositions 
for further discussion : 

1. Traumatic stenosis from partial enterectomy and longitu- 
dinal suturing of the wound becomes a source of danger from 
obstruction or perforation, in all cases where the lumen of the bowel 
is reduced more than one-half in size. 

2. Longitudinal suturing of wounds on the mesenteric side of 
the intestine should never be practiced, as such a procedure is 
invariably followed by gangrene and perforation by intercepting the 
vascular supply to the portion of bowel which corresponds to 
the mesenteric defect. 

3. The immediate cause of gangrene in circular constriction of 
a loop of intestine is due to obstruction of the venous circulation, 
and takes place first in the majority of cases at a point most remote 
from the cause of the obstruction. 



CONCLUSIONS. 209 

4 On the convex surface of the bowel a defect an inch in 
width, from injury or operation, can be closed by transverse suturing 
without causing obstruction by flexion. In such cases the stenosis 
is subsequently corrected by a compensating bulging or dilatation 
of the mesenteric side of the bowel. 

5. Closing a wound of such dimensions on the mesenteric side 
of the bowel by transverse suturing may give rise to intestinal 
obstruction by flexion, and to gangrene and perforation by seriously 
impairing the arterial supply to, and venous return from, the portion 
of bowel corresponding with the mesenteric defect. 

6. Flexion caused by inflammatory and other extrinsic causes 
gives rise to intestinal obstruction only in case the functional 
capacity of the flexed portion of the bowel has been impaired or 
suspended by the causes which have produced the flexion, or by 
subsequent pathological conditions which have occurred independ- 
ently of the flexion. 

7. As in flexion, a volvulus gives rise to symptoms of obstruc- 
tion, when the causes which have given rise to a rotation upon its 
axis of a loop of bowel have at the same time produced an impair- 
ment or suspension of peristalsis in the portion of bowel which 
constitutes the volvulus; or when a diminution or suspension of 
peristalsis follows in consequence of the degree or extent of the 
rotation. 

8. Accumulation of intestinal contents above the seat of in- 
vagination is one of the most important factors which prevents 
spontaneous reduction, and which determines gangrene of the 
intussusceptum and perforation of the boweL 

9. Spontaneous disinvagination is not more frequent in ascend- 
ing than descending invagination. 

10. The immediate or direct cause of gangrene of the intus- 
susceptum is obstruction to the return of venous blood by constric- 
tion at the neck of the intussuscipiens. 

11. Heo-csBcal invagination, when recent, can frequently be 
reduced by distention of the colon and rectum with water; but this 
method of reduction must be practiced with the greatest caution and 
gentleness, as over-diskention of the colon and rectum is productive 
of multiple longitudinal lacerations of the peritoneal coat, an acci- 
dent which is followed by the gravest consequences. 

14 



210 INTESTINAL SURGERY. 

12. The competency of the ileo-csocal TalTe can only be over- 
come by over-distention of the csecnm, and is effected by e mechanical 
separation of the margins of the Talve; consequently it is imprudent 
to attempt the treatment of intestinal obstruction beyond the ileo- 
caecal region by injections per rectum. 

13. Resection of more than six feet of the small intestine in 
dogs is uniformly fatal; the cause of death in such cases is always 
attributable to the immediate effects of the trauma. 

14. Besection of more than four feet of the small intestine in 
dogs is incompatible with normal digestion, absorption and nutrition, 
and often results in death from marasmus. 

15. In cases of extensive intestinal resection, the remaining 
portion of the intestinal tract undergoes compensatory hypertrophy, 
which microscopically is apparent by thickening of the intestinal 
coats and increased vascularization. 

16. Physiological exclusion of an extensive portion of the 
intestinal tract does not impair digestion, absorption and nutrition 
as seriously as the removal of a similar portion by resection. 

17. Fsecal accumulation does not take place in the excluded 
portion of the intestinal canal. 

18. The excluded portion of the bowel undergoes progressive 

atrophy. 

19. A modification of Jobert's invagination suture by lining 
the intussusceptum with a thin flexible rubber ring, and the substitu- 
tion of catgut for silk sutures is preferable to circular enterorrhaphy 
by the Czemy-Lembert suture. 

20. The line of suturing, or neck of intussuscipiens, should be 
covered by a flap or graft of omentum in all cases of circular resec- 
tion, as this procedure furnishes an additional protection against 
perforation. 

21. In circular enterorrhaphy, the continuity of the peritoneal 
surface of the ends of the bowel to be united should be procured 
where the mesentery is detached, by uniting the peritoneum with a 
fine catgut suture before the bowel is sutured, as this modification 
of the ordinary method furnishes a better security against perfora- 
tion on the mesenteric side. 

22. In cases of complete division of an intestine, if it is 
deemed advisable not to resort to circular enterorrhaphy, one or both 



CONCLUSIONS. 211 

ends of the bowel should be closed by inTagination to the depth of 
aa inch, and three stitches of the continued suture embracing only 
the peritoneal and muscular coats. 

23. The formation of a fistulous communication between the 
bowel above and below the seat of the obstruction should take 
the place of resection and circular enterorrhaphy in all cases where it 
is impossible or impracticable to remove the cause of obstruction, or 
where after excision it would be impossible to restore the continuity 
of the intestinal canal by suturing, or where the pathological condi- 
tions which gave rise to the obstruction do not constitute an intrinsic 
source of danger. 

24. The formation of an artificial anus in the treatment of 
intestinal obstructions should be practiced only in cases where con- 
tinuity of the intestinal canal cannot be restored by making an 
intestinal anastomosi& 

25. Gastro-enterostomy, jejuno-ileostomy and ileo-ileostomy 
should always be made by lateral opposition with partially or com- 
pletely decalcified perforated bone plates. 

26. In making an intestinal anastomosis for obstruction in the 
csecum, or colon, the communication above and below the seat of 
obstruction can be established by lateral apposition with perforated 
approximation plates, or by lateral implantation of the ileum into 
the colon or rectum. 

27. An ileo-colostomy, or ileo-rectostomy by approximation 
with decalcified perforated bone plates, or by lateral implantation, 
should be done in all cases of irreducible ileo-csecal invagination, 
where the local signs do not indicate the existence of gangrene or 
impending perforation. 

28. In all cases of impending gangrene or perforation, the 
invaginated portion should be excised, both ends of the bowel per- 
manently closed, and the continuity of the intestinal canal restored 
by making an ileo-colostomy or ileo-rectostomy. 

29. The restoration of the continuity of the intestinal canal by 
perforated approximation plates, or by lateral implantation, should 
be resorted to in all cases where circular enterorrhaphy is impossible 
on accoimt of the difference in size of the lumina of the two ends of 
the bowel 



212 INTESTINAL SURGERY. 

80. In oases of mtdtiple gonshot wonnds of the intestines 
involying the lateral or convex side of the bowel, the formation of 
intestinal anastomosis by perforated decalcified bone plates shotQd 
be preferred to suturing, as this procedure is equally, if not more 
safe, and requires less tima 

81. Definitive healing of the intestinal wound is only initiated 
after the formation of a network of new vessels in the product of 
tissue proliferation from the approximated serous surfaces. 

82. Under favorable circumstances quite firm adhesions are 
found within the peritoneal surfaces in six to twelve hours, which 
effectually resist the pressure from within outward. 

88. Scarification of the peritoneum at the seat of coaptation 
hastens the formation of adhesions and the definitive healing of the 
intestinal wound. 

84 Omental grafts, from one to two inches in width, and 
sufficiently long to completely encircle the bowel, retain their vitality, 
become firmly adherent in from twelve to eighteen hours, and are 
freely supplied with blood-vessels in from eighteen to forty-eight 
hours. 

85. Omental transplantation, or omental grafting, should be 
done in every circular resection or suturing of large wounds of 
the stomach or intestines, as this procedure favors healing of the 
viscerA wound, and affords an additional protection against 
perforation. 



Methods of Intestinal Anastomosis. 



te within ths 
of otiMrao- 



INTISTIMAL ANABTOHOaiB BT FsBITOBATItD DE0AI.OmED BoNI-PLATBa 
Plate wltblp wflon b«l<nr M>t ot ApproiliiiMlou ol lnleaOne br 



ITeedlea pMMd tmm 

Bnbber ring within within ontwonl tbronsli 

wwel fliBd b7 oon- entire wall ol bowel ud 



Put to be laTagl- 



. Avthor's MoDtFic&Ticw OF Jobebt'b Sutube. 



EECTAL INSUFFLATION OF HTDEOGEN GAS AN 

INFALLIBLE TEST IN THE DIAGNOSIS OF 

VISCEEAL INJUEY OF THE GASTEO- 

INTESTINAL CANAL IN PENE- 

TEATiNG Wounds of 

THE ABDOMEN. 



The operatiye treatment of penetrating wonnds of the abdomen^ 
complicated by Yisceral injury of the gastro-intestinal canal is now 
sanctioned by the best snrgical authorities, and may be considered 
as a well-established procedure, based as it is upon the results of 
experimentation and clinical experience. A yisceral wound of the 
stomach or any portion of the intestinal canal sufficient in size to give 
rise to extravasation into the peritoneal cavity, must be looked upon 
as a mortal injury unless promptly treated by abdominal section. A 
number of well authenticated cases are on record where a wound in 
the stomach or the large intestine healed, and the patients recovered 
without the intervention of surgery, but these instances are so few 
that, practically, the force of the preceding statement remains unim- 
paired. After a careful study of an immense amount of clinical 
material Otis came to the important conclusion that gunshot injuries 
of the small intestines under the old expectant treatment, without 
exception resulted in death; and that is a sufficiently cogent argu- 
ment in favor of their treatment by laparotomy as affording the 
only chance of recovery. 

The great difficulty that presents itself to the surgeon in the 
absence of positive symptoms, is the differential diagnosis between a 
simple penetrating wound and a penetrating wound complicated by 
injury of the gastro-intestinal canaL While the existence of serious 
intra-abdominal hsemorrhage can usually be readily recognized by 
well marked physical signs and a complexus of symptoms which 
points to sudden diminution of 4ntra-arterial pressure, and thus fur- 
nishes one of the positive indications for treatment by lapaiotomyi 

215 



216 INTESTINAL SURGERY. 

the well-known fact remains that a visceral injury of the stomach or 
intestines seldom gives rise to symptoms upon which the surgeon 
could rely in making a positive diagnosis. 

In the treatment of penetrating wounds of the abdomen lapar- 
otomy is resorted to either (1) for the purpose of arresting danger- 
ous haemorrhage, or (2) for the detection and treatment of a wound 
or wounds of its hollow viscera. The first indication is readily 
recognized, and the diagnosis not .only justifies the operation, but 
imposes it as a stem duty upon the surgeon, from which he should 
never shrink. The recognition of the second indication offers 
greater difficulties, and the uncertainty of diagnosis which surrounds 
such cases is used as a sufficient argument by many in opposing the 
^adoption of timely and efficient surgical treatment, and is responsi- 
ble for the loss of many lives which otherwise might have been 
saved. The uncertainty of diagnosis must remain in the way of a 
more general adoption of laparotomy in the treatment of penetrating 
wounds of the abdomen, in the case of timid surgeons, and the same 
cause may lead to most unpleasant medico-legal complications in 
the practice of bolder and more aggressive operators. 

Clinical experience and statistics have demonstrated the impor- 
tance of making a distinction between punctured and gunshot 
wounds in the abdomen, both in reference to diagnosis and treat- 
ment. It is well known that penetrating stab-wounds are less likely 
to be complicated by visceral injury than bullet wounds, conse- 
quently this class of injuries offers a more favorable prognosis and 
does not call so uniformly for treatment by abdominal section. That 
penetrating gunshot wounds of the abdomen do not always implicate 
the gastro-intestinal canal has been well demonstrated by experi- 
ment and clinical observation. During the last two years three cases 
of bullet wounds of the abdomen came under my observation where 
no doubt could be entertained that penetration had taken place, and 
yet all the patients recovered without operation. In all three cases 
the bullet had taken an antero-posterior direction. As in private 
practice the treatment of penetrating wounds of the abdomen usually 
involves great medico-legal responsibilities, it becomes of the 
greatest importance to arrive at positive conclusions in reference 
to the character of the injury, before the patient is subjected to the 
additional risks to life incident to an abdominal section. 



RECTAL INSUFFLATION OF HYDROGEN GAS. 217 

We will suppose a case. In a quarrel a man is shot in the 
abdomen. The assailant is placed under arrest The snrgeon who 
is called establishes the fact that the bullet has entered the abdomi- 
nal cayity, and from the point of entrance and its probable direction, 
he has reason to believe that it has wonnded some part of the gastro- 
intestinal canal, and he concludes to verify his diagnosis hj an 
exploratory laparotomy; the operation is performed, and the most 
carefnl examination made, but no visceral wound is found. The 
wound is closed and the patient dies on the third or fourth day of 
septic peritonitis. The attorney for the state charges the defendant 
with murder. 

The defense will very naturally raise the questions: ''Did the 
man die of the injury, or the operation?" "Shall the defendant be 
tried for assault and battery, or for murder f" During the trial the 
attending surgeon is made the target for a volley of a medley of 
scientific and unscientific questions by the cunning attorney for the 
defense in his attempt to save his client from the gallows or state 
prison for life, at the expense of the reputation of the surgeon and 
the respect and good name of the art and science of surgery. This 
picture is not overdrawn. Such cases have happened and will 
happen again. It is apparent that if some infallible diagnostic test 
could be applied in cases of penetrating wounds of the abdomen 
which would indicate to the surgeon the presence or absence of 
visceral lesions of the gastro-intestinal canal, the indication for 
aggressive treatment would become clear and the medico-legal 
responsibility of the operator would be reduced to a minimum. 

As we can never expect by a study of symptoms or by the ordi- 
nary physical examination to fill this gap, I was induced to search 
for some reliable test which in such cases should prove that the 
penetrating bullet or instrument had injured the gastro-intestinal 
canal. It occurred to me that a wound in the stomach or intestine 
should be sought for in some such way as the plumber locates a 
leak in a gas-pipe. The first object to be accomplished was to prove 
the permeability of the entire gastro-intestinal canal to inflation of 
air, and the next step was to find some innocuous gas which, when 
inflated, would escape from the intestinal wound into the peritoneal 
cavity, and from there through the external wound, where its pres- 
ence could be proved by some infallible test 



218 INTESTINAL SURGERY. 

I. Permeability of the Deo-Ciecal Talve to Beetal Insuffla- 
tion of Air or Gas. 

A great deal has been said and written in reference to the per- 
meability of the ileo-C8Qcal valve to injections of fluids into the rectum, 
or to the insufflation of air or gasea The majority of those who 
have studied this subject clinically or by experiment make the posi- 
tive assertion that the ileo-csecal valve is perfectly competent, and 
effectually guards the ileum against the entrance of both fluids and 
gases forced into the rectum, while others insist that it is permeable 
only in exceptional cases, and only a few claim that its resistance can 
be overcome by a moderate degree of pressure. Heschl^ made a 
number of experiments and satisfied himself that the ileo-csBcal 
valve serves as a safe and perfect barrier against the entrance of 
fluids from below. In testing the resisting power of the coats of 
the intestine he found that the serous coat of the colon gave way 
first to overdistention, while the remaining tunics yielded subse- 
quently to a somewhat slighter pressure. The small intestine of a 
child on being subjected to overdistention ruptured first on the 
mesenteric side, the place where acquired diverticula are found. 

Bull' has found that in the adult one litre of water injected by 
the rectum will reach the csBCum, but that the entire capacity of 
the large intestine is from four to five litres. He is of the opinion 
that in the living body, fluid cannot be forced beyond the ileo-csecal 
valve, although ancient and modem experimenters claim to have 
succeeded in the cadaver. He affirms that when the rectum is dis- 
tended by air, the ileo-csecal valve is rendered incompetent and the 
air passes into the small intestines. 

Oantani' is a firm believer in the permeability of the ileo-csecal 
valve to fluid rectal injections. In one instance he treated a case of 
coprostasis by an injection of a litre and a half of oil per rectum, 
and an hour later a part of the oil was ejected by vomiting. He 
advises that the intestinal tract above the ileo-csecal valve should be 
utilized as an absorbing surface in cases requiring rectal alimenta- 

1 Znr Meohanik diastaltisohen Darmperforationen. Wiener Med. Woohen- 
Bohrift, No. 1, 1881. 

> Virohow'B Jahresbericht, B. 11, 1878, 8. 205. 
* Virohow's Jahresbericht, B. 11, 1879, S. 180. 



PERMEABILITY OF ILEO-CJECAh VALVE. 



219 



tion, and that when in a diseased condition it should be treated by 
topical applications. 

