INTESTINAL ANASTOMOSIS. 
BY 
ROBERT ABBE, M.D., 
SURGEON TO ST. LUKE’S HOSPITAL, NEW YORK ; CONSULTING SURGEON TO THE 
HOSPITAL FOR RUPTURED AND CRIPPLED ; PROFESSOR OF CLINICAL 
SURGERY IN THE POST-GRADUATE HOSPITAL. INTESTINAL ANASTOMOSIS 
BY 
EGBERT ABBE, M.D., 
SURGEON TO ST. LUKE’S HOSPITAL, NEW YORK; CONSULTING SURGEON TO THE 
HOSPITAL FOR RUPTURED AND CRIPPLED ; PROFESSOR OF CLINICAL 
SURGERY IN THE POST-GRADUATE HOSPITAL. 
TRANSACTIONS OP THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
MAY 8, 1889. 
REPRINTED PROM THE 
PHILADELPHIA; 
WM. J. DORN AX, PRINTER. 
1889. INTESTINAL ANASTOMOSIS. 
ROBERT ABBE, M.D., 
SURGEON TO ST. LUKE’S HOSPITAL, NEW YORK; CONSULTING SURGEON TO THE HOSPITAL FOR RUPTURED 
AND CRIPPLED; PROFESSOR OF CLINICAL SURGERY IN THE POST-GRADUATE HOSPITAL. 
[Bead May 8, 1889.] 
About three years ago a lady came to me from the South with 
a fecal fistula in the right groin, resulting from the sloughing of five 
inches of intestine in a strangulated hernia. Three physicians had 
made intelligent operative efforts to close it, and left her only worse 
off, as the distal end had slipped back and been lost in the abdomen. 
The case was a challenge to surgical skill. During several months I 
made careful and conscientious attempts to cure her. At first, the 
abdomen was opened to search for the distal end; it could not be 
found. Therefore, I stitched the proximal end and the ascending 
colon side by side in the wound, and a few days later opened the 
colon. A permanent channel was thus established between ileum and 
colon, when the fistula was capped, and some movements occurred per 
anum. Dupuytren’s enterotome was then applied, and the spur cut 
through for two and a half inches. Still the big fistula leaked most 
of its contents. 
Two elaborate plastic operations were then done, using the ab- 
dominal skin after the manner of Czymanowski, by which I had closed 
urethral fistulse. But these proved futile, and she remained with the 
usual excoriated abdomen, filthy wound, and marasmus. My colleague, 
Dr. Mcßurney, then tried a partial resection of the edges, with inver- 
sion and suturing, and from this operation she died. 
I have narrated briefly this case to illustrate what you know repre- 
sents a considerable class of sufferers whose fecal fistulse until very 
recently have baffled the surgeon. Such cases rankle in the memory 
of us all, as marking the limit at which successful work comes to a 
halt. To-day, thanks to the untiring energy and genius of Dr. Senn, 4 
ABBE, 
of Milwaukee, such, and many other cases, can be offered the hope of 
immediate relief by intestinal anastomosis. 
The principle of intestinal anastomosis is by no means new. It is 
on the technique of operative procedure only that its appeal to renewed 
favor rests. I need not narrate to you the methods formerly in vogue 
to restore the intestinal canal. Plastic operations, resections with 
circular enterorraphy, and lateral apposition with suturing, have had 
a certain value for many years; the unanswerable objections to them 
all being a dangerous consumption of time, frequent leakage, and 
secondary abscesses. With Semi’s researches, new life has been in- 
fused into this branch of surgery. I will not review his work, but 
remind you for the moment that it covers the ground of the experi- 
mental production of intestinal flexion, volvulus, stenosis, invagination, 
and resection, and in reparative work the study of two methods of 
restoring the intestinal canal—lateral implantation of a smaller into a 
larger gut, and lateral apposition of openings into similar portions of 
bowel. The outcome of it all has been an anastomosis of an inter- 
rupted intestinal canal by the safe and speedy method of using decal- 
cified bone plates for approximation. I believe the value of this 
method will soon be recognized everywhere. His experiments have 
already been repeated by several and the results uniformly verified. 
Those done by Mr. F. B. Jessett and Mr. Victor Horsley, and re- 
ported six weeks since to the Royal Medical and Chirurgical Society, 
are noteworthy, Jessett adds his statistics to those of Senn and 
Curtis, and finds that approximation by the Czerny-Lembert method 
showed a mortality of about 86J per cent, against 25 per cent, by 
the method of lateral implantation, and 7J by means of Senn’s bone 
approximation disks. A method which thus offers an advantage ten 
times as great as the old one in mortality, and that can be done in 
one-third or one-quarter of the time, may well inspire enthusiasm. 
The application of this principle to man has as yet been limited. 
Dr. Senn has in six cases applied the plate method in gastro-enteros- 
tomy for cancer of the pylorus with results detailed in four of them 
in his Intestinal Surgery. The two recently done are also successful. 
Dr. Fenger, of Chicago, and Dr. Hunter, of Minneapolis, have also 
used them. Successful each in one case. Dr. Ransohoff, of Cin- 
cinnati, operated Dec. 81st for gastro-enterostomy by plates in a case 
of malignant pyloric stenosis with excellent success. 
