Compliments of the Author. 
NOTES 
ON 
Intestinal Surgery. 
, BY 
WILLIAM B. VAN LENNEP, A.M., M.D., 
PHILADELPHIA, PA. 
Reprinted from the Hahnemannian Monthly, December, 1891. NOTES ON 
INTESTINAL SURGERY. 
BY 
WILLIAM B. VAN LENNEP, A.M., M.D., 
PHILADBtPHTA, pa. 
I had the honor, at the Pittsburgh meeting two years ago, to pre- 
sent a resume of some experimental intestinal work, and, as a result, 
suggested a modification in the technique of circular enterorrhaphy. 
In support of this I showed specimens taken from a number of 
dogs, and reported a successful clinical case. By a rare piece of good 
fortune I have, within a few days, been enabled to make the history 
of this first-recorded operation by this method complete. It seems 
but right, then, that this report should be presented to the Society, 
the members of which so kindly listened to the incomplete history 
of the case, as well as the experiments that led up to the technique 
employed. 
As stated in my former paper, the patient was operated for stran- 
gulated hernia, twelve inches of gangrenous intestine resected, and 
the ends united with rings or splints of rubber drainage-tubing in a 
manner that will be referred to more fully further on. It was also 
stated that she made a good recovery, the opening being treated after 
the method of McBurney. 
While her general health and, particularly, the bowel functions 
were excellent, the hernia relapsed within a year, working downward 
and inward alongside the vulva until it attained a considerable size. 
For a time a truss retained it, but soon this was insufficient. With 
the protrusion came dragging pain in the abdomen, which finally in- 
capacitated her for her household duties. This was so severe that I 
was inclined to attribute it to traction on adhesions. To these symp- 
toms were added recurring warnings of impending strangulation, so 
that, finally, both she and her husband insisted on relief by opera- 
tion. This was the ordinary one for radical cure, and was done, as 
before, at the Hahnemann Hospital,-splitting the sac up to the -2 
abdominal opening; detachment and amputation of the former; 
accurate suture of the peritonaeum to insure a smooth surface with- 
out a dimple (when the opening is small the neck of the sac is tied); 
buried suture, without drainage, of all the overlying structures, layer 
by layer; antiseptic dressing. 
I have now practiced this method (Czerny-Riesel) a number of 
times without any mortality and with as good ultimate results as 
with any other. The smooth peritonaeum, and the restoration of 
structures to their former relation as much as possible, seems prefer- 
able to a large scar, however hard it may be at first. As time elapses 
it softens and, in contracting, draws down a dimple in the perito- 
naeum to which it is attached. Such a dimple, of course, guarantees 
recurrence. 
In the sac was found adherent large bowel, which was replaced, 
and the finger introduced with the expectation of finding the re- 
sected gut attached near the opening. There were no adhesions at 
all. Several loops of small intestine were successively drawn out 
in the vain hope of happening on the desired spot, when the patient, 
obligingly, commenced to gag, and the first loop that rolled out was 
the one we were after. 
The line of union was marked by the slightest furrow, across 
which stretched several thin, soft bridges of connective tissue. The 
mesentery scarcely showed any scar, making it almost impossible to 
find the line of suture. There was but one single adhesion to the 
mesentery of the gut, about a foot away. This produced such a 
gradual flexion that no obstruction could result; it was divided, and 
the oozing stopped by a stitch. The size of the intestine when 
spread out was exactly the same above, below, and at the line of 
union. It remained but to prove that there was no encroachment 
on the calibre inside. Here fortune came again to the rescue; there 
was a round worm, eight to ten inches long, above the line of union, 
and it gradually worked into this point. I was then able to roll the 
intestinal wall between the worm, like a finger inside, and my finger 
outside. This demonstrated beyond a doubt that there was no thick- 
ening in the wall. 
Such a complete history gives food for thought, and enables us to 
draw some useful conclusions.* 
* To this case should be added another successful one. A. Deniosten, of Bucha- 
rest, in a brochure recently received, reports a case of peritoneal tuberculosis, in 
which he successfully resected ten centimetres of damaged gut, and united the ends 
according to this method. 3- 
It has been stated that the peritonaeum of the dog is much more 
tolerant than that of the human being. In my experiments I in- 
variably found adhesions, except where omental grafts were used. 