Behrens^ concluded from his experiments^ that it reqnired the 
insufflation per rectum of one and one-eighth litres of air to reach 
the ileum through the ileo-csecal valve. In his experiments he had 
no difficulty in overcoming the competency of the ileo-csBcal valve 
by rectal insufflation of air. 

Debierre^ made numerous experiments on the cadaver to test 
the permeability of the ileo-csecal valve to rectal injections of fluids 
or inflation of air. The results which he obtained wore not constant. 
In some subjects the valve proved only permeable to air, in others, 
to both air and water, while in some no air or fluids could be forced 
into the ileum by any degree of force. When the intestine was left 
in situ the valve was found less permeable than when the intestine 
had been removed from the body. He attributed the different 
degrees of competency of the valve to variations in the anatomical 
construction of the valve. If both lips of the valve were equal in 
length, or if the lower lip was longer the valve was found imper- 
meable. It proved permeable in cases where the lower lip was 
shorter, contracted, and smaller than the upper. In the last instance, 
the advancing volume of fluid or air lifted the upper valve, while 
in the former structure of the valve, the margins of the lips of the 
valve were pressed against each other, perfectly shutting off all com- 
munication between the colon and the ileum. 

Mr. Lucas ^ enumerates the following objections against forcible 
rectal injections of water as a means of reducing invagination: 

1. Owing to its weight it exerts much too strong lateral 
pressure for the intestine safely to bear, and he has found it easy to* 
rupture the bowel after death by forcing in water. 

2. Should reduction have been accomplished, the contact of 
a large quantity of water with the large bowel is apt to increase 
the tendency to diarrhcBa. He claims very properly, that air, on the 
other hand, is a natural occupant of the intestinal canal, and whilst 

^Ueber den Werth der EliziBtliohen Anftreibnng des Diokdarmes mit 
Qasen n. Flftssigkeiten. Gdttingen. Dissertation. 1886. 

^ La yalvnle de Banhin oonsid^r^e oomme bani^re des apothioaires. Lyon 
M^dioale, No. 45, 1885. 

* On Inversion with Inflation in the Cure of Intussnsoeption. The Lan- 
cet, January 16, 1886. 



220 INTESTINAL SURGERY. 

its pressure is of the gentlest its presence excites no nnnattiral 
peristaltic action. He administers an ansesthetic to the point of 
relaxation before the inflation is attempted. 

Dawson' made a number of experiments on the cadaver and 
came to the conclusion that when the ileo-csBcal valve is in a normal 
condition it effectually guards the small intestine against the ingress 
of fluids from below. Illoway' has devised a force-pump which he 
strongly recommends for the purpose of forcing water beyond the 
ileo-C8Bcal valve, in case the seat of an intestinal obstruction is located 
above that point. He reports four cases of intestinal obstruction 
treated by this method, three of which recovered. Battey" asserts the 
permeability of the entire alimentary canal by enema, and verifles 
his statement by the recital of his own clinical experience and 
experiments upon the cadaver. 

Ziemssen recommends inflation of the rectum for diagnostic 
and therapeutic purposes and proceeds as follows: A rectal tube 
about six inches long is carried into the anus and fixed by pressing 
together the nates, the patient lying on the back. A funnel is then 
connected with the rectal tube by means of rubber tubing. For 
complete inflation of the large intestine three drams of bicarbonate 
of soda and four and a half drams of tartaric acid are separately dis- 
solved in water and portions of either solution alternately added. 
To prevent sudden overdistention of the bowel it is advised to add 
the solutions at intervals of several minutes. A veiy important use 
of this method is to diagnosticate the position of contractions, stric- 
tures, or occlusion of the intestine in cases in which it is desirable 
to operate, and also to show the position of peritoneal adhesions. 
The result of his observations has led him to believe that, as a rule, 
the small intestine is completely closed to the entrance of substances 
from the colon, by the ileo-csecal valve. Under the influence of 
deep chloroform narcosis, however, this resistance is lessened, and 
fluids can be thrown into the small intestine. 

Since this work has gone to press my attention has been called 
by Dr. Eastman, of Indianapolis, to a paper on " Fifty Laparotomies," 
etc, which he published in Progress, for January, 1888, in which 

^ Lancet and Clinic, Feb. 21, 1885. 

' American Jonrnal Medical Sciences, Vol. 41, p. 168. 

' Transactions of the American Medical Association, 1878. 



PERMEABILITY OF ILEOCECAL VALVE. 221 

he describes a case of pelvic abscess where he resorted to Bergeon's 
method of rectal insufflation of sulphuretted hydrogen gas after 
the abscess was opened, to determine whether it communicated with 
the large intestine. In the same paper appears a case of resection 
of the colon where the same test was used after suturing, to prove 
the efficiency of the sutures. 

In my paper read at the last International Medical Congress^ 
the following experiments appear, which illustrate the difficulty in 
overcoming the resistance of the ileo-csBcal valve by rectal injections 
of water: 

Experiment 23, While completely nnder the inflaence of ether, an incision 
was made through the linea alba of a cat, sufficiently long to render the ileo- 
c»cal region readily accessible to light. An incision was made into the ilenm 
jnst above the valve and by gently retracting the margins of the womid, the 
valve could be distinctly seen. Water was then injected into the rectmn, and 
as the csBomn became well distended it could be readily seen that the valve 
became tense and appeared like a circular cnrtain, preventing effectnally the 
escape even of a drop of fluid into the ileum. The competency of the valve 
was only overcome by overdistention of the ciBCum, which mechanically sepa- 
rated its margins, allowing a flue stream of water to escape into the ileum. 
The insufficiency of the valve was clearly caused by great distention of the 
083cum. That such a degree of distention is attended by no inconsiderable 
danger, was proved by this experiment, as the cat was immediately killed, and 
on examination of the colon and rectum, a number of longitudinal rents of 
the peritoneal coat was found. 

Experiment 24, In this experiment a cat was fully narcotized with ether 
and while the body was inverted, water was injected per rectum in sufficient 
quantity and adequate force, by means of an elastic syringe, to ascertain the 
force requjired to overcome the resistance offered by the ileo-csBcal valve. 
Oreat distention of the osecum could be clearly mapped out by percussion and 
palpation before any fluid passed into the ileum. As soon as the obstruction 
at the valve was overcome, the water rushed through the small intestines, and 
having traversed the entire alimentary canal, issued from the mouth. About 
a quart of water was forced through in this manner. The animal was killed 
and the gastro-intestinal canal carefully examined for injuries. Two longi- 
tudinal lacerations of the peritoneal surface of the rectum, over an inch in 
length, were found on opposite sides of the bowel. 

Experiment 25, This experiment was conducted in the same manner as 
the foregoing, only that the cat was not etherized. More than a quart of 
water was forced through the entire alimentary canal from anus to mouth. 
The animal lived for eight days, but suffered during the whole time with 

^An Experimental Contribution to Intestinal Surgery with Special 
Beference to the Treatment of Intestinal Obstruction. 



222 INTESTINAL SUBOERY. 

symptoms of ileo-oolitis. A post-mortem examination was not made, although 
the symptoms manifested dnring life leave no donbt that they resulted from 
injuries inflicted by the injection. 

It will thus be seen that in the three cases where fluid was 
forced beyond the ileo-osecal valve, in two of them the post-mortem 
revealed multiple lacerations of the peritoneal coat of the large 
intestines, while the third animal sickened immediately after the 
experiment was made, and died eight days later from the effects 
of the injuries inflicted. These experiments combined with clinical 
experience leave no further doubt that, practically, the ileo-csBcal 
valve is not permeable to fluids from below, .and that for diagnostic 
and therapeutic uses it is unsafe and unjustifiable to attempt to 
force fluids beyond the ileo-csecal valve. We should a priori expect 
that air and gases, on account of their less weight and greater 
elasticity than water, could be forced along the intestinal canal with 
less force, and for that reason alone, if for no other, should be pre- 
ferred to water in cases where it appears desirable to distend the 
intestine above the ileo-csBcal valve. The results obtained by experi- 
mental research in the past speak in favor of rectal inflation by air 
or gas in all cases where for diagnostic or therapeutic purposes it 
becomes necessary to dilate the entire or a portion of the gastro- 
intestinal canaL 

I. Rectal Insufflation of Air. 

Experiment 1.^ Dog, weight seventy -five poxmds. The animal was pro* 
foxmdly an»sthetized, and by means of an ordinary elastic syringe, air was 
forced through the rectnm nntil the whole abdomen became distended and 
tympanitic. The abdominal cavity was opened in the median line, and the 
whole intestinal canal was found distended. An incision abont an inch in 
length was made abont the middle of the small intestines, when air escaped, 
and abont one foot of the intestine on either side of the wonnd collapsed. 
The remaining portion of the intestines remained unaffected by the incision. 
The animal was killed, and every part of the entire gastro-intestinal canal 
carefully examined for injuries. The ileo-cadcal valve remained intact, and 
no evidence of rupture of any of the coats of the intestines could be detected. 

Experimeni 2. Dog, weight twelve pounds. Under full aneesthesia the 
gastro-intestinal canal was inflated in the same manner as in the preceding 
experiment, and the inflation was carried to the same extent. On opening the 

^ These experiments were made at the Ooxmty Hospital, and my thanks 
are due to Dr. M. E. Connel, superintendent of the hospital, and his assistantSy 
and Dr. Wm. Mackie of Milwaukee, for valuable assistance. 



RECTAL INSUFFLATION OF AIR, 223 

abdomen in the median line the distended loops of the intestines protruded 
from the wound, and partial exventration was allowed to take place for the 
purpose of examining the intestine for injuries. The closest inspection failed 
to detect evidences of partial or complete rupture of any of the tunics. One 
of the distended coils of intestine was incised at opposite points on the lateral 
aspect, the incisions being an inch in length. Only a limited segment of the 
bowel on each side of the wounds collapsed, and although the peristalsis was 
active, more remote portions were emptied very slowly. The woxmds were 
united transversely for the purpose of making an artificial diverticulum. The 
animal recovered without any untoward symptoms. 

Experiment 3, Dog, weight thirteen pounds. Animal profoundly etherized, 
and air inflated as in former experiments. The distended colon could be 
clearly mapped out by percussion before a gurgling soxmd in the region of the 
ileo-C8BC€d valve indicated that the air had entered the ileum. After this had 
occurred the middle of the abdomen became prominent and tympanitic. As 
soon as the resistance offered by the ileo-caacal valve had been overcome, 
it required less force to distend the remaining portion of the gastro-intestinal 
canal. The inflation was carried to the extent of distending the stomach, an 
event which was easHy recognized by a considerable prominence in the 
epigastric region which was tympanitic on percussion. At this time an 
elastic tube was inserted into the stomach, and its free end immersed under 
water. Bubbles of air escaped freely, and the abdominal distention was 
materially diminished. As the inflation was continued the air would escape 
through the stomach-tube, showing that a moving current of air existed 
between the rectal tube and the stomach tube. The abdominal distention 
which remained after the experiment had completely disappeared after 
eighteen hours, and the animal never manifested pain or any other symptoms 
of disease. 

Experiment 4, Dog, weight fifteen poxmds. In this experiment inflation 
was practiced without aniesthesia. The rigidity of the abdominal muscles 
greatly interfered with the distention of the colon to a requisite degree 
to overcome the competency of the iLeo-csBcal valve. The passage of air from 
the csecum into the ileum through the Heo-ceecal valve was announced by an 
audible gurgling sound which was repeated at intervals, as the ceecum, after 
partial collapse, was again distended by renewing the inflation. The insuffla- 
tion was continued until the stomach became distended by air, which caused 
vomiting and copious eructations of air. The dog remained in perfect health 
after the inflation. 

These experiments prove the feasibility of forcing air through 
the entire alimentary canal from below upwards. In not a single 
experiment could any structural changes be found in the walls of the 
intestine, and all animals not killed immediately after the experiment 
recovered. The results of these experiments contrast strongly with 
those by rectal injections with water where the same objects were in 



224 INTESTINAL SURGERY. 

view. In the latter experiments the force requisite to overcome the 
ileo-C8Bcal valve invariably produced lacerations of the peritoneal 
coat of the bowel, which in themselves would constitute a grave 
source of danger. 

It now became necessary for me to prove that the ileo-C8Bcal 
region in man in so far resembled that of the dog, that the ileo- 
csecal valve could be rendered more readily incompetent by inflation 
of air than by injections of fluids. The following two experiments 
were made for this purpose: 

Experiment 5, A young man, twenty-five years of age, a patient in the 
Milwankee Hospital, under treatment for a tumor in the epigastric region, was 
subjected to the experiment. He was placed flat on the back. On percussion 
the whole umbilical region was found flat and the abdominal wall retracted. 
No anaBsthesia. With an ordinary elastic syringe air was injected slowly into 
the rectum. As inflation progressed the outlines of the entire colon could be 
dearly seen and accurately mapped out by percussion. The c»cal region 
especiaUy became very prominent. The inflation was continued very slowly, 
and as soon as the air passed through the ileo-cadcal valve, the hypogastric and 
umbilical regions began to rise and resonance replaced the former dullness on 
percussion. The arrival of air in the stomach was indicated by distention of 
the epigastric region, disappearance of the contour of the tumor and resonance 
on percussion. During the whole process of inflation the patient only com- 
plained of a slight pain in the splenic flexure of the colon, and a sensation of 
fullness in the abdomen. As soon as it became apparez^t thbt the stomach 
was distended by air, a stomach-tube was introduced and its free end placed 
under water. As the inflation was continued, bubbles of air continued to escape. 
On assuming the erect position the patient complained of colicky pains in the 
umbilical region, which were undoubtedly caused by an exaggerated peristalsisl 
The pain, however, soon disappeared, and on the foUowing day he was as weU 
as usual. 

Experiment 6, Adult male, suffering from neurasthenia. Experiment and 
result the same as in No. 5, only that in this case the pain due to distention of 
the colon was referred to the ileo-caecal region, and the colicky pain in the 
umbilical region persisted for a longer time. The air was again forced from 
anus to mouth without causing any injury whatever and only moderate degree 
of pain for a short time. 

The foregoing experiments demonstrate conclusively that in the 
human subject by a moderate degree of force, short of producing 
any injury of the tunics of the intestines, air can be forced along the 
entire alimentary tract, and that this procedure can be resorted to 
with perfect safety for diagnostic and therapeutic purposes in all 
cases where the tissues of the intestinal wall have not suffered too 
much loss of resistance from antecedent pathological changes. 



INFLATION OF GAS THROUGH STOMACH. 225 

2. Inflation of Alimentary Canal through Stomach Tube. 

We should naturally expect that the alimentary canal could be 
inflated with more ease and with a less degree of force by following 
the normal peristaltic wave. That this is not the case will be seen 
from the following experiments: 

Experiment 7. Dog, weight forty poonds (18 kilograms). After com- 
plete anesthesia was effected a flexible rubber tnbe was introduced into the 
stomach, and the free end of the tnbe connected with a four-gallon rubber 
balloon containing hydrogen gas, by means of a rubber tube. Between the 
gas reservoir and the stomach-tube a manometer was interposed, registering 
accurately the force used in making the inflation. The inflation was made by 
compressing the rubber bag. A tube was introduced into the rectum to facili- 
tate the escape of gas that might reach this portion of the intestinal tract. 
Under a pressure of one pound and a half the stomach dilated rapidly, and 
later the entire abdomen became distended and resonant on percussion, but 
no gas escaped per rectum. When the pressure was increased to two poxmds 
(.9 kilogram), no further distention of the abdomen took place, as the gas 
escaped along the side of the stomach tube. At this time respiration became 
greatly embarrassed, but was relieved on allowing gas to escape through the 
stomach-tube. On compressing the abdomen firmly the distention disappeared 
almobt completely; at the same time a large quantity of gas continued to 
escape through the stomach-tube. Inflation was renewed, and under a pressure 
of one pound and a half, the abdomen again became uniformly distended. 
When the pressure was increased to two pounds (.9 kilogram) the dog sud- 
denly died, and all efforts at resuscitation failed. On opening the abdomen 
the stomach was found enormously distended, reaching three inches below the 
umbilicus, occupying almost the entire abdominal cavity. The upper half of 
the small intestines was distended; numerous points of sharp flexions were 
found among the different distended ooUs. The distended stomach had 
evidently encroached so much upon the abdominal space as to render the 
greater part of the intestinal canal impermeable by pressure. 

Experiment 8. Dog, weight fifteen pounds. After the animal was placed 
fully xmder the influence of ether, the abdomen was opened and the cascum 
and lower portion of Ueum drawn forward into the wound, and a large aspi- 
rator needle inserted into the ileum just above the ileo-c»oal valve. Through 
a rubber tube hydrogen gas was forced into the stomach. Under one pound 
(.45 kilogram) of pressure, the stomach and upper portion of the intestines 
dilated readily. When the force was increased, the gas returned through the 
oesophagus along the sides of the stomach-tube. 

