MULTIPLE (TRIPLE) STRICTURE OF 
PROBABLE TUBERCULAR ORIGIN 
WITHIN THIRTEEN INCHES (33 CM.) OF 
THE JEJUNUM. 
Resection and Circular Enterorrhaphy by Maunsell’s 
Method, Followed by Complete Recovery; with 
Remarks on Multiple Intestinal Strictures. 
BY 
RUDOLPH MATAS, M.D., 
OF NEW ORLEANS, LA. 
FROM 
THE PHILADELPHIA MEDICAL JOUBNAL 
1898. [Reprinted from The Philadelphia Medical Journal, July 9, 1898.] 
MULTIPLE (TRIPLE) STRICTURE OF PROBABLE 
TUBERCULAR ORIGIN WITHIN THIRTEEN INCHES 
(33 CM.) OF THE JEJUNUM. 
Resection and Circular Enterorrhapliy by Maunsell’s 
Method, Followed by Complete Recovery; with Re- 
marks on Multiple Intestinal Strictures. 
RUDOLPH MATAS, M.D., 
of New Orleans, La. 
While the comparatively recent contributions of 
Bouilly, Schier, Billroth, Durante, Czerny, Koenig, 
Salzer, Hofmeister, and others have fully established 
the importance of the tubercular process as a frequent 
and most important cause of stricture in the ileocecal 
region, the occurrence of multiple stricture of the small 
intestine attributed to this cause is not so generally 
recognized, and I trust that reference to this subject, 
and the presentation of an illustrative case, will not be 
considered superfluous. I have been prompted to pre- 
sent this observation not only because I believe that 
the subject itself is wmrthy of agitation, but also be- 
cause the type of the strictures observed and the mul- 
tiple character of lesions in the jejunum, so far away 
from the favorite seat of tubercular infection, viz., the 
ileum and the ileocecal region, justify its present record 
as a rare occurrence. Furthermore, as an illustration 
of the value of enterectomy and the method adopted in 
performing it (Maunsell’s method), I believe it also 
presents technical features which may have some bear- 
ings on the history of the operative treatment of this 
condition, which is still in process of evolution. 
In the latter part of April, 1896, I was consulted by Mr. 
W. H., of Texas, a cipiT en»ho^ry,,tqr flfe reliet Qt an obscure 2 
complaint which had very gradually but progressively un- 
dermined his health during the last 20 years. He is a tall 
man, over 6 feet in height, and 46 years of age. When the 
patient was referred to me through the kindness of my col- 
league, Professor Elliott, he presented an exceedingly thin, 
weak, and gaunt-looking appearance. In addition to his 
profound emaciation, his face indicated long and continuous 
suffering. He at once referred all his troubles to his ab- 
domen, which had been the seat of paroxysmal attacks of 
pain, of variable intensity, since 1869, and which, in view 
of their repeated occurrence, foreshadowed the more serious 
complaint that now existed.* His troubles had not become 
distinctly localized until about 2 months ago, when he felt 
a slight but distinct tumefaction in the left umbilical and 
lumbar regions. The appearance of this swelling coincided 
with a most violent paroxysm of pain, vomiting, fever, and 
constipation, which threatened his life for several days, when 
the acute symptoms gradually subsided, leaving a large, ten- 
der mass, which is at present distinctly recognized on abdom- 
inal palpation. 
Upon examination I found the abdomen exceedingly thin 
and retracted. By palpation and inspection a distinct tumor 
could be recognized in the lower part of the left half of the 
abdomen. The center of the swelling occupied a spot which 
was crossed by a line drawn from the umbilicus to the left 
anterior superior iliac spine. In size, contour, and mobility 
the tumor suggested a large movable left kidney. The mass 
could be moved up and down from the costal arch to the 
iliac crest; laterally from the umbilicus to the lumbar region. 
The mass spontaneously shifted its position, and was larger at 
times than at others. An experienced physician, who had 
seen him at his home, believed that this was a floating 
kidney, which caused crises of abdominal pain from torsion 
of the pedicle. He had consulted numerous physicians dur- 
ing the many years that he had suffered with his complaint. 
In the beginning of his complaint he was treated for gastral- 
gia, then for intestinal indigestion, gall-stones, renal colic, 
etc., but nothing gave him any permanent relief. His de- 
scription of his symptoms was, nevertheless, very striking 
and suggestive. 
When he came to me he could eat anything, as far as 
simple admission of food into the stomach was concerned. 
His stomach accepted all food without rejecting it, but about 
two hours after ingesting his meals he would begin to suffer 
most intolerable and agonizing pain in the left hypochon- 
driac and umbilical regions, which was accompanied by 
persistent nausea and vomiting. This condition of intoler- 
able suffering would culminate in such unbearable and agon- 
* From 1871 to 1877, while at school, he was almost entirely free from pain. 
