Chapter XLVIII: The Small Intestines (2)

14. =Postoperative Obstruction.=--Finally cases of postoperative obstruction are met with in a way to bring disappointment and disaster when everything else has seemed favorable, and constitute a clinical type without any distinct pathological foundation. Most of them are due either to some form of paralytic ileus, or else to local or general peritonitis with its combined sequels of paralysis and adhesion by the gluing of portions covered with exudate. Some of these cases will justify reopening the abdomen, while in others the condition is absolutely helpless because of the septic element present.

=General Symptoms of Acute Intestinal Obstruction.=--Certain symptoms and signs characterize all cases of acute intestinal obstruction and may be, therefore, included as common to each; consequently they may be considered collectively. The cardinal indications are _pain_, _vomiting_, _constipation_, _distention_, and _collapse_.

_Pain_ may be the first indication, and usually is so in invagination, volvulus, and mechanical obstructions generally. It is usually of violent paroxysmal character, continuing at least during the earlier stages, rapidly wearing away the patient’s strength, diminishing as distention increases and nerve endings become paralyzed.

_Vomiting_ is an early or late feature, according to the portion of the alimentary canal obstructed. The more prompt its occurrence presumably the higher in the small bowel the defect. In consequence of the remedies usually administered it will be found that when nothing but stomach contents are ejected it is easier to produce fecal evacuation from below, while the greater the difficulty in securing a return from the lower bowel the lower the obstruction and the more likely the vomited material to become fecal in character. Vomiting once begun is usually continuous until relief is afforded or the patient utterly exhausted.

_Constipation_ or obstipation sooner or later characterize these cases. The tenesmus of intussusception, with the passage of bloody mucus, which may occur in this form, or in volvulus, for instance, does not imply that the bowel itself is not obstructed, nor does the emptying of the larger bowel of an accumulated load necessarily imply that the fecal stream is in motion. Even the passage of flatus usually is promptly shut off, and it is the gas which forms and cannot escape that produces the distention.

_Distention_ gradually becomes excessive, the abdomen becoming ballooned and extremely tympanitic on percussion, while its surface becomes shiny because so stretched. This _meteorism_ is in large degree due to the formation of gas within the bowel proper, but is permitted by the additional features of paralysis of intestinal muscle and weakening of that of the abdominal wall. As it increases the diaphragm is pressed upward and respiration is much impeded, while even the bladder may be compressed below. It affords another reason why fluid which is taken into the stomach is quickly ejected.

Characteristic _collapse_ comes on more or less promptly, according to the nature of the exciting cause, and the date of its occurrence is in some degree an index of its violence.

In dealing with obstructive cases any history that may bear upon the conditions, as of previous peritonitis, appendicitis, of so-called dyspepsia which might indicate gallstone disease or gastric ulcer, or of pelvic conditions which might indicate pyosalpinx or the like, should be obtained. The manner of onset should be learned, whether acute or gradual, with the relative date of the occurrence of pain, vomiting, and stools, along with their character, if there be anything distinctive therein. Past and present history being secured, the most methodical examination of the body should be made, including the physiognomy and general conditions, the attitude (_e. g._, whether the knees are drawn up, whether the patient is able easily to turn), the type of respiration, and the amount of restlessness. The character of the abdominal movements during respiration should also be noted, as well as the presence of any prominence or the indications of violent peristalsis. By palpation the degree and location of greatest tenderness, the presence of muscle spasm or of tumor may be learned. _Careful examination of all the ordinary hernial outlets_ should be made and the rectum and vagina explored. Revelations thus obtained may also prompt a careful physical examination of the chest. Percussion will show the presence of free or localized fluid or gas, while localized dulness may denote a loop of intestine distended with fluid or impacted feces. Auscultation will enable the surgeon to hear the sounds produced by violent peristalsis or to note the absence of movement within the bowel. A study of the temperature and the pulse may reveal much in certain cases, especially the inflammatory, and particularly in appendicitis, while the urine may be examined for indican, and a differential blood count made.

_Meteorism, constipation, and fecal vomiting of themselves indicate acute obstruction_, but furnish no aid as to the nature of the exciting cause. They are, however, sufficient to indicate the wisdom of immediate intervention.

Pathologically every case of intestinal obstruction has an interest of its own. _Surgically, however_, they are readily grouped _as a class of cases in which operation should always be performed early_, inasmuch as it offers the better prospect of relief and in which death is the inevitable spontaneous termination. It can scarcely be imagined how a more distressing case than an acute strangulation can be allowed to go to its fatal termination without being offered the prospect of a judicious operation, if only performed early. The disfavor with which operation is received by the general physician, as well as by laymen, is due to the fact that too much time is wasted with futile drug treatment, and that the golden hours when surgical intervention might save are allowed to pass unutilized. Of most of these cases it may be said that dying after operation they have died _in spite of it rather than in consequence of it_.

This is particularly true with intussusception and volvulus in young children or infants. Within six hours, in such cases, the harm which may be done is necessarily fatal, and to keep them for a day or more, dosing them with cathartics or making strenuous efforts to relax invagination, is to deprive them of the only measure which offers them any chance. The disrepute into which operative treatment of these cases has fallen in certain quarters is due, then, solely to the fact that the physician does not call the surgeon early, because there is a time in the history of nearly every one of them when it could be saved were mechanical relief afforded.