Experiment 9. Dog, medium size. This animal was killed to ascertain 
the results of an experiment made for another purpose. Rubber balloon con- 
taining hydrogen gas, and manometer were used for making the inflation. 
The tube through which the inflation was made was tied in the oesophagus. 
The abdomen was distended enormously, and on increasing the pressure to 

16 



226 INTESTINAL 8URQERY. 

m 

three and three-fourths pounds (1.7 kilograms), still no gas escaped throngh 
the rectal tube. The abdomen was then opened, when the stomach was found 
so enormously distended that it filled almost the entire abdominal cavity. 
Abont one-fourth of the length of the small intestines was found distended, 
and among the distended loops numerous acute flexions could be seen. After 
the abdomen was opened, under long and continuous distention, the peritoneal 
coTcring of the stomach gave way, when the manometer registered only one 
pound and a half of pressure. 

Experiment 10, Dog, weight eighteen pounds (8 kilograms). Immedi- 
ately after death the oesophagus was isolated and the tube of the hydrogen 
gas Inflator securely tied in, and a glass tube was inserted into the rectum. 
Under a pressure of two and three-fourths poxmds (1.2 kilograms), registered 
by the manometer, the gas first dilated the stomach and then passed along the 
intestines until it escaped in a steady stream through the rectal tube, where it 
was ignited. On opening the abdomen the stomach was found greatly dis- 
tended, while the distention of the intestines was a great deal less marked. 
None of the tunics of the stomach or intestines were injured. 

Experiment 11, Dog, weight twenty pounds (9 kilograms). Animal 
etherized and a flexible tube connected with the gas inflator introduced into 
the stomach, and a glass tube into the rectum. On inflation the stomach 
became gradually distended, and when the pressure had reached one pound 
and a half (.7 kilogram), the dog Tomited and a good deal of gas escaped at 
the same time. Inflation was again commenced and was followed by uniform 
distention and tympanites oyer the entire abdomen; when the pressure 
reached two pounds and a half (1.1 kilograms), the gas escaped from the 
rectum, and when ignited burned with a steady blue flame. The experiment 
was followed by no unfavorable symptoms. 

Experiment 12, Dog, weight twelve pounds (5.4 kilograms). Under the 
influence of ether inflation with hydrogen gas in the same manner as in last 
experiment. As soon as the stomach became well distended, and the manom- 
eter registered one pound and a half of pressure, vomiting occurred, attended 
by a free escape of gas, which was followed by collapse of the distended 
epigastric region. When inflation was resumed, it was noted that any increase 
of pressure over one pound (.45 kilogram) was followed by regurgitation of 
gas, and on this account it was found impossible to inflate the lower portion 
of the intestinal tract. No unfavorable symptoms followed the experiment. 

Eosperiment 13, Dog, weight twenty-eight pounds (12.7 kilograms). Under 
the influence of ether inflation of hydrogen gas through the stomach tube. 
As soon as the pressure was increased to more than one pound (.45 kilo- 
gram) the gas escaped along the sides of the tube through the oesophagus; 
consequently only the upper portion of the abdomen could be distended, and 
the inflation evidently did not extend much beyond the stomach. The experi- 
ment was repeated several times with the same result. The animal remained 
perfectly well after the experiment. 

Experiment 14, Dog, weight twelve pounds (5.4 kilograms). Inflation of 
stomach by hydrogen gas under full aneesthesia. The effect of the infla- 



PRESSURE EXPERIMENTS. 227 

tion was the same as in the last experiment; only the stomach and npper 
portion of the small intestines conld be distended and farther inflation was 
impossible, as the gas escaped from the stomach as soon as the pressure 
exceeded one pound (.45 kilogram). A large aspirator needle was pnshed 
through the linea alba into the stomach, and the gas which escaped through it, 
on being lighted, burned with the characteristic blue flame. After the needle - 
was withdrawn, the inflation was continued to ascertain if the puncture in the 
atomach would allow the escape of gas into the peritoneal cayity. The infla- 
tion was continued until the entire abdomen was distended by the gas. That 
the distention and tympanites was due to the presence of gas in the peritoneal 
cavity became eyident, as it remained after the stomach had been emptied of 
its gas, and on percussion it was ascertained that the entire liver dullness had 
disappeared. The dog recovered without symptoms of peritonitis or any 
other ill-effects from the experiment. 

These experiments demonstrate conclnsivelj that it is more 
difficult to inflate the alimentary canal from above downwards than 
from below upwards, as in the living animal I succeeded only in one 
instance in forcing hydrogen gas from mouth to anus, while in others 
a degree of force sufficient to rupture the peritoneal coat of the 
stomach, only effected distention of the stomach and upper portion 
of intestinal canal. It is evident that great distention of the 
stomach constitutes an important factor in causing or aggravating 
intestinal obstruction, as it effects compression which causes 
impermeability of the intestines, or aggravates conditions arising 
from an antecedent partial permeability, by producing sharp flexions 
among the distended coils of the intestines. For diagnostic and 
surgical purposes the stomach can be readily inflated almost to any 
extent through a stomach tube, and when it becomes necessary to 
ascertain the presence of a visceral wound or perforation of this 
organ, this method of inflation may be resorted to with advantage. 
• 

3. Experiments to Determine the Degree of Force which 
is Necessary to Overcome the Resistance Offered 

by the Ileo-Cscal Valve. 

Accurate experiments to determine the force required to render 
the ileo-csecal valve incompetent by insufflation of air or gas having 
not heretofore been made, as it is exceedingly important to obtain 
some accurate information on this subject, the following experiments 
were made. In all experiments air or hydrogen gas was used. The 
inflation was made with a rubber balloon. The pressure was esti- 



228 INTESTINAL SURGERY. 

mated either with a merocuy gauge or with a manometer, as used bj 
gas-fitters and plmnbers. The manometer or mercury gauge was 
connected hj means of rubber tubing with the rectal tube on one 
side and the rubber balloon on the other. The rubber balloon in 
which the hydrogen gas was collected held four gallons, and numer- 
ous experiments showed that when the gas was forced through the 
opening of a stopcock, the lumen of which was about the size of a 
knitting needle, a compression equal to two hundred pounds (91 
kilograms) would never register more than three pounds (1.4 kilo- 
grams) of pressure. In the living subject the escape of air or gas 
from the rectxmi was prevented by an assistant pressing the margins 
of the anus firmly against the rectal tube. 

Experiment 15. Dog, weight thirty-five pomids (16 kilograms). Imme- 
diately after death the lower portion of the reotun was isolated and the 
rectal tube inserted and fixed in its place by tying a string firmly around 
the rectum. The abdomen was opened and the intestines left in situ. The 
ileum was ont transversely six inches above the ileo-cecal valve and a glass 
tnbe inserted into the distal end, which was also tied in. Hydrogen gas was 
inflated from a rubber. baUoon. Under a pressure of three-quarters of a 
pound (.3 kilogram) the osBOum was dilated, and a moment later the gas 
escaped from the glass tube and was ignited; the flame remained steady 
under a pressure of from one-half to three-quarters of a pound (.2 to .8 
kilogram). 

EQcperiment 16. Dog, weight twenty pounds (9 kilograms). Same as in 
the preceding experiment, only that the resistance of the ileo-ciBcal valve was 
overcome under a pressure of one-half pound (.2 kilogram). The distention 
of colon and csBcum was moderate, and signs of injury to the tunics could not 
be found in either experiment. 

Experiment 17, Dog, weight twenty-three pounds (10 kilograms). In 
this experiment the abdomen was opened immediately after death, and a large 
hypodermic needle inserted into the ileum a short distance above the ileo- 
08dcal valve before the inflation of hydrogen gas was made. A pressure of 
three-quarters of a pound (.3 kilogram) was sufficient to force the gas through 
the ileo-ceecal valve and through the needle; the valve remained open under a 
steady pressure of one-half pound (.2 kilogram). 

Having determined that air and gas could be forced beyond the 
ileo-C8Bcal valve in dogs under very low pressure, varying from one- 
half to three-quarters of a pound, I proceeded to test the degree of 
resistance of the ileo-csecal valve in the human subject. 

ExpeHment 18. Strong, healthy young man. The subject was placed flat 
upon his back and hydrogen gas was inflated from a rubber baUoon. At first 
the gas was forced in very slowly under a pressure of one poxmd and a hall 



PRESSURE EXPERIMENTS. 229 

(.7 kilogram), which distended the colon yiBibly as far as the csecnm. Ab 
the distention appeared to remain the same, the pressure was increased to two 
pomids (.9 kilogram), when suddenly the indicator of the manometer receded 
to one pound (.45 kilogram), and the umbilical region became prominent 
and resonant, showing condusiyely that the ileo-csBcal Talve had been passed 
and the small intestines were filling rapidly with gas. As soon as the whole 
abdomen had become distended and tympanitic, the manometer again regis- 
tered one pound and a half (.7 kilogram) of pressure, and remained at this 
figure for some time after further inflation was discontinued by turning the 
stopcock. 

Experiment 19, Young man, in good health. Experiment conducted in 
the same manner as before. After the colon and cadcum had been well dilated 
the manometer registered two and one-quarter pounds (1 kilogram), and the 
umbilical region became prominent and resonant. As the inflation advanced 
the average pressure was one pound and three-quarters (.8 kilogram), and 
twice it was increased to two and a half pounds (1.1 kilograms), when the 
patient complained of pain in the umbilical region. As soon as the stopcock 
was turned the pressure sank to three-quarters of a pound (.3 kilogram). 

These two experiments prove that in a normal condition the 
ileo-csecal valve in a healthy adult person is overcome hj rectal 
inflation imder a pressnre of one and a half to two and a quarter 
pounds (.7 to 1.1 kilograms). This amount of pressure is not 
sufficient to injure the ttmics of a healthy intestine, and in both 
instances the subjects of the experiments complained but little of 
the immediate or remote effects of the experiments. As the result 
of numerous observations, I can state that when the inflation is made 
slowly and continuously there is less danger of injuring the intes- 
tines than when the inflation is made rapidly, or with interruptions. 
Slow and gradual distention of the csecum is best adapted to 
overcome the competency of the ileo-csecal valve, by effecting dias- 
tasis of the margins of the valve. A rubber balloon holding from 
two to four gallons (10 to 20 litres) recommends itself as the most 
efficient and safest instrument for making rectal insufflation for 
therapeutic or diagnostic purposes. 

The following experiments were made to determine: 

4. The Amount of Pressure Necessary to Force Hydrogen 
Ga3 Through the Entire Alimentary Canal 

by Rectal Inflation. 

Experiment 20, Dog, weight thirty-fiye pounds (16 kUograms). Immedi- 
ately after death rectal inflation of hydrogen gas was made, and a pressnre of 
one ponnd (.45 kilogram) sufficed to distend the entire abdominal cavity, and 



230 INTESTINAL SURGERY. 

when a tube was introdnoed into the stomach and a burning taper applied to 
its end, a blue flame at onoe appeared and continued as long as the inflation 
was kept np under the same pressure. 

Experiment 21, Dog, weight twelve pounds (5.4 kilograms). Under ether 
narcosis rectal inflation of hydrogen gas from rubber balloon. The ileo-csBcal 
yalye offered very little resistance, and as soon as the manometer registered 
one pound and a half (.7 kilogram) of pressure the gas escaped through the 
stomach tube which had been introduced previously, and on applying a lighted 
taper it burned with a continuous flame as long as the inflation was continued. 

Experiment 22, Dog, weight twenty pounds (9 kilograms). Experiment 
and result same as in last; the pressure never exceeded one pound and a half 
(.7 kilogram). 

Experiment 23, Dog, weight nineteen pounds (8.6 kilograms). In this 
experiment no anadsthetio was used, and in consequence the pressure had to be 
increased to three pounds (1.4 kilograms) before the gas escaped through the 
stomach tube. On account of the violent contractions of the abdominal muscles 
the escape of gas was intermittent, the flame being frequently extinguished 
by an absence of the gas. 

Experiment 24, Dog, weight twenty-one pounds (9.6 kilograms). The 
animal being completely under the influence of ether the abdomen was opened 
in the median line, and the ileo-cascal region made accessible to sight. Hydro- 
gen gas was inflated per rectum, and under a pressure of three-quarters of a 
pound (.3 kilogram) readily passed the ileo-C89cal valve, and under one pound 
of pressure it ascended the intestinal canal, and in a few seconds reached the 
stomach. A tube was introduced into the stomach, and as the gas escaped it 
was ignited and burned with a steady flame. 

Experiment 25, Dog, weight eighteen pounds (8 kilograms). Rectal 
insu£Elation of hydrogen gas, the dog being fully under the influence of an 
aneesthetic. The colon and cascum were only slightly distended when the gas, 
under one-quarter of a pound (.1 kilogram) of pressure, passed the ileo-cadcal 
valve. Under one pound (.45 kilogram) of pressure, the abdomen became uni- 
formly distended and tympanitic, and when a tube was introduced into the 
stomach the escaping gas was ignited and burned with a steady flame as long 
as the pressure was continued. 

Experiment 26, Dog, weight twenty pounds (9 kilograms). Animal ether- 
ized, and when completely relaxed hydrogen gas was inflated per rectum, and 
passed the ileo^caBoal valve under a pressure of half a pound (.2 kilogram). The 
stomach became distended under a pressure of one pound and a half (.7 kilo- 
gram), and on the introduction of a tube the escaping gas was ignited and 
burned with a continuous flame as long as the manometer registered half a 
pound (.2 kilogram) of pressure. 

In all animals where the insufflation was not complicated hj 
abdominal section, no unpleasant symptoms followed the experiments. 
All of the animals recovered as rapidly as after an ordinary ether nar- 
cosis. In all of the experiments the pressure fell rapidly after the 



RESISTANCE OF STOMACH TO DIA8TALTIC FORCE, 231 

ileo-C8Bcal valve had been opened, bnt the pressure had again to be 
increased before the gas reached the stomach. It usually required 
one-half to one pound more pressure to force gas through the entire 
alimentary canal than when it was forced only through the ileo-C8Bcal 
valve. Whenever it becomes desirable to conduct the hydrogen gas 
a considerable distance along the intestines, or through the entire 
alimentary canal, it is exceedingly important to proceed slowly with 
the inflation, as under slow distention half a pound (.2 kilogram) of 
pressure will accomplish in time a greater degree of distention than 
four times this amount of pressure if the force is applied quickly, 
and only for a short time, and is attended by much less risk of 
injury to the coats of the intestines. I am quite convinced that in 
the dog, rectal insufflation of hydrogen gas made under a pressure of 
one-quarter of a pound, if made very slowly, the abdominal walls 
being completely relaxed by an anaesthetic, will not only overcome 
the resistance offered by the ileo-csecal valve, but will prove sufficient 
to force the gas through the whole length of the alimentary canaL 

I have already sufficiently demonstrated the permeability of the 
ileo-csecal valve and the entire alimentary canal in animals and man 
to rectal insufflation of air and gas, and I shall now endeavor to 
establish the safety of this procedure as a diagnostic and therapeutic 
measure by showing: 

II. The Resistance of Diflferent Portions of the Gastro- 
intestinal Canal to Diastaltie Force. 

I. Stomach. 

Experiment 27. Large, heedthy, adult dog. Experiment made immedi- 
ately after death. Stomach in situ* (Esophagos tied and distention made 
with a force pnmp from pyloric orifice, the organ being rapidly dilated with 
air. When the manometer registered eight and one-half pounds (8.9 kilo- 
grams) of pressure, the stomach was distended at least eight times its normal 
size, when a rent in the peritoneal coTering an inch and a half in length 
parallel to, and near the omental attachment, occurred. 

Experiment 28. Middle-aged man, died of sepsis. The whole gastro-in- 
teetinal canal showed marked eyidences of septic gastro-entero-colitis, the 
mucous membrane being softened, yery vascular, and dotted with numerous 
hsBmorrhagic infarcts. Organ in situ inflated with air in the same manner as 
in last experiment. Longitudinal rupture of peritoneal coat along anterior 
surface under two and one-half pounds of pressure (1.1 kilograms), and when 
it was increased to three pounds (1.4 kilograms), the whole thickness of the 
wall at the lesser cnryature ruptured. 



282 INTESTINAL SURGERY. 

2. Small Intestines. 

Experiment 29, Snbjeot same as in experiment 28. Lower portion of 
ileum under five pounds (2.3 kilograms) of pressure, became emphysematous 
along mesenteric attachment, and ruptured completely as soon as the mano- 
meter registered five and three-fourths pounds (2.6 kilograms) of pressure. 