In 1879 he had a spell of vomiting and purging, with intense abdominal pain, 
which confined him to his bed eight weeks. 3 
izing pain that only large doses of morphin (one and two 
grains), administered hypodermically by his wife, would 
suffice to quiet him. At times, when he committed any 
indiscretion in his diet the pains were so violent that even 
morphin failed to relieve him, and chloroform by inhalation 
had to be appealed to to allay his sufferings. Coarse food, 
fruit, and vegetables were always certain to provoke these 
attacks. When he limited his nourishment to milk and 
soups he suffered less pain. After years of experimentation 
with various articles of diet, he finally gave up everything 
but milk and beef-tea. Lately even milk would disagree 
with him, and following the advice of his physicians he had 
been compelled to resort to nutrient enemas to assist his 
nutrition. His condition became very much worse after the 
appearance of the abdominal tumor. After the lump had 
formed he soon realized that any indulgence in solid food 
might cost him his life, so that when I saw him he lived on 
an exclusively fluid diet. In the vomiting that followed the 
ingestion of even soft, semi-fluids (eggs, oatmeal, corn-meal) 
he noticed that frequently no relief would come to him until 
he had expelled every particle of the food taken. 
He described his abdominal pains as “colics,” which began 
intermittingly, but rapidly became continuous and agonizing. 
Before the acme of the paroxysms was reached he felt his 
bowels contracting and twisting in an indescribable manner, 
but these movements were soon lost to the touch, owing to 
the extreme rigidity of the abdominal muscles, which became 
spasmodically contracted and hard as a “wooden board.” 
His bowels were usually constipated, a condition which he 
attributed to the frequent use of morphin, and he was often 
compelled to resort to purgatives, salines, Seidlitz powders, 
and castor-oil to relax them. At times a diarrhea would set 
in without any assignable cause. 
In view of the progressive aggravation of his condition, he 
finally decided to have a radical operation performed that 
would release him, no matter at what risk, from his present 
“martyrdom.” 
In questioning him as to his family-history, I learned that 
he was the descendant of very healthy and long-lived parents, 
except a grandfather on the paternal side, who had suc- 
cumbed to some pulmonary trouble. His contemporary 
relatives had not suffered from known pulmonary or cancer- 
ous lesions; he had no children. As far as his personal 
history was concerned, he said that up to the age of twenty 
he had enjoyed exceptionally good health. He had never 
had any suspicion of venereal disease ; he never indulged in 
alcoholics. He remembered, however, that in his childhood 
he had a protracted and rebellious diarrhea, from which he 
had apparently fully recovered when the first signs of his 
present illness (occasional colics) led him to remember his 
early bowel-ailment, though he failed to associate this with 4 
his present condition. He had had malarial intermittent 
fever in his childhood and pneumonia in 1872. A careful 
general examination failed to reveal any sign of disease in 
any part of the body but the abdomen. 
In my mind, the history given by the patient clearly 
indicated an obstructive intestinal lesion, but what was 
the nature of the obstruction, what the character of the 
tumor that was now so clearly discernible in the abdomen 
—was not so plainly defined. The long period of time 
that had elapsed since the beginning was not compat- 
ible with the primary existence of a malignant neo- 
plasm—the tumor in the abdomen having developed 
suddenly and only in the previous two months. 
A secondary carcinoma of the intestine engrafted 
upon an old intestinal lesion was possible, however. 
A displaced kidney following the relaxation of the peri- 
toneum, consequent upon a progressive emaciation and 
fat-absorption (nephroptosis), suggested itself as another 
possible diagnosis. But the right kidney was not dis- 
placed, and there was no evidence of the relaxation and 
displacement of the colon or other viscera which Glen- 
ard and others have so clearly described as “ enteropto- 
sis ” and “ splanchnoptosis,” and which is so likely 
to be associated with fat-absorption and peritoneal re- 
laxation. 
Then there were no rellex renal symptoms; no ab- 
dominal sensations referable to the bladder or urinary 
apparatus, which are likely to exist in such cases. In 
addition, the urine was perfectly normal, though scant 
and of high specific gravity. The possibility of simple 
stricture from previous ulceration did not suggest itself, 
as the patient’s history of previous diarrhea in early 
childhood was not remembered until subsequent events 
and cross-questionings on my part served to revive the 
recollection of an early bowel-complaint. 
Other possible conditions, of course, suggested them- 
selves to account for the tumor, but none appeared sat- 5 
isfactory or conclusive. I, therefore, could not arrive 
at any complete diagnosis, except that there was some 
form of obstruction of the bowels associated with the 
development of an abdominal tumor of unknown nature 
and origin, but probably connected with the small in- 
testine. I, therefore, agreed with the patient that the 
best course to pursue would be to perform an explora- 
tory celiotomy—a conclusion which he hailed with 
great satisfaction. 
The man was admitted to the New Orleans Sanitarium, 
and after a few days of careful preparation, during which he 
was given gentle laxatives and strengthened with hypoder- 
mics of strychnin and digitalin, and by enemas of peptonized 
foods, he was operated on on April 24, 1896. Under ether a 
median incision was made between the umbilicus and pubis 
large enough to allow the hand to palpate the mass. No 
clear idea could be obtained of the nature of the tumor until 
it was brought to the surface, where it was recognized as a 
loop of small intestine, which was twisted upon itself very 
much like an elongated (H) omega. It was largely covered 
by the omentum, which was firmly adherent in many places. 
