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CONTENTS. 
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JULY, 1894 
SOME EXPERIMENTS UPON THE PRIM£ VLT, WITH REPORT 
OF A NEW METHOD IN ENTERORRHAPHY; ITS 
TECHNIQUE AND RESULTS. 
BY BEN. B. CATES, M.D., 
Demonstrator of Anatomy and Operative Surgery in the Tennessee Medical College. SOME EXPERIMENTS UPON THE PRIM2E VLE, WITH 
REPORT OF A NEW METHOD IN ENTEROR- 
RHAPHY ; ITS TECHNIQUE AND 
RESULTS.1 
From the time of Celsus to the days of Lembert, operations upon 
the primae vise were few and far between ; owing, no doubt, to the sur- 
geons of that era failing to appreciate the fact that the serosa and 
mucosa would not adhere to each other. It was left for Bichat to 
demonstrate that mucous and serous surfaces had no tendency to affiliate. 
However, after Lembert had established his law regarding the 
healing of intestinal wounds, to wit : that in the regeneration of wounds 
of the intestines, either as the result of pathological changes, or as 
the result of trauma, the serosae must be applied directly vis-a-vis, 
surgeons began to awaken from their lethargy, and to seek more 
knowledge regarding this important subject by experiments upon the 
lower animals. The many devices - mechanical and otherwise- 
which they used in their experiments are both interesting and instruc- 
tive, for they eventually paved the way for the various methods now in 
vogue. Again, on the other hand, very little progress was made in 
intestinal surgery until Sir Joseph Lister instituted the use of the aseptic 
ligature in surgical practice. 
Since then, surgeons have been stimulated to renewed endeavor 
through the instrumentality of N. Senn, who might well be styled 
the pioneer in recent surgical procedures upon the primae viae. He 
demonstrated that with perfect asepsis many of the dangers formerly 
encountered in this field are shorn of their horrors. He showed 
that after a great number of experiments upon animals with the 
ligature alone, and then with some mechanical contrivance associ- 
ated with the ligature, that the best results were to be obtained by 
the use of the latter method, which after many trials with absorb- 
able and non-absorbable material led him to adopt his decalcified bone 
plates. No matter what method is used, the ultimate object is to 
obtain a certain amount of serosa for approximation, and to secure rest, 
as it were, for the coaptated parts. 
As no one procedure is applicable in all affections of the intes- 
tinal tract, it is well for the surgeon to familiarize himself with the 
1 Read at the Tennessee State Medical Association, held at Memphis, Tenn., April u, 1894. 2 
Ben. B. Cates. 
most practicable methods, so as to be able to meet any emergency 
that may arise. In order to thoroughly understand the technique of 
operations in this situation, experiment upon animals offers the best 
field to exercise his dexterity. Therefore, while it is not the intent or 
purpose of the writer-having respect to the main point of the paper- 
to embrace within the scope of this thesis any lengthy account of the 
trial operation upon the primae vise underwent before being recognized 
as a legitimate surgical procedure, nevertheless, before entering upon 
any detailed description of our experiments a brief re stem e of intestinal 
operations may be instructive. 
The first mention of any procedure upon the intestinal tract wras 
of the suture, the continuous or Glover's suture finding most favor. 
This was soon followed by the use of hollow cylinders of elder, over 
which the bowel wras stitched. Salceto used the dry intestine of ani- 
mals, and also the trachea of animals in the same way. These experi- 
menters did not stitch bodies in the gut. Later, Du Verger used the 
tracheal support, but modified it from its predecessors by including it 
in the suture. In the same way Sabatier used card-board covered with 
some unguent. All these processes were, according to Senn, denominated 
differently as that of the four masters, who used four stitches ; that of 
Du Verger who used two ; of Sabatier who used one. These were still 
further modified by Ritsch by "passing the thread from side to side 
through the centre of the bowel and the cylinder, when the ends were 
twisted and brought out of the external wound.'' 
Watson recommended a cylinder of fish-glue, and operated suc- 
cessfully on a dog. Von Walther, on the other hand, used a tube of 
India-rubber. Guy de Schauliac used the Glover suture. Richard 
Wiseman (1686), Purman (1730), and Mr. Samuel Sharp (1769) wrote 
upon intestinal injuries, advising the use of the Glover suture. In 
complete transverse wounds of intestines cures had followed adhesion 
of proximal end of gut in wound. Paracelsus proposed in transverse 
wounds of intestines the formation of an artificial anus. Finally, 
Palfyn advised that in all wounds of intestines that were accessible, to 
bring visceral wound in contact with external wound, and hold in posi- 
tion with suture passed through mesentery till adhesions formed. 