EoBperiment 30, Dog, weight twenty pounds (9 kilograms). Immediately 
after death the lower part of the ileum, with mesenteric attachment intact, 
was gradually distended and remained intact until a pressure of ten pounds 
(4.6 kilograms) was reached, when air escaped between the two serous layers 
of the mesentery, showing that minute ruptures at numerous points had taken 
place. When the distention had reached its maximum, the segrment of bowel 
inflated was elongated twice its normal length. 

Experiment 31, Upper portion of ileum of same animal when distended 
to its utmost gave way under a pressure of eight pounds (8.G kilograms), the 
peritoneal coat on convex side rupturing to the extent of two inches (51 mm.) 
parallel to the axis of the bowel. 

Experiment 32, The middle portion of the small intestines, when sub- 
jected, to a pressure of eight pounds (8.6 kilograms), sustained a longitudinal 
rupture of the peritoneum on convex surface, and the remaining tunics gaye 
way when the pressure was increased to nine pounds (4.1 kilograms). 

r 3. Colon. 

Experiment 33, Subject same as experiments 28 and 29. Experiment was 
made twenty-four hours after death. Colon and caecum apparently very much 
softened and mucous membrane in a state of inflammation. One foot (30 cm.) 
of the transverse colon isolated and gradually distended, when the peri- 
toneal coat along the border of one of the longitudinal bands ruptured under 
a pressure of two pounds and a half (1.1 kilograms). The peritoneal lacera- 
tion became very extensive before the remaining . tunics ruptured under a 
pressure of four pounds (1.8 kilograms). 

Eoeperiment 34. Dog, weight eighteen pounds (8.2 kilograms). Imme- 
diately after death the ileum was tied just above the cseoum, and the inflation 
made per rectum. Air was pumped in gradually with a force-pump and when 
the pressure reached ten pounds and a half (4.8 kilograms), air escaped 
between the peritoneal layers of the meso -colon; at this stage the longitudinal 
distention of the bowel exceeded twice its normal length. 

Experiment 35, Dog, weight twenty-three pounds (10.4 kilograms). 
Experiment the same as the preceding. Air was pumped in rapidly until the 
mercury gauge registered ten and a half pounds (4.8 kilograms) of pressure, 
when the sigmoid flexure on its free surface gave way with a loud report, the 
rent being about one inch and a half (38 mm.) in length. 

Eoeperiment 36, Dog, weight eighteen pounds (8.2 kilograms). Entire 
colon distended by rectal inflation of air, the ileum being tied just above the 
ileo-caecal valve. Under a pressure of six pounds (2.7 kilograms), the peri- 
toneum ruptured in a longitudinal direction, opposite the meso-colon, and 
the remaining tunics gave way a little later, under the same pressure. 



DISTENTION OF O ASTRO-INTESTINAL CANAL, 238 

These experiments are of the greatest importance in showing 
that the pressure which was found necessary to apply in rupturing 
a healthy intestine, was greatly in excess of that which is required 
to force air through the ileo-csecal valve, or even the whole length 
of the alimentary canal. It only requires from one-quarter of a 
pound to a pound and a half (.1 to .7 kilogram) of pressure to force 
air through the ileo-caecal valve, and from half a pound to two 
pounds and a half (.2 to 1.1 kilograms) to force it from anus to 
mouth, while even the weakest portion of the gastro-intestinal canal 
effectually resisted a distending force of from eight to ten pounds 
(3.6 to 45 kilograms). 

The experiments on the human cadaver, where the resisting 
power of the gastro-intestinal canal to diastaltic force was greatly 
reduced by ante-mortem pathological changes, show that under such 
circumstances it would have been safe to resort to inflation, as the 
pressure required to rupture the colon or small intestines exceeded 
that which has been found adequate to force air or gas beyond the 
ileo-csecal valve, or even the entire length of the alimentary canal. 
When an intestine is slowly distended to its utmost capacity by 
inflation of air or gas, and the pressure is maintained uninterruptedly, 
rupture occurs at one of two points; either a longitudinal laceration 
of the peritoneal coat takes pleice on the convex surface of the bowel 
opposite the mesenteric atteichment, or minute ruptures on the 
mesenteric side give rise to extravasation of air or gas between the 
two serous layers of the mesentery. In either case, if the pressure 
is increased, complete rupture takes place at the point where the 
laceration fir^t commenced. 

III. Distention of Gastro-Intestlnal Canal by Bectal 

Insufflation of Hydrogen Gas. 

In this section will be found an account of the experiments 
which were made preliminary to the practical application of the 
hydrogen gas test as a diagnostic measure in penetrating wounds 
of the abdomen, and which furnish only so many more demonstra- 
tions of the permeability of the ileo-csecal valve and the entire 
alimentary canal to rectal inflation of hydrogen gas. 

Experirnent 37. Dog, weight fifteen pounds (6.8 kilograms). Under ether 
anaesthesia, hydrogen gas from rubber balloon was slowly forced into the 
reotnm nntil the entire anterior abdominal wall had become nniformly dis- 



• • 



• • 



234 INTESTINAL SURGERY. 

tended and tympanitic, when the distended stomach was pmictnred with a 
large aspirator neelOle and gas escaped in a steady stream, which when ignited 
burned with a continnoos flame. After a considerable portion of the gas had 
been evacnated in this manner the upper abdominal region receded, and the 
flame was extinguished. The animal reooyered without any untoward 
symptoms. 

Experiment 38, Dog, weight seyenteen pounds (7.7 kilograms). Without 
anfidsthesia hydrogen gas was inflated per rectum until it escaped through a 
tube which had been introduced into the stomach. As it escaped from the 
stomach tube it was ignited and burned with a large blue flame. The abdom- 
inal muscles were so rigid that distention was neyer well marked, and the 
inflation required a good deal more force thai\ in animals where muscular 
.rigidity had been oyercome by an anaBsthetic. The dog remained perfectly 
well after the experiment, and in a few hours the remaining tympanites had 
disappeared. 

Experiment B9, Dog, weight thirty-flye pounds (15.8 kilograms). No 
ansBsthetic used. On account of rigidity of abdominal muscles it required 
persistent efforts to force hydrogen gas from rubber balloon per rectum 
through the whole alimentary canaL As soon as the stomach had become 
distended by the gas, the animal yomited; at the same time gas escaped 
by repeated eructations. The animal manifested no signs of suffering after 
the experiment. 

Experiment 40. Dog, weight twenty-seyen pounds (12.2 kilograms). 
Under ansBSthesia hydrogen gas was inflated per rectum until it escaped 
through tube which had been introduced into the stomach; a lighted taper 
was applied to the free end of the tube, and the gas ignited and burned with 
the characteristic blue flame. 

ExperimsrU 41. Large Newfoundland dog. Under ansBsthesia a duoden- 
ostomy was made, and hydrogen gas injected per recttun and ignited as it 
escaped from a rubber tube, which had been inserted into the distal portion 
of the bowel through the flstula. 

Experiment 42, Adult male; abdominal organs healthy; no ansBsthesia. 
Inflation of hydrogen gas per rectum. The gas was stored In a four-gallon 
(9 litres) rubber balloon and was forced into the recttun by compression. As 
the distention progressed the colon could be distinctly mapped out from 
sigmoid flexure to csBCum by inspection and percussion. As soon as the 
caBCum had become yisibly prominent, a stethoscope was applied over the ileo- 
ceBcal region, and as the valye became incompetent by oyerdistention of 
caBCum, a distinct gurgling sound could be heard as the gas entered the ileum. 
Wheneyer inflation was arrested the gurgling sound disappeared, but was 
heard again wheneyer the ileo-c8Bcal yalye was opened by renewed inflation. 

Distention of the small intestines was attended by resonance 
and prominence of umbilical and hypogastric regions. The incom- 
petency of the ileo-csecal valve was invariably annomiced by a 
reduction in the pressure. The patient complained of a sensation 



DISTENTION OF QASTRO-INTESTINAL CANAL. 235 

of distention in the umbilical region and intermittent colicky pains 
which, however, disappeared completely after a few hours. The 
pain appeared to be less severe than after similar experiments with 
inflation of air. 

Experiment 43, Yonng man in oomparatively good health. . Inflation 
same as in preceding experiment. Aascnltation over ileo-cseoal valve revealed 
the same sounds as the gas escaped from the colon into the ileum. The sound 
seemed to vary somewhat according to the size of the opening in the valve 
and the force used in making the inflation, and always disappeared as the 
valve closed after suspension of inflation. The colicky pains subsided as 
the small intestines emptied themselves of their new contents. The assistant 
who compressed the rubber balloon was always able to announce the beginning 
of the incompetency of the ileo-caBCbl valve, by experiencing a sudden 
diminution in the pressure. 

Experiment 44, Adult male, suffering from gastric catarrh. Hydrogen 
gas inflation per rectxmi to extent of causing great distention of abdomen, 
which caused the hepatic dullness to ascend at least two inches. Auscultatory 
signs the same. Sharp colicky pains in the umbilical region were relieved by 
a free escape of gas through rectum. 

Expenment 45, Hysterical female. Abdomen flat and dull on percussion 
from umbilicus to pubes; no resonance over sigmoid flexure. Bectal inflation 
with hydrogen gas. Compression of rubber balloon corresponding to only 
one-fourth pound (.1 kilogram) of pressure readily dilated the whole colon, its 
course being indicated by a distinct prominence and tympanitic resonance 
from sigmoid flexure to ceectun. Under the same pressure the gas escaped 
with little or no resistance through the ileo-csBcal valve from the colon into 
the ileum, the occurrence being attended by the characteristic auscultatory 
sounds and followed by distention and resonance of space from umbilicus to 
pubes. Amount of gas inflated about four litres. The patient complained of 
some pain in the region of the splenic flexure of the colon during the disten- 
tion of the colon, and later of slight intermittent pain in the region of the 
umbilicus. 

Experiment 46, Middle-aged womdta, suffering from retroversion of the 
uterus. Abdomen flaccid and dull on percussion in the median line from 
umbilicus to pubes. Rectum distended with hardened faeces. Hydrogen gas 
inflated in the usual manner. The mercury gauge registered two and a half 
pounds (1.1 kilograms) of pressure before the gas reached the sigmoid flexure, 
after this it fell to one pound (.46 kilogram), and the inflation progressed 
without any further resistance. As soon as the gas passed through the ileo- 
C8Bcal valve the pressure fell to three-quarters of a pound (.3 kilogram), and 
remained so during the inflation of the small intestines, slight variations 
marking the opening and closing of the ileo-cascal valve. As the umbilical 
and hypogastric regions became prominent and tympanitic the patient com- 
plained of a griping pain. About eight litres of gas were injected. A few 
hours after the experiment all symptoms had disappeared. 



286 INTESTINAL SURGERY. 

Experiment 47, Female recently operated on for laceration of perineum. 
Beotnm empty. Abdomen flaccid; umbilical, hypogastric, and right iliac 
regions dull on percussion. The inflation was made yery slowly and the 
pressure never exceeded one pound (.45 kilogram). As the large intestine 
became distended the transverse colon came plainly into view. On ausculta- 
tion over the ileo-csBcal yalve the escape of gas into the ileum was marked by 
a blowing sound, which was increased or diminished in pitch by the degree of 
pressure. As the lower portion of the small intestines became distended the 
lower part of the abdomen became prominent and tympanitic, and the patient 
complained of colicky pains. About three litres of gas were inflated; In half 
an hour the patient appeared as well as before inflation. 

Experiment 48, Middle-aged physician suffering from typhlitis. This 
was the second attack, and the acute symptoms had subsided. Over the cascum 
a circumscribed area of dullness and tenderness. On palpation it appeared 
as though the swelling were adherent to the anterior abdominal wall. The 
area of dullness was outlined externally by pencil marks, before inflation was 
commenced. As the colon became distended under a pressure of one-fourth 
of a pound (.1 kilogram), the circumscribed, indurated region became more 
prominent, imparting to the palpating flngers the feeling of hardness, but on 
percussion it was resonant, showing condusiyely that the inflamed and indu- 
rated wall of the ceecum had been lifted forward by the pressure of the gas. 
Under the same pressure the gas escaped in a continuous stream into the 
ileum, its passage -through the ileo-c»cal yalve being attended by a* well- 
marked blowing, gurgling sound. The patient felt the entrance of gas into 
the ileum distinctly, and complained soon after of a slight colicky pain in the 
umbilical region. The space between umbilicus and pubes, which before infla- 
tion was completely dull on percussion, now became more prominent and 
tympanitic. Only two litres of gas were used in this experiment. 

Experiment 49. Toung physician in perfect health. Region between 
umbilicus and pubes perfectly dull on percussion, also left iliac fossa. Infla- 
tion of four litres of hydrogen gas under one-third of a pound (.16 kilogram) 
pressure. The outlines of the distended colon could be clearly seen and 
marked out by percussion before the gas escaped into the small intestines. 
The passage of gas through the ileo^aecal Talve was again attended by a well- 
marked gurgling sound, after which the entire abdomen became prominent 
and tympanitic. The patient felt a sensation of distention during the infla- 
tion of the colon, and as the small intestines became distended, complained 
of griping pains. Gas escaped freely by eructations and per rectum, which 
soon relieyed the colicky pains in the umbilical region. 

Experiment 50. Medical student in robust health. Region from umbilicus 
to pubes flat on percussion, while the course of the entire colon was tympan- 
itic. Rectal inflation with hydrogen gas. When the resistance of the ileo- 
C8Bcal valye was overcome the mercury gauge registered one-half pound (.2 
kilogram) of pressure. The passage of gas through the ileo-caecal yalve was 
attended by a gurgling sound which was heard at some distance by a number 
of persons present in the room. Later a continuous blowing (almost amphoric) 



DISTENTION OF GA8TR0-INTE8TINAL CANAL. 237 

soimd oonld be heard oyer the ileo-oeaoal yalye. The snbjeot of the ezperi- 
ment was oonsoions of the passage of gas from colon into ileum, and soon 
after complained of a colicky pain which he referred to the umbilical region. 
The whole abdomen became uniformly distended and tympanitic on percus- 
sion, and the distress caused by the great distention was only relieyed by a 
free escape of gas by eructations and through the rectum. Four litres of g&n 
were used in this experiment. 

Eoeperiment 51, Young physician in good health. Bectal inflation of four 
litres of hydrogen gas under a pressure of only one-third pound (.15 kilogram). 
I>istention of colon well-marked preyious to escape of gas through the ileo- 
cascal yalve. As soon as the gas entered the ileum the middle and lower 
portion of the abdomen became distended and tympanitic. The inflation was 
continued until the stomach became distended and gas escaped by eructation. 
The subject of the experiment complained of quite seyere colicky pains as 
long as the small intestines remained distended by gas. 

Experiment 52, The writer of this paper, being desirous of experiencing 
himself the sensations which would be caused by inflation of hydrogen gas, 
submitted himself to experimentation under a pressure of one-half pound (.2 
kilogram). Nearly six litres of gas were inflated per rectum. The distention 
of the colon caused simply a feeling of distention along its course, but as 
soon as the gas escaped into the ileum colicky pains were experienced, which 
increased as insufflation adyanced, and only ceased after all the gas had 
escaped, an hour and a half later. When the intestines and the stomach had 
become fully distended, the feeling of distention was distressing, and was 
attended by a sensation of faintness which caused a profuse clammy perspi- 
ration. A great deal of the gas escaped by eructation, which was followed 
by great relief. The colicky pain attending inflation of the small intestines by 
air or gas, was eyidently caused by increased peristaltic action of the bowels 
in their attempt to expel their contents, as it always assumed an intermittent 
type and subsided promptly after the escape of the gas. 

In none of these experiments did the pressure in overcoming 
the resistance offered by the ileo-csBcal valve exceed one pound (.45 
kilogram), and often a steady, long-6ontinued pressure of one-fourth 
or one-third of a pound (.1 to .15 kilogram) sufficed. Every time 
the ileo-csecal valve was rendered incompetent by distention of the 
caecum, the pressure was promptly diminished owing to the escape 
of gas from the colon into the ileum. In the experiment where the 
inflation was made in a case of typhlitis, the ileo-csecal valve offered 
no resistance, and the gas escaped freely into the ileum. The valve 
in all probability had been rendered partially or completely incom- 
petent during the course of local inflammation, or the indurated, 
thickened walls of the csecum, when distended during the inflation, 
were better adapted to effect incompetency of the valve. These 



288 INTESTINAL 8UROERY. 

experiments also famish strong proof of the fact that inflation, to be 
safe and effective, should be done very slowly under a low, steady 
pressure, continued only for a short time; and is attended by no 
risks whatever of rupturing a healthy intestine and, when cautiously 
practiced, can be resorted to even in cases where the resisting 
power of the intestinal wall has been diminished by antecedent 
pathological processes. 