An extended search fails to find other recorded cases. My own 
experience includes some experiments on dogs, and two successful 
applications to the human subject. The man whom I first operated INTESTINAL ANASTOMOSIS. 
5 
on lived three and a half months after I united his ascending and 
transverse colon by Senn’s plates on either side of a malignant 
stenosis of the hepatic flexure of the colon. His case has been fully 
reported in the New York Medical Journal, March 23d, last. 
The essential points of the case were, progressive obstruction, enor- 
mous fecal accumulation, marasmus, and finally collapse—relieved by 
a colotomy done when he was in extremis, and followed six weeks 
later by colo-colostomy with Senn’s plates, ISTov. 14, 1888. After this 
he rapidly gained and in three months was enjoying excellent health. 
Suddenly there ensued a painless diarrhoea that could not be checked. 
Rapid emaciation and death followed ill twenty days. Autopsy 
showed that nature had made an artificial opening between the 
duodenum and transverse colon at the site of malignant stricture. 
Thus all the small intestine had been excluded, and food passed prac- 
tically from his stomach directly into his colon undigested ; and starva- 
tion followed. 
The specimen which you see shows perfectly the aperture between 
the portions of colon. It is an oval the long diameter of which is an 
inch and a quarter; nearly as long as the incision made three months 
before. It shows there is little to be feared from the contraction of 
the opening, and it also shows that an opening very much smaller 
than the diameter of the bowel is competent to allow one part to 
empty into another. 
I would have been very glad to be able to make a larger opening, 
but this was about the maximum possible by using Senn’s plates. 
The patient had had daily evacuation of the bowels, but it had been 
half the time through the use of mild cathartics. A larger opening 
would have obviated the use of these. 
The needs of this case, coupled with the facts that I had not been 
able to get large enough plates to suit the colon, and that the prepara- 
tion of decalcified bone plates consumed several days and considerable 
labor, led me to review the ground that had been gone over to get a 
more available material. I was aware that almost every known solu- 
ble substance had been tried, including cartilage which Jobert and 
others had used. I devised a ring of rubber made in segments 
fastened by catgut which would fall apart after a few days, but aban- 
doned that when I made a stiff one entirely of catgut, which, being 
wholly digestible, would accomplish what the plates of bone would 
and then disappear. I made some small sets and tried them on a dog, 
with the assistance of Dr. Weir and Dr. B. Farquhar Curtis. The 
beautiful results are seen in these two specimens. When the gut was 6 
ABBE, 
cut, the ends were invaginated and sutured by continuous Lembert 
stitch. The two ends being laid side by side, a longitudinal cut was 
made in each near its end, a ring slipped into the gap in each and 
four sutures on the ring stitched through the edge of the gap. The 
corresponding threads now being tied, pulled the two rings together, 
and the edges of the opening were thus sandwiched, as it were, be- 
tween two rings. Four extra silk stitches were added outside to pre- 
vent the lips of the cuts puffing out between the first threads. 
The proof of the security of apposition is seen in the dog’s recovery. 
Evacuations were free and regular after the operation, and each of 
these specimens were taken out with the dog in perfect health nine 
days after the operation. The union was so perfect that the intestine 
would have burst elsewhere sooner than given way at this place. 
The catgut had entirely gone; a few of the silk threads that held 
them were yet loosely hanging in the puncture points, ready to come 
out on slight pulling. The coils of approximated gut, though per- 
forming their functions well, showed considerable contortion, and in 
two later experiments, the results of which are here seen, I turned 
the divided ends to look in opposite directions with better result. 
These were done on the same dog at the same time, and were made to 
show a class of physicians the advantage of this method where mul- 
tiple resections of the gut might be called for, as in gunshot wounds. 
Four inches of intestine were cut out at each place, and the catgut 
apposition rings applied, the ends being reversed. The result has 
been perfect. A very large aperture of communication has been ob- 
tained by the long narrow ring, which so easily slips into the bowel. 
The twisting of the adherent coils was not nearly so much as in the 
former case. lam convinced that by the two expedients of using 
long narrow apposition rings to obtain a large opening, and by placing 
the intestines as suggested, to obtain continuous peristaltic wave, we 
obviate a temporary blocking of the operated part which must obtain 
with the bone plates and small openings, and which leads to much 
twisting. 
In this experiment it took exactly fifteen minutes to resect and 
complete each apposition. This includes a continuous outside silk 
suture around the circumference of the ring, which was applied quicker 
than half the number of interrupted sutures could have been. 
An opportunity now came to put in practice the method above de- 
scribed. In November last a woman of slight build and thirty years 
old came under my care at St. Luke’s Hospital, with a history of 
uterine disorder for two years, and presenting a small tumor in the INTESTINAL ANASTOMOSIS. 