In addition to this it was plastered and held in its peculiar 
shape by bands of old peritoneal exudates and pseudo-mem- 
branous formations. After enlarging the abdominal incision 
a little further, the entire loop of bowel with its mesentery 
was completely extruded from the abdominal incision, and 
a search was made for further abnormalities in the remainder 
of the intestine, but none was discovered. The bowel was 
traced upward toward the stomach, and at a distance of 
about 3 feet from the tumor the terminus of the duodenum 
was recognized at the crossing of the superior mesenterip 
artery. Further exploration of the small intestine downward 
from the tumor, toward the cecum, revealed a perfectly nor- 
mal condition. 
A further examination of the diseased loop showed that it 
was evidently a portion of the jejunum. The valvulse conni- 
ventes were in some places remarkably thick and large, and 
could be distinctly felt through the bowel-walls, which were 
abnormally dilated above the loop. It was difficult to deter- 
mine that the abnormal bowel was strictured at all until 
several bands of adhesions and masses of adherent omentum 
which covered it had been removed. It was then easily per- 
ceived that the bowel was contracted and very thick in sev- 
eral places. The coats of the bowel in the loop were thick- 
ened throughout. In some places where the omentum was 
adherent there were areas of marked injection of the serosa, 
and fresh flakes showing recent patches of localized peri- 6 
tonitis. The mesentery connected with this loop was 
unusually thick, injected and edematous, thus contrasting 
markedly with the other portions of the mesentery, which 
was very thin and almost translucent. The thickening of 
the mesentery appeared to be due to chronic infiltration, 
with inflammatory edema and exudates. The mesenteric 
glands corresponding to this area were also distinctly en- 
larged and hard. 
As the patient had withstood the exploration without any 
evidences of serious shock, I decided to excise the entire 
loop with its corresponding mesentery and to perform a 
circular enterorrhaphy. The intestine was completely empty 
of all contents, and in a very favorable condition for ex- 
tirpation. After thoroughly protecting the peritoneal cavity 
with towels, so that the operation would be performed out- 
side of the abdomen, the loop that was to be excised was 
completely excluded by clamping it with long, thin-bladed 
forceps. The healthy bowel beyond this point was com- 
pressed by two long intestinal clamps applied over thin 
sponges and aided by the fingers of an assistant. The in- 
tervening healthy portion of the bowel was then divided 
with scissors and with it a wedge-shaped section of the mes- 
entery was removed. The bleeding from the mesentery was 
provisionally controlled by forcipressure as the vessels were 
divided and permanently controlled by suturing the cut 
edges together with continued fine silk sutures. By this 
means the entire thickened and abnormal mesentery was 
removed. The Maunsell procedure for circular enteror- 
rhaphy was then adopted, and in less than twenty minutes a 
very satisfactory joint was secured. A few extra sutures, 
made with fine silk, aided in giving greater security to the 
joint, and, by burying the through-and-through sutures of 
the Maunsell procedure, effectually diminished the risk of 
sepsis. 
After completing the enterorrhaphy and thoroughly wash- 
ing the united surfaces with normal salt-solution, the joint 
was dropped into the peritoneal cavity, two long but narrow 
iodoform-gauze drains were placed on each side of the united 
bowel so as to surround the line of suture completely. The 
thin edge of the abdominal wound was now closed com- 
pletely with silkworm and catgut sutures, except at the 
center, which was allowed to remain open to give exit to the 
gauze strips. The operation consumed one hour, but the 
patient suffered very little from shock, though he was fre- 
quently nauseated and attempted to vomit. He recovered 
rapidly, though he suffered from nausea and vomiting until 
the third day, when, after the administration of one ounce 
of Epsom salt by enema, he had a free watery evacuation 
of the bowel, and was greatly relieved in every way. 
The gauze packs were removed on the third day. Their 
removal was followed shortly afterward by the escape of 7 
some flatus per anum, and the patient was much relieved of 
pain caused by the active peristalsis and gurgling of the 
bowels. Nothing was given by the mouth except a few 
spoonfuls of very hot water and broken ice until the fourth 
day. The patient was stimulated regularly by the hypoder- 
mic injection of gr. of strychnin every 6 hours. Water 
and food were furnished by rectal enemata administered 
systematically every 5 hours. These enemas consisted of 
1 teaspoonful of beef-juice, 1 tablespoonful of whisky, 5-10 
minims of digitalis, and 6 to 8 ounces of water. 
After the operation the specimen was examined and found 
to represent 13 inches of very much altered jejunum. It 
presented three exceedingly narrow constrictions, the largest 
of which barely allowed a No. 5 E. catheter to pass through it. 
They were situated as follows: The first and second strictures 
were separated by an interval of nearly 5 inches; the sec- 
ond and third by an interval of 2 inches. The strictures 
were caused by very thick circular rings of hypertrophied 
cicatricial' tissue. At the point of constriction the mucous 
membrane was smooth, pale, and apparently divested of all 
epithelial covering. A dense ring of cicatricial tissue occupied 
the submucous tissues and indicated that the original ulcer- 
ation, which had undoubtedly existed at some time past, but 
was now entirely healed, had begun in the sub-epithelial 
strata and penetrated the submucous layers. At several 
points the excessive outpour of exudates and agglutination 
of the omentum to the serosa showed that the ulceration 
had threatened to perforate the bowel completely. The 
bowel was distinctly sacculated in the spaces between the 
strictures. In the vicinity of the strictures the muscular and 
submucous coats were remarkably hypertrophied. The mes- 
enteric glands had undergone a sclerogenic process, and, 
though larger than usual, were firm and hard, except in the 
center, which showed some foci of caseation undergoing cal- 
cification and other conservative involution-changes. It 
was evident that the original infection that had irritated 
them had been almost completely eliminated. 