=Treatment.=--There are certain cases of obstruction by fecal impaction or lodgement of enteroliths which may be successfully treated by internal or non-operative means. Could these always be diagnosticated it would be known when not to operate. But to wait until paralysis of the bowel has occurred, or gangrene due to stasis, or perforation have taken place, or septic peritonitis has set in, is to wait far longer than circumstances justify and reflects on those responsible for the delay rather than on the operator or the operation. In general terms, _acute intestinal obstruction is always a surgical disease_.

It is not necessary to wait for accurate diagnosis--_recognition of the existence of obstruction alone is all that is required_. Conditions rapidly aggravate themselves, and strength is rapidly lost, if we wait for more than distinctive symptoms. _There is no palliative treatment save operation, and the drugs and other harsh measures which are often prescribed serve to intensify and aggravate rather than to relieve._ Anodynes given, though administered with the most humane intent, serve only to mask conditions and lead to delay.

Exploration once resolved upon, careful judgment must decide as to where to place the incision. If local indications be present they may be followed. If there be good reason to believe that the original cause was an acute appendicitis, then the incision may be placed upon the right side. In the absence of all indications the surgeon operates most safely in the middle line by an incision below, above, or around the umbilicus, as circumstances may indicate. Edema of the subserous tissue or of the abdominal muscles indicates the presence of pus beneath. Peritoneum should be sought and opened with care, as in the presence of much distended bowel injury to the same may easily occur. The opening once made the operator will be embarrassed from that time until the conclusion of the operation by the distention of the bowels--at least those above the obstruction, and by their being constantly in the way. If a mechanical cause for obstruction be found it will be noted that the intestine above is more distended than that below, which latter may be collapsed and apparently smaller than natural. Thus if a constricting band be found, or an internal hernia, the removal of the obstructing cause will permit of prompt restoration of equal gaseous pressure between the parts above and below.

Scarcely any surgical emergency requires wiser discretion than do cases of this kind. Bands may be double ligated and divided, kinks straightened out, twists untwisted, invaginations withdrawn, if this be possible by reasonable effort. On the other hand the surgeon should be prepared to find bowel which has apparently lost its vitality or is actually necrotic, either for a few inches or for several feet, and he will soon realize that to leave such gangrenous masses within the abdomen is to accomplish naught, while to remove them is to subject the patient to a procedure longer and more severe than he can bear. He must, then, decide whether to close the abdomen for form’s sake and let the patient die a natural death, or whether to undertake the risk of resection, or perhaps to leave a considerable portion of the intestinal canal upon the outside of the body, opening it and establishing an artificial anus in the hope that the sloughing portion may be cast off, and that the artificial anus, having served its purpose, may be subsequently closed by another operation. Such cases live, though not very often. Here, perhaps as often as anywhere, can be seen the most desperate expedient succeed and the most trifling measure fail.

Another question is what to do with distended and paralyzed intestine, especially when it appears impossible to restore it to the abdominal cavity. Paralyzed as it is, it is almost too much to hope that it may recover its tone, and distended as it is, it is practically unmanageable. To open it at one point would be to empty several loops, at least of gas and probably of fluid fecal matter, all of which will help. One cannot but reflect on the toxic nature of all fecal matter so retained and feel that could it all be evacuated the patient would, other things being equal, be in vastly better condition. And so operators have often made openings, taking all possible precautions to prevent contamination, and have not only evacuated a considerable length of the intestinal canal, but, as suggested by Mixter and others, have washed it out.

A more perfect method, however, of accomplishing this purpose has been suggested by Monks, of Boston, in the use of a large glass tube, from twenty to twenty-four inches in length, strong and with smooth ends. He has shown how, an opening having been made, say just above the obstruction, it is possible by manipulating the bowel with gauze pads to draw it over the tube (as shown in Fig. 563), to an extent of several feet, and to thus more completely evacuate it than could be accomplished in any other way. Monks is undoubtedly entitled to priority for this suggestion over Moynihan, who has elaborately figured and described it. All in all this permits better management and more complete effect than any other method. The bowel having been emptied, the opening is closed by the usual double row of sutures and is then easily dropped back into the abdominal cavity. Cases occur where this procedure might be carried out at two different points, say above and below the obstruction.

Method of inserting a tube (through an enterostomy opening) a considerable distance into the intestine by drawing the intestine around it with the help of a piece of dry gauze. The tube used in this case has a curved extremity, the opening being on the concavity of the curve. It is shown entire at the lower left corner of the illustration. The longer the abdominal incision and the longer the tube the greater the length of intestine which may be drawn upon it and emptied of its contents. (Monks.)]

What may be done with the obstruction produced by local and septic peritonitis, such as is especially seen in acute cases of cholecystitis, appendicitis, and pyosalpinx? Here the surgeon deals not only with twisted, kinked, and obstructed bowel, tensely distended, but with much infected lymph and perhaps a collection of pus and a gangrenous appendix. Such a condition becomes appalling and every such case should be dealt with upon its merits. Any collection of pus should be evacuated and drained, and it must then be decided whether to endeavor to withdraw entangled loops, disengage and straighten them out, or to be content with an artificial anus for temporary purposes, the latter often being the safer course, even though it may lead to a tedious convalescence and the necessity for subsequent operation. It might even be advisable to evacuate pus and remove a sloughing appendix, if it were easily found, and then make an enterostomy, opening at some other point, in order to keep the two procedures and fields of activity quite distinct.