7 
right iliac fossa. She had vomited, become anaemic, suffered much 
local pain, and had developed night-sweats with slight hectic. Pyo- 
salpinx was diagnosed and operation advised. A five-inch median cut 
was made above the pubes. The diseased mass with omentum and 
coils of small intestine intimately adherent, was found to be a suppu- 
rating ovary as large as a goose-egg. Some intestines were stripped 
off, others seemed too firm. One of my assistants, a distinguished 
disciple of Mr. Tait, being asked to examine to see whether the tumor 
could be removed, or whether it had best be scraped out and drained, 
succeeded, while examining, in digging the ovary from its bed, after 
the manner of Tait, who says no tumor of this character need ever be 
left no matter how firmly adherent. I was surprised and delighted to 
be shown that this mass could be thus removed by the fingers. Not- 
withstanding that the suppuration had been disseminated in the wound, 
it was readily douched away by copious hot-water affusions ; but great 
chagrin followed the immediate discovery that a circle more than anj 
inch in diameter had been torn from the side of an adherent loop of 
intestine and was on the tumor. Feces appeared at once in the deep 
cul-de-sac of the pelvis. I promptly found and sutured the damaged 
bowel, irrigated and applied a tamponade of iodoform gauze lightly, 
and closed the wound except for drainage. Two days later, feces 
welled up in the wound, and a horrible, and, I feared, a hopeless fecal 
fistula was thenceforth established. 
During the following six months the patient passed through not 
only the suffering incident to her fecal fistula, but also a severe attack 
of scarlet fever with acute desquamative nephritis. And when I 
returned to hospital duty I found her emaciated and weighing less 
than seventy pounds. Her abdominal wound healed, except over the 
pubis, where a long funnel-shaped wound, lined by poor granulations, 
gave vent to her entire fecal discharge, which came from the depths 
of the pelvis. The skin about it was sadly excoriated, and too tender 
to allow adhesive straps to retain dressings. She was of a cheerful 
disposition, and hopefully looked to me to relieve her, even at the risk 
of life, which had become a burden. With the picture in my mind 
of the intestines matted together, and in the midst of all a portion 
whose lumen was destroyed, from which feces poured in the site of the 
ovarian abscess, I looked upon the case with grave doubt of cure. 
The more so, because she had been subject to a hectic, with daily 
exacerbation of temperature to 102° and 103° up to the day of 
operation. My experiments with intestinal anastomosis, however, 8 
ABBE, 
gave hope, and on March 22d—six weeks ago—I operated in the 
presence, among others, of your President, Dr. Keen. 
Ether anaesthesia was used, notwithstanding she had five per cent, 
of albumin in her urine. 
I dissected out the poor cicatrix around the funnel-shaped fistula, 
and opened the laparotomy wound upward. The intestines in the 
entire lower abdomen were matted firmly together, and uniformly 
studded with miliary tubercles. The pathologist’s report confirms 
this, and I presume the original ovarian mass was a tubercular ovary, 
though I regret to say it was mislaid at the operation. With great 
care the intestine leading to the fistula was dissected out on either 
side of it for four inches, and cut squarely across. The ends were 
then turned in for half an inch and closed by a single row of con- 
tinuous Lembert sutures of fine black silk. It was impossible here to 
turn the ends in opposite directions, and they were laid side by side, 
split open longitudinally for an inch and three-quarters, nearly to the 
end, and united by catgut apposition rings, with a half-dozen rein- 
forcing silk stitches outside. The entire wound was douched liberally 
with hot water, and a portion of the deeply adherent gut between the 
cut ends was further dissected away. The wound was closed, except 
for a light tamponade of gauze at the site of the fistula. 
The patient rallied nicely, had no pain whatever afterward, and no 
feces came into the wound. She had a little vomiting the next day, 
but retained koumys and champagne, an ounce every two hours, in 
drachm doses. At the end of the fourth day, her temperature having 
risen to 102°, I gave liq. magnes. citrat. Sjv, and repeated. Three 
natural and painless movements passed by the rectum for the first 
time in six months, and her temperature fell to 100°. 
Daily movements took place from that time on, at first assisted by 
four ounces of magnesia every third day. The wound granulated 
nicely, and no feces have ever appeared there. 
The patient walked about after the fourth week, and is restored in 
appetite and health. She now gains three pounds weekly, is free 
from pain, and is making a happy convalescence. Her evacuations 
are normal and regular, well formed, and occur without the use of 
medicines. 
Thus is completed a proof of the efficacy of a new method, treating 
a malady which I know of no other method as competent to cope with. 
I can hardly conceive of a fecal fistula in any part of the bowel 
(except, perhaps, low in the rectum), that may not be safely cured by 
this method, provided the distal portion is not blocked by disease. INTESTINAL ANASTOMOSIS. 
9 
In cases of gangrenous hernia, bullet or other wounds requiring 
exsection of a portion of the bowel, it may be applied at once, or after 
an artificial anus is established and the patient is convalescing. 
No surgeon or physician need hesitate to make a fistula to relieve 
obstruction, or in other suitable cases where the equipment to com- 
plete the immediate anastomosis is not at hand, or where the patient’s 
condition will not endure much interference, as in the first case nar- 
rated. 
Two weeks ago my friend, Dr. Charles Mcßurney, applied a set 
of my catgut rings to a case of gastro-enterostomy, and writes as 
follows: 
“ The case was one of cancer of the pylorus which caused total obstruction. 
