THE RELATIVE MERITS OF THE VARIOUS METHODS OF INTESTINAL ANASTOMOSIS

R. C. COFFEY
1902 Journal of the American Medical Association (JAMA)  
ture of one of the abdominal viscera without external signs has been made. Bather a few laparotomies in vain than allow the former mortality rate to continue. It is our duty when called to such a case to examine it most painstakingly for some of the above general and local symptoms and inquire carefully into the manner of injury. Seen in the early hours, before the anemia has become too acute or the danger of sepsis too great, laparotomy or nephrotomy should be advised. The incision should be
more » ... ncision should be made in the median line above the umbilicus if we suspect a rupture of the liver, spleen or stomach, and below it if we fear one of the small intestine, colon or bladder. It can be enlarged, if necessary, to the right or left. For injuries of the kidney an oblique lumbar incision, which can be extended into the peritoneum if necessary, is best. If a large quan-. tity of blood escapes it should be sponged out and search made for rupture of the liver, then for one of the spleen, kidney or abdominal vessels. A suture with non-cutting needle and silk is best for the liver if the tear is small. If larger it is best to tampon. For small lacerations of the spleen suture and tampon will at times .suffice, but for the majority of cases only splenectomy will suffice, because as in my own case, the tissue will be so friable that sutures will tear out and tampons become displaced. In ruptures of the gastrointestinal tract the tear, if longitudinal, should be closed transversely by Lembert suture, and vice versa to avoid a stricture. At times resection may be necessary. It should be remembered that the ileum is most often frequently the seat of injury. In extraperitoneal rupture of the kidney the tampon will suffice if the organ is not too extensively lacerated. If the latter is the case primary nephrectomy will give the best results. In intraperitoneal rupture of the kidney the peritoneum must be stripped up until the tear is found and the kidney then treated as for the extraperitoneal variety of rupture, removing all clots from the peritoneal cavity first. In rupture of the bladder, the prevesical (extraperitoneal) space should be first exposed, the bladder opened and explored with the finger; if a tear has been found it should be sutured with catgut, if outside the peritoneum, and then the pelvic connective tissue drained. Tf intraperitoneal it is best closed with a Lembert silk suture. In general it is useless to operate on cases when peritonitis has begun. Apparent shock should not deter from early operation. While we are waiting for it to pass off the patient may die of acute anemia. Shock should be treated in the ordinary manner. The anemia will respond best to salt solution. Do not give morphin if a ruptured intestine is suspected. In conclusion let me again urge the profession in general and surgeons especially to examine these cases carefully and operate on them early if we wish to reduce the present relatively high mortality. Growth of the Hair.-Dr. Jolly's work on the chemical composition of horse-hair shows that functional activity attains its maximum in the black hairs, which contain infinitely more phosphate of iron than red or blonde hairs. Falling of the hair is often observed in nursing animals; similarly, nursing women lose a great deal of hair. This is apparently caused by the fact that the phosphates are not fixed in the hairs, but are carried away by the milk secretion. Loss of hair in arthritic persons is quite different. An arthritic patient is one whose cellular nutritive functions are modified by his disease, and in whom the hairs effect the permanent fixation of the phosphates in themselves in a very imperfect manner.-Abstract from La Presse Med. At the outset I will state that my paper will be confined entirely to mechanical and experimental work. My work consists of six hundred and fifty experimental operations on the dead intestine and twenty on living pigs. Fifty operations were done in 1895 and 1896; two hundred in 1900; two hundred during 1901, and two hundred during the present year. All types of methods have been tested. No operation has been brought into the contest until it had been done more than twenty-five times. For speed, an average of time in ten operations of a kind has been taken. For accuracy the dead gut has been sewed, distended with air and sunk in water. Final results have been tested on living pigs killed two to three months after operation. Pigs have been used instead of dogs because the intestines are more like human. Pig. I.-Connell continuous suture hanging in a pig's intestine, two and one-half months after an operation. MERITS FROM A MECHANICAL STANDPOINT. In considering the various methods of intestinal anastomosis our decision must be based upon three classes of work : mechanical, experimental and clinical. Under the head of mechanical work we have three points for consideration : speed, accuracy and adaptability. Under the head of speed we found merit in the following order : Murphy button, Frank's coupler, Connell suture, crushable button and various forceps operation, Halsted's operation, Maunsell's operation. Under the head of accuracy and immediate results I have found them in the following order : Crushable button with two rows of continuous suture, Connell suture, crushable button with one row of sutures, Halsted's method and various intestinal forceps. Of the three mechanical points we are to consider adaptability is, in my opinion, far more important than the other two. For instance, a doctor is summoned to see a ease that "has been shot." He seizes a few instruments hurriedly and goes to the scene. He
doi:10.1001/jama.1902.52480440017001d fatcat:j542kytaqffrbpzpcjdpme6goa