A case may occasionally be seen where the question of affording some relief is paramount to every other consideration, and where, at the same time, the patient’s condition is such as to make anything extra-hazardous. I have saved life under conditions of this kind by making a simple enterostomy under cocaine, the intent being only to attach a loop of distended bowel to the parietal peritoneum and to open it then or a little later, thus establishing an artificial anus. This may be done with local cocaine anesthesia. I have even seen the fecal fistula thus produced close spontaneously in the course of time, and, while the exact character of the lesion was never known, have had the satisfaction of thus saving a life which I believe would otherwise have been lost.

One of the most unfortunate accidents that can occur during operation for acute obstruction is to have the patient practically drown in his own fecal vomit. This may occur either on the operating table or soon after leaving it. The term implies simply this--that there is regurgitation of fecal matter into the stomach, and that as this is ejected by a patient in his unconscious condition he is not able to prevent its aspiration into the trachea, with the occurrence of all that essentially constitutes drowning. Even a few ounces of fluid material drawn into the lungs, under these circumstances, would be sufficient to cause asphyxia and death.

The accident is to be prevented not alone by _lavage_, both before and at the conclusion of the operation, but by placing the patient upon his side in such a way that any gush of fluid into the mouth may escape from it and not be sucked into the lung. The amount of fluid that may arise is sometimes astonishing. The introduction of harmless fluid, under these circumstances, would be sufficient, but the entrance into the lungs of a viscid, offensive, and septic fluid, even in small quantity, would quickly serve to induce a septic pneumonia if nothing else. The accident once having occurred, resuscitation is almost impossible. Under the relaxation of anesthesia it may occur without outcry and almost unsuspected, and with the patient on his back, death may be determined even before the attendant has noticed anything particularly wrong. To prevent this accident tubes have been devised having balloons around them which can be inflated with air, to the desired degree, and the esophagus thus be plugged.

Hence it will be seen that the surgeon should temper his measures to the condition of the case, its exigencies and its surroundings. Operation, therefore, may be exceedingly mild or exceedingly severe, taxing the resources of the best-equipped clinic.

Strangulations recognized from surface indications are usually dealt with according to standard indications. Those discovered only after abdominal section are to be dealt with each on its merits.

CHRONIC OBSTRUCTION OF THE BOWEL.

The expressions of chronic obstruction are essentially those of acute, in which they usually terminate, occurring meantime in milder degree. Their causes are nowise different from those tabulated above.

=Symptoms.=--The symptoms of chronic obstruction are those of intermittent colic, constipation, perhaps with local tenderness, with change in shape of the abdomen due to the primary cause or to intestinal distention, and in many instances with some characteristic appearance or shape of the feces. Thus the stools are often loose, or scybalous masses when removed by cathartics, and these are followed by diarrheal stools containing many gaseous bubbles. Obstruction of the lower bowel will frequently cause the hardened fecal masses to assume a tape-like shape. With increasing obstruction there is increasing severity of symptoms, until finally they become acute.

=Treatment.=--The treatment of chronic obstruction is also operative, either radical or palliative. When the exciting cause can not only be detected on exploration but removed, it should be radical. If, however, this be not possible then enterostomy or entero-anastomosis only can be practised. Thus in cancer of the rectum or sigmoid, colostomy is the last resort. In cancer of the bowel above the sigmoid anastomosis may relieve the obstruction and permit the patient to linger until he dies of the natural progress of the disease.

Here, as elsewhere, operation should not be too long delayed. To wait for a chronic obstruction to merge into one of the acute forms, and then to wait until the patient is moribund, is to have deliberately deprived him of that which otherwise might have prolonged his life.

For chronic obstruction whose cause is not easily revealed the hypothesis of cancer affords the most common explanation. This may be intrinsic or extrinsic, so far as the bowel itself is concerned, the results however not differing. It matters but little whether cancer is producing an annular stricture or involving a considerable extent of bowel, something should be done. When health has gradually failed, and obstructive symptoms have come on slowly, and when distinct cachexia is present the presence of cancer within the abdomen may be suspected. When a distinct tumor is palpable or when the abdomen gradually fills with fluid there is little doubt. When to these signs is added _pigmentation of the abdominal wall_ the diagnosis may be considered certain. Even now exploratory section is justified, in the hope that some operative measure may offer comfort and at least temporary relief.

On the other hand, when obstructive symptoms appear and increase without the accompaniment of other serious indications, it may be hoped that the condition is benign rather than malignant. Obstruction with ascites may possibly be due to _tuberculous_ lesions, which are not uncommon, especially in children. The recognition of enlarged mesenteric nodes would corroborate this diagnosis. A history of typhoid fever or of injuries or foreign bodies might confirm the theory of cicatricial stenosis. The possibility of enteroptosis of the colon and impaction of hardened fecal matters should not be disregarded and that of enteroliths, especially gallstones, not forgotten.

FECAL FISTULA; ARTIFICIAL ANUS.

