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of the Intestine,' which was a valuable contribution to the knowledge of intestinal repair. Modern methods proper, however, began with the labors of Lembert, he being the first to call the attention of the surgical world to the fact that it was the contact of serous surfaces which was necessary for union to take place. These facts were given by him to the world in 1825-6.

“Intestinal anastomosis may be spoken of under two heads: First, without mechanical aid. Second, with mechanical aid.”

You are all perhaps aware of the great difficulties encountered in doing an end-to-end anastomosis without some support to the gut.

Maunsell, recognizing this fact, devised, as he thought, a better plan ; but as we all know, it, too, has its serious disadvantages, the slit in the bowel and the through-and-through sutures being prolific sources of sepsis. “Recent mechanical aid to intestinal suture and anastomosis began in 1887 with Senn's decalcified bone plates," which a decade since flashed upon our professional vision, has long since disappeared beneath the horizon, leaving scarcely a glimmer of their once promised glory. “Senn may be called the pioneer of this department of surgery; but, as above stated, his lateral anastomosis has fallen into disrepute; because of the difficulty in obtaining decalcified bone of sufficient size to enable a surgeon to get an opening large enough for the passage of the contents of the bowels."

An interval now elapsed, which may be called the dark ages of modern intestinal surgery, when another lurid glare flashed athwart the surgical world, heralding the birth of Dawbarn's lateral anastomosis, who it is claimed did the first intestinal work with the aid of vegetable plates, publishing the result of his labors in the New York Medical Record, June 27, 1891. After blazing the comet of a season, this most unsurgical operation too found an untimely end.

Lateral anastomosis should never be done by choice, and should never take the place of the end-to-end operation. The end-to-end operation, when successfully performed, re-establishes the alimentary canal, generally without any diminution of its caliber, while the opening made in the lateral anastomosis as time goes on becomes contracted to such an extent that the feces can not pass.

Discarding the above operations as uncalled for in the great majority of cases, we now find the much-lauded Murphy button in full possession of the intestinal field. This method, which in every detail is superior to its vanquished brethren, has yet difficulties many and obvious, which

have long since sat in dumb appeal before the court of surgical jurisprudence.

Summoning a few of the principal ones before this august tribunal, we will examine them one by one. In the first place, when the bowel has been made ready for the operation, a purse-string suture is passed completely around each end of the severed gut, oftentimes proving a tedious task. One-half of the button is then passed into each end of the bowel, very frequently after repeated efforts, and the above-mentioned sutures tied snugly over them before the button is locked. The opening in the button is small, rendering it absolutely necessary to keep the contents of the bowels in a fluid state, otherwise the button becomes occluded, and this way may cause both the patient and the surgeon some discomfort. Frequently the button never comes away, and

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FIG. 2.-Cylinder introduced into one end of the bowel, showing the invaginated portion.

laparotomy must be performed for its removal; as has occurred in the practices of Drs. Wyeth and Abbe, of New York City. In Dr. Wyeth's case he removed the button by abdominal section, after its having remained in the belly one hundred and twenty-seven days.

It is taught by most surgeons that if the condition of the patient will not justify a long operation, instead of doing a resection where strangulation and necrosis exist, the ends of the bowel must be drawn down and stitched to the abdominal wound, forming a fecal fistula, thereby rendering imperative a secondary operation.

I claim the above procedure is, in the majority of cases, unwise and unsurgical from the fact that with my technique an end-to-end anastomosis can be done in just as little time. With the above testimony before you, I beg leave to introduce my own method, known to my fellow-students as Johnson's end-to-end anastomosis of the intestines. The belly is opened under strict aseptic precautions, as in any case of

laparotomy, and the bowei drawn out through the wound, stripped, and tied off with strips of sterile gauze. The point at which the bowel is tied must be determined by the surgeon in each individual case; but in all cases the gauze should pass through the mesentery at least three inches from the bowel and be tied with a slip-knot. The peritoneal cavity is now well packed with pads of sterile gauze to absorb any. leakage occurring during the operation.