The excised bowel contained a little fluid, but no hard 
particles of food. The high situation of the strictures, about 
three feet from the terminus of the duodenum, or four feet 
from the pylorus, partially accounted for the remarkable 
escape of the patient for so many years from the dangers of 
total obstruction; the liquid character of the intestinal con- 
tents at this point preventing a total fecal obstruction, which 
would have been more likely to occur in lower portions of 
the intestine. The frequent and desperate attacks of colic, 
with vomiting, prove, however, that at times even very soft 
and easily digested foods would reach the strictures without 
sufficient maceration and succeeded in temporarily blocking 
up the opening of at least one of the strictures. 
It should be stated that the existence of multiple strictures 8 
was not recognized until after the operation, when the excised 
piece of gut wras opened, and it was found to be distinctly 
strictured at the points referred to. 
In these places the strictures were formed by thick, concen- 
trically hypertrophied rings of cicatricial tissue. 
The patient began to eat soft-boiled eggs and milk on the 
fourth day after the operation. After this, more food of a 
semi-solid consistence was given with a great deal of water, 
until the end of the twelfth day, when some chicken-tea and 
more solid food were added. When he left the Sanitarium 
(May 27), 34 days after the operation, he could eat three full 
meals a day without experiencing the least distress or incon- 
venience. It is now (March 27, 1898) one year and eleven 
months since the operation was performed, and the patient 
has steadily gained in weight and strength. From less than 
100 pounds, which he weighed when he came to see me, he 
now weighs nearly 180 pounds. He pursues his vocation 
without interruption. The only event that marred his re- 
covery for a short time was the formation of a small abscess 
in the center of the scar of the abdominal incision. This 
abscess opened spontaneously about three months after his 
return home. He came back to me in considerable alarm, 
but I was soon able to relieve his mind by extracting six 
knots of ligatures which, I presume,had been detached from 
the mesentery. After the removal of these knots of silk 
threads, the sinus healed rapidly, and the patient has never 
been annoyed since. He now eats of everything, enjoys his 
food, and never complains of his bowels. 
The points of interest presented by this case are : 1. 
The difficulties, almost insurmountable, in making a 
satisfactory diagnosis of the true condition before oper- 
ation. 2. The difficulty and practical impossibility of 
determining the true nature of the obstructive lesion 
until after the removal of the diseased bowel, which was 
opened and found to present three distinct strictures. 
3. The unusually high position of the lesions in the 
jejunum. 4. The unusually long and slow evolution of 
the stenotic process (over 20 years). 5. The appa- 
rently complete disappearance or cure of the primary 
ulcerative cause—tuberculosis. 6. The repeated re- 
covery of the patient from numerous attacks of acute 
obstruction brought about by the plugging of the 
narrow orifices of the strictures by food-masses or other 
accidental causes. 7. The existence of a tumor simu- 9 
lating a displaced organ or neoplasm, a condition 
which evidently resulted from repeated attacks of local- 
ized peritonitis, which caused adhesion of the intestinal 
coils and omentum and the outpour of a mass of plastic 
Specimen of jejunum resected from multiple tubercular strictures. 
exudate, evidently intended by nature as a conservative 
process to protect the bowel from rupture during the 
attacks of acute obstruction caused by the plugging of 10 
the strictures. 8. The marked hypertrophy of the 
muscularis of the intestine, especially on the proximal 
(gastric) side of the strictures—a compensatory process 
to aid the bowel in propelling the intestinal contents 
through the narrow constrictions. 9. The survival of 
the patient under these dangerous conditions without 
fatal permanent obstruction, owing in a great measure 
to the liquid character of the contents of the intestine 
in the constricted portion. 10. The limitation of the 
ulcerative process that led to the stenosis to a restricted 
portion of the bowel, as ascertained by a careful exami- 
nation of the entire bowel-tract during the operation. 
11. The apparently complete and permanent cure 
obtained by the operative procedure adopted, viz., ente- 
rectomy. 12. The simplicity and security of Maun- 
sell’s method of circular enterorrhaphy as applied in 
this case. 
Apart from the features of individual interest pre- 
sented by this case, there are a few general but all- 
important questions that it suggests which it will be 
well to consider. Among these the problems that relate 
to diagnosis are most prominent. How is the diagnosis 
of multiple stricture of the small intestine to be made 
intra vitam apart from operation? If there are obstruc- 
tive symptoms, and the history of the case suggests, as 
in this instance, the classical signs of progressive steno- 
sis of the bowel, we, of course, endeavor to know wdiat 
is the nature of the strictures—i. e., are they of tuber- 
cular, syphilitic, digestive, so-called catarrhal, peptic— 
or are they neoplastic, and especially cancerous? Then, 
are the strictures single or multiple ? What is the 
amount of bowel involved ? If the strictures are mul- 
tiple, it is especially desirable to know in what part of 
the intestinal tract they are situated, and what is the 
distance that separates the obstructed portions. Again, 
if strictures exist, are they causing the obstructive 11 
symptoms in virtue solely of pure cicatricial contraction 
of the lumen, or are they clue to simple accidental 
plugging, or to secondary inflammatory processes, etc.? 