A fecal fistula implies any communication between the intestinal tract and the exterior of the body or one of its other cavities. Thus it is possible to have a _rectovaginal_ fistula as well as a vesicovaginal. In rare instances we may meet also with intestinal communication with the bladder, the other viscera, or even the pleura or lungs.

Fecal fistulas are always abnormal productions, and result either from congenital causes, previous injury, or disease. Among the traumatic causes may be mentioned penetrations or ruptures of the intestines, injuries to the bowel occurring in the course of abdominal operations (for instance, the inclusion of some part of the bowel wall within a ligature or suture), while the pathological causes include the possibilities of perforation of any form of ulcerative lesion, cancer, actinomycosis, or the secondary sloughing which may follow appendicitis, or even the pressure of a drainage tube. Fistulas result also from escape of foreign bodes (for instance enteroliths or bone fragments), which may work their way into some other viscus, or out through the abdominal wall to the body surface. Old pelvic and abdominal abscesses also occasionally cause perforation and fecal fistulas. These fistulous tracts may be long or short, and direct or indirect. They may also permit the escape of a large amount of fecal matter or the smallest appreciable amount. The majority of them tend to close spontaneously in the course of time, but this time is sometimes so prolonged that a surgical operation is preferable to waiting for natural processes. The communications may be high in the intestinal canal. In such a case matter that escapes will be but partially digested and will have the character of chyme rather than of feces; and patients suffer in consequence, as products of digestion are not complete and opportunities for absorption have been too limited, and they are deprived of all that should normally happen further along in the bowel. In such a case there is temptation to operate much earlier than is advisable. Another form of fistula results from certain cases of strangulated hernia, in consequence of necrosis of the strangulated loop of bowel. In fact this is true of any of the mechanical causes of acute obstruction, where this expedient may be resorted to under compulsion and we produce a fistula as an emergency measure.

The difference between intestinal or fecal fistula and artificial anus is that the former is an undesirable and untoward event, whereas the latter is deliberately produced by operation practised for the purpose. _Artificial anus_ is in the main limited to cases of cancerous or other hopeless or inoperable obstruction of the lower bowel, and in such case is purely a palliative measure. It is made occasionally at the upper end of the colon in order to give a diseased colon physiological rest and permit of more perfect irrigation of that tube, the intent being to later close the opening. It is an inevitable emergency measure in certain cases of acute obstruction, where the patient is in no condition to bear anything more extensive or prolonged.

The operation for making an artificial anus, usually referred to as _enterostomy_ or _colostomy_, will be described below.

Fecal fistulas should be treated largely according to their causes; when they are the product of actinomycotic or cancerous disease little can be done, and perhaps nothing should be. On the other hand, when resulting from traumatism, from sloughing of some portion of the bowel, or from strangulation, much can be accomplished.

A small, fistulous tract should be kept clean and stimulated occasionally with silver nitrate or something of the kind, and perhaps by introducing into it every day a small piece of gauze, which provokes the granulation process as well as fills the opening. It is bad practice, however, to simply close the outer end and let the lower portion distend with feces. Much will depend upon whether it now connects with the bowel. This may be determined by injecting into the fistula some methyl blue and then noting the subsequent stools. When communication with the bowel is evidently free the surgeon may feel like making a deeper operation, perhaps with intestinal suture or even intestinal resection, whereas if there be little or no actual fecal leakage it may be sufficient to enlarge the outer end of the fistula, to thoroughly scrape it with the sharp spoon, and then, lightly packing it, see it close with granulations. A passage-way which is exceedingly short may be treated by simple superficial plastic operation, including freshening of the entire margin of the opening and the passage around it, and a purse-string suture, with or without a circular incision of the skin. By drawing this suture tight the external opening may be closed. This is a neat way in which to dispose of a small fistulous opening resulting from a previous enterostomy or appendicitis operation.

A _rectovaginal fistula_ may be closed by formal operation, similar to that for closure of a _vesicovaginal fistula_, based upon the simple principle of freshening the edges of the opening and then holding them together with suitably placed sutures. A rectovesical fistula would, in most instances at least, require a laparotomy, with careful separation of the rectum from the bladder, and then a separate suture of each opening. Such an operation might be quite difficult, made so not by its plan of performance but by the conditions which necessitated it. Any bladder thus attacked should be kept perfectly empty for several days by the use of a self-retaining catheter. Every case of fecal communication with any large abscess cavity, or through the diaphragm, directly or indirectly, as with a bronchus, should be treated on its individual merits, it being a grave question whether operation would be indicated or not.

Certain fecal fistulas will justify more formidable operation, in which, after opening the abdomen and carefully protecting its contents against contamination, the adhesions should be separated entirely and that portion of the bowel which is involved removed, making either an end-to-end suture or a lateral approximation. If this be done it will be best also to completely excise the old fistulous tract through the abdominal wall, and to remove everything that was involved in the previous condition.

It is possible to atone for almost every opening of this character, save those produced by some seriously malignant disease. If such a condition be the result of cancerous extension then it is practically hopeless.

OPERATIONS UPON THE INTESTINE.