The patient would not consent to an operation until he was nearly moribund. 
The anastomosis was made between the highest part of the jejunum and the 
anterior of the stomach, near the greater curvature, and about three inches 
from the pylorus. 
“ The operation was perfectly easy and rapid, and the rings acted per- 
fectly. The whole operation took forty-five minutes, much time being lost 
on account of imperfect washing of the stomach beforehand. I think it 
could easily be done inside of thirty minutes. 
“ Death occurred from inanition about twelve hours later. On careful 
post-mortem test, the stomach being filled with colored fluid and held up, 
absolutely no leakage at the site of operation occurred.” 
To make the rings most efficiently the following steps must be ob- 
served : A moderately heavy catgut is chosen; taken from alcohol or 
juniper oil, it is wound loosely on a test-tube and soaked in hot water. 
It soon kinks up, and were it not on a tube could hardly be unravelled. 
After a while it is straightened out, allowed to untwist, wound again 
loosely, and soaked in hot water once more, until it ceases to twist. 
It is then ready to make up into rings, which will lie perfectly flat. 
Eight or ten turns over two pins stuck in a cork two inches apart, 
will make a bundle somewhat smaller than a lead pencil. These may 
be tied, at four places with fine silk, to secure the strands parallel 
while being wound round like a cable, with a continuous piece of the 
same catgut. The end of the piece is secured by threading it into a 
Hagedorn needle, and transfixing the whole bundle obliquely with it 
at the place of finishing. Thus there are no knots, and it is difficult 
to find the point of beginning. 
The ring is now a long oval with an inside diameter of two inches, 
and in thickness smaller than a pencil. Six strong but small braided 
silk threads are now fixed to each ring, equidistant, on the face look- 
ing toward the other ring which is to be laid against it. 10 
DISCUSSION. 
No knots are used. A needle pierces the ring between the strands, 
carrying the thread, which is drawn through, all but eight inches, and 
wound once and a half round, sinking between the encircling catgut, 
piercing the ring again, and cut off. The rings, which have now been 
water-soaked, are ready for use if needed for emergency; but, if pos- 
sible, they should be kept awhile in alcohol, under pressure between two 
glass slides, the threads being curled up within the oval, and the sides 
being pressed together after the glasses are tightly tied together. The 
ring thus becomes a long oval with parallel sides, and soon becomes 
harder and flattened on its faces. Moreover, it shrinks a trifle in 
alcohol, to swell again in the intestine and give additional security. 
In using the rings, I find it saves time to have each thread have its 
own needle. The intestine is pierced from within outivard less than 
a quarter of an inch from its cut edge. The ring should be laid on a 
damp folded towel with threads in order and needles stuck in the 
towel, which is held by the assistant close to the bowel, while the 
operator quickly pulls the threads through and passes the ring into 
the interior of the bowel. When the threads are tied and cut off, the 
apposition is perfect, but by a quickly made running suture outside 
all, a half inch of peritoneal surface is at once secured beyond the 
possibility of leakage. More than this is superfluous, for the edges 
held between the rings act as valves. 
In invaginating the end of the cut intestine after exsection, one 
will delay a long while if he tries to turn in first one and then the 
other edge, and will also find the mesentery try to turn in after it on 
the attached side. My rule is to trim back the mesentery at least a 
half inch from the end. Then seizing both lips with toothed forceps, 
plunge them directly into the lumen. The entire edge usually follows, 
and one holds them by the left index finger and thumb while a quick 
running overhand suture of the slit thus formed is made. 
DISCUSSION. 
Dr. John Ashhurst, Jr. : I think that we are all much obliged to Dr. 
Abbe for coming here and giving us this clear demonstration of a mode of 
dealing with intestinal fistulse which I regard as one of the greatest improve- 
ments introduced in the whole field of abdominal surgery—certainly of in- 
testinal surgery. As Dr. Abbe has said, the old methods of dealing with in- 
testinal fistulse are not satisfactory, either as regards the time required for 
their success, when they do succeed, or as regards the prospect of success 11 
DISCUSSION. 
itself. The use of Dupuytren’s enterotome, or of some other form of entero- 
tome, is attended with the least risk of any of the methods which can properly 
be called operative. A few cases have been cured by Desault’s compress, 
which was particularly recommended by the late Dr. Otis, and where the 
fistula is small, a cure may sometimes be effected by some variety of plastic 
operation. A case of this kind was under my care some years ago; the open- 
ing was small and I succeeded in closing it by a deep dissection without 
opening the abdominal cavity. As a rule, however, such treatment will not 
succeed. 
Then we have resection with circular enterorrhaphy, Avhich has been prac- 
tised with success in a number of cases, but wThich is a tedious operation, and 
always liable to end in failure. It is difficult to make the apposition per- 
fectly accurate ; and even if this is accomplished, there is of necessity such 
narrowing of the gut at the point of suture, due to the turning in of the two 
ends of the bowel, that it often lays the foundation for a fresh stricture. I 
therefore consider, as I have already said, this plan of lateral anastomosis to 
be one of the greatest improvements made in this department of surgery. I 
have not had the opportunity of using either the bone plates of Prof. Senn 
or the catgut rings of Dr. Abbe, but am disposed to think that the rings are 
better than the plates. Besides giving a larger opening, they would seem to 
be more easy of adjustment, more likely to adapt themselves to the shape of 
the parts, and more apt to effect accurate apposition. 