The importance of these questions is self-evident to 
the operator or practitioner who is confronted with such 
problems. A careful analysis of the patient’s history 
and clinical phenomena will greatly elucidate the case 
and aid in approximating the diagnosis. But a com- 
plete and satisfactory diagnosis is impossible in unfor- 
tunately too many, if not the majority, of cases. Next 
to determining the true nature of the obstruction and 
its location, the question that interests the operator 
most directly is that which refers to the number of the 
strictures and their situation when these are multiple. 
But here, again, unfortunately, these questions must 
remain unanswered until an exploratory celiotomy 
reveals the actual state of affairs. For this reason we 
see that there are few cases recorded in which the 
diagnosis has been accurately made before actual 
exploration. It may be also truly said that there are 
few abdominal conditions which justify more often an 
exploratory celiotomy, and which, after this has been 
undertaken, more thoroughly tax the resources and 
judgment of the operator. For this reason it is plain, 
also, that the surgery of intestinal stricture is of com- 
paratively recent origin, and in fact owes its birth to 
the conditions which have made surgical intervention 
in the peritoneum successful, viz., the aseptic practice 
and perfected technic of the last two decades. 
As the multiple strictures of the small intestine are 
those which offer the greatest complexity, it will not 
be amiss to inquire into the relative frequency of this 
class of obstructions. In his classical monograph on 
intestinal obstruction (American edition, 1884), Treves 
presents us with a synopsis of 78 cases of stricture that 
he was able to gather in the literature of the subject up 12 
to 1884. Of these, 26 were cases of stricture of the small) 
intestine, 8 cases of stricture at the ileocecal valve, and 
44 of stenosis of the colon. Of the 26 cases of stricture of 
the small intestine, 10 were due to cicatrix after ulcer;. 
2 to cicatrix after injury ; 4 following after strangulated 
hernia, and 10 after cancer. Of the cicatricial strictures 
of the small bowel, the most frequent in spite of their 
actual variety are, no doubt, those due to primary or 
secondary tubercular infection. It is now recognized 
that, notwithstanding the frequency of tuberculosis of 
the bowel, this condition is rarely followed by complete 
cicatricial stenosis. Yet it is undeniable, in the light of 
recent experience, that tubercular ulceration in the 
bowel is capable of producing obstructive conditions; 
not so much because of cicatricial retraction, but, as 
Koenig, Czerny and Hofmeister have demonstrated, 
from the fact that deep-seated tubercular ulcer will give 
rise to so much secondary inflammatory thickening, 
edema, and plastic exudation, that the lumen of the 
bowel will be narrowed and obstructed. In other words, 
a distinction must be made between the hypertrophic 
inflammatory type of tubercular stricture, which is 
relatively common, and the circular or cicatricial form, 
which is very rare, and is a sequel of cicatrizing surface- 
infection. In confirmation of this statement we find 
that “ Eisenhardt, of Munich, as a result of 1000 post- 
mortem examinations made upon tubercular subjects, 
found evidences of tuberculosis in the bowel-tract in 566 
cases, and yet in only 9 was the bowel strictured from 
this cause.” On the other hand, Hofmeister,1 from 
whom I have borrowed this statement, has been able 
to collect 83 reported cases in which operative inter- 
vention wTas practised for stenotic lesions caused by 
tuberculosis. In 13 of the cases collected by Hof- 
meister the operations were performed for multiple tu- 
bercular strictures; in 60 cases for single strictures. In 13 
8 cases multiple strictures existed, but these were only 
recognized at the post-mortem, as no operation was 
performed. 
All of these cases (91) were reported in the period 
beginning with 1880—i. e., within the last 17 years. 
Again, if we were to examine the older literature of the 
subject—i. e., that which preceded the present operative 
period, we would find in the anatomical descriptions 
given by the careful observers of the last century, and 
of the first half of the present, that a great many cases of 
single and multiple strictures of the small intestine were 
reported, which would strongly suggest a greater im- 
portance of the tubercular process in the causation of 
intestinal stricture than is usually accorded to it. In 
this connection the observations of Lalouette (1776), 
Billot (1809), Combe, C. (1813), Thillaye (1813), Bailey 
(1816), Heyne (1826), Goodrich (1829), Darrach (1829), 
Greenhow (1821), Roepke (1834), Roberts (1832), Roki- 
tanski (1839), Ossipowski (1840), Hickley (1841), Cons- 
bruch (1842), Landgraff (1843), Oppolzer (1841), Perrin 
(1852), Millard (1859), Lancereau (1859), Peter (1862), 
Dumontpallier (1863), etc., would be especially instruc- 
tive to the student of the subject, not only from a 
pathogenetic point of view but as a clinical study of 
multiple stricture-formation in the bowel as well.2 
But as it is not my intention to discuss the pathology 
and clincal history of cicatricial stricture of the bowel 
except in so far as to call attention to its growing 
importance in the practice of abdominal surgery, I 
shall simply limit my remarks to intestinal strictures 
of tubercular origin, as these have a direct bearing upon 
the case reported in this paper. In reviewing some of 
the phases of this subject, I shall draw largely from the 
recent and valuable contribution by Fr. Hofmeister, of 
Tubingen, previously quoted, to which I now freely 
acknowledge my indebtedness. 14 
To begin, it is interesting to know the number of 
strictures that may be found in one individual case. 