=Intestinal Suture.=--Intestinal suture is by no means a new or modern operation. It was spoken of by the ancient writers and was evidently practised in the middle ages by the “Four Masters” of the School of Salernum and their followers. But until it was reduced to a science by the French surgeons, Jobert and Lembert, during the first quarter of the past century, it was always a hazardous measure. Success with intestinal suture depends upon exact hemostasis of the edges to be united and their accurate approximation in layers (_i. e._, mucosa to mucosa and serous and muscular coat to its like). Save when haste compels, this accurate application is effected by two distinct suture rows, the first or deeper (of hardened gut) made to include the mucosa alone, the suture being usually continuous, but knotted at intervals, with stitches close together and drawn tightly to amply secure against leakage from the relatively large vessels of this membrane. It is better to apply this row by itself, as any suture drawn through the mucosa and out again through the serous coat is liable to contaminate the latter, it being much better to keep the contaminated row of sutures distinct. The first row having been applied and the surface carefully cleansed the operator may then coapt the balance of the annular wound by a continuous row of fine silk sutures, made to include the serous and muscular coats and to avoid the mucosa. The stomach and the colon are sufficiently thick to take a row of rather coarse sutures for this purpose, but most of the small intestine is so thin-walled that these need to be applied with caution as well as with dexterity.

Every row of sutures should be so applied and directed that the lumen of the bowel be not reduced by its presence, it being a serious matter to greatly encroach upon the diameter of the bowel, since obstruction will thereby be favored and extra tension made upon the sutures (Figs. 564 and 565).

Application of the interrupted Lembert suture. (Richardson.)]

The continuous Lembert stitch. (Richardson.)]

So many different forms of intestinal suture have been devised that it is useless to attempt here to describe them all.

Any minute puncture of the bowel may be closed by purse-string suture. Any perforating wound should be not only first carefully cleansed, but also slightly enlarged, cutting away its more or less contused margins in order that fresh, viable tissue may be exposed. This is particularly true of gunshot wounds. Many of the operations now practised include inversion of the end of the bowel, a method illustrated in Fig. 566, showing a method equally applicable to burying the stump after removing the appendix, closing the end of a portion of the small or even the large bowel.

Most operators now use for the mucosa a carefully prepared and reliable chromicized catgut, the smaller size being preferable, with the ends cut short after the knots are tied. It is well also to use for intestinal suture needles which are round rather than made with cutting edges, as by the latter openings are made larger and vessels sometimes cut, this requiring the insertion of extra sutures for their securement. Whether the operator shall use curved or straight needles, and shall do the work with his fingers or depend upon various forms of needle holders, is purely a matter of choice and training. _Success or failure depend not so much upon the needle holder as upon the holder of the needle_, and his care and attention to detail. In the presence of multiple lesions the procedure may have to be repeated to meet each indication.

=Anastomotic Operations.=--For the general application of the principle of anastomosis to intestinal work the profession is largely indebted to Senn. The principle having been once recognized will never be rejected, but methods have already varied much from those first introduced, and will be improved by the substitution of simpler procedures for the more complex.

In general an anastomotic opening may be made between any distinct portions of the alimentary canal, and almost any one part may be thus, as it were, connected up with any other. Gastrojejunostomy has already been described. Only under compulsion does one thus connect the stomach with any other part of the alimentary canal. From the jejunum down to the rectum one may, however, effect attachments of this kind at any desired point. These operations are in the main done for one of the following purposes:

(_a_) In cases of obstruction of the bowel;

(_b_) For the purpose of exclusion of a certain length; or

(_c_) As a substitute for end-to-end reunion, after resection of a
portion of the bowel.

The method of performance will depend not so much upon the nature of the difficulty requiring the operation as upon the condition of the patient, the equipment, and the operative skill of the surgeon. With a patient in extremely serious condition that method which may be most quickly performed is obviously the best. When time and method are under control, then that is best which can be most perfectly performed by the operator, or that which he is compelled to adopt, as when, for instance, he resorts to a suture method because he has no button at hand.

In order to simplify the subject as much as possible the following methods alone will be mentioned here:

The _method by suture_ is essentially similar to that described as gastro-anastomosis, the surfaces which are to be brought together being properly placed, and approximated, first, by a row of silk suture, the openings being then made with excision of a strip of mucosa, and the mucosa being next sutured with chromic gut, first on the further side, then on the near side of the opening, after which the serous membranes are accurately sutured around the opening by continuation of the first row of silk sutures. The actual opening made for the purpose should be at least an inch in length, preferably an inch and a half or more, while when the lower bowel is attached to the colon such an opening may well have a length of at least 2¹⁄₂ inches, for if successful it will be followed by a certain degree of cicatricial contraction and will never remain of its original size (Figs. 566, 567, 568 and 569). The suture may be combined with the _elastic ligature_, the method again being similar to that for uniting the jejunum with the stomach, already described. The rubber ligature used for the purpose is of the same size, and there is no difference to be made in the directions already given. The elastic ligature, however, can not be relied upon in emergency cases where it is necessary to effect a communication at once. It is serviceable only in instances where there is a leeway of at least three or four days. This method has for one of its advantages the fact that in its performance it is not necessary to clamp or secure the bowel by any instrument, simply to empty it for the moment with the fingers, it not being opened during the operation by anything save the needle puncture, which is promptly filled with the rubber. It does require, however, that the rubber used for the purpose shall be reliable and new, it being unfortunately the case that pure rubber which will last for a long time is seldom found in the market.