As I was searching for an innocuous, non-irritating gas which, 
when inflated into the gastro-intestinal canal, would escape into the 
peritoneal cavity in case a wound or perforation existed, and had 
decided on trying hydrogen gas, it became necessary to study 
experimentally the effect of this gas on the different tissues of the 
living body. The numerous inflation experiments on man and dogs 
have demonstrated the safety of pure hydrogen gas when employed 
in this manner, as not in a single instance were any immediate or 
remote toxic symptoms observed which could be referred to absorp- 
tion of the gas; hence we have the assurance that the inflation of a 
large quantity of hydrogen gas is unattended by any risk whatever 
as far as intoxication is concerned. The following experiments 
also show the innocuity and non-irritating qualities of hydrogen gas 
when brought in contact with the tissues most susceptible to inflam- 
matory reaction in the living body; at the same time they show that 
hydrogen gas is removed by absorption in a comparatively short 
time, when injected into serous cavities or into the subcutaneous 
connective tissue: 

IT. Hydrogen Gas Is Innocuons and Non-Irritating when 

Brought In Contact with Liying Tissues and is 

Promptly BemoTed by Absorption. 

I. Peritoneal Cavity. 

Experiment 53. Dog, weight forty-flye ponnds. A oironmsoribed spot to 
the light of the linea alba was shaved and thoroughly disinfected, and through 
this space, a well disinfected, medinm sized trocar was plnnged into the peri- 
toneal cavity. To the cannula of the trocar the rubber tube of the inflation 
balloon charged with hydrogen gas was attached, and the whole peritoneal 
cavity filled with gas by compressing the baUoon. About four litres of gas 
were injected. No gas escaped upon the withdrawal of the cannula and the 
puncture was sealed with cotton and iodoform oollodium. The animal 
appeared to suffer but little pain, and the next day the tympanites had dis- 
appeared and the dog was as frisky and lively as before the inflation. Two 



RECTAL INSUFFLATION IN GUNSHOT WOUNDS. 239 

days after the experiment was made the dog was killed and the peritoneal 
oayity carefully examined. Not a trace of the gas remained and the peritonenm 
thronghont presented a normal appearance. 

2. Pleural Cavity. 

Eocperiment 54. Dog, weight twenty-five pounds. After thorough dis- 
infection, an aseptic hollow needle was inserted- between the seventh and 
eighth ribs in the axillary line into the left pleural cavity, and hydrogen gas 
from rubber balloon forced through it until the pleural cavity was thoroughly 
distended. On making a physical examination of the chest at this time the 
apex of the heart was found to the right of the sternum; vesicular breathing 
on left side absent; abnormal resonance on percussion of this side. The res- 
pirations became superficial and greatly increased in frequency. On with- 
drawing the needle no gas escaped externally, but a circumscribed subcutaneous 
emphysema which appeared, showed that some of the gas had escaped through 
the puncture in the pleura into the subcutaneous connective tissue. Twenty- 
four hours after the inflation the dog appeared to be in perfect health. The 
normal relations in the chest had become restored and the subcutaneous 
emphysema was less extensive. The animal was kept under observation for 
a considerable length of time, but at no time could symptoms of pleuritis be 
detected. 

3. Subcutaneous Cellular Tissue. 

Experiment 55. Old dog, weight forty-three pounds. A small, perfectly 
aseptic trocar was inserted through the skin into the loose cellular tissue in 
the right inguinal region, and through the cannula two litres of gas were 
injected, the gas distributing itself through the loose connective tissue over 
a large surface of the body. Upon the withdrawal of the cannula the puncture 
was hermetically sealed with iodoforni collodium and cotton. The subcuta- 
neous emphysema disappeared completely in forty-eight hours, and no traces 
of inflammation could be found at the point of puncture, or at any place 
where the gas had come in contact with the tissues. 

Experiment 56, Dog, weight twenty-flve pounds. Subcutaneous inflation 
of two litres of hydrogen gas through the cannula of a small trocar into the 
left side of the chest. The subcutaneous emphysema reached from the clavicle 
and axilla on that side to the crest of the ilitmi, the gas at some points elevat- 
ing the skin at least four inches from the subjacent tissues. The gas was 
absorbed somewhat more slowly than in the preceding experiment, but three 
days after the inflation no trace of emphysema could be detected, and the 
subcutaneous connective tissue was as pliable and movable as before the 
inflation. 

T. Bectal Insufflation of Hydrogen Gas in the Diagnosis 
of Penetrating Gunshot Wonnds of f he Abdomen. 

In these experiments the animals were strapped on one of 
Pasteur's opiating tables. Abdomen shaved, and after complete 



240 INTESTINAL SURGERY. 

etherization the shooting was done at short range with a thirty-two 
calibre revolver. Inflation of hydrogen gas was preicticed immedi- 
ately after the shot was flred, and after its diagnostic value was 
carefully studied, the abdomen was opened and its contents exam- 
ined for visceral injuries. In all cases where the colon was perforated, 
inflation could be done under very slight pressure, as the gas readily 
escaped ixito the peritoneal cavity, and from there through the bullet 
wound in the abdominal wall, where it was ignited as it escaped. As 
it is not my object at present to give the result of the operative treat- 
ment, the .experiments will only be described in reference to diagnosis 
as verified by abdominal section; but in every case an attempt was 
made to save the life of the animal by operative treatment, and in a 
few instances the efforts were rewarded by success. 

Experimefnt 57. Dog, weight thixty poxmdB. The abdomen was opened 
by an incision through the linea alba and a ooil of the small intestine was 
drawn forward into the wound, and an incision half an inch (18 mm.) in 
length was made on the oonyez side and the intestine returned. A small glass 
tube was inserted into lower angle of wound, and the rest of the wound closed 
by sutures. About two litres of hydrogen gas were inflated per rectum, when 
the gas escaped through the glass tube, and when ignited burned with a 
continuous steady blue flame as long as the inflation was continued. The 
wound was opened and a smaU quantity of gas was found in the peritoneal 
cavity. The whole intestinal tract below the visceral wound was found 
moderately distended by gas, while above the wound the intestine was normal 
in size. 

Experiment 58, Dog, weight fifteen pounds. When the dog was com- 
ple'tely under the influence of ether, hydrogen gas was forced from anus to 
mouth, and while the abdomen was stiU moderately distended the animal was 
shot in the abdomen, the bullet being directed transversely from the point of 
entrance on the side of the abdomen two inches (5 cm.) to the right of the 
median line, and on a level with the umbilicus. On appliying a lighted taper 
to wound of entrance, and compressing the abdomen, hydrogen gas escaped 
and was ignited. When the inflation was resumed the gas burned with a 
continuous flame at the wound of entrance. The abdomen was then opened 
and two perforations in the stomach were found, one on the anterior surface 
near the pylorus, and the other on posterior surface at the cardiac extremity, 
about an inch above the omental attachment. The distention of the stomach 
by hydrogen gas had brought this organ within range of the track of the 
bullet. 

Experiment 59. Dog, weight twenty pounds. Under complete ansBsthesia 
the animal was shot in the abdomen, the bullet taking the same direction as in 
the previous experiment, only that the track was about an inch (2.5 cm.) 
above the umbilicus. Immediately after the shooting hydrogen gas was 



RECTAL INSUFFLATION IN GUNSHOT WOUNDS. 241 

inflated per reotnm, and its presence in the abdominal oavity became evident 
by a marked tympanites, absence of liver dnllness, and later by a localized 
emphysema aromid the womid of entrance. As the pressure was continued 
bubbles of gas escaped, and on applying a lighted taper, ignited with a feeble 
explosive report. The abdomen was opened, and the stomach showed two 
perforations, one jnst above the omental attachment near the pylorns, and the 
other on the same level at the cardiac extremity. Little hsemorrhage, and no 
-extravasation of contents of stomach. 

Experiment 60, Dog, weight thirty pounds. Animal aneesthetized and shot 
in abdomen at a range of two feet; wound of entrance two inches to the right 
of, and on a level with the umbilicus. Wound of exit one inch above the 
middle of left crest of ilium. Inflation of hydrogen gas per rectum soon 
caused extensive tympanites, and as but little force had been used, the con- 
clusion was drawn that some part of the descending colon had been injured. 
As the gas did not readily escape through the bullet wounds, a small cannula 
was inserted into the abdominal cavity through the wound of entrance, when 
the gas escaped freely and was ignited. On opening the abdomen examination 
revealed the following visceral injuries: Two perforations in the descending 
colon; four in the ileum, within a distance of ten inches of the ileo-cadcal 
valve; eight in the upper part of the ileum, within the space of one foot 
(80.5 cm.) of the intestine. The mesentery was perforated at three points, 
and a ntmiber of mesenteric vessels of considerable size were severed, which 
gave rise to profuse hsmorrhage. 

Experiment 61, Large coach dog. The animal was completely etherized, 
and shot in the abdomen at close range. Wound of entrance midway between 
linea alba and vertebral column on left side, a little below the level of the 
umbilicus; wound of exit close to the last lumbar vertebra over crest of iUum 
on opposite side. Bectal inflation of hydrogen gas undor slight pressure at 
once produced diffuse tympanites, and the gas escaped freely through wound 
of entrance, where it was ignited and burned with a large steady blue flame 
as long as the inflation was continued. On opening the abdomen gas escaped, 
but inspection showed that the small intestines contained no gas, a condition 
which pointed to the colon as the seat of perforation. One perforation was 
found in the anterior wall of the sigmoid flexure, and two perforations in the 
C89cum. In the small intestines two perforations were found in the ileum near 
the C8BCum, and three in the upper portion of * the jejuntmi. Among the other 
organs injured were the spleen, and the receptaoulum chyli; a number of per- 
forations were found in the mesentery. 

Experimavd 62, Large dog. Profound ether narcosis. Shot in the abdo- 
men, the bullet entering on a level with the umbilicus and about one inch to 
the left of the median line. Point of exit two inches from spinal column, 
and a little above the lower border of the chest. On inflating the rectum with 
hydrogen gas, hardly any force was required to distend the abdomen, and for 
this reason it was believed that the colon in some part of its course had been 
injured. Gas escaped readily through the wound of entrance, where it was 
lighted and burned with the characteristic blue flame. The abdomen when 

16 



242 INTESTINAL SURGERY. 

opened was found almost completely filled with blood. The sonroe of tbiB 
profuse hsBmorrhage was the right kidney which showed a perforation through 
the centre. An examination of the gastro-intestinal canal revealed two 
perforations of the oaBonm, and five, of the small intestines. After passing 
through the kidney the bnllet perforated the diaphragm, traversed the pleural 
cavity, and escaped through the chest wall two inches (6 cm.) to the right of 
the spine. 

Experiment 63. Old dog, weight thirty-five pounds. Thoroughly etherized 
and shot in the abdomen, the bullet entering three inches (7.6 cm.) to the right 
of, and an inch and a half (8.8 cm.) below the umbilicus, passing almost trans- 
versely through the Lbdominal cavity and escaping ai a corresponding point 
on left side. Inflation of hydrogen gas was attempted, but failed on account 
of the apparatus being out of order. The abdomen was opened and no gas 
was found even in the colon. Twelve perforations of the small intestmes were 
found, and a number of perforations of the mesentery, which had caused pro- 
fuse haemorrhage. 

EoBperiment 64. Large, black dog. Etherized and shot in the abdomen; 
wound of entrance three inches (7.6 cm.) to the right of, and an inch and a 
half below the umbilicus; wound of exit near a corresponding point on 
opposite side, the bullet taking nearly a transverse course. Rectal inflation of 
hydrogen gas gave a prompt positive result. The abdomen was opened and 
five perforations of small intestine were found, besides laceration of thoracic 
duct, and a number of perforations in mesentery. Oolon and small intestine 
below the lowest point of perforation contained gas, while above the lowest 
perforation the bowel contained no gas. 

Experiment 65, Dog, weight twenty-five pounds. Under full ansesthesia* 
the animal was shot in the abdomen, the buUet passing in a nearly transverse 
direction through the abdominal cavity an inch and a half below the umbilicus 
from point of entrance; wound of exit midway between linea alba and spine. 
Bectal insufflation of hydrogen gas made under very low pressure, led to 
rapid distention of the abdomen, an occurrence which furnished strong 
evidence that the gas had escaped through a perforation in the colon into the 
peritoneal cavity. The gas escaped in bubbles through the wound of entrance* 
and when a lighted taper was held near the wound, it burned with a jet vary- 
ing in size. On opening the abdomen gas escaped from the peritoneal cavity; 
small intestines empty, and only a small amount of gas in the colon. The 
following intra-peritoneal . injuries were found: Four perforations of die 
duodenum, two of the jejunum, and one of the oeeoum; also a perforation 
nearly through the centre of the left kidney, laceration of the receptaculum 
chyli, and a number of perforations in the mesentery. The bullet was found 
between the left kidney and the abdominal walL 

In all of these experiments the bullet was fired through the 
abdomen from side to side transversely, or somewhat obliquely, 
directions which invariably brought into the track of the bullet a 
number of intestinal coils, and often the colon. In the two experi- 



RECTAL INSUFFLATION IN GUNSHOT WOUNDS. 248 

ments where the track of the bullet was a little higher up, the 
intestines escaped, but the stomach showed two perforations, one 
near the pyloric, and the other near the cardiac extremity. Bectal 
insufflation of hydrogen gas proved an infallible test in every 
instance, except in the case where it failed on account of the infla- 
tion apparatus being out of order. Contrary to the experience of 
other experimenters, 1 found that faecal extravasation does not 
uniformly take place soon after gunshot wounds of the intestines; 
in the cases where I observed it, some part of the colon had been 
wounded. Intestinal inflation does not, therefore, tend to increase 
the frequency of* this occurrence, and must, on this account, be 
looked upon as a harmless measure. 

Inflation, as a preliminary measure, greatly expedites the first 
step in the operation of abdominal section in cases where the intes- 
tine has been perforated or injured, as the gas which escapes into 
the peritoneal cavity separates the intestines from the anterior 
abdominal wall, and the incision can be made safely and rapidly 
without fear of wounding the intestines. Penetrating wounds of 
the abdomen, where the course of the bullet is in an opposite direc- 
tion to that which has been described in the preceding experiments, 
that is, in an antero-posterior direction, may not implicate the intes- 
tines at all; or if visceral injury is inflicted, it is more likely that 
only a single perforation exists, and never does the surgeon meet 
with such a multiplicity of lesions as have been cited above. Unless 
the surgeon can ascertain beforehand, that in a case of penetrating 
wound of the abdomen an injuiy to some pbrtion of the gastro- 
intestinal canal exists, the very means which he resorts to in making 
an anatomical diagnosis is often an imminent source of danger, as 
only too often he may have to examine every inch of the gastro- 
intestinal canal for this purpose, a procedure which is always 
attended by great risk to life. If by such a simple and harmless 
procedure as insufflation of hydrogen gas, he can satisfy himself 
that the gastro-intestinal canal is perforated, the course to pursue 
becomes clear — ^to open the abdomen, seek for the perforation until 
he finds it, and adopt proper treatment for the visceral injury. 

Oases have also happened in which the operator opened the 
abdomen, sought for, found and treated one or more perforations 
and, on making the autopsy a day or two later found, to his great 
x^hagrin and sorrow, a perforation which he had overlooked at the 



244 INTESTINAL 8UBGEEY. 

time of operation. It seems to me that in cases in which any doubt 
exists as to the integrity of the remaining portion of the intestinal 
canal, after closing one or more perforations, it would be advisable 
to search for additional perforations by resorting again to slow and 
careful inflation before the abdominal wound is closed. If no other 
perforations exist the gas will be confined to the interior of the 
gastro-intestinal canal, and if the stomach or intestines at some point 
difficult of access are injured, the leakage of gas through the perfo- 
rations will lead the surgeon to the wound. 

In the practical application of rectal insufflation of hydrogen 
gas, as a means of diagnosis in penetrating wounds of the abdomen, 
the field of possible operation should be carefully prepared by shav- 
ing and disinfection before inflation. After thorough disinfection of 
the external wound or wounds, and the field of operation, the patient 
should be placed thoroughly under the influence of an ansBsthetic 
for the purpose of relaxing the abdominal muscles, which greatly 
facilitates the inflation. 

In the absence of a Wolfs bottle, hydrogen gas can be readily 
generated in a large wide-mouthed bottle into which a small handful 
of chips of pure zinc is placed. The mouth of the bottle is closed 
with a cork with two perforations, through which two glass tubes are 
inserted, one for the purpose of pouring in water and sulphuric acid, 
and the other, which should be bent nearly at right angles, for lead- 
ing away the gas. This glass tube and a rubber balloon with a 
capacity of sixteen litres of gas are connected by means of a rubber 
tube. In from five to ten minutes the requisite amount of gas can 
be generated and everything is ready for the inflation. The rubber 
tube connecting the balloon with the rectal tip of an ordinary 
syringe should be interrupted by a stop-cock, so that the escape of 
gas can be prevented whenever inflation is temporarily suspended. 
The return of gas along the sides of the rectal tip can be readily 
prevented by an assistant pressing the anal margins flrmly against it. 