On this point we find that in 20 recorded cases of 
multiple strictures collected by Hofmeister, there were 
5 cases (Koenig, Voltz, Esmarch, Meyer, Eisenhardt) 
in which there were two strictures in each individual; 
three, four, and five strictures were found in cases reported 
by Frank, Koeberle, Trendelenburg, respectively; six 
strictures existed in each one of the patients reported 
by Litten and Homen; seven strictures in Rotter’s case; 
eight in Friinkel’s, and finally, twelve, the greatest num- 
ber thus far recorded in the same subject, in the cases 
reported by Frankel (second case), Koenig, and Hof- 
meister respectively. In 6 cases the number of 
strictures is not accurately stated, and only vague 
designations are used, as “ numerous constrictions,” etc. 
The vast majority of these (tubercular strictures) are 
found in the ileum. 
Only in one case were the only existing strictures 
discovered in the colon (Eisenhardt, postmortem exam- 
ination). Sometimes one or more strictures coexist 
with typical tubercular tumors of the ileocecal region, 
the ileal strictures being situated at a greater or less 
distance from the valve (Billroth, Koenig, Frank, 
Esmarch). But precisely in those cases which are dis- 
tinguished by the greatest number of contractions 
(from 4 upward), the ileum is exclusively the seat of 
these constrictions. Furthermore, it is a notable fact 
that it is precisely when the strictures are multiple and 
are situated in the small intestine that we are likely to 
notice the most perfect type of cicatricial constriction— 
i. e., the involution or healed form of intestinal tubercu- 
losis. These peculiarities are typically illustrated by 
my case, in which almost all vestige of the original 
infection was lost in the cicatrizing process. In this 
case, probably the highest (nearest to the pylorus) 15 
multiple tubercular stricture thus far recorded, the 
tubercular process exhibited a remarkably slow and 
benign evolution. This fact is in accordance with the 
suggestion of Hofmeister, that in the small intestine 
tubercular ulcer exhibits a greater tendency to cicatrize 
and develop circular or annular constriction, because 
the infection is primarily more superficial (surface- 
infection), while in the lower bowel, where single stric- 
tures occur most often, the tubercular infiltrations are 
deeper and more extensive, and the thick, wide, hyper- 
trophic type of intestinal tuberculosis, as described by 
Koenig, is the rule. 
The distance of the single strictures from one to an- 
other varies most widely (from a few centimeters to a 
half meter). In a case reported by Trendelenburg five 
strictures were distributed over a distance of 42 cm. 
(about 16f in.) In Koeberle’s celebrated case there 
were four strictures in over 205 cm. (over 83 in.) of ex- 
cised intestine. Boiffin even speaks of multiple stric- 
tures over the whole small intestine. 
As to the length of the individual strictures, it is nota- 
ble that in the course of multiple constriction in the 
small intestine the tendency of the stricture is to form 
narrow rings. In others they form elongated tubular 
contractions (8 cm., Meyer, Eisenhardt). Sometimes 
in strictures which are closely approximated, as in my 
case, the local conditions distinctly simulate the hyper- 
trophic tumor-like forms of tuberculosis that are more 
clearly identified with the ileocecal region. 
As to the caliber of the strictures, they vary extremely, 
rarely, if ever, constituting an absolute atresia, but 
often closing so much as to barely admit a small No. 4 
catheter, or even a fine probe. 
Great interest attaches to the anatomical changes 
that are observed in the affected bowel above the stric- 
ture (afferent portion), and in the intestinal wall of the 16 
strictured portion. The relationship of acute obstruc- 
tion by fecal and food-masses to stricture, without 
actual atresia, and the sudden relief of some of these 
patients, even when on the verge of dissolution, should 
be remembered; but these, considerations must be 
passed by with a mere reference in order to reach the 
most important phase of the subject, viz., the manage- 
ment and mode of intervention which is indicated in 
strictures, and in multiple strictures especially. 
On this point the status of surgical evidence is fur- 
nished very thoroughly by Hofmeister, and I can do 
no better than to quote his summary : “ In 83 collected 
cases of intestinal strictures of all kinds in which sur- 
gical interference was resorted to, including in this 6 
exploratory celiotomies, 52 patients recovered (62.65%), 
and of the 26 fatal cases (31.33%), in only 16 (19.3%) 
death was more or less directly attributable to the 
operation. Of course, the value of these statistical 
conclusions is exceedingly debatable, for it is probable 
that many fatal cases are not reported, and the use of 
the word ‘ cure ’ is also very elastic, and, to say the 
least, uncertain, especially when unaccompanied by 
detailed explanations. But the individual reports of 
some surgeons who have recorded their uninterrupted 
cases in series are more instructive, as, for example, 
Czerny’s experience, which embraces the reports of 11 
cases of intestinal tuberculosis, with 3 deaths (2 of 
which were attributed to the operation), and 6 cures, 
which after one to three years were still under observa- 
tion and doing well, and two other cases that had 
proved to be incurable, and were presumably only 
temporarily relieved. 