The treatment and care were the same, and yet here was but one 
single weak adhesion near the mesenteric junction. No omental 
graft was applied either. The line of union was perfect, and with 
a minimum amount of inflammatory action, as shown in the presence 
of the bridges of scar-tissue across the slight groove. 
Stricture has been one of the arguments used against circular en- 
terorrhaphy, and the specimens I presented, taken from dogs killed 
from a few days to several weeks after operation, showed a percepti- 
ble encroachment on the calibre of the gut. Either there was no 
stricture in this case, or it subsequently disappeared. The latter 
is, of course, hardly possible. It is worth while to remember that 
a stricture must occlude over one-half the lumen before producing 
obstructive symptoms, and that a constriction that might be danger- 
ous in the gut of a dog would do no harm in the more capacious 
human intestine. 
In trying to avoid stricture one is apt to weaken the line of union 
by apposing too little surface. These two dangers can be avoided 
by strict attention to some of the details of the technique, which, I 
think, will bear repetition. After resection, the pouting mucous 
membrane is trimmed down. The peritonaeum and muscular coat 
can then be turned in to an extent corresponding to the thickness of 
the mucosa and submucosa before the stricture can begin. The four 
catgut strands attached to each ring are then passed through the 
entire wall very close to the free edge of the mucous membrane. 
There is no danger of these sutures cutting through the firm fibrous 
submucosa. This is an important structure in any intestinal suture, 
and, once recognized, can never be forgotten. It is the foundation 
for stitches applied from within or without. The weak spot, the 
mesenteric junction, is next fortified by drawing the two edges to- 
gether with a few interrupted sutures of silk on the inside, and 
catgut on the outside. The corresponding catgut strands from the 
rings are then tied, and the tendency to eversion between them over- 
come by a few (three or four) interrupted stitches of silk. The 
bridges of connective tissues spoken of corresponded with the loca- 
tion of the silk sutures which no doubt had become encapsulated. 
No trace of the silk could be felt. A rapidly-applied continuous 
stitch brings the peritonaeum evenly together over all, and is carried 
down the divided mesentery. Finally, the patency of the gut and 4 
the completeness of the union are tested by pressing together the 
walls below with the fingers, and forcing the intestinal contents into 
the united portion from above. A leak will be readily demonstrated 
and closed. In a case reported by me last year, death was due to sec- 
ondary obstruction, the cause of which was below the united point- 
Grert pressure was necessarily brought to bear on the rings and 
the line of union, but there was no leakage.* 
The rings have several advantages: 1. They keep the lumen 
open and prevent dangerous overstretching. 2. They hold the 
edges together with an elastic pressure which will not produce 
sloughing. 3. They do away with the necessity of 60, 70 or 80 
laboriously-applied stitches. 4. They enable us to use a contin- 
uous suture over all, which, without their support, would constrict 
the intestines like a purse string. 5. The catgut strands swell up 
and prevent leakage, and in this respect have a decided advantage 
over silk. 
While many American surgeons advocate lateral anastomosis after 
resection, surgical opinion in Europe and even in this country leans 
towards the ideal end-to-end union. This is evident from the fre- 
quently reported cases of circular enterorrhaphy, and is expressed 
by Gerster in the last edition of his work on Aseptic and Antiseptic 
Surgery, page 162. After speaking of Senn's and Abbe's work and 
suggestions, he says 
" The development of the new operation was brought to its logical 
culmination by a homoeopathic practitioner of Philadelphia, who, 
after excising twelve inches of intestines for gangrene, successfully 
united the gut, end to end, by means of rings made of ordinary rubber 
drainage-tubing." 
Lateral anastomosis undoubtedly has a field where it is desired to 
exclude certain areas (" physiological exclusion ") or unite portions 
of the intestine of unequal size, e.g., gastro-enterostomy, ileo-colos- 
tomy, etc. After resection, however, I have noticed and reported, 
besides the adhesions, a tendency to distortion or twisting, apparently 
dependent on the tortuous current. In addition to this there were 
accumulations in the blind culs-de-sac. The great advantage claimed 
for this method is that it apposes extensive serous surfaces and favors 
firmer union. This is aided by scarification. In this connection I 
* Hahnemannian Monthly, October, 1890. 
f It is not necessary to quote the "trimmings" with which the author sees fit 
or feels compelled to apologize for his honesty. 5 
was much impressed by an article read at the last Congress of Sur- 
geons, in Berlin by Kummer.* 
The method he proposes, and successfully practised on dogs and 
the human cadaver, is the following : After transverse section, the 
white line, the submucosa, is readily recognized. This is intimately 
united to the mucous membrane, but can be easily separated from the 
muscular coat. Seizing the mucosa and submucosa with forceps, the 
muscularis and serosa are pushed off and turned back like a cuff 
with the finger nail to the extent of a little more than half an inch. 