Entero-anastomosis of intestinal loops which have been resected and the bowel ends closed; the first row of sutures has been applied and the line of opening indicated. (Lejars.)]

Suture of the distal edges of the mucosa.]

Insertion of the last (fourth) row of sutures. (Lejars.)]

Resection of intestine with lateral anastomosis. Posterior suture inserted. The free ends of the bowel inverted and sutured. (Richardson.)]

The button method depends for its success upon a mechanical device of Murphy, known everywhere as the “_Murphy button_,” or upon one of its modifications. Fig. 570 illustrates the component parts of this device, which is made in various sizes and, in fact, in various shapes for different purposes, though the circular forms suffice for practically all cases. In Fig. 572 it is seen in actual use, while Figs. 573 and 574 illustrate the method of its insertion and securement.

The Murphy button.]

End-to-end union of intestine by means of the Murphy button: the two portions of the Murphy button, held in position by purse-string sutures, are ready to be pressed together. (Richardson.)]

Union--end to end--with the Murphy button.]

The underlying principle of the Murphy button is that each half can be inserted separately and that then, by pressing these halves together, an opening is at once afforded from one part of the bowel to the other. If the halves be pressed together with the proper degree of firmness they produce, first, adhesion between considerable areas around their circumference, followed in the course of a few days by a necrosis of the central portion, which sloughs because deprived of its circulation by the pressure. So soon as this separation or sloughing is complete the button drops into the intestinal canal, being completely loosened, and is now carried along by peristalsis and by the fecal current from above, its position shifting as would that of a scybalous mass or a fecal concretion, until it finally emerges from the intestinal tube, being passed from the anus. How soon it will thus appear will depend in large measure upon the point of the intestinal canal into which it is thus intruded. If this be high up it will be slower in appearing. If low down it may be expected sooner. While it usually appears within ten days or two weeks it may, however, be longer retained, and in one case of my own was not passed for three months, although the anastomosis was made with the ascending colon, into which it must have dropped.

Fig. 573 shows one of the halves held in the grasp of a forceps, being inserted into a small buttonhole opening just large enough to receive it, around which there has been passed a buttonhole or purse-string suture of silk. This portion once thus inserted should not be lost within the bowel, it being necessary to retain control of it by the forceps until its application to the other half. Both halves being inserted and brought opposite to each other, as in Fig. 574, the smaller is introduced into the larger, and they are then pressed together until the included serous surfaces are brought into contact, with sufficient pressure inflicted to bleach them, in order that their subsequent necrosis may be ensured. A circular row of sutures should now be placed around the surfaces thus applied, in order to more widely secure them in contact. The procedure being completed in this way, the parts are dropped back into the abdomen and the abdominal wound closed.

Introduction of one-half of a Murphy button. (Bergmann.)]

Intestinal anastomosis with a Murphy button, showing the halves in position ready to be pushed together. (Bergmann.)]

_End-to-end reunion_ can be accomplished by the same method, or the end of the small intestine may be applied to the side of the large, after a method which will be best understood by reference to Fig. 571, it being necessary here to draw the squarely cut end of the intestine around the button with a circular suture, and, at the same time, to so grasp the button that it shall not recede into and be lost in the bowel.

Small buttons have been made for the purpose of uniting the gall-bladder to the upper bowel and extra large ones are made for the large intestine.

The particular advantage of the button method is the shortness of the time required for its performance, as it can be conducted in a few moments by one who might take four times as many minutes in using sutures. The disadvantages attaching to it are these: (1) That it depends for its success upon necrosis, _i. e._, of the part of the bowel included within its grasp; (2) that it might itself serve as a foreign body and produce acute obstruction, a not unknown event; (3) that it is not always at hand, especially in emergency cases, and that to rely upon it is to be limited in one’s abilities.

There is but little question that, when properly performed, the simple suture methods are the best of all, and the operator who has never seen a button used should abstain from its use. Still it has given many good results. My belief is that the better the surgeon’s judgment, and the more developed his skill, the less he will rely upon any mechanical expedient of this character, and the more upon what he can accomplish with the needle in his own fingers.

_End-to-side anastomosis_ is in no essential respect different from resection, only it may be done for the purpose of exclusion when nothing is absolutely removed. Thus in case of cancer of the cecum a lateral implantation can be made of a lower loop of the ileum upon the side of the ascending colon, using for this purpose a button, having divided the ileum on the proximal side of the ileocecal valve, and turned in both ends and invaginated the stumps. Here one resects nothing, but makes a direct communication between the bowel above and below the cancer, short-circuiting the intestinal canal, as electricians would say, and all for the purpose of giving temporary relief. Thus end-to-side or end-to-end anastomosis may be made, according as circumstances dictate, and, if one chooses, with the Murphy button.