“ If we restrict our study to multiple strictures we 
find 13 cases which were operated upon (including 3 
exploratory celiotomies) with 8 recoveries (61.54%), 
and 5 deaths (38.46%), of which 3 (23.1%) are attribu- 17 
table to the operation. If we were permitted to con- 
clude from this statistical evidence alone, it would 
appear that the risks of operation in the multiple variety 
are about the same as in the single cases, but this con- 
clusion is of no value, practically, since the operator 
who undertakes an exploration for stricture of the 
bowel never knows whether he will find a single or a 
multiple stenotic condition. In other words, when he 
undertakes an operation of this character he must al- 
ways bear in mind the possibility of multiple strictures. 
He must give due consideration to this possible con- 
tingency, and must be prepared to act accordingly. 
“ While it may appear theoretically much more sim- 
ple to deal radically with single than with multiple 
strictures, there are single strictures which may offer 
insurmountable difficulties in the way of complete re- 
moval. Under all circumstances, the condition of the 
patient at the time of operation is the dominant con- 
sideration. How much traumatism can he stand? 
How long can he be kept under the anesthetic? are 
questions that must be answered before final action is 
taken. Of course, the ideal of surgical treatment in 
dealing with strictures of the bowel would be enteredomy 
or resection of the diseased and strictured sections. 
“ The fact that in 50 complete resections for tubercular 
strictures, including cases in which an artificial anus 
was left after the excision, resulting in 34 cures (68%) 
and 15 deaths (30%), of which 12 (24%) are ascribable 
to the impracticability of resection, does not condemn 
the surgeon to inactivity. On the contrary, almost as 
good results may be obtained by entero-anastomosis (5 
cases with 5 cures) which will permit the re-establish- 
ment of the fecal circulation with a minimum of 
danger and often with prospect of radical cure. An- 
other procedure which we owe to the Billroth school, 
and which bids fair to supplant enterostomy in certain 18 
cases, though still a procedure that is in an evolutionary 
stage, is ‘partial exclusion of the obstructed and diseased 
portion of the bowel. While total exclusion of the bowel 
is to be condemned, partial exclusion, as practised by 
Salzer, Bardenheuer, Hochenegg, Frank, Korte, and 
Eiselsberg, Obalinski, and Kammerer in this country, 
is at least worthy of trial in certain cases. It consists in 
the absolute isolation of the strictured portion of bowel, 
with anastomosis or enterorrhaphy of the proximal and 
distal ends on each side of the excluded portion. The 
excluded portion is partially sutured to the abdominal 
incision, and an opening (enterostomy) is made to permit 
drainage of the isolated part. The advantages that may 
be claimed for this procedure over simple entero-anasto- 
mosis are, that while partial exclusion permits a re- 
establishment of the fecal circulation, the diseased 
bowel is entirely excluded from the contaminating con- 
tact of the feces, and that by this means the bowel is 
given absolute physiological rest. By this means invo- 
lution and atrophy of the diseased area are favored, and 
a permanent cure may be obtained. It has the advan- 
tage over total resection that it obviates shock, hemor- 
rhage, and other complications that might result from 
an attempt at excision of a diseased area.” 
Two other modes of relief are now left for considera- 
tion, and these are enterostomy or the formation of an 
artificial anus on the Nelaton plan, and enteroplasty on 
the plan of the Heinecke-Mikulicz pyloroplasty—by 
which the stricture is enlarged by the modus operandi 
of this well-known procedure. 
In cases of multiple stricture the surgical conditions 
are altered extraordinarily according to the number and 
the situation of the individual strictures. The more 
favorable cases are those in which the constrictions are 
closely distributed over relatively short sections of the 
intestine. In these cases, as illustrated by the writer’s 19 
report, the strictures must be treated collectively, as if 
there were only one long stricture, and resection (enter- 
ectomy) should be the operation of election (vide cases 
reported by Koenig, Trendelenburg, Frank, and the 
author). On the other hand, when only a few (two) 
strictures exist, but these are separated by a long dis- 
tance of sound intestine, the best course to follow is to 
attack the individual stenosis separately, and to resect, 
if possible, each single one in turn (Voltz, Esmarch), 
To this ideal treatment, which removes the diseased 
part without sacrificing more intestine than that which 
is absolutely necessary, there are very narrow limita- 
tions. It stands to reason that we cannot ask too much 
of the usually ill-nourished patient, whose powers of 
resistance have been reduced to a minimum by the 
condition which calls for the operation. It is in these 
extreme conditions, and when confronted by a great 
number of widely distributed strictures that the judg- 
ment of the operator is more severely taxed. The 
questions then resolve themselves into: Shall we re- 
sect the entire strictured area? Shall we exclude it? 
or perform anastomosis ? or enterectomy ? or can any 
operation be performed that will yield even a palliative 
result ? 
Cases of this complex type, in which many strictures 
of narrow caliber were distributed over the greater por- 
tion of the small intestine, are recorded by Boiffin, 
Frankel, Rotter, Koenig, and Hofmeister. 