The suggestion of Dr. Abbe that the two portions of gut should be so 
placed that the peristaltic wave may be continuous, seems to me also of much 
value. One would certainly suppose that this would render the restoration of 
the natural function easier than for the intestinal contents to be made to turn 
a sharp corner, as it were, in passing from one portion of the bowel to the 
other. 
Of the various terms used to designate this operation, lateral anastomosis 
is, I think, the best. It expresses exactly what is meant, and every one is 
familiar with the term anastomosis as applied to the union, for instance, of 
one vessel with another. The terms gastro-enterostomy, entero-colostomy, and 
the like are open to a certain amount of objection, since the latter portion of 
these terms implies the formation of a mouth. Although it may be a little 
out of the direct line of the discussion, I would call attention to the abuse of 
the term enterostomy as applied to an opening for the establishment of an 
artificial or false anus. The term enterostomy means the formation of a 
mouth in the intestine. It has a proper application in the operation of 
Surmay for the making a mouth in.the upper part of the small intestine in 
cases of pyloric obstruction, just as gastrostomy is employed for the operation 
of making a mouth in the stomach in cases of obstruction of the oesophagus. 
This is proper, but to apply the word enterostomy to signify the formation of 
an artificial anus is an abuse of terms; for a mouth is not used for the 
passage of fecal matter, but for the introduction of food. There is to some 
degree the same objection to the terms gastro-enterostomy, etc., whereas to 
speak of lateral anastomosis of the stomach and intestine, or of the gall- 
bladder and intestine, etc., would not be liable to misapprehension, since, 
although etymologically the word anastomosis means a joining of mouths, it 12 
DISCUSSION. 
has by long usage come to have a special and definite signification in medical 
nomenclature. 
Dr. J. Price ; Every surgeon has welcomed Senn’s new method, which 
promises such perfect results within certain limits, but these limits must be 
recognized. I will again urge and emphasize what I have so often spoken of 
in this Society, that the first province of the surgeon is to save life and re- 
lieve suffering, and to these ends he should direct all his efforts. The ideal 
operation is an after-consideration. 
Obstruction of the bowel presents itself in two general forms, acute and 
chronic. In the acute form the condition of the patient is almost always 
perilous. Shock and collapse are prominent, and in many cases a long opera- 
tion will be the last straw. This, I think, is called attention to by Dr. Abbe 
when speaking of his first case. The large number of acute cases are due to 
kinking, twisting, or strangulation by bands. Here simple releasing is all 
that is necessary. This has been my experience in pelvic cases, in which we 
most commonly find adhesions and disease of a knuckle or more of the intes- 
tine. As in Dr. Abbe’s case, it is exceedingly common to find a diseased 
bowel adherent to a pus tube or abscess of the ovary. It is often a question 
whether we shall do a resection or trust to trimming and suturing. I have 
many times in the most careful enucleations torn the bowel through to the 
mucous coat and have found a piece on the pus tube or ovary. I have in 
these cases always stitched the serous coat without narrowing the calibre of 
'the bowel. In but one instance have I seen a fecal fistula. That was in the 
case of an inexperienced man where I had not full sway. The fistula, how- 
ever, lasted only a few days, and the patient made a perfect recovery. 
Some time ago I reported a group of cases, and called attention to the 
frequency of intestinal obstruction due to tubal disease as a primary cause. 
In any case in which the obstruction has existed a few days, the portion of 
bowel involved becomes extensively diseased, often necessitating, as in gan- 
grenous hernia, resection. Here the establishment of the continuity of the 
bowel must be supplemented by the removal of the diseased section, and the 
operation is usually a failure. Again the bowel is diseased for some distance 
from the lesion, and experience shows that plastic work on diseased intestines 
is exceedingly perilous. The sutures will slough out and leave fistulas. 
Whether excision with lateral anastomosis will accomplish better results 
than resection, the making of an artificial anus followed by an ideal opera- 
tion, is an open question. In chronic cases and secondary operations, the 
patient will, as a rule, bear more operative interference, and it is in this class 
of cases that lateral anastomosis will give the best results. In malignant 
cases it will afford temporary relief and prolong life. 
Some figures illustrating these points in regard to diseased bowel were 
given before the Royal Academy of Medicine last year by Mr. I. S. McArdle, 
of Dublin. Of 76 cases of resection for gangrenous hernia 41 died; 4of 
these died from overloaded bowel, a very common complication in chronic 
cases. Sometimes, as a result of this, the serous coat is broken throughout. 
Of 13 resections for intussusception, 10 died from gangrene from suturing in- 
flamed tissues. Of 49 resections with artificial anus, 19 died—l 4in collapse 
and 5 from yielding of the suture—4 of these cases being at the mesenteric DISCUSSION. 