The inflation must always he made slowly, as long continued^ 
uninterrupted pressure accomplishes most effectually lateral and 
longitudinal dilatation of the ccecum; conditions which render the 
ileo-C8Bcal valve incompetent, and which must be secured before 
inflation of the small intestines is possible. The entrance of gas 
from the colon into the ileum is always attended by a diminution of 



RECTAL INSUFFLATION IN GUNSHOT WOUNDS. 245 

^ pressure, and its occurrence can inyariably be recognized by a 
gurgling or blowing sound over the ileOt-C8Bcal yalve, sometimes 
sufficiently loud to be heard at some distance. 

If, after inflation, abdominal distention and tympanites be from 
the very first diffuse, and liver dullness has disappeared, it is a 
certain indication that they are due to the presence of gas in the 
peritoneal cavity, and not to distention of the gastro-intestinal 
canal. If, on the other hand, the distention and tympanites follow 
the course of the colon, and after the entrance of the gas through 
the ileo-C8Bcal valve, are circumscribed and limited to the umbilical 
and hypogastric regions, and gradually extend to the upper portion 
of the abdomen, and the liver dullness is displaced upwards, they are 
in all probability caused by a gradual and successive inflation of the 
intact bowel in an upward direction. 

In some penetrating wounds of the abdomen it is difficult, if 
not impossible to follow the course of the bullet through the abdom- 
inal wall with a probe or finger, on account of the relative change of 
position of the different layers of tissues in the track of the bullet, 
obliterating the canal; but even in these cases a moderate distention 
of the peritoneal cavity by an accumulation of gas outside of the 
intestines, will force bubbles of gas through the tortuous canal. By 
this sign the surgeon may know positively that some portion of the 
gastro-intestinal canal has been perforated; and in order to prove 
that the bubbles which escape are part of the hydrogen gas which 
has been inflated, he applies a lighted match or taper. If it is 
hydrogen gas it will ignite with a slight explosive report, and bum 
with a characteristic blue flame. The burning of the escaping 
hydrogen gas on the surface of the external wound is a most effective 
means in securing for the wound an aseptic condition, and on that 
account, the escaping gas should be lighted, both for diagnostic an4 
therapeutic purposes, in all cases in which rectal insufflation of 
hydrogen gas reveals the presence of visceral injuries of the gastro- 
intestinal canal. 

As hydrogen gas from its low specific gravity will always occupy 
the highest space in a cavity partially filled with fluids, it is neces- 
sary to place the external abdominal wound in such a position that 
blood or any other fluid that may be present in the abdominal cavity 
will not interfere with its ready escape. If the wound is anterior 



246 INTESTINAL SURGERY. 

the patient must be placed in the dorsal position; if lateral, on the 
opposite side, daring the inflation. If during inflation, early and 
diffuse tympanites takes place, it speaks in favor of perforation of 
the colon. 

Shotdd the external wound prevent the escape of gas from the 
peritoneal cavity, by sliding of the different layers of tissue of the 
wound in the abdominal wall, or by the presence of a coagolum in 
the track made by the bullet, it becomes necessary to secure a suffi- 
cient degree of patency of the wound for the escape of gas, by careful 
probing or the removal of coagulated blood. The finding of perfo- 
rations is filao greatly facilitated by inflation, as the bowel below the 
lowest perforation will always be found at least slightly dilated by 
gas. If this perforation is now closed and additional perforations 
are suspected to exist, the inflation can be repeated, and the bowel 
will again become distended as far as the next perforation, and this 
process can be repeated until the entire intestinal canal has been 
examined. By searching for leaking points in this manner, but little 
manipulation of the intestines becomes necessary, and thus one of 
the great sources of danger in the operative treatment of woxmds or 
perforationis of the gastro-intestinal canal is avoided. 

The moderate distention of the intestines left after treating the 
visceral wounds, never interfered with the return of the intestines 
into the abdominal cavity or the closure of the external wound in 
any of the experiments; and the numerous observations made in 
reference to the disappearance of the gas by absorption, or escape 
through the natural outlets, are conclusive in showing that the dis- 
tention due to the presence of the gas disappears in a remarkably 
short time. It can therefore be safely stated that rectal insufflation 
of hydrogen gas in the diagnosis and treatment of penetrating 
wounds of the abdomen, does not interfere with an ideal healing of 
the visceral and laparotomy wounds. 

After a careful study of the subject of rectal insufflation of 
hydrogen gas in its various aspects, I do not hesitate to recommend 
its adoption in practice as an infallible diagnostic test in demon- 
strating the existence of a wound of the gastro-intestinal canal in 
penetrating wounds of the abdomen, or perforations from any other 
cause, without resorting to an exploratory laparotomy. 



CONCLUSIONS. 247 

In oondnsion I beg leave to submit the following propositions: 

1. The entire alimentary canal is permeable to rectal insuffla- 
tion of air or gas. 

2. Inflation of the entire alimentary canal from above down- 
wards through a stomach tube seldom succeeds, and should there- 
fore only be resorted to in demonstrating the "presence of a perforation 
or wound of the stomach, and for locating other lesions in the organ 
or its inmiediate vicinity. 

8. The ileo-C8dcal valve is rendered incompetent and permea- 
ble, by rectal insufflation of air or gas under a pressure varying 
from one-fourth of a pound to two pounds. 

4. Air or gas can be forced through the whole alimentary 
canal from anus to mouth, under a pressure varying from one-third 
of a pound to two pounds and a half. 

5. Bectal insufflation of air or gas to be both safe and effective 

must be done very slowly and without interruptions. 

% 

6. The safest and most effective rectal insufflator is a rubber 
balloon large enough to hold sixteen litres of air or gas. 

7. Hydrogen gas should be preferred to atmospheric air or 
other gases for purposes of inflation in all cases where this pro- 
cedure is indicated. 

8. The resisting power of the intestinal wall is nearly the 
same throughout the entire length of the canal, and in a normal 
condition yields to diastaltic force of from eight to twelve pounds of 
pressure. When rupture takes place it either occurs as a longitudi- 
nal laceration of the peritoneum on the convex surface of the bowel, 
or as multiple ruptures from within outwards, at the mesenteric 
attachment. The former result follows rapid, and the latter slow 
inflation. 

9. Hydrogen gas is devoid of toxic properties, non-irritating 
when brought in contact with living tissues, and rapidly absorbed 
from the connective tissue spaces and all of the large serous cavities. 

10. The escape of air or gas through the ileo-csecal valve from 
below upwards is always attended by a blowing or gurgling sound, 
heard most distinctly over the ileo-csecal region, and by a sudden 
diminution of t)ressure. 



248 INTESTINAL 8UBGEBT. 

11. The incompetency of the ileo-C8Bcal Talve is caused by a 
lateral and longitudinal distention of the csBCum, which mechanically 
separates the margins of the yalve. 

12. In gunshot or punctured wounds of the gastro-intestinal 
canal, insufflation of hydtogen gas enables the surgeon to demon- 
strate positively the existence of the yisceral injury, without incur- 
ring the risks and medico-legal responsibilities incident to an 
exploratory laparotomy. 



INFLATION OF THE STOMACH WITH HTDEOGEN 

GAS IN THE DIAGNOSIS OF WOUNDS AND 

PEEFOEATIONS OF THIS OEGAN, WITH 

THE EEPOET OF A OASE.^ 



In my paper on '^Bectal Insufflation of Hydrogen Gas as an 
Infallible Test in the Diagnosis of Visceral Injury of the Gastro- 
intestinal Canal in Penetrating Wounds of the Abdomen," read in 
the Surgical Section of the American Medical Association, I inci- 
dentally called the attention of the medical profession to the value 
of inflation of the stomach as a diagnostic measure, in cases of injury 
or perforation of this organ, in that part of the paper which treated 
of inflation of the alimentary canal through the stomach tube. We 
should naturally expect that the alimentary canal could be inflated 
with more ease and with a less degree of force by following the nor- 
mal peristaltio wave. That this is not the case can be seen from the 
experiments given in detail in the paper referred to. 

These experiments denK)nstrate conclusively that it is more 
difficult to inflate the alimentary canaj from above downward than 
from below upward; as in the living animal I succeeded in only one 
instance in forcing hydrogen gas from the motith to the anus, while 
in others, a degree of force sufficient to rupture the peritoneal coat 
of the stomach, only effected distention of the stomach and upper 
portion of the intestinal canal. It is evident that great distention 
of the stomach constitutes an important factor in causing or aggra- 
vating intestinal obstruction, as it effects compression, which again 
causes impermeability of the intestines, or aggravates conditionis 
arising from an antecedent partial permeability, by producing sharp 
flexions among the distended coils of the intestines. 

For diagnostic and surgical purposes, the stpmach can be 
readily inflated almost to any extent through a stomach tube, and 
when it becomes necessary to ascertain the presence of a visceral 

249 



260 intestWal surgery. 

wound or perforation of this organj this method of inflation may be 
resorted to with advantage. 

I have recently had an excellent opportunity to apply this test 
in a case of gunshot wound of the chest and abdomen, in which, 
without it, it would have been impossible to make a correct diagno- 
sis. The insufflation made the diagnosis positive, and the informa- 
tion obtained from it justified the treatment by laparotomy, although 
the general symptoms were so grave that it appeared doubtful if the 
patient would live long enough to complete the operation. 

0. H., seventy-two years of age, was brought to the Milwaukee Hospital 
by the police patrol, at 7 ▲.]£., July 9, 1888, for a snioidal pistol (44-oalibre 
bulldog) wound of the ohest, inflicted about two hours preyiously. Pistol held 
in the left hand, as ascertained from the patient and confirmed subsequently 
by examination of the direction of the buUet. The patient stated that he had 
pointed the pistol toward the heart. 

Examination^ 7 a.m. Wound of entrance situated in the left sixth inter- 
costal space, surrounded by emphysema. Seventh rib fractured at junction 
of cartilage and bone. No wound of exit. Patient conscious; complains of 
severe pain in the epigastric region, increased by pressure. Pulse rapid and 
weak. Vomits and expectorates blood. Area of liver dullness diminished. 
Percussion and respiratory sounds normaL No evidence of heemo- or 
pneumo-thorax. 

9 A.M. Flexible tube introduced and stomach inflated with hydrogen gas 
from a four-gallon rubber baUoon. Inflation effected by continuous pressure 
on the balloon. Gas escaped and ignited at the wound of entrance with an 
audible sound. Field of operation thoroughly disinfected. Patient etherized 
and laparotomy made by incision from the ensif orm cartilage to the umbilicus. 
The omentum and stomach wei^ drawn forward into the wound. A large 
perforation, about one and a half inches in length (due to the oblique 
direction of the bullet)^ was found in the stomach, midway between the 
pylorus and the cardiac end, on the greater curvature. Stomach partially 
filled with coagulated blood. With the index finger introduced through this- 
perforation, another was detected on the lesser curvature and near the cardiac 
end. - The omentum, which was adherent to the colon, was torn through and 
exploration of the posterior surface of the stomach failed to reveal the old 
site of the second wound, which was felt by the digital exploration of the 
interior of the organ. The blood-dots were removed from the stomach by 
irrigation through the lower wound. 

For the purpose of locating with accuracy the second wound, the stomach 
was inflated through the bullet wound on the anterior surface with hydrogen 
gas, the escape of which made it easy to locate the second wound. The 
omental opening wias enlarged by tearing, and the perforation was discovered 
on the posterior surface at the lesser curvature and close to the cardiac orifice. 
Great difficulty was experienced in dragging the stomach sufficiently forward 
and downward into the abdominal incision to suture the perforation, which 



infIation of stomacs by hydroqes oab. 251 

was two luohea in length. It waa dosed hj a oontinnons Lembert autiue of 
Bilk, the anteTior vonnd by b Ozerny-LembeTt sntuiB. 

ConaideTsble blood wbb found behind the Etomaoh, in the region of the 
panotesB. The tuemOTrhage had evidentl; taken place from laoerated veeeels 
of oonBideiable eiza at both peTfaTationa, as well ae from Tsaaela in the pio- 
peritoneal apace. Probable direction of the bullet from above downvaid, 
backwaid and to the right. A.t this etage oollapae from shock and hEsmOTrhage 
enperrened. The body was partially inverted and a saline infoudation of 
fifteen onnoea Of a siz-tentha per oent. salt aolntion performed. Brand; naa 
injected anbcntaneously and the faradio onrrent applied to the phrenio and 
pneomogaatrio nervea withont any apparent effect. Death ooonrred before 
the abdominal voond oonld be oloaed. 

The abdominal incision nsji aatnred and inflation of hydrogen gaa per 
'teotnm, made to test the condition of the antiized stomach. A. stomach tube 
was iutiodnoed and the gae, nnder a pressore of not more than a. pound, 
fOToed through the entire gaatro-lntestinal oanel, igniting and burning with « 
oontinaoos flame as' it escaped from the end of the atomaoh-tnbe, nhiuh 
Bhowed that no gas escaped through the sutured wounds. Post-mortem was 
made imraedlately. Wound of entrance in the ..jith interooatal apace, Beveuth 
rib fractured at junction of cartilage and bone, both pleural cavities obliter- 
ated by adheaions, margin of lower lobe of left lung perforated, pericardium 
intact, lacerated opening in diaphragm admitting two flngert. Perforations 
in Btomaoh aa deeoribed. Liver and apleen not injured, nppei mai^^ of tail 
of panoreaa lacerated. Bullet peaaed to the left of the aorta, entered the left 
cms of the diaphragm, fractured the laat rib at the neck and perforated the 
spinal column, entering between the last dorsal and the flrst lumbar vertebra, 
escaping through the body of the latter and fracturing its right tranaverae 
prpoese. Bullet found in the suboutaneona conneotive tiesne of right lumbar 
region. The spinal canal was opened by the bullet in ita paaaage through the 
vertebra, and loose fragments of bone la; in the canaL The membranes of 
the oord were intact and the cord itself nninjnred. 

The locfttion of tbe wotmd of entrance in this oaee, did not 
indicate that the ballet had entered the abdominal cavity, nuless the 
revolTer vas held in the left hand; in that case, as it was directed 
toward the heart, the track of the bullet would be necessarily down- 
ward, backward and from left to right. Taking it for granted ^hRh 
the bullet took this direction, it would still have been pot 
for the Btomach to escape injmy. The circtunscribed emphy 
around the external wound and the hsemoptyaia, as weU at 
location of the wound, left no doubt that the lower lobe of the 
was injured. The absence of hEemothorax and pneiimotborai 
explained by the post-mortem, as the left pleural cavity was f 
completely obliterated by adhesions. Under a pressure of not 
than half a pound to the square inch, the hydrogen gas was f< 



262 INTESTINAL SURGERY. 

through the external wound, where it was lighted and bnmed in a 
large continuous flame until it was extinguished hj compression 
with a large moist sponge. Very little gas was foxmd in the 
peritoneal cavity. 

In perforation of the stomach without an external wound, infla- 
tion of the organ with hydrogen gas will render the abdomen 
universally tympanitic; as the gas will escape into the peritoneal 
cavity and, as it always occupies the highest plane, on account of its 
low specific gravity, it will push the abdominal organs backward. 
Thus it happens that the liver dullness disappears completely, which 
fact alone, if established, makes tiie diagnosis of perforation positive, 
unless the organ is fixed in its place by peritoneal adhesions, the 
result of a previous peri^hepatitis. 

In cases of perforating ulcer of the stomach or duodenum, if 
this simple diagnostic measure is resorted to in time, it will prove 
the means, by prompt surgical treatment, of saving many a life that 
would have been sacrificed under the expectant plan of treatment. 

It has been claimed that hydrogen gas is objectionable for 
purposes of inflation, as when it is mixed with a certain proportion 
of oxygen or atmospheric air it forms an explosive compound. 
Against this argument I can say that no accidents of any kind have 
occurred during any of my numerous experiments on animals, nor in 
the few cases in which it has been applied in practice. Hydrogen 
gas has the lowest specific gravity of all the gases known, and on 
this account, as well as from its non-toxic qualities, it should always 
be preferred to other gases, or to atmospheric air simple or medi- 
cated. The hydrogen gas test, if successful, appeals both to the sense 
of sight and hearing in cases of perforating wounds. The prepara- 
tion of the gas is so simple and rapid that its use is applicable not 
only in hospital and city, but also in country practice. 