The haemorrhage is trifling. The mucous cylinders are now resected 
close to the base of the reflected cuffs, and united by sutures. These 
cuffs are then turned back and considerable serous surfaces united. 
The projection is outward, and not into the intestinal lumen, as in the 
ordinary Lembert suture. Again the weak point in end-to-end 
union, the mesenteric attachment, is well protected because, owing 
to the abundant flap, ample serous surfaces can be accurately approxi- 
mated. Furthermore, in the Lembert suture there is always danger 
that a stitch may perforate the mucosa and give rise to fatal leakage. 
With this method such an accident is impossible. In one experi- 
ment the mucous membrane was not united, and the autopsy showed 
a fiecal abscess between this and the muscularis, although no symp- 
toms had been caused by it before the dog was killed. That the 
musculo-peritoneal flaps are well nourished was proven by the fact 
that no gangrene was observed, and that after injecting a colored so- 
lution into the circulation, it was found as freely distributed through 
the flaps as through the rest of the intestine. The specimens 
showed neither any vestige of stricture nor any distension of the gut 
above the point of union. 
I have recently made some experiments with a view of testing 
this method. Its advantages are the very slight stricture as com- 
pared with ordinary circular enterorrhaphy and the extent of serous 
surfaces that can be brought into contact. This is particularly use- 
ful at the mesenteric junction. It has the drawback, however, of the 
slow interrupted suture, two layers of which must be carefully 
applied as in the ordinary operation. In consequence of this, I have 
practiced it with the following modification : after preparing the 
cuffs and amputating the mucous cylinders, the rubber rings are in- 
troduced, and the edges of the mucosa and submucosa are drawn to- 
gether. The union is completed by a continuous suture of catgut. 
* Beilage zum Centralblatt fur Chirurgie, No. 26, 1891, and "Gleaning" in 
Hahnkmannian Monthly, August, 1891. 6 
The cuffs are then turned back, and the serous surfaces drawn to- 
gether with another similar suture of the same material or of fine 
silk. Here, too, the rings permit the use of the running stitch, and 
have, in fact, all the advantages already spoken of. 
The disadvantages of the operation are the additional time con- 
sumed, even with this modification, and the danger that the flaps 
will slough. The latter complication is to be guarded against by 
care in peeling off the cuffs; practice can alone make perfect in this 
manipulation. Sloughing may be produced, too, if the outside 
sutures are applied too deeply and too tightly. I have met with 
these accidents in two experiments. Although Kummer has demon- 
strated by injection that there is an ample blood supply in a half- 
inch or longer flap, it seems safer to turn back less. Superficial 
scarification will hasten and make the union firmer. 
Clinical experience can alone decide the place of this new method. 
If it is shown that the double support of two rows of sutures and 
the abundance of serous surface add to the safety of the operation, 
the extra time is a minor consideration when cut down by the use of 
the rings and the continuous suture. 
In conclusion I would urge upon my surgical colleagues, the im- 
portance of experimental work on the intestines. Not only is this 
necessary for the general surgeon, but also for the gynaecologist, who 
enters the abdomen. This work differs so essentially from other sur- 
gical technique, that, without practical experience, the general sur- 
geon is no more fitted to do it than he is to operate on the eye. 
Such experience can be readily obtained by practicing on the human 
cadaver and, better still, on the lower animals, preferably dogs. 
If we exercise the same care with the latter as with human beings, 
we cannot be charged with cruelty, and will train ourselves to that 
scrupulous attention to detail so essential to success. 
It would seem desirable that we should have in each section of 
the country, one or more men familiar with intestinal technique, and 
ready to treat those emergencies so often met with, such as obstruc- 
tions, internal and external, perforations, etc. In this way these 
conditions would be more generally and quickly recognized, and the 
life-saving treatment carried out without delay.