The section of gut to be removed is now cut out with the scissors along with a V-shaped piece of mesentery corresponding to the length of the bowel, and excised, and the ends of the bowel irrigated well with warm normal salt solution, and wiped dry with sterile gauze. The mesenteric junction of both ends of the bowel is securely closed, and a cylinder two inches in length (Fig. 1) (made of a potato, carrot, beet, parsnip, or in fact any vegetable from which a cylinder of the

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size of the gut to be operated upon can be made) is passed into one end of the severed bowel. As it enters the gut is sufficiently invaginated (Fig. 2) to bring peritoneum in contact with peritoneum of the opposite end of the bowel treated in a similar manner upon the other end of the cylinder. The cylinder is seized between the thumb and the index finger of the left hand and held steadily, while with an ordinary cambric needle, armed with a very fine silk thread, the two ends of the bowel are united by the introduction of a suture every one sixteenth of an inch, until coaptation is complete (Fig. 3). The sutures should only include the serous and muscular coats of the bowel, and are tied by the assistant as introduced, and they should in all cases be interrupted and cut very short. The opening in the mesentery may be closed either by continuous or interrupted sutures. Particular pains should be taken to close the mesenteric junction, as herein lies the great danger of leakage, sepsis, and death. The cylinder is left in situ (Fig. 3), as it does not interfere with union or the passage of the feces.

Being of vegetable composition, it will be readily digested to such an extent as to allow it to pass down the alimentary canal without giving notice of its movements.

The anastomosis being completed, the gauze pads are removed from the peritoneal cavity and the bowel replaced. The abdominal wound is closed, and I would suggest by the method of Richelot, of Paris; an ordinary cat-gut suture is passed through the upper angle of the peritoneal wound and tied, leaving the end of the suture long. The peritoneum is then closed with a continuous suture. When the lower angle of the wound is reached the same suture is carried through the edges of the recti muscles, and they are closed with a continuous suture to the upper end of the wound and tied. The skin and cellular tissues are closed with silkworm gut sutures, and the wound dressed with iodoform, sterile gauze, cotton, and bandage.

Allow me to state that I believe cylinders of gelatine or spermaceti could be used for this purpose with perfect satisfaction. Any objection offered to the instability of the cylinder is refuted by actual observation, as in a case observed in the city of New York. A patient in almost a moribund condition upon whom this operation was performed survived but a few hours, and on opening the abdomen it was found that plastic material had been thrown out in such quantities that the stitches were completely hidden. If under the decidedly unfavorable circumstances above cited sufficient vitality exists to deposit lymph to that extent, how much better result may we hope to attain when the condition of the patient is more auspicious ?

Gentlemen of the surgical jury, Johnson's end-to-end anastomosis is before you. Judge it in your wisdom, and as you are strong be merciful.




In the American Practitioner and News, May 15, 1898, No. 10, page 373, in an article on “Laparotomy During Pregnancy,” Dr. Turner Anderson speaks about the difficulty of a diagnosis of early pregnancy, saying: “This, I take it, should not create any great surprise when we consider how difficult it is to diagnosticate early pregnancy even when uncomplicated; but when pregnancy is associated with intrapelvic or abdominal disease, the diagnosis is often impossible.

“It certainly is very important to know that pregnancy does exist in a surgical case; but the rational signs of pregnancy are so unsatisfactory that they may tend to confuse rather than assist in diagnosis, and even after the sensible signs become possible, they, too, are often so obscured by co-existing diseased conditions as to prevent diagnosis."

That this is often true of many instances must not be denied. In general we distinguish sure signs of pregnancy and probable signs. We call a sign sure if it by itself would be satisfactory to establish an absolute diagnosis, such as fetal heart-sounds and quickening. Among probable signs there are the changes of the sexual organs and other organs, and finally the nervous symptoms. The so-called probable signs are of different importance; one of the most important signs of these probable ones is the bluish color of the vaginal mucous membrane. The general view that an absolutely sure diagnosis of pregnancy may be made out only in the later months, but not in the early stage, is certainly justified.

One of the most absolute signs of pregnancy we must, so we should think, find in the uterus itself; and, indeed, we do find one symptom that was emphasized as the surest sign of early pregnancy quite particularly by my teacher in obstetrics and gynecology, Prof. Dr. Alfred Hegar, in Fredburg, Germany. He, indeed, considers this sign as a particular characteristic to pregnancy. Hegar calls it the compressibility of the pregnant uterus. If you make a bimanual examination, one finger of your one hand in the vagina, or better in the rectum, and the other hand on the exterior abdominal wall, you will be able to compress the part of the uterus a little above the internal mouth, where the body of the uterus begins, and quite especially in the median line of the uterus, not so much on the two sides. The term compressibility” is preferred by Hegar to the term “softness of the tissue," because it is not so much the softness, well-known for a length of time, but the very compressibility that Hegar regards as characteristic.

The evidence of compressibility is given, the uterus being in normal anteflexion, by introducing the index-finger into the anterior vaginal vault and putting the fingers of the other hand on the abdominal wall, reaching over the fundus to the posterior uterus wall. The fundus should then be pushed downward by pressure exerted through the abdominal walls. The fingers will be brought within the reach of the index-finger. If the uterus is in retroversion, you must introduce your

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