_Resection of some portion of the large or small intestine_ is required under a variety of different circumstances. Thus after certain injuries, contusion and rupture, or numerous punctures or gunshot perforations, it may be decided to remove a considerable length of bowel rather than be compelled to give special attention to a number of distinct lesions, believing it a time-saving measure, and, therefore, for the welfare of the individual. The same measure will be indicated when, either by injury or disease, the blood supply of any portion of the bowel is apparently compromised or certainly shut off. Here necrosis is so certainly to be expected, or perhaps has already occurred, in such a way as to necessitate removal of whatever length of bowel may thus be involved. Several of those cases, already mentioned, which produce obstruction of the bowel will demand resection, as, for instance, when reduction of an invagination is impossible, with gangrene threatening. In a few instances extensive gangrene, precipitated by embolism or thrombosis of the mesenteric vessels, has been successfully treated by resection of considerable lengths of bowel. Again, the bowel is resected for closure of fecal fistula or artificial anus, as well as for relief of stricture due to various causes. Finally, nearly all of the tumors of the intestine itself, and especially all of the malignant forms, will require removal of at least a few inches of gut, save in those cases where this is shown to be impracticable because of the presence of cancer elsewhere, in which case it may be sufficient to make an anastomosis.

When intestinal resection is not an emergency measure there should be as much preparation as the case will permit, including lavage of the stomach, the ingestion of sterilized food, the use of antiseptics and the most thorough emptying of the bowel which can be accomplished.[58]

[58] Sanderson has suggested a new method of sterilization of the
interior of the bowel at the time of operation. He injects a solution
of acetozone through a hypodermic needle, or, after opening the
bowel, freely irrigates with the same.

One of the greatest difficulties attendant upon the operation is the avoidance of all contamination by contact of peritoneum with intestinal contents. Against this the most minute precautions should be taken. This is never an easy matter, and in the presence of distended bowels and the emergency of acute obstruction it sometimes taxes every resource at hand. A variety of clamps have been devised by different operators, the intent being to so clasp the bowel beneath their blades as to completely occlude it. These blades are covered with sterilized rubber tubing to keep them from acting too harshly, and it is necessary to use pressure upon the handles with great discretion, lest permanent injury be done to the bloodvessels. The bloodvessels of the bowel are essentially terminal, and the blood supply should be kept sufficient for every part which is not removed. These vessels are, moreover, numerous and relatively large, and hemorrhage is not always easy of control, especially when clamps are not at hand. As a substitute for clamps tapes of sterilized gauze may be used, being tied around the bowel, or the fingers of a reliable assistant may be substituted. Such use of the fingers is not easy nor simple, not only because they become tired and relax their grasp, but since they slip so easily, and because the escape of one drop of fecal matter may cause a fatal contamination.

Resection of the bowel may imply in one case a removal of but two or three inches of its length, while the other extreme is not reached until several feet of bowel have been removed. I have been able to successfully remove eight feet and nine inches of intestine, the lower part including the cecum and a portion of the ascending colon, and there are now on record nearly twenty cases where over 200 Cm. of bowel have been resected, nearly all of them recovering. Success in this procedure depends partly upon the condition necessitating the operation, as well as the general condition of the patient, but in no small measure hangs upon the perfection of the operator’s technique.

End-to-end or circular anastomosis by enterorrhaphy. First row of distal sutures in serosa. (Type of needle differs from that used in this country). (Lejars.)]

Completion of last row of sutures, begun as shown in Fig. 575. (Lejars.)]

Whatever be the condition which requires such resection it should be made sufficiently extensive to completely include and permit the total removal of the diseased or injured portion. The abdominal incision should be large enough to permit the delivery upon the surface of the body of all that portion to be removed. Unless this be done the difficulties are greatly enhanced. Save where there is some distinct indication for opening elsewhere, this incision is made in the middle line. The compromised bowel having been sought and thus delivered and one having decided exactly where to divide it, clamps are so placed both above and below each line of division as to prevent leakage. Underneath the bowel to be thus divided gauze is placed in such a way as to receive the small amount of discharge which will escape from the portion between the clamps. The exposed bowel surfaces should then be thoroughly cleaned, the contaminated gauze removed, fresh pieces substituted for it, and the other division of bowel made in the same way. While in some cases it may be well to tie off the mesenteric border and secure all its vessels before dividing the bowel, this may at other times be delayed until after the division. At all events it is the next step. Whether the mesentery shall be simply separated along the intestinal border and tied off in small portions, one after another, or whether a triangular resection of a portion of the mesentery itself should be made, securing the larger vessels nearer to its root, will depend on the nature of the case and upon whether the mesentery itself be involved in the disease. In dealing with cancer it is often necessary to remove, at the same time, every enlarged lymphatic. It may be inferred that no incision or tear, no matter how short, can be made in these tissues without danger of subsequent hemorrhage unless the parts be secured against it. A series of ligatures and sutures is therefore called for here which may consume no small proportion of the entire time of the operation. (See Figs. 575 and 576.)

All that portion of bowel which has been condemned having been removed and a careful toilet of the parts having been made the surgeon next proceeds to restore the bowel lumen. A V-shaped defect in the mesentery should be united with sutures. The line of former mesenteric border left after removal of bowel should be not only carefully protected with ligatures, but the whole margin should be overcast and so folded in or drawn together in tucks as to make it easy to bring the bowel ends together without undue stress.

FIG. 578

Circular anastomosis of portions of the bowel having different lumina. (Bergmann.)]