I have recently been able to make a correct diagnosis in several 
cases of obscure abdominal tumors, by resorting to stomach and 
rectal inflation of hydrogen gas, which, without these diagnostic 
measures, would have been impossible, short of exploratory laparot- 
omy. The relation of tumors of the abdominal cavity to the 
different organs and the peritoneal cavity, can be mapped out and 
studied with great .accuracy by dilating the stomach and different 
portions of the intestinal canal, at intervals, by inflation with this 
harmless and readily procurable gas. 



TWO CASES OF GUNSHOT WOUND OF THE ABDO- 

MEN, ILLUSTRATING THE USE OF EEOTAL 

INSUFFLATION WITH HTDEOGEN GAS 

AS A DIAGNOSTIC MEASURE.' 



Oasb I. J. J., eizteen years of age, was ont hunting with some oompan- 
ionS) on Snnday, September 9, 1888, one of whom accidentally discharged his 
22-calibre rifle at a distance of abont one hxmdred and fifty feet, the bullet 
striking the patient in the abdomen. The injnry caused bnt little pain, and 
immediately after the accident, the patient walked abont forty yards to a farm 
house, where he was placed in bed. From there he was conveyed on a cot, in 
a farmer's wagon, to the Milwaukee Hospital, some six miles distant. The 
accident occurred about noon, and he arrived at the hospital at 3 p. ic. 

Examination. Patient complained of considerable pain in the abdomen; 
pulse 80 and soft; his general appearance indicated no serious injury. On 
xmdressing him, a bullet wound, with omentum protruding, was found two 
inches to the right of the middle line, and on a level with the anterior superior 
spine of the ilium. Left iliac region dull on percussion; and in right, a 
cracked-pot sound was elicited on percussion. A rectal enema was adminis- 
tered, and was followed by a free feecal discharge, without admixture of blood. 
On washing the fasces afterward, the bullet was found. 

Operation, Ether, as an anassthetic; thorough disinfection of abdominal 
wall; rectal insufflation of hydrogen gas, followed by the escape of bubbles 
of the gas, within a few seconds, at the wound of entrance, into which had 
been placed a haemostatic forceps, the blades separated so as to render the 
canal patent. The gas was lighted, and after thorough cauterization of the 
wound by the flame, was extinguished by the application of a wet sponge. 

Laparotomy by median incision, eight inches in length, from pnbes 
upward. About a pint of fluid blood in the peritoneal cavity, and haemor- 
rhage continuing from the mesenteric veins at two points of perforation on 
the mesenteric side of the bowel, and to a less extent from perforations of the 
mesentery, arrested by ligating en masse. Within a distance of four feet, 
near the middle of the ileum, were found ten perforations, two of which were 
at the mesenteric border; also four perforations of the mesentery. Another 
perforation of the bowel was found within four inches of the ileo-caecal valve 
on the convex side of the intestine, making so far eleven in all. All were 
dosed by Ozemy-Lembert sutures. At two points the perforations were so 
dose together that it was found necessary to invert half the circumference of 

258 



254 INTESTINAL SURGERY. 

the bowel on the convex side, thus prodnoing considerable narrowing of its 
Inmen. 

Two hours had been consumed in arresting the haemorrhage and closing 
the eleven perforations, and the patient at this time had become pulseless; 
yet it was deemed absolutely necessary to determine beyond all doubt if any 
more perforations existed, by repeating the rectal insufflation of hydrogen 
gas. On repeating this test it was found that gas escaped freely from the 
pelvic cavity, without reaching the ileo-cascal region, showing that at least 
one more perforation was below this point. The sigmoid flexure was brought 
into the woxmd and compressed between the index finger and thumb. Insuf- 
flation was again followed by escape of gas, demonstrating that the perfora- 
tion was below this point. Inch by inch the bowel was examined by this 
method in a downward direction, until a perforation was found in the anterior 
portion of the rectum, at a point where the peritoneum covering its anterior 
wall is reflected upon the bladder, This perforation was rendered accessible 
to direct treatment by an assistant making traction on the colon, and by 
keeping the margins of the wound well retracted by means of a pair of 
Hegar's retractors. It was closed by five Lembert sutures, with the greatest 
difficulty, on account of its deep situation, and the inadequate light furnished 
by two candles. 

From the perforations in the ileum there escaped pieces of green apples 
and intestinal contents, and from that in the rectum, fluid f »ces. 

The peritoneal cavity was freely irrigated with a one-third per cent, solu- 
tion of salicylic acid. After completion of peritoneal toilet, a glass drain was 
introduced in such a manner that the distal open end was placed opposite the 
sutured rectal wound, and the abdominal incision closed in the usual manner. 

Whiskey was freely administered hypodermically during the operation 
and after its completion, as the patient remained pulseless for half em hour. 

Time of operation two and a half hours. 

The foot of the bed was elevated and dry heat applied to the extremities. 

10 p. M. Temp. 99.5° F.; pulse rapid and weak. About one ounce of 
bloody serum withdrawn from glass drain. 

Sept 10th. 8 a. m. Temp. 99° F.; pulse 126. Clear serum only in the 
drain; about one drachm withdrawn every three hours. During the day the 
patient was slightly delirious, and in the absence of the nurse he got out of 
bed and walked across the ward to another bed. 8 p. m. Temp. 99.8° F.; 
pulse 144. Some tympanites. Ordered one drachm of turpentine in half a 
pint of warm water, as an enema, which was followed by free discharge of 
fsBces and flatus. 

11th. Temp, normal; pulse 104. Natural passage from bowels; delirium 
continues. 

12th. Temp, normal; pulse 96. Delirium disappeared. Allowed liquid 
food in small quantities. 

13th. Pulse 72. The contents of the glass drain have a suspicious fascal 
odor. Glass, replaced by rubber drain. Slight diarrhoea, which relieved the 
tympanites. 



RECTAL INSUFFLATION IN GUNSHOT WOUNDS, 255 

14th, 9 A. M. Temp. 101*" F.; pnlse 126. A fasoal fistnla has formed along 
the track of the drainage-tnbe. Large rubber tube introdnoed through the 
annS) and left in rectam to allow free escape of fluid fsBoes. Fluid injected 
into fistula does not flow through the reqtal tube. Rectum disinfected eyery 
four hours with saturated salicylic acid solution. 

17th, Temp, normal; pulse 108. Free discharge of fluid fteces from 
rectal tube and fistula. 

18th, Sutures remoTcd from the abdominal incision; only deep parts 
united; granulating surfaces approximated by strips of adhesive plaster over 
an antiseptic compress. 

19th, Fluid flows freely from fistula through the rectal tube. No fasces 
have escaped through fistula for twelve hours. 

20th, Bectal tube withdrawn, followed by return of feecal'discharge 
through fistula. 

Oct, 1st, The discharge of faeces through the fistula has been gradually 
diminishing, and has now ceased. 

19th, Fistulous track completely closed. Abdominal incision all healed, 
except a small granulating surface at lower angle. 

Patient discharged cured, November 3d. 

Bbmabks. — The subjective symptoms in this case four hours 
after injury, and after transporting the patient a distance of six 
miles, furnished no indications whatever of the extent of visceral 
injury which was found on exploring the abdominal -cavity. The 
rectal insufflation of hydrogen gas at once rendered the diagnosis 
positive, and pointed out the nefiessity of treatment by abdominal 
section. Eleven perforations were found and sutured without much 
difficulty, but the last perforation in the deepest portion of the 
pelvis could not have been found by any other means of diagnosis 
short of rectal insufflation. Had this perforation been overlooked, 
death from septic peritonitis would have been inevitable. Drainage 
was resorted to in this case, not only from the fact that fsecal 
extravasation had taken place, but also for the reason that owing to 
the difficulty in gaining access to the rectal wound, I feared that the 
suturing was not as perfect as it should be, and by proper drainage 
I wished to prevent possible extravasation into the peritoneal cavity 
from this cause. Subsequent events showed the propriety of this 
precaution. 

Oasb II. J. E. (case of Drs. Gudden, Steele, and Gk>rdon, of Oshkosh), 
eighteen years of age, was out target-shooting with a companion, who, while 
raising his 22-calibre rifle to his shoulder, accidentally discharged it; the 
bullet struck the patient in the abdomen. He was about forty feet distant, 
and almost directly facing his companion. When first seen by Dr. Gudden, 



256 INTESTINAL SURGERY. 

within half an hour after the injnry was xeoeiyed, he was Buffering severe 
pain in the abdomen, was pale, covered with cold, clammy perspiration, and 
vomited frequently. He was placed in a carriage and conveyed to his home, 
a distance of two miles. During the journey, the severity of the abdominal 
pain was so increased by the motions of the carriage, as to necessitate repeated 
stops. 

I saw the patient, with the above-named physicians, October 9th, 4 a. m., 
twelve hours after the accident. 

EoDamination. The wound of entrance was found to be at the outer 
margin of the left rectus, about one inch below the level of the umbilicus. 
Abdomen dull on percussion in left iliac region, pulse 140, temperature 100° F. 
Penetration of the abdomen was proved by the introduction of a grooved 
director, which was left in place during the insufflation of the hydrogen gas. 

The patient was placed under the influence of chloroform, and during the 
operation the narcosis was maintained with ether. The abdomen was thor- 
oughly disinfected, and rectal insufflation of hydrogen gas practiced to 
ascertain if any perforation of the intestine existed. Under a pressure of 
about half a pound to the square inch, and the use of one-quarter of a gallon 
of gas, in a few minutes the gas escaped along the groove of the director, and, 
on applying a match, lighted as it escaped. The flame was now extinguished 
by a moist sponge, and the abdomen opened by a median incision, five inches 
in length, extending from the umbilicus to near the pubes. 

On exposing the peritoneum at the lower angle of the incision, through 
this membrane there was observed a structure closely resembling an over- 
distended bladder. That this structure was a distended bladder was improba- 
ble, as the patient had urinated before the aneesthetic was administered. The 
peritoneum was carefully incised between two forceps, and divided upon a 
grooved director to the same extent as the external incision, and it was then 
discovered that what appeared to be an over-distended bladder, was a coil of 
small intestine distended with blood to twice its normal size. The whole 
pelvic cavity was found filled with fiuid blood. On withdrawing the small 
intestine, five perforations near the jxmction of the jejunum and ileum, and 
within a distance of three feet, were found; four occurred in pairs on the 
lateral aspect of the bowel, and one at the mesenteric attachment. All the 
perforations were disproportionately large to the size of the bullet, and would 
easily admit the tip of the index finger. The intestine, at the point of injury, 
was covered with a thick layer of recent plastic lymph, and the parietal peri- 
toneum presented all the evidences of a beginning diffuse septic peritonitis. 
The intestine, which was over-distended by blood-clots for about three feet, 
was emptied and irrigated with a one-third per cent, solution of salicylic acid, 
which was used for constant irrigation during the entire time required in 
suturing the perforations, which were closed by Ozemy-Lembert sutures. 

Further examination disclosed four perforations of the mesentery, from 
two of which quite profuse venous hsBmorrhage was still going on. The 
haemorrhage was arrested by ligature en masses by passing a needle threaded 



RECTAL INSUFFLATION IN OUNSHOT WOUNDS. 257 

with fine silk, throngh the entire thickness of the mesentery, on either side of 
the perforations. 

Beotal insufflation of hydrogen gas was repeated, so as to asoertain if 
any other perforations existed; and the gas after it had been gently forced 
beyond the highest perforation, was made to traverse the balance of the 
entire intestinal canal by drawing forward loops of the intestine and retaxn- 
ing them as examined without farther insufflation. This procednre was f oxmd 
entirely satisfactory and practical, as the gas on account of its low specific 
gravity, readily entered the highest point in the prolapsed intestinal loop. 

The abdominal cavity was irrigated with salicylic acid solution, nmnerons 
coagnla removed, the toilet completed, a glass drain introduced into the 
pelvis, and the abdomen closed. 

Duration of operation two hours. Patient collapsed, pupils greatly 
dilated, and almost pulseless in spite of repeated hypodermic injections of 
brandy, which were administered when signs of collapse became apparent, 
throughout the operation. Enema of a teacupful of warm water and two 
ounces of brandy. Foot of bed elevated and external dry heat applied. 

In an hour and a half he rallied somewhat from the operation, but again 
sank and died at 3 p. m., eight hours after the completion of the operation. 

Post^nurrtem eighteen hours after death (Drs. Steele, Gudden, Gk)rdon). 
Circumscribed peritonitis present at time of operating, now diffuse; very 
little fluid in abdominal cavity; several small blood-dots in vicinity of 
transverse colon. The perforations were all securely closed, and the bullet 
was found in the soft tissues to the right of the spinal column, between the 
fourth and fifth lumbar vertebrsB, and near the ascending colon. The bullet, 
though only of 22-calibre, was oblong, and may thus explain the xmusually 
large size of the perforations. 

Bemabks. — This case* compared with the foregoing, furnishes a 
strong argument in favor of early operative interference in cases of 
gunshot or stab wounds of the abdomen, in which the existence of 
visceral lesions can be demonstrated by rectal insufflation of hydro- 
gen gas. In the first case, although twelve perforations were found 
and sutured, and f secal extravasation had taken place, no evidences of 
peritonitis were found, and the patient recovered. In this case, 
twelve hours intervened between the time the injury was received 
and the treatment by laparotomy, during which time a septic peri- 
tonitis had developed, the extension of which the operation did not 
arrest, and from the effects of which the patient died. 



17 



INDEX. 



A: 



Pagb 
.BDOMEN, Diagnosis by rectal insufflation with hydrogen gas of gun- 
shot wound of — ^with reports of oases 253 

Diagnosis by rectal insufflation with hydrogen gas of 
injury of gastro-intestinal canal in penetrating 

wounds of 215 

Beotal insufflation of hydrogen gas in diagnosis of gnnshot 

wonnds of. Experiments 239 

Abdominal compression in intestinal obstruction 22 

Section in intestinal obstruction 27 

Tumors. Diagnosis of — by inflation with hydrogen gas 252 

Acquired or cicatricial stenosis « 123 

Acute invagin'ation. Pathology of 88 

Adhesion experiments 199 

Adhesions as a cause of intestinal obstruction 104 

of intestine. Laparotomy in 58 

After-treatment. Laparotomy 61 

Age of invagination patients 83 

Air. Rectal insufflation of. Experiments 222 

Alimentary canal. Force necessary for rectal inflation of entire — ^with 

hydrogen gas. Experiments 229 

Inflation of — through stomach-tube, Experiments . . . 225 

Anaesthesia in laparotomy 83 ' 

Anastomosis, Intestinal 48, 177 

by perforated plates in jejuno-ileostomy. Experi- 
ments 185 

by sutures in jejuno-ileostomy. Experiments... 188 

Experiments 45 

Illustrations 218 

in gastro-enterostomy. Experimepts 180 

in invagination 59 

in pyloric stenosis 50 

in strangulated hernia 52 

Operation 48 

Physiological exclusion by 52 

Anatomical location of invagination 78 

Anatomico-pathological forms of obstruction 62 

Appendix vermiformis, strangulation by ; 114 

Apposition, ileo-colostomy by lateral. Experiments 192 

259 



260 INDEX. 

Paos 
ArtifLoial inteBtinal obstmotion 146 

Asoar^des, intestinal obstmotion from 74 



B 



AND, Laparotomy in strangnlation by .••.••«•*.. 57 

Bands, strangulation by ligamentous,. 110 

Biliary oalonH 62 

Bone-platee. Ulostrations 218 

Preparation of deoaloifled 179 

Bryant 15, 86, 81, 126 

BnU , , ..••.....«•... 9, 118, 188, 218 

U ALOULI, Biliary ..••••••••••«««. * • • * « • • * . • • * « • « « . • 62 

Oaroinoma 181 

Oatarrhal and nloeratiye enteritis 137 

Chemical irritation of serous enrf aoes. Experiments 208 

Ohronio inyagination, pathology of 86 

Oioatrioial or acquired stenosis 123 

Oircnlar constriction, stenosis by. Experiments ' 147 

Enterorrhaphy 166 

Experiments 170 

Oolo-reotostomy. Experiments 198 

Golon, distention of, with flnids in intestinal obstmotion 8 

Excision of. Experiments 161 

Invagination of, into rectnm 81 

Resistance of, to diastaltio force. Experiments 282 

Tnbage of, in intestinal obstruction 16 

Oolotomy in intestinal obstmotion 25 

in invagination ', 89 

Oompression of abdomen in intestinal obstruction 22 

Oonolusions, intestinal obstruction 208 

Rectal insufflation of hydrogen gas 247 

Concretions, intestinal 72 

Congenital, non-malignant stenosis 121 

Connel, M. E 144, 178, 222 

Constriction, stenosis by circular. Experiments 147 

Czemy-Lembert sutures, objections to 167 



D: 



'ECALCIFIED bone-plates, preparation of 179 

Definition of intestinal obstruction 4 

Diagnosis of gxmshot woxmd of abdomen by rectal insufflation with hydro- 
gen gas, with reports of cases 253 

of injuries of gastro-intestinal canal in penetrating woxmds of 

abdomen by rectal insufflation with hydrogen gas 215 

of obscure abdominal tumors by inflation with hydrogen gas. . 252 



INDEX. 261 

Paox 

Diagnosis of perforation of stomach by inflation with hydrogen gas 252 

of wounds of the stomach by inflation with hydrogen gas, with 

report of case 249 

Diastaltic force, resistance of gastro-intestinal canal to. Experiments. . . 231 

Directions for preparing deoalcifled l^one-plates 179 

Disinvagination 95 

Distention of colon with flnids in intestinal obstruction 8 

of gastro-intestinal canal by rectal insufflation of hydrogen 

gas. Experiments 238 

DiverticTilmn, laparotomy in strangulation by * 57 

Strangulation by 110 

Strangulation from Meckel's 115 

Dnodennm, diagnosis by inflation with hydrogen gas of nicer of . 252 

Dynamic intestinal obstruction caused by suspension of peristalsis 184 



JllNTEREOTOMY 54 

Experiments . .^ 158 

Stenosis by partial. Experiments \ 146 

Enteritis, catarrhal and ulcerative 187 

Entero-lithiasis 62 

Enterotomy in intestinal obstruction 22 

in invagination 90 

Enterorrhaphyt circular 166 

Experiments 170 

Examination, intra-abdominal, in laparotomy 86 

Excision of colon. Experiments 161 

Experimental Oontribution, treatment of intestinal obstruction 141 

Experiments, Adhesion 199 

Chemical irritation of serous surfaces 208 

Circular enterorrhaphy 170 

Colo-rectostomy 198 

Distention of gastro-intestinal canal by i^ectal insufflation of 

hydrogen gas 283 

Enterectomy 158 

Excision of colon 161 

Flexion 149 

Force necessary for rectal inflation of entire alimentary 

canal with hydrogen gas 229 

Force necessary to overcome resistance of ileo-csBcal valve . 227 

Foreign bodies 68 

General remarks on 144 

Heo-colostomy by implantation 189 

Heo-oolostomy by lateral apposition 192 

Heo-colostomy by perforated plates 195 

Ileo'-rectostomy w 197 



262 INDEX. 

Pagb 

EzperimentB, Inflation of alimentary oanal through 8tomaoh*tnbe 226 

Innoenity of hydrogen gas in contact with living tissues. 

