A CASE OF ILE0C0L0ST0MY BY THE 
MURPHY METHOD; 
Excision of the Cecum ; Total Exclusion of a Portion 
of the Ileum (Entero-Apokleisis). 
BY 
CLAYTON PARKHILL, M.D., 
OF DENVER, COL. ; 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY AND CLINICAL SURGERY 
IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF COLORADO; 
VISITING SURGEON TO ST. LUKE’S AND ARAPAHOE 
COUNTY HOSPITALS, ETC. 
FROM 
THE MEDICAL NEWS, 
October 12, 1895. [Reprinted from The Medical News, October 12, 1895.] 
A CASE OF ILEOCOLOSTOMY BY THE 
MURPHY METHOD; EXCISION OF THE 
CECUM; TOTAL EXCLUSION OF 
A PORTION OF THE ILEUM 
(ENTERO-APOKLEISIS). 
By CLAYTON PARKHILL, M.D., 
OF DENVER, COL. J 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY AND 
CLINICAL SURGERY IN THE MEDICAL DEPARTMENT OF 
THE UNIVERSITY OF COLORADO,* VISITING 
SURGEON TO ST. LUKE’S AND ARAPAHOE 
COUNTY HOSPITALS, ETC. 
At the beginning of my last term of service in the 
Arapahoe County Hospital I found in the wards a pa- 
tient, E. B., twenty years old, who had been admitted 
August 4, 1894, to the service of one of my colleagues. 
He was suffering at that time with an appendicitis, with 
a perityphlitic abscess. He was operated upon for the re- 
moval of the appendix and the evacuation of the pus. 
Within a few days the walls of the cecum gave way in 
several places, and a fecal fistula was formed. My col- 
league operated upon him subsequently, with a view to 
closing the cecal openings by sutures, but was unsuc- 
cessful. 
When the man came under my care, on September i, 
1894, he was greatly emaciated, and suffered much pain. 
There were four large fistulae in the outer wall of the 
cecum, through which all the fecal matter was discharged. 
The opening in the abdominal wall had a length of 
about five inches and a width of two-and-half, and was 
suppurating profusely. I was convinced that any further 2 
attempt to close the fistulse by sutures would fail, so I 
decided to effect an anastomosis between the ileum and 
the colon, in order to shut off the cecum from the fecal 
circulation. 
I operated on September 14,1894. My incision began 
about an inch below the cartilage of the ninth rib, ex- 
tending downward and slightly inward for six inches, 
in a line midway between the margin of the fistulous 
opening and the linea alba. When the section of the ab- 
dominal wall had been made, exploration disclosed the 
fact that the suppurating focus about the head of the 
cecum had been very perfectly circumscribed by loops 
of intestine matted together by adhesions. 
With comparatively little difficulty I discovered, as I 
thought, the terminal portion of the ileum. This I cut 
across at a point about three fourths of an inch from what 
1 believed to be the valve. Leaving a clamp on the 
short portion of the gut, I caried the other end upward, 
and by means of the largest size Murphy button made an 
end-to-side anastomosis with the beginning of the hepatic 
flexure of the colon. I then closed the end of the ileum 
left attached to the cecum below. I used first a continu- 
ous suture and then invaginated the line of union by a 
row of Lembert sutures. After a careful toilet of the 
peritoneum the abdominal wound was closed, the cecum 
was plugged with gauze, and the usual dressing applied. 
In the patient’s weak condition it was out of the ques- 
tion to think of excising the cecum at that time. In 
fact I was very doubtful when the patient was put on the 
table if he would survive an intestinal anastomosis. He 
rallied from the operation, however, very satisfactorily, 
showing almost no evidence of shock. His progress 
toward recovery was uninterrupted and exceedingly 
rapid. As it was impossible to weigh him before the 
operation I have no means of judging with accuracy as 
to his gain in weight, but my impression is that it was not 
less than a pound each day for a month. 3 
On the eleventh day after the operation the sutures 
were removed from the abdominal wound, and this was 
found to be perfectly united. The cecum was kept 
plugged with gauze, notwithstanding which there was 
some discharge of fecal matter, although the main por- 
tion of the feces was passed naturally. The button was 
passed from the rectum on the thirteenth day. I was 
determined to see if nature would close the defect in the 
cecum and in the abdominal wall, and so had the patient 
discharged from the hospital on October 31st. At the 
end of a month he was readmitted, begging for a second 
operation. The fistula had contracted to about two- 
thirds of its original size, and there was still some regur- 
gitation of fecal matter. The man’s general health was 
excellent. On December 8th I operated a second time. 
Before beginning the second operation I passed my finger 
into the colon and examined the site of the anastomosis. 
I had used the largest size Murphy button in the set. I 
found that the opening was barely large enough to admit 
the end of my index-finger as far as the base of the nail. 
On measuring my finger at that point I find that it has 
a circumference of exactly two inches, while the button 
used had a circumference of three-and-a-quarter inches. 
Entering at the fistulous opening I dissected the large 
bowel loose from its attachments, and cut it across some- 
what above the junction of the cecum with the ascend- 
ing colon. I then closed the colon by a continuous 
suture, reinforced by a series of Lembert sutures. Then 
taking up the cecum, I dissected it downward to the ileo- 
cecal valve. On passing my finger through the valve I 
discovered that in my first operation I had not cut the