The sutures by which the divided bowel is restored should begin at the mesenteric border, and every care should be taken to make the joint at this point absolutely water-tight. Suture methods have been described. To unite bowel ends of the same diameter it is an easy matter to suture together first the mucosa and then the outer layer, so long as the intestine is on the outside of the body and equally accessible on all sides (Fig. 578). The surgeon is sometimes compelled to do this work within the body cavity, as in resection of the rectum for cancer. It may be advisable to first place a row of sutures between the serosa and muscularis on the further side of the margins to be united, then to close the mucosa completely around, and then to finish the outer layer of sutures. So long as differences of size are not conspicuous, end-to-end approximation can be made almost anywhere. When, however, it is necessary to attach small bowel to large, the size of the larger opening should be reduced to fit the smaller, or one or both ends may be closed, turning in the stump, as already described, and then making lateral or end-to-side anastomosis. Any such anastomotic opening should be so placed, and bowel so directed, that there shall be no interference in the direction of the natural bowel stream, failure to observe this precaution producing not only added immediate danger but more or less permanent obstruction (Figs. 579 and 580).

Isoperistaltic lateral apposition.]

Antiperistaltic lateral apposition (bad).]

All that has been said above with regard to the Murphy button and its use in anastomotic operations holds equally good here with regard to its usefulness after resection.

Numerous devices, either instruments for the purpose of holding the bowel together while it is sutured, or of affording substitutes for the Murphy button, have been planned by operators all over the world. There are few of them, however, which give any better results than the simple methods above described, to which I prefer to limit description here because of their very simplicity.

Intestinal suture or any other method of completing the resection having been finished, a careful toilet of all exposed parts should be made, by which bowel may be dropped back into the abdominal cavity and the latter closed without drainage.

The _subsequent management_ of these cases will consist in two or three days’ starvation, in order that peristalsis may be reduced to a minimum, the patient being meanwhile fed by the rectum. Then will come a time when both fluid food, and cathartics a little later, should be gently and discriminately administered. Any satisfactory suture method will rarely give way after forty-eight hours. Buttons, on the contrary, may break loose after many days or even weeks, and this fact affords another argument against their use.

Enterostomy; preliminary fixation of a loop of bowel to the peritoneum. (Lejars.)]

Enterostomy; fixation of margins of opened gut to skin. (Lejars.)]

=Enterostomy.=--Enterostomy for establishment of fecal fistula, or _artificial anus_, is performed for relief purposes and sometimes as an emergency measure. It consists in attaching some portion of the bowel, naturally that above the constriction or disease which compels the operation, to the parietal peritoneum through a small wound in the abdominal wall. When the large intestine is opened for this purpose the operation is usually referred to as a _colostomy_, and this preferably is done in the left iliac region. When enterostomy of the smaller bowel is preferable it may be done at any point on the abdominal surface. Thus if through a median incision a condition be found necessitating it the bowel should be attached at the lower end of the abdominal opening, for here drainage will be better and contamination less likely. When enterostomy is done for acute obstruction, it is preferable to place the opening in one iliac fossa or the other.

Enterostomy consists essentially of the following steps: opening through the abdomen, recognition of the parietal peritoneum, which is seized with forceps on either side, opened and secured with these forceps, after which the first tensely distended loop of bowel which presents is taken, and, with a series of fine sutures in a round needle, the serous surface of the gut is attached to the margins of the parietal peritoneum (Figs. 581 and 582). In the more desperate cases a portion of the bowel may be brought out through the wound and fixed there in such a way that it cannot recede. If the emergency is great the bowel may be immediately punctured, the patient so placed and so protected that fecal contents shall escape away from the body rather than over it. If one can take a little time he may wait a few hours for the adhesion which is sure to take place between the peritoneal surfaces and the consequent shutting off of the abdominal cavity from the outer wound. Thus after twelve hours the surface of bowel exposed through the wound may be punctured either with a knife, scissors, or the actual cautery, and this may be done without causing pain to the patient. Escape of bowel contents will instantly ensue after puncture. After permitting all to escape that will, abundant protection should be provided for the reception of the discharges, which will continue at reduced rate. The best way to do this is to pass into the bowel in the proper direction a rubber tube, as large as it can accommodate, or a glass tube, bent at an angle, which shall connect with a flexible tube, and thus conduct away all discharge.

Another method of performing the operation is to bring out the loop of bowel, open and empty it, then to introduce a glass or rubber tube, around which is snugly fastened the bowel margin. The intestine is then stitched in place and the tube so arranged as to conduct away all discharge.

Just how much may be expected of such a relief opening will depend upon the case. These operations, especially for cancer of the rectum or the lower bowel, may prolong life for two or three years. An emergency opening into the small bowel for relief of acute obstruction may need to be kept open for but a few days, after which the tube may be removed and the fecal fistula be allowed gradually to contract. According to the case an intestinal resection may be made or the opening may be closed by one of the plastic methods.

=Appendicostomy.=--Appendicostomy is the more complete form of carrying out a suggestion first made by Hale White, of opening the colon on the right side in cases of intractable colitis. Gibson suggested to accomplish this by a method similar to Kader’s for gastrostomy, making a valvular colostomy through which the colon might be irrigated, without escape of feces. In 1902, Weir, intending to do this operation, found the appendix rising so invitingly into the wound that the inspiration occurred to him, and was promptly acted upon, to utilize it for the purpose.