13 
border. The success of these operations depends largely upon the accuracy 
with which the sutures are applied. 
There seem to be but few anatomical points at which this method cannot 
be applied. Dr. Abbe speaks of the rectum as being about the only point. 
There are a few lesions liable to occur at this point; for instance, stricture due 
to ectopic gestation. I recently saw a case in which two inches of the bowel 
were intentionally removed with the product of conception. There it was 
not possible to do more than place the ends of the bowel in apposition, and 
do the best suturing that could be done under the circumstances. The result 
in this case was simply surprising. It was impossible to make an artificial 
anus as the adhesions were too great. Notwithstanding the difficulty in ap- 
proximating the ends of the bowel there was at no time any discharge of gas 
or feces from the wound, and the patient made a perfect recovery. 
Dr. J. M. Barton: I am greatly interested in the subject discussed by 
Dr. Abbe, and I think that his suggestion of catgut rings in place of the 
bone plates of Dr. Senn is a valuable addition to surgery. So unsatisfactory 
have the other methods proved that they are rarely ased. It is really a ques- 
tion whether gastro-enterostomy, as performed by the older methods used 
before the investigations of Dr. Senn, is a justifiable operation. By the 
method described to-night, the mortality must be much lessened. 
Some time ago, in a case in which I operated for strangulated hernia, there 
was a loss of ten or twelve inches of intestine, followed by inflammatory 
peritonitis. The section was made some weeks subsequently, by my colleague 
Dr. Gross, who was then on duty, with the object of bringing the two ends 
together. This was found to be impossible on account of the matting of the 
parts. Dr. Gross, therefore, took the distal extremity of the upper bowel, 
made an opening into the colon, and brought them together outside of the 
wound and applied Dupuytren’s enterotome. The reapplication of the in- 
strument two or three times cured the artificial anus and a fistula was left 
from which there was very little leakage. After removing a section of can- 
cerous bowel I adopted this procedure with success. I found in 24 re- 
ported cases, that in 15 where the bowel was at once brought together by the 
older methods there were 9 deaths; while in 9 cases where a temporary anal 
fistula was formed, there were but 4 deaths. By the latter method I have had 
several successes. The only difficulty is the frequent application of the 
enterotome and the persistence of a fistula. This need not necessarily be 
troublesome. I saw, to-day, a patient whom I recently treated, leaving a 
fistula through which sixty or seventy per cent, of the matter was discharged. 
He reports to-day that nothing has passed through the fistula for three weeks. 
The method suggested by Dr. Abbe presents such advantages that I shall be 
prepared to use it in the future. I have prepared the plates of Senn, and 
have had them ready for use several times, but the small size of the opening 
made me fear they would not act well, and I adopted other methods. 
Dr. C. B. Penrose : My experience with this operation of intestinal anas- 
tomosis is limited entirely to experiments on the dog. The results may be 
of some interest because I used a method somewhat different from those men- 
tioned. Instead of using the bone plate of Senn or the catgut ring referred 
to by Dr. Abbe, I used a rubber ring sewed together with catgut; instead of 
using silk sutures I employed catgut. In five or six days the catgut would 14 
DISCUSSION. 
be absorbed, and the rubber would adapt itself to any shape for passage 
through the intestinal tract. In all cases the rings passed within ten days 
after the operation. There is no advantage in this method over those men- 
tioned, except that the material employed may be obtained when bone or 
catgut is not available. This specimen from a small dog shows the shape of 
the opening left. The rubber disks can be cut of the necessary size and 
shape from ordinary sheet rubber. In most of my experiments, instead of 
using reinforcing Lembert sutures, I placed a circular omental graft around 
the line of union. 
De. Ashhurst: I should like to add a few words to what I have already 
said. Ido not understand Dr. Abbe to recommend that intestinal anasto- 
mosis should be adopted in the treatment of intestinal obstruction, but in 
cases of fistula which may result from obstruction or other causes. I think 
that it is a well-established fact in surgery that the line of safety in intestinal 
obstruction in which it is necessary to remove a portion of the bowel, is to 
establish a temporary false anus, and to postpone to a subsequent occasion the 
attempt to restore the continuity of the bowel by this or some other method. 
The only exception recognized is where the portion of the bowel removed is 
so high up or where it is so large that a great portion of the intestine would 
be thrown out of use. For instance, if it were necessary to remove a portion 
of the jejunum high up, the establishment of an artificial anus would leave 
so small a portion of the bowel for digestion, that the patient would starve to 
death, and in such a case it would be proper to endeavor to restore the con- 
tinuity of the gut at once, although the immediate danger of the operation 
would be thereby increased. Where, however, the portion removed was 
lower down in the small intestine, or in the large intestine, the proper course 
would be to make a temporary artificial anus, let the patient get over the 
effects of the obstruction, and at a future time endeavor to restore the con- 
tinuity of the bowel by whatever method might seem proper. 
Dr. William Hunt: I have performed a number of operations, plastic 
and others, for the cure of artificial anus; in some the opening was large, in 
others it was small. I have met with only partial success. Unless the open- 
ing was very small, Ido not recall a case of complete cure. I think that the 
method suggested to-night offers the best means we have of operating in cases 
of non-malignant disease of the bowel. I have, however, had no personal 
experience with it. Ante-mortem operations on malignant disease of the in- 
testine have no attractions for me. 
Dr. John B. Egberts : While I have had no experience with this method, 
the demonstrations which we have had to-night convince me that directly 
and indirectly a great deal of good will be done by this method of Senn, 
Abbe, and Penrose. I vividly recall a case that I lost because I was not 
sufficiently familiar with these operations to shoulder the responsibility of 
making an artificial anus. This case was seen shortly after Senn’s method 
had been described. I was called to operate on a strangulated hernia in the 
country where the patient could not receive much subsequent surgical atten- 
tion. I found the bowel pretty blue. I debated some time whether it would 
be better to make an artificial anus or return the bowel. I thought that I 
had seen the circulation return in bowels as blue as this one, and taking all 
the circumstances of the case into consideration, decided to return the bowel. DISCUSSION. 
15 
The external wound healed rapidly and well, and everything appeared to be 
right, when suddenly on the fifth or sixth day, in the absence of the attend- 
ing physician, the patient was seized with intense abdominal pain and ex- 
pired in a few hours from what I undoubtedly think was a perforation made 
by a slough of the intestinal wall. If I had been present, I would have done 
an immediate laparotomy. I think if I had such a case, after hearing this 
paper; that I should be much more likely to make an artificial anus, and run 
the risk of curing it subsequently by intestinal anastomosis. 
Another indirect result of this method of operating will be that we shall 
deal with malignant disease more satisfactorily than has been the case here- 
tofore. I hardly share Dr. Hunt’s averseness to attacking malignant disease. 
After making this artificial anastomosis in a case of malignant disease of the 
intestine, it becomes a proper question whether at a subsequent time the ab- 
domen should not be opened and the cancerous mass be excised with the 
hope of a radical cure. I believe that in many cases of malignant disease, 
early, radical, and repeated removal may finally effect a cure. Ido not see 
why with this method we cannot attack malignant disease of the intestine at 
a much earlier period. I have never been inclined to adopt the excisions 
done at Vienna and other places for intestinal and pyloric malignant growths, 
but with lateral anastomosis there is possibly a chance for a safe or even a 
radical cure by operation. 
We should not try to make an ideal operation in prolonged obstruction 
with a distended gut, but relieve obstruction and subsequently treat the arti- 
ficial anus left. The indirect results of the efforts of Senn, of Abbe, and of 
Penrose will be greater than any of us imagine to-night. 
Dr. M. Price : This paper has much interest for me, and three months 
ago would of been of vast service. I had a case of strangulation the result 
of epithelioma involving four inches of the bowel, the obstruction being 
almost complete. The obstruction had continued eleven days, but the jiatient 
was in moderately good condition. With the method which has been described 
to-night it would have been easy to unite the two portions of bowel, and this 
would have saved an immense amount of trouble and annoyance. The 
patient is of a nervous, irritable temperament, and the application of Dupuy- 
tren’s instrument causes great annoyance. The subsequent management of 
the case will probably be difficult, unless this method be adopted. The belly 
is large and flabby, and the closure of the external wound will probably be 
a matter of difficulty. 
The paper is of much value to me for other reasons. Eight days ago I was 
called to a case of strangulated hernia. The bowel appeared to be in an 
almost gangrenous condition, and it was decided to resect three or four inches 
of it. After releasing the constriction the color returned to the bowel, and 
we concluded to allow it to remain. The patient is making a good recovery. 
There was a case where I had decided to resect. If I had had the appliances 
shown to-night, I have not the slightest doubt that resection would have been 
done, and I believe that the results would have been as good. 
In pelvic work it is impossible in some cases to avoid tearing the bowel; 
having such an easy method of closure I should not fear the result. I should 
have no hesitation in cutting out a portion of the bowel diseased and 16 
DISCUSSION. 
thickened, which offers very little chance of good recovery, and bring the 
portions of the bowel together by the method suggested by Dr. Abbe. 
Dr. J. M. Baldy ; It is evident to every one the immense strides we have 
made in intestinal surgery since Semi introduced his practice of lateral ap- 
proximation. There is one point in the discussion which has not been dwelt 
upon; that is, the comparative value of the three materials which have been 
mentioned. One great objection to the bone plate of Senn is the small 
calibre of the opening which results. Again, the material must pass by the 
bowel, and in doing so the piece of bone may possibly cause damage. To a 
great extent these objections are obviated by the rings of catgut. If these 
rings are examined closely it will be seen that they are very hard, large, and 
thick, and that it would be improbable that they should be absorbed in the 
length of time it would take for them to become loose. In ten days the rings 
used by Dr. Penrose had passed. We should not expect this ring of catgut 
to be absorbed in that time. If it should not be absorbed, it would not pass 
as readily as the rubber ring. The latter would cause no more trouble than 
so much tripe. The rubber rings could be readily kept for any length of 
time. The catgut rings, as Dr. Abbe explained, must be kept under com- 
pression in some solution, and must be carefully prepared by a comparatively 
tedious process. This is all obviated in the rubber ring. The approximation 
by rubber seems to have some advantage over catgut, and the catgut is a most 
decided advance on the bone plates. 
Dr. F. H. Gross ; In the case of artificial anus (the result of gangrene in 
strangulated hernia) referred to by Dr. Barton, I failed to find the lower end 
of the divided small intestine after judicious search, but reestablished the 
anastomosis between the small and large intestine by exposing the caecum, and 
attaching thereto, by means of Dupuytren’s enterotome, the upper portion of 
the divided bowel, and succeeded in converting the artificial anus into a fecal 
fistula, so that thereafter a portion of the feces passed per anum and a portion 
through the fistula. I have never felt satisfied that the lower end of the 
bowel could not be found, and in saying so to a medical friend, some time 
afterward, he remarked: “That critics might find fault where clinicians 
found impossibilities.” There was some matting together of tissues to hinder 
the search. 
I have, at least, the melancholy satisfaction in learning this evening that 
in a similar case another surgeon failed to find the lower end of a parted 
intestine. 
The President, Dr. W. W. Keen : I want only to say a word in regard 
to one of the cases narrated by Dr. Abbe. I was present at the operation, 
and certainly a more unfavorable case could not be imagined. The woman 
appeared upon the verge of the grave, and I expected to hear of her death in 
the course of a week, if not even earlier. It seemed impossible that she 
should recover, not only from the great emaciation, but also from the opera- 
tion, which was necessarily very prolonged and very difficult, in consequence 
of the matting together of the intestines and surrounding parts. I certainly 
think that we are to be congratulated upon having such a valuable paper upon 
such an important topic, and that Dr. Abbe is to be congratulated upon such 
favorable results in such an unfavorable case. DISCUSSION. 
17 
I should scarcely have said anything, but I can hardly agree with the last 
remarks of Dr. Ashhurst in reference to making an artificial anus rather than 
performing immediate lateral anastomosis of the bowel. This seems to expose 
the patient to a greater risk, as it involves the performance of two operations 
instead of one; one an operation of necessity when the artificial anus would 
be made, and second a laparotomy when the lateral anastomosis would be 
made, which always involves some risks. I can see no valid reason why a 
patient requiring the formation of an artificial anus in many, if not in most 
cases, might not have the advantage of immediate lateral anastomosis, and 
thus avoid two operations, as the lateral anastomosis operation would be hardly 
more prolonged and involve no greater risk than the formation of an artificial 
anus, if, indeed, it is attended with as much risk. I should like to hear Dr. 
Abbe’s views on this point. If I correctly understood the paper, this method 
was proposed not only for the relief of existing fecal fistulse, but also for other 
conditions, such as shot-wounds, excision of the bowel, etc., which would 
require the formation of an artificial anus. 
Dk. Pobert Abbe : I did speak of the use of this method in the immediate 
apposition of the intestine in dangerous cases, but I did not intend to empha- 
size this point. lam rather inclined to agree with Dr. Ashhurst in thinking 
that it is a matter for general recommendation that an artificial anus should 
be established. The discretion of a surgeon of considerable experience will, 
however, allow him to make immediate apposition in certain cases, but, for 
universal recommendation I think that often it would be attended with 
additional risk. If the patient may be hastened over the shock and an 
artificial anus established in a few moments, the second operation for anas- 
tomosis under favorable circumstances is attended practically with little risk. 
In cases of serious obstruction, lasting for three or four days with shock and 
intestines over-distended, I think that an artificial anus should be established. 
With regard to the suggestion of Dr. Penrose, I think that some such device 
as he suggests may succeed everything that has yet been thought of. Ido 
not vaunt the use of catgut rings as having any supremacy. I think that 
Senn’s plates have advantages. In gastro-enterostomy they would be less 
easily digested than the catgut, but these simple rings have two or three un- 
doubted advantages. 
With regard to the absorption of catgut I know that it occurs in less than 
ten days. In both of the earlier specimens the catgut is gone, and in these 
the intestine was removed at the end of nine days. It will probably be ab- 
sorbed in four or five days. 
The catgut rings which you have been examining were taken out of 
alcohol and now after drying seem too pliant for service, but if placed in water 
they would at once stiffen up into dense, firm rings. When taken out of 
the alcohol and put in the intestine they swell a little, giving additional 
firmness and very tight apposition. Senn, in his experiments, oftentimes 
found the plates plugged by hair, straw, etc., which the dog had swallowed. 
This built up an obstruction at the operated part which produced serious 
trouble. These rings on the contrary have a very large aperture from the 
first—as large as two inches. In this narrowed form it slips readily into 
the incision in the bowel which closes over it, while the diamond-shaped 18 
DISCUSSION. 
plates of Senn cause a curling over of the edge of the stretched small intes- 
tine. When the outside sutures are applied with catgut rings there is from 
one-fourth to one-half an inch of the two serous coats in contact. If you 
have more than that, as you do with bone plates, you take something from 
the lumen of the bowel which would be better left. 
It has simply been the pleasure which I have had in reporting these cases 
that has led me to emphasize these methods to-night.