De la Peyronie still further modified Palfyn's method by stitching 
" the bowel at the same time to the margin of the external wound.'' 
Benjamin Bell treated transverse wounds of intestines by bringing 
both ends of divided gut in external wound, and holding them there 
with sutures. Reybard accomplished the same purpose by using a 
small piece of wood with two sutures, each of which embraced the 
entire thickness of bowel wall and abdominal wall. Garengeot, Lar- 
rey, and B. Bell each modified the Glover suture. Bertrandi and A New Method of Enterorrhaphy. 
3 
Pettit devised the sutura transgressiva. La Dran, Richter, and Loeffler 
each devised a suture. 
The different sutures thus far devised not meeting with the success 
their promoters anticipated, surgeons began casting about for other 
methods of treating complete transverse wounds of intestine. As early 
as 1730 Ramdohr recommended invagination in complete transverse 
wounds of intestines, and reported a successful case thus treated, occur- 
ring in a soldier. Louis, B. Bell, Chopart, and Desault modified Ram- 
dohr's method. Travers modified the method of Ramdohr, Louis, Bell, 
and others, by cutting the thread short to the knot, then returning the 
intestine into the abdomen, and not keeping it in contact with external 
wound as his predecessors had done. In due course Dupuytren devised 
his suture, which is the continued suture with a Lembert stitch. Dieffen- 
bach, on the other hand, while using the continued suture, included 
only the peritoneal coat. 
Nelaton spoke favorably of Gely's suture, which was modified by 
Blatin, who used two threads of different color. Emmert's suture is 
simply a double series of Lembert's suture on either side of the wound, 
the corresponding sutures being tied, and the margins of the wound 
inverted. Bonnison used insect pins held together with sutures. 
Jobert (1827), recognizing Lembert's law, modified Ramdohr's method 
by turning in the edge of the lower end of cut gut before inserting 
intussusceptum into intussuscepiens. 
Amussat, as early as 1834, used with invagination a hollow cylin- 
der of elder with a circular groove in the centre. A thread was tied 
around the bowel at this groove, which soon cut its way into the lumen, 
freeing the cylinder, and leaving the bowel adherent at the con- 
striction. Choise, in 1837, used in his experiments, in lieu of the elder 
cylinder, the trachea of an animal, and then encircled the bowel over 
trachea with ligature, as in Amussat's operation. Subsequently he 
used cork with good result. 
As early as 1826, Denans used rings of metal, which he introduced 
into end of bowel, in his experiments on transverse wounds of intes- 
tines in making end-to-end union. Then, inverting ends of bowel over 
rings, and holding them together with a smaller but wider ring, which 
he inserted into end ring. The rings subsequently relieved them- 
selves by pressure-atrophy, and left the bowel ends firmly adherent. 
Baudens modified Denans's operation by using a single cylinder with 
a transverse groove in the centre, and two rubber rings. Henrotz used 
rings with metallic points, which perforated the mucous membrane, 
and held it opposed to the mucous membrane in opposite end of cut 
bowel by perforating the opposite ring. He again ignored Lembert's 
law, and was thus doomed to failure. 4 
Ben. B. Cates. 
In longitudinal wounds of intestine, Beranger-Feraud used clamps 
of cork with insect pins. The pins punctured entire thickness of bowel 
wall and, penetrating the opposite cut edge, buried themselves in a cor- 
responding piece of cork. The corks relieved themselves by pressure- 
atrophy leaving the serosae in apposition and adherent. Bobrick (1850) 
used for the same purpose a clamp of sheet lead or silver, by which he 
held the inverted edges of bowel together till adhesions formed. 
As none of these procedures met the desired indication in the 
treatment of intestinal affections, the inventive and constructive genius 
of surgeons was exercised to the utmost to devise some method whereby 
an ideal suture could be employed in treating disease or trauma of this 
tract. And after much painstaking research and honest endeavor, forti- 
fied by a large number of experiments upon animals, we have the 
present splendid achievements of modern surgery. 
Since the Lembert suture alone did not effect the ideal result in 
approximating the cut edges of the bowel, other surgeons have still 
further devised modifications of his procedure, some of ■which are 
useful, while others are interesting only from an historical stand-point. 
Among those sutures that have been devised to overcome the defects 
of the Lembert stitch-to wit, that the cut edges were not accurately 
approximated, thus allowing the secretion of intestines to contaminate 
wound-maybe mentioned Gussenbauer's, which, according to Barker, 
entered the serous and muscular coats a short distance from the cut 
edge and was brought out again. He then entered a second time through 
serosa and muscular coat, emerging on cut edge of wound superficial 
to mucosa. It was then entered at the opposite point in the cut edge 
and carried through the bowel coat in the reverse direction. 
Czerny further modified the Lembert by using a double row 
of stitches. His first set entering serosa, included bowel wall down to 
mucosa and came out on cut edge. Then, entering at opposite point on 
cut edge, passed out on serosa in reverse direction. The second row 
was Lembert's suture and was placed in interval between two stitches 
of first row. This was intended to reinforce first row and bring more 
serosa in apposition. Again Woelfler has modified the Czerny stitch in 
circular enterorrhaphy by entering his suture between muscular and 
mucous coats on the cut edges and tying within the lumen of the gut. 
He includes, though, only the two outer layers of bowel, the second 
row being applied as in Czerny's second row. Mr. C. S. Bishop, of 
Manchester, has devised a very interesting suture which he used quite 
successfully in his experimental work. 
Kummer first excised a circular ring of mucous membrane which 
he sutured separately and then brought inverted serosae together with 
interrupted sutures. Chaput only scraped mucosa to denude it of epi- A New Method of Enterorrhaphy. 
5 
thelium. M. E. Connell, of Milwaukee, M. L. Harris, of Chicago, and 
Maunsell, of New Zealand, have each devised new methods in circular 
enterorrhaphy, which are both interesting and instructive and well 
worth the attention of surgeons. 
In an end-to-end union of the intestine, Senn employs a modifica- 
tion of Jobert's operation, a method which he lauds very highly. 
Neubert modified the plan of Amussat by using, instead of cylin- 
ders of elder, hollow cylinders of bone, and reports good results. 
Recently, however, Dr. John B. Murphy, of Chicago, has devised and 
successfully employed, both on animals and human subjects, a very 
ingenious contrivance in the shape of a button. While some have 
deprecated its usefulness in intestinal surgery, in the hands of Dr. 
Murphy and other surgeons very brilliant results have followed its 
adoption, especially in operations for establishing a communication 
between gall-bladder and intestine. Therefore, before relegating it to 
oblivion, as some would do, it certainly deserves the further attention 
of the profession. Professor Adelbert Raumauge, of Buenos Ayres, has 
also an instrument intended for the same purpose as the Murphy 
button. 
Since Senn with his decalcified bone plates proved by his demon- 
strations on the lower animals, and subsequently on man, that the fecal 
circulation, stopped from any cause whatever, could be restored by a 
fistulous opening in bowel above and below the obstruction and that 
the cut-off part would not be to the patient's disadvantage, a great 
many substances have been used by surgeons to accomplish the same 
purpose as the bone plates, such as catgut rings by Abbe and Matas ; 
catgut mats by Davis, of Birmingham ; segmented rubber rings by 
Brokaw ; rawhide and segmented rubber plates by Robinson ; cartilage 
plates by Stamm ; chromicized gelatin plates by Shrively and Simon- 
son ; potato plates by Dawborn, and Swedish turnip plates by Von 
Boracz. H. Littlewood, an English surgeon, has modified Senn's 
method by using bone plates with decalcified bone cylinder in centre of 
approximation plates, thus doing away with sutures. But he further 
enhanced the strength of approximated serosae by inserting sutures 
around plate. Sachs's method is a modification of Senn's. He also 
strengthens approximation plates with sutures. Professor A. W. Mayo 
Robson uses decalcified bone bobbin for effecting approximation of 
bowel and reports a number of successful operations upon man. 
However, whatever method is used by the surgeon it seems that 
there is, according to one of the great lights in this department of the 
healing art, something yet lacking. For in a very elaborate and ex- 
haustive paper, delivered by N. Senn before the Military Surgeons of 
the National Guard of the United States of America, he says, "We 6 
Ben. B. Cates. 
have reason to believe that the technique of intestinal suturing remains 
an unfinished chapter, and that the ideal method of uniting intestinal 
wounds has yet to be devised." 
For the purpose of familiarizing myself with the technique of 
intestinal surgery and of testing the efficacy of hydrogen gas in locating 
perforations of the primae vise I instituted some observations upon ani- 
mals, the result of which experiments I hereby offer. And before 
entering into a discussion of our experiments I wish to say that these 
operations were performed in my laboratory at the Tennessee Medical 
College, and as far as the technique is concerned were done under the 
strictest detail as regards the antiseptic treatment of wounds,-i.e.y 
the field of operation was shaved, thoroughly washed with strong 
antiseptic solution and alcohol. The instruments, sponges, utensils, 
hands of operator and assistants were likewise rendered thoroughly 
aseptic. On the other hand, there was no preparation as regards 
the condition of the animal before or after the operation. Neverthe- 
less, after the abdomen was entered I was very careful to prevent any 
extravasation into abdominal cavity by drawing only that portion of 
primae viae intended for operation into external wound, and packing 
bichloride gauze around gut at margin of wound ; I then displaced 
fecal matter away from field of operation by pressing on either side of 
gut with my fingers, and tying elastic ligature around gut above and 
below point of incision in bowel,-which incision wras long enough to 
admit plates and ligatures armed with needles, which were passed 
through bowel wall from within out, these threads were then tied to 
corresponding threads in another portion of bowel : this ligature 
around bowel prevented fecal regurgitation from contaminating wound, 
embarrassing operation and also causing septic peritonitis. As for the 
diet subsequent to closing external wound, no attention was paid to it, 
the dog being allowed to run about and eat what it wished. 
Experiment I.-Medium-sized cat. Made incision through linea 
alba, and excised two inches of gut eighteen inches above ileo cecal 
valve, and restored continuity of bowel by Senn's invagination method. 
Recovered from operation. Bowels moved once and vomited once. 
Lived twenty-four hours. 
Post-mortem.-Examination showed diffused septic peritonitis. 
Omentum partially adhered to gut. Perforation of bowel at site of 
operation near mesenteric attachment. 
Experiment II.-Small-sized bitch. Opened abdomen through 
linea alba, and excised two inches of ileum twelve inches above ileo- 
cecal valve, and brought ends together with Czerny-Lembert suture. 
Transplanted omental ring around gut at seat of operation and secured 
with catgut. Considerable hemorrhage from mesentery. Closed wound A New Method of Enterorrhaphy. 
7 
in abdomen with deep catgut and superficial silk sutures. Lived forty- 
eight hours. 
Post-mortem.-Diffused septic peritonitis. Bowels matted together. 
Perforation at point of union of intestine near mesenteric attachment. 
Omental graft not adhered. 
Experiment III.-Yearling pointer bitch. Opened abdomen through 
linea alba, and excised two inches of bowel above ileo-cecal valve. 
Used Senn's invagination method, and in addition buoyed up the 
coaptated parts with Lembert's suture in interval of two invagination 
sutures. Dog made a rapid and uninterrupted recovery, and was alive 
and well seven months afterwards, when I lost all trace of her, she 
having borne a litter of pups in the mean time. 
Experiment IV.-Large white dog, weight sixty pounds. Made 
incision in median line of abdomen, and forty-three inches above cecum 
made jej uno-ileostomy (cutting off six inches of bowel from fecal circu- 
lation) with cartilage plates and sutures. The cartilage plates were 
reinforced with Dieffenbach's suture of catgut thread. Nothnagel's 
test corroborated. Thirteen days after operation killed dog. 
Post mortem.-Omentum adhered to gut around fistulous opening, 
on examination, fistulous communication was large enough to admit 
thumb to metacarpo-phalangeal joint. 
Experiment V.-Large black dog; weight fifty pounds. Opened 
abdomen in median line, and divided gut forty-one inches above ileo- 
cecal fissure, inverted ends, and applied continuous catgut suture. Then 
made lateral anastomosis with cartilage plate three inches from inverted 
ends of bowel. Fistulous opening on convex side of bowel one inch 
long. Reinforced plates with Dieffenbach's continuous catgut suture. 
Nothnagel's test corroborated. Animal killed twenty-two days after 
operation. External wound healed. Omentum adhered to inner surface 
of abdominal wound and to sides of bowel at anastomosis. On prox- 
imal side of anastomosis bowel dilated for six inches. New opening 
in bowel admits the right index finger up to the second joint; in fact, 
as large as lumen of bowel at distal side of operation. 
Experiment VI.-Large black dog, weight sixty pounds. Opened 
abdomen in linea alba extending from xiphoid cartilage three inches 
towards umbilicus. Made gastro duodenostomy with cartilage plates 
between anterior surface of stomach and convex surface of duodenum. 
Strengthened plates with Dieffenbach's suture of catgut. Closed 
abdominal wound with superficial and deep sutures, and had just 
finished operation when dog expired. Used chloroform in early part 
of operation because dog hard to manage ; later used ether. 
Experiment VII. Large black dog, weight forty-nine pounds. 
Made incision in median line from xiphoid cartilage to umbilicus. 8 
Ben. B. Cates. 
Drew stomach into wound. Tore through omentum and made incision 
in posterior surface of stomach one and one-half inches long, and 
inserted a partially-ossified cartilage plate, and united this to a similar 
opening in ileum, forty-three inches above cecum, and backed up plates 
with Dieffenbach's suture. Then closed abdominal wound with super- 
ficial and deep sutures. Animal rallied well, and was killed ten days 
after operation. Abdominal wound healed. Opening between stomach 
and intestines closed except a small fistula about the size of a knitting- 
needle. Omentum adhered to bowels, forming several loops. 
Experiment VIII.-Large black-and-white spotted hound. Ether- 
ized him, and after placing him on table, shot him twice in abdomen 
with Flobert rifle at short range. First shot entered on left side a little 
below and three and one-half inches to left of umbilicus. Second, one 
inch nearer median line on same level as former, and buried itself 
beneath skin on left side. The line of entrance of first ball could not 
be traced (hence cause of second shot) owing to change in relative 
position of abdominal muscles. Entering grooved director into second 
wound of entrance, I then attempted Senn's hydrogen-gas test by 
placing nozzle of glass tube high in rectum, with negative results. 
After repeated attempts with considerable pressure, I abandoned the 
experiment, and proceeded to open abdominal cavity to find cause of 
failure. The rectum, sigmoid flexure, and part of ascending colon 
were impacted with hardened feces. Abdominal cavity filled with 
blood. The ascending colon was perforated at its commencement; the 
transverse colon was perforated in two places. There were five perfor- 
ations in small intestines. Spleen wounded in two places, and owing 
to uncontrollable hemorrhage, I removed it after tying it with cobbler's 
stitch. There was considerable oozing from wound of mesentery, 
which I also stopped with cobbler's stitch of catgut. There was no 
escape of fecal matter except in descending colon, where gut was 
impacted with it, and then only when I attempted to close wound. I 
closed wound in rest of primae vise with catgut sutures. Closed wound 
in abdomen with deep sutures. Dog died of shock in less than one 
hour. Hydrogen gas introduced above impaction in colon escaped at 
opening in transverse colon, and burned with characteristic flame. 
Experiment IX.-Small black dog. Etherized and tried Senn's 
hydrogen-gas test in rectum. But after repeated trials and heavy press- 
ure failed from impaction of feces in bowel. 
Experiment X.-Large black dog. Made incision in median line. 
After bringing cecum in wound, excised it with five inches of ascending 
colon, with three inches of lower extremity of ileum. Then, alter 
invaginating cut ends of gut and using Dieffenbach's suture with catgut 
thread, I made ileo-colostomy by lateral anastomosis with cartilage A New Method of Enterorrhaphy. 
9 
plates. I then reinforced plates at side and at proximal extremity with 
Dieffenbach's suture of catgut, leaving distal end of plate unsupported. 
Dog rallied well, and on following day was running about. However, 
forty-eight hours after operation the dog died. Necropsy showed about 
one-half pint of bloody serum in abdomen, very offensive, and at 
extremity of plate not reinforced with suture there was a dark-colored 
liquid mixed with feces oozing out between approximated surfaces of 
gut. Wherever the catgut sutures had been inserted, they were covered 
over and entirely hidden from view by a plastic exudate, thus com- 
pletely preventing escape of fecal matter. This showed it was not 
sufficient to trust to tying of plates alone. 
Experiment XI.-Medium-sized black dog. Opened abdomen 
through right linea semilunaris and removed cecum with three inches 
of ascending colon, and ten inches of ileum, using cobbler's stitch on 
mesentery of removed portion of gut. Invaginated cut ends of gut, 
and made ileo-colostomy by lateral anastomosis with cartilage plate, 
reinforced with Dieffenbach's suture. Dog lived twelve hours. Ne- 
cropsy showed that in one ligature I had included mesentery supplying 
four to five feet of small intestine. The gut supplied by ligatured 
mesentery was gangrenous. 
Experiment XII.-Large white dog. Opened abdomen through 
right linea semilunaris and removed cecum with three inches of ascend- 
ing colon and two inches of ileum. Used two sutures on mesentery 
supplying removed gut, then tore mesentery off of gut; scarcely any 
hemorrhage. Invaginated cut ends of gut, and then did ileo-colostomy 
by lateral anastomosis with cartilage plates. Reinforced plates with 
catgut sutures and Dieffenbach's stitch round entire circumference, 
except distal end. Dog rallied and lived twenty-four hours. Post- 
mortem showed septic peritonitis. About half a pint of dirty, dish- 
water-looking, offensive fluid in abdominal cavity. Invaginated ends 
of cut gut covered over with plastic lymph. Where cartilage plates 
were reinforced with catgut they were completely covered over with 
plastic lymph, shutting off escaping feces. At end of plates not re- 
inforced the secretions from bowel were exuding. 
Experiment XIII.-Full-grown bull-dog. Opened the abdomen 
through right linea semilunaris. Removed cecum with three inches of 
ascending colon and two inches of ileum. Closed bowel with Dief- 
fenbach's stitch of catgut, and made ileo-colostomy by lateral anas- 
tomosis with cartilage plates. Bowel on one side of plates tore 
through, and plates difficult to handle, having a tendency to slip about. 
Nevertheless, closed rent and used Dieffenbach's suture with catgut 
thread around entire circumference of cartilage plate. Clamped arteries 
running through mesentery to cut off gut with hemostatic forceps till 10 
Ben. B. Cates. 
operation completed, then tore mesentery away from cut off bowel. 
No hemorrhage. Closed wound in abdomen with three sets of sutures. 
Dog rallied well and lived thirty hours. Necropsy showed septic peri- 
tonitis due to perforation opposite weak point in bowel where plate 
had torn through. About one-half pint of dark, offensive liquid in 
abdominal cavity. Around circumference of plates all the sutures 
entirely covered with plastic exudate. 
Experiment XIV.-Medium-sized black dog. Opened abdomen 
in right linea semilunaris. Hard to find cecum. Had to eventrate. 
Removed cecum with three inches of ascending colon and three inches 
of ileum. Invaginated ends and inserted Lembert's suture. Great 
difficulty in invaginating ileum. Clamped artery supplying cut off 
gut with hemostatic forceps. Tore mesentery from cut off gut. No 
hemorrhage. Made lateral ileo-colostomy with cartilage plates. Scraped 
approximated surface of serosae. Made Dieffenbach's suture around 
entire circumference of plates. Closed wound in abdomen with one 
row of sutures only. Dog never rallied, and died of shock fourteen 
hours after operation. Necropsy. Invaginated ends of gut adherent 
and partially covered with plastic lymph. Surface of gut in apposition 
by lateral anastomosis firmly adherent. Dieffenbach's suture partially 
covered with plastic exudate. 
Experiment XV.-White-and-tan dog, weight sixty pounds. Made 
incision through right linea semilunaris. Removed cecum and two 
inches of ileum. Invaginated cut ends of gut and held in position with 
Lembert's suture. Made ileo-colostomy by lateral anastomosis with 
cartilage plates, using Dieffenbach's suture with catgut thread. Closed 
belly wound with deep catgut and superficial silk sutures. Dog lived 
twelve hours and died of shock. Necropsy. Invaginated ends partly 
covered with lymph. The sutures and entire surface of approximated 
bowel on one side of cartilage plates covered with plastic lymph. 
As all the above experiments were made with cartilage plates 
(secured from the scapula of the ox), which were oftentimes difficult 
to manage, having a tendency to slip about, even after being in position 
in bowel, and the sutures had penetrated entire thickness of bowel wall. 
Therefore I have adopted in lieu of the plates and sutures a button 
which I have demonstrated by experiments upon the lower animals to 
be superior, besides more expeditious than bone plates, cartilage plates, 
potato plates, the rings of Denans and Henrotz in use half a century 
ago, the buttons of Murphy and Raumauge of more recent date, or any 
other mechanical contrivance yet devised for lateral anastomosis. 
Again, because approximation with plates is not so accurate as in the 
use of the button, and in the hands of an inexpert surgeon the intes- 
tinal secretions are more liable to escape between plates. The button A New Method of Enteror? haphy. 
11 
I use in my experiments consists of a male and a female portion. The 
female portion of button was made of brass (though for obvious 
reason aluminum or silver would have been better), and has a base 
seven-sixteenths of an inch in diameter, with a small cylinder projecting 
from it about three-sixteenths of an inch long, hollow from end to end, 
and with a slit on either side of cylinder reaching nearly to base. The 
male button, which is solid, consists of a base five-sixteenths of an 
inch in diameter with a neck one-fourth of an inch long. This fits into 
and may penetrate beyond base of female button. 
To make buttons easier of introduction the female is accompanied 
by a sharp steel point about one inch long, which has a neck guarded 
by shoulder, and this neck fits into apex of cylinder of female button. 
The male button is also accompanied by a sharp-pointed cap, one inch 
long, hollow at its base. This fits over neck of male button. 
The technique of the operation when using the button is the same 
as when using the plates, till after the incision-the desired length-is 
made in the intestine, when an assistant arms the female portion with 
the steel point, which you quickly thrust through entire thickness of 
bowel wall from within out, commencing on lower side of fissure. 
Then fitting the sharp spike or cap over male button, it is passed 
through a corresponding point in opposite cut edge of bowel from 
within out. The male is then fitted in female button and pushed home 
from within the lumen of bowel. In like manner the angles of fissure 
are approximated, leaving the upper sides of opening to be closed last. 
Here the surgeon, after inserting buttons, is to grasp the base of male 
and female button separately with tissue forceps, and, after inverting 
cut edges of wounds with buttons in situ so as to bring the serosae 
vis-it-vis, engages male button in female and pushes it home from 
without through bowel wall. 
The following experiments demonstrated the feasibility of my 
method : 
Experiment XVI.-Large white dog, weight sixty pounds. Made 
incision in median line three inches long. Cut off intestinal circulation, 
three inches long, thirty inches from pylorus. Made ileo-ileostomy- 
the fistula being one inch long-and introduced my buttons with one 
cartilage plate which carried the male buttons. There was considerable 
laceration of bowel on one side of plate (owing to plate slipping), which 
was closed with catgut. Reinforced cartilage around entire circumfer- 
ence with Dieffenbach's suture. Closed belly wound with deep and 
superficial sutures. Dog vomited frequently on this and on following 
day. On second day omentum protruded through wound in abdomen. 
I tied ligature around this and then cut off protrusion, after which I 
fastened stump in wound with cobbler's stitches. Dog did well. Five 12 
Ben. B. Cates. 
days after operation killed animal. Necropsy showed omentum adhered 
to wound in abdomen and also to bowel where rent was closed. On 
1 
F1§. 2. 
F.g. 
fig- 5. 
Fig. i.-Female button accompanied by sharp steel point to facilitate 
introduction. 
Fig. 2.-Male button accompanied by sharp spike to facilitate intro- 
duction. 
Fig. 3.-Jejuno-ileostomy with four buttons forty-tw'o inches from 
cecum. Incision on rectal side five days after operation, showing three 
buttons around fistulous opening, having ulcerated through one thick- 
ness of coaptated bowels. One button has relieved itself by pressure- 
atrophy and passed away. 
Fig. 4.-Gastro-jejunostomy with four buttons. Opening on distal 
side of bowel showing fistula and one button still in situ twenty-eight 
days after operation, the other three having relieved themselves by press- 
ure-atrophy and passed away. A New Method of Enterorrhaphy. 
13 
opening bowel on rectal or distal side I found one button gone and 
others ulcerating through. Passed entire thumb through fistulous 
opening. Unfortunately specimen -was allowed to spoil. 
Experiment XVII.-Large black dog, old, weight fifty pounds. 
Made incision in median line of abdomen, and did a jejuno-ileostomy 
forty-two inches from cecum, cutting off four inches of bowel from 
fecal circulation. Made incision in bowel two inches long, and intro- 
duced four buttons without plate. There was some ectropium of 
mucosa, which was overcome by tightening buttons. Strengthened 
buttons on each side by Dieffenbach's suture of catgut. Closed wound 
in belly with superficial and deep sutures. Dog rallied and was killed 
five days after operation. Necropsy showed omentum adhered around 
sides of operation enhanced with catgut. This I tore away, and found 
catgut not absorbed. Adhesion on one side of incision and at end of 
incision not very firm. Did not irritate approximate serosae. Made 
incision through bowTel on distal side. All of buttons except one on 
side had ulcerated through one thickness of coaptated bowels, as can 
be seen in specimen. 
Experiment XVIII.-Gray-and-tan bird dog, weight forty pounds. 
Made incision in median line of abdomen extending from xiphoid carti- 
lage to below umbilicus. Brought stomach into wound, and on its 
anterior surface made incision one inch long, then joined it to a similar 
incision on convex surface of bowel twenty-six inches from pylorus with 
four of my buttons. Then reinforced button around anastomosis by 
Dieffenbach's suture with catgut thread. Closed belly wound with 
deep catgut and superficial silkworm-gut sutures. Dog rallied and 
made a rapid and uninterrupted recovery. On second day and for 
several days afterwards feces were covered with blood. On eighteenth 
day first button passed, and between eighteenth and twenty-fourth day 
passed second. On twenty-eighth day after operation killed dog. 
Necropsy showed external wound healed. Omentum adhered on 
posterior surface of opposed bowels. Found a third button in lower 
part of rectum. One button still in situ, and bowel firmly adherent, firm 
union having occurred between opposed bowels. Opening between 
stomach and intestines large enough to admit right index finger to 
first joint, as can be seen in specimen. 
In conclusion I submit the following observations : 
(1) Perforations occurring at site of operation when making in- 
vagination are more liable to be near mesenteric attachment. 
(2) Nothnagel's test was corroborated three times. 
(3) When using hydrogen gas in locating perforation and obstruc- 
tion in the primae vise, we must be sure there is no occlusion in the 
rectum, such as hardened feces, etc. 14 
Ben. B. Cates. 
(4) In excision of cecum, when ligatures are applied to mesentery 
to stop hemorrhage, there is liability of including the arterial supply of 
bowrel not in area of cut off gut. 
(5) That it is not absolutely necessary to apply a ligature to 
mesenteric arteries in the cut off gut, simply compressing with hemo- 
static forceps and tearing the mesentery from its attachment to cut off 
gut being sufficient. 
(6) That in making lateral anastomosis or end to-end union of 
bowel while a slight scarification of the opposed serosae would, as first 
pointed out by Davis, of Birmingham, hasten the adhesion and conse- 
quent definite union of coaptated parts, this may be ignored where the 
adherent surfaces are backed up by sutures. 
(7) That where the coaptated parts are reinforced by sutures, such 
as catgut, a frame-work is formed for the plastic exudate, which is 
quickly thrown out, thereby shutting off any avenue for the intestinal 
contents to escape into abdominal cavity. 
(8) Wherever sutures are applied to serosae they will be covered 
with plastic exudate within twelve to forty-eight hours. 
(9) That buttons offer many advantages as sutures over plates in 
making approximation of bowels by lateral anastomosis. Firstly, 
time, which is such an important factor in these operations, is greatly 
reduced. Secondly, they do not slip about and thus annoy and vex 
the surgeon. Thirdly, the approximation surface can be reduced or in- 
creased at the surgeon's will. Fourthly, they act as splints to the bowel 
and bring the coaptated parts into closer union, and the ectropium, 
which is sometimes troublesome to the surgeon, is easily controlled ; 
and, lastly, the button, when it frees itself by pressure-atrophy, will, 
on account of its small size, easily pass through the ileo-cecal fissure. 
(10) Wherever the fistulous communication between the bowel is 
over an inch in length, a button should be inserted every three-quarters 
of an inch to prevent ectropium and to bring bowel into closer union. 
(11) That lateral anastomosis as a surgical procedure offers better 
ulterior results in restoring the fecal circulation than end-to-end union 
of bowel, because in former method, when the opening is long enough, 
it is not followed by so great traumatic stenosis as in end-to-end union. 
(12) That in making this anastomosis my button is superior to plates. 
And therefore I offer it to the surgeons of America (in lieu of plates), to 
whose hands its future usefulness as a surgical procedure is consigned. 
(13) That whatever procedure is adopted, it is safer to back up or 
reinforce the circumference of fistulous communication in coaptated 
bowels with sutures of fine aseptic silk, which will encapsulate itself, 
or catgut, which will be ultimately absorbed, the Dupuytren or the 
Dieflfenbach suture being the quickest and easiest applied.