Experiments 288 

Intestinal anastomosis 44 

by jperf orated plates in jejnno-ileos- 

tomy 186 

by sntores in Jejnno-ileostomy 183 

Invagination 162 

' Mechanical obstruction 186 

Nothnagel's test 172 

Omental grafting 206 

Permeability of ileo-C8Boal valve 167, 221 

Physiological exclusion 168 

Rectal insufflation of air 222 

Rectal insufflation of hydrogen gas in diagnosis of' gunshot 

wounds of abdomen 239 

Resistance of gastro-intestinal canal to diastaltio force. . . . 231 

Stenosis by circular constriction 147 

by partial enterectomy 146 

Transplantation of omental flap 173 

Traumatic irritation of serous surfaces 200 

Volvulus 99, 161 

Perforated plates (not bone) 178 

Exploration, manual, by rectum in intestinal obstruction . . . . ^ 18 

Exventration 188 



F. 



MCES, Intestinal obstruction from retention of 76 

Flexion as a cause of intestinal obstruction 104 

Experiments 149 

of intestine, laparotomy in 68 

Force necessary for rectal inflation of entire alimentary oanal with 

hydrogen gas. Experiments 229 

to overcome resistance of ileo-c8Bcal valve. Experiments. 227 

Foreign bodies. Experiments 63 

Treatment of 70 

Frequency of intestinal obstruction , 6 

(j^LL-STONES, Impacted 62 

Gastro-enterostomy, intestinal anastomosis in. Experiments 180 

Gastro-intestinal canal, distention of, by rectal insufflation of hydrogen gas. 

Experiments ^ 283 

injuries in penetrating wounds of abdomen. Diagnosis 

by rectal insufflation of hydrogen gas 216 

Grafts, Omental 60 

Experiments 206 



INDEX. 263 

Paqb 
Ounshot wound of abdomen. Diagnosis by rectal insufflation with hydro- 
gen gas, with reports of oases 253 

Beotal insufflation of hydrogen gas in diag- 
nosis of. Experiments 239 



H: 



.EBNIA, Strangulated, Anastomosis in 52 

Heusner 68, 136 

Hydrogen, rectal insufflation of snlphnretted 221 

Hydrogen gas, Diagnosis of gunshot wound of abdomen, by rectal insuffla- 
tion of — ^with reports of cases 258 

Obscnre abdominal tumors by inflation with . . . 252 

Perforation of stomach by inflation with 252 

Distention of gastro-intestinal canal by rectal insufflation 

of. Experiments 233 

Force necessary for rectal inflation of entire alimentary 

canal with. Experiments 229 

Inflation in diagnosis of wounds of the stomach, with report 

of case 249 

Innocuous in contact with living tissues. Experiments . . 238 

Method of rectal insufflation of 244 

Rectal insufflation of. Conclusions 247 

in diagnosis of gunshot wound of 

abdomen. Experiments 239 

in diagnosis of injuries of gastro- 
intestinal canal in penetrating 

wounds of abdomen 215 

in intestinal obstruction 12 

in invagination 88 



I 



LEO-C.92CAL valve. Force necessary to overcome resistance of. Experi- 
ments 227 

Permeability of 218 

Permeability of. Experiments 157, 221 

Heo-colostomy by implantation. Experiments 189 

by lateral apposition. Experiments 192 

by perforated plates. Experiments 195 

Heo-rectostomy. Experiments 197 

Illustration. Intestinal anastomosis 218 

Modification of Jobert's suture 213 

Impacted gall-stones .' 62 

Implantation in ileo-colostomy. Experiments 189 

Incision in laparotomy 34 

Indications for operation for intestinal obstruction 143 

Inflation of alimentary canal through stomach tube. Experiments 225 



264 INDEX. 

Pasi 
Inflation with hydrogen gas in diagnosis of obsonre abdominal tumors. . 252 

perforation of the stomach. . 252 
wonnds of the stomach. Oase. 249 

Innocoity of hydrogen gas in contact with living tissues. Experiments. 238 

Insufflation, Rectal, of hydrogen gas in intestinal obstruction 12 

Invagination 88 

Intestinal Adhesions, laparotomy in 58 

Anastomosis 48, 177 

by perforated plates in Jejnno-ileostomy. Experi- 
ments 185 

by sntnres in Jejxmo-ileostomy. Experiments .... 183 

Experiments 45 

Illustrations 213 

in gastro-enterostomy. Experiments 180 

in invagination 95 

in pyloric stenosis 50 

Operation 48 

Concretions 72 

Flexion, laparotomy in 58 

Obstmction, Abdominal section in 27 

after laparotomy 107, 109 

after ovariotomy 59, 107, 109 

after pelvic peritonitis 109 

Anatomico-pathological forms of 62 

Artificial 146 

Oolotomy in 25 

Oompression of abdomen in 22 

Oonclusions 208 

Definition of 4 

Distention of colon with fluid in 8 

Enterotomy in 22 

Experimental contribution to treatment of 141 

Flexion and adhesions as a cause of 104 

Frequency of 5 

from ascarides 74 

from invagination 78 

from retained faeces 76 

from round worms 75 

from suspension of peristalsis 134 

from tumors 127 

Indications for operation 143 

Irrigation of stomach in 6 

Manual exploration by the rectum in 18 

Parasites as a cause of 74 

Puncture of intestine in 20 

Bectal insufflation of hydrogen gas in 12 



INDEX. 265 

Pagb 
Intestinal Obstmotiont Bisks in operation for 144 

Surgical resooroes in <. 6 

Snrgioal treatment of 1 

Taxis and massage in 19 

Tnbage of colon in 16 

Intestine, Inyagination of small — ^into reotmn 79 

Pnnotnre of, in intestinal obstruction 20 

Intestines, resistance of small — to diastaltic force. Experiments 232 

Intra-abdominal examination in laparotomy 86 

Intussusception, laparotomy in 92 

Invagination, Age of patients 83 

Anatomical location of 78 

Colotomy in 89 

Enterotomy in 90 

Experiments 152 

Intestinal anastomosis in 95 

Intestinal obstruction from 78 

Laparotomy in 91 

Mortality of 83 

of colon into rectum 81 

of small intestine into rectum 79 

Pathology of acute 83 

Pathology of chronic 86 

Rectal insufflation of hydrogen gas in 88 

Resection in *. 96 

Treatment of 87 

Tumors as a cause of 80 

Irrigation of stomach in intestinal obstruction 6 

Irritation, chemical, of serous surfaces. Experiments 203 

traumatic, of serous surfaces. Experiments 200 



J 



EJXJNO-ILEOSTOMY, Intestinal anastomosis by perforated plates. 

Experiments 185 

Intestinal anastomosis by sutures. Experiments 188 

Jobert's Suture, Author's modification of 167 

Author's modification of. Illustration 218 



K: 



ROENLEIN : 131 

Ktlmmell 32, 34, 39 



L 



jAPARO-ENTEROTOMY 64 

Laparatomy, After-treatment 61 

AnsBsthesia in 33 



266 nrDEH. 

Paob 
Laparotomy in fleXiOn of inteBtlne •••••••*••••«• 68 

in intestinal adhedonB 68 

in intestinal obatrnotion 27 

in intnssosoeption 92 

in inyagination 91 

in strangulation by band or diyertionlimi 59 

Incision in 84 

Intestinal obstniotion after 107, 109 

Intra-abdominal examination in 86 

Preparations for 82 

StatistloB of 28 

Leichtenstem 6, 66, 78, 88, 85, 87, 98, 152 

Lneas , 10, 219 



M, 



ADELUKO 8, 84, 88, 56, 127, 167 

ICalignant Stenosis 127 

Tnmors 129 

Mannal exploration by rectnm in inteitinal obatrnotion 18 

Massage, taxis and, in intestinal obatrnotion 19 

Maydl 25, 124 

Mtehanioal obstmotion 184 

Experiment 185 

Meckel's diyertioalnm, strangnlation from 115 

Method of rectal insufflation of hydrogen gas 244 

Modification of Jobert's suture. Author's 167 

Illustration 213 

Mortality of invagination 83 



N. 



ON-MALIGNANT Stenosis 121 

Tumors 128 

Nothnagel's test. Experiments 171 



a 



^BALINSKI 34, 105, 112, 188 

Objections to Ozemy-Lembert sutures 167 

Omental flap, transplantation of 172 

Grafting. Experiments 205 

Grafts 60 

Operation for intestinal anastomosis 48 

for intestinal obstruction, indications for 148 

for intestinal obstruction. Bisks 144 

Operative treatment of obstruction 48 

Ovariotomy, intestinal obstruction after 59, 107, 109 



R 



INDEX. 267 

Pagk 

ABASITES as a baose of intestinal obstrncjbion ...*.!...,...., 74 

Pathology of aonte invagination 83 

of ohronio invagination 86 

Pelvio peritonitis, intestinal obstrnotion after 109 

Perforated plates, ileo-oolostomy by. Experiments 195 

in jejoiio-ileostomy, intestinal anastomosis by. Expe- 
riments ' 185 

(not bone). Experiments with 178 

Perforation of stomach. Diagnosis by inflation with hydrogen gas 252 

Peristalsis^ suspension of, as a canse of intestinal obstruction 134 

Peritoneal cavity, innocnity of hydrogen gas in. Experiments 288 

Toilette of 60 

Peritonitis 136 

Intestinal obstrnotion after pelvio 109 

Permeability of ileo-csBcal valve 218 

of ileo-089oal valve. Experiments 157, 221 

Physiological exclusion by anastomosis 52 

Experiments 168 

Plates, ileo-oolostomy by perforated. Experiments 195 

(not bone). Experiments with perforated 178 

perforated, in jejnno-ileostomy, intestinal anastomosis by. Experi- 
ments 185 

Preparation of decalcified bone , 179 

Pleural cavity, innocuity of hydrogen gas in. Experiments 239 

Pregnancy, volvulus in 102 

Preparation of decalcified bone-plates 179 

Puncture of intestine in intestinal obstruction 20 

Pyloric stenosis, intestinal anastomosis in 50 



R 



EOTAL infiation of entire alimentary canal with hydrogen gas. Force 

necessary for. Experiments 229 

Insufflation of air. Experiments 222 

of hydrogen gas. Conclusions 247 

of hydrogen gas. Diagnosis of gunshot wound of 

abdomen by — with reports of cases 253 

of hydrogen gas. Distention of gastro-intestinal 

canal by. Experiments 283 

of hydrogen gas in diagnosis of gunshot wounds 

of abdomen. Experiments 239 

of hydrogen gas, in diagnosis of injury of gastro- 
intestinal canal in penetrating wounds of 

abdomen 215 

of hydrogen gas in intestinal obstruction 12 

of hydrogen gas in invagination 88 

of hydrogen gas. Method of 244 



268 INDEX. 

Paov 

Beotal faBnfflation of BQlphnretted hydrogen 221 

Beotam, inyagination of colon into 81 

Invagination of small intestine into 79 

Manual exploration by, in intestinal obstrootion 18 

Remarks on experiments 144 

Beseotion in inyagination , 96 

Resistance of ileo-csocal TalTe. Force necessary to OTercome. Experi- 
ments 227 

of gastro-intestinal canal to diastaltic force. Experiments. . . 231 

Risks of operation for intestinal obstrnotion 144 

Round worms, intestinal obstrnotion from 76 

Rydygier 94 



s, 



lAROOMA 129 

Serons surfaces, chemical irritation of. Experiments 208 

Tramnatio irritation of. Experiments 200 

Small intestines, resistance of, to diastaltic force. Experiments 232 

Statistics of laparotomy 28 

Stenosis, acquired or cicatricial 128 

by circular constriction. Experiments 147 

by partial enterectomy. Experiments 146 

Malignant .' 127 

Non-malignant, congenital 121 

Pyloric, intestinal anastomosis in *. . . . 60 

Stomach, diagnosis by inflation with hydrogen gas of ulcer of 262 

Inflation with hydrogen gas in diagnosis of wounds of, with 

report of case 249 

Irrigation of, in intestinal obstruction 6 

Perforation of, diagnosis of by inflation with hydrogen gas 262 

Resistance of, to diastaltic force. Experiments 231 

Tube, inflation of alimentary canal through. Experiments 226 

Strangulated hernia, anastomosis in 62 

Strangulation by band or diverticulum, laparotomy in 67 

by ligamentous bands or diverticula 110 

• by vermiform appendix 114 

from MeokePs diverticulum 116 

Subcutaneous cellular tissue, innoouity of hydrogen gas in. Experiments 239 

Sulphuretted hydrogen, rectal insufflation of 221 

Surgical resources in intestinal obstruction 

Treatment of intestinal obstruction 1 

Suspension of peristalsis as a cause of intestinal obstruction 134 

Suture, Author's modification of Jobert's 167 

Modification of Jobert's. Illustration 218 

Sutures, intestinal anastomosis in jejuno-ileostomy by. Experiments... 183 
Objections to Ozerny-Lembert 167 



INDEX. 269 

TPaos 
AXIS and massage in intestinal obstrnotion 119 

Toilette of peritoneal cavity ^ 60 

Transplantation of omental flap 172 

Tranmatio irritation of serons surfaces. Experiments 200 

Treatment of foreign bodies 70 

of invagination 87 

of Yolynlns ; , 108 

Treves 66, 78, 86, 92, 124 

Tnbage of colon in intestinal obstrnotion 16 

Tomor as a cause of invagination 80 

Tumors, intestinal obstruction from -. .* 127 

Malignant 129 

Non-malignant 128 

Obscure abdominal, diagnosis of, by inflation with hydrogen gas 252 
Tympanites 184 

U LOERATIVB enteritis 187 

Ulcer of stomach or duodenum, diagnosis of, by inflation with hydrogen 

gas 252 

Volvulus 98 

Experiments 99, 151 

in pregnancy 102 

Treatment 103 

VV OUKDS, gunshot, of abdomen. Diagnosis of, by rectal Insufflation 

with hydrogen gas, with reports of cases 258 

of the stomach. Diagnosis of, by inflation with hydrogen 

gas, with report of case 249 

penetrating, of abdomen. Diagnosis of, by rectal insufflation 
I of hydrogen gas, of gastro-intestinal injuries in 215 



i 



LANE MEDICAL LIBRARY 



To avoid fine, this book should be returned on 
or before the date last stamped below.