It is very plain that when a very large portion of 
the bowel is involved total resection of the affected 
bowel is out of the question; Koeberle, it is true, suc- 
ceeded in successfully removing 205 cm. of the ileum, 
and though he has had a few imitators, it is very 
doubtful that the sacrifice of so much bowel is physio- 
logically safe or compatible with sound surgery. At 
any rate, success in such wholesale sacrifice of the 20 
bowel must follow as a very rare and exceptional event. 
To dream of relief by resection would be preposterous 
in those cases in which the whole intestine is marked 
by cicatricial rings at variable and irregular intervals. 
In such extreme cases, which are, fortunately, clinical 
curiosities, there is nothing to be done but to close the 
abdomen and simply let the patient await the end. In 
cases of lesser severity a wise compromise may be 
made between individual resections of the stricture, 
entero-anastomosis and exclusion. As to enterostomy, 
on the Nelaton plan, it should always be kept in view 
only as an emergency operation when dealing with 
strictures or obstructions that are situated in the colon 
or low down in the ileum. If applied too high in the 
intestine the physiological exclusion of the remainder 
will result fatally in a few days, as the progressive 
emaciation and malnutrition will so diminish the pa- 
tient’s powers of resistance as to unfit him for further 
intervention. Finally, I shall close by adding two im- 
portant recommendations made by Hofmeister: 1. In 
cases which present a history of gradual obstruction of 
the lower bowel the surgeon should be prepared to find 
multiple strictures, and in all such cases the explora- 
tion will not be complete until the entire bowel-tract 
has passed under the eye and finger of the operator. 
2. If called upon to operate for an acute obstruction 
(ileus) in a case of chronic obstipation, and there is 
much distention with gas, it is best to make a free ab- 
dominal incision at once, as Kussmaul suggests, by 
which the entire bowel-mass can be rapidly examined 
and the seat of the obstruction promptly determined. 
It is only by this procedure that a proper diagnosis can 
be made and a proper decision quickly arrived at. 
Again,8 one of the prime requisites to success in the 
operative treatment of stricture of the bowel is not to 
wait too long after the onset of the symptoms which 21 
indicate chronic obstruction (repeated but intermittent 
paroxysms of abdominal pain with vomiting, obstipa- 
tion, etc.), before proceeding to exploratory celiotomy. 
It is evident that when a stricture becomes markedly 
narrowed its lumen is liable to sudden obstruction by 
accidental fecal plugging. Under these circumstances 
all the phenomena of acute ileus are liable to present 
themselves rapidly, and the tympanites which compli- 
cates this condition will be added to the original dif- 
ficulties of the case. Remembering that the chances of 
perfecting the intestinal technic are infinitely greater 
when the intestinal tract is empty, we should advise early 
exploration in a calm period whenever a careful and long- 
observed history strongly suggested the possibility of 
chronic obstruction from the causes herein referred to. 
Finally, a last word in reference to the special 
method of performing enterectomy in this case—Maun- 
sell’s method. I have had occasion to apply Maunsell’s 
principle of invagination and intramucous suture 
through a fenestrum, in 6 cases of enterorrhaphy, in- 
cluding three gastro enterostomies. In every instance 
but one I have found the joint reliable and safe, and 
the method itself very practical and of easy applica- 
tion. But Maunsell’s method is not applicable to all 
cases. The chief technical contraindication for its per- 
formance is a very thick fat or inflamed mesentery, as 
this decidedly interferes with the amount of invagina- 
tion required for a good suture. In such cases, Czerny- 
Lembert or other simple suture-methods are preferable. 
A thick mesentery is also in the way of the proper 
application of the Murphy button, which in my ex- 
perience is less safe, but a little more rapid, than the 
Maunsell method. In cases of multiple strictures at 
long distances, which would justify repeated resections 
at the same sitting, it is probable that a judicious com- 
bination of methods, viz., the button for the distal 22 
stricture, with Maunsell’s suture-method for the highest, 
or even the button alone, would expedite the termina- 
tion of the operation and yield the most satisfactory 
results. 
REFERENCES. 
1 Hofineister : Beilrdge zwr klin. Chirurg., 3. Heft, Jan., 1897. 
2 Full references to contributions by authors quoted in this paragraph will be 
found on p. 65, “Intestines (stricture of),” Index-Catalog, Surgeon-General’s 
Library, Washington, vii, 1886. 
3 A valuable report of a case of multiple tuberct lar strictures of the small 
intestine has been contributed recently to the A’orsk Mag. Latgevidensk., Jan., 
1898, an abstract of which has appeared in Semaine Medicate, p. 88, No. 11, Feb. 
26, 1898, and in the very interesting and valuable experimental and clinical 
paper on ‘ Intestinal Tuberculosis and its Surgical Treatment,” by Dr. Oreste 
Marsarucci (II Policlinico, Rome, Anno v., No. 4, Feb. 15, 1898), which 1 regret 
has reached me too late to be utilized in the preparation of this paper. An 
exhaustive paper on “Intestinal Tuberculosis in its Surgical Aspect” is also 
being prepared by my distinguished friend, Prof. Senn, which I know will prove 
to be one of the most instructive contributions that has appeared in this country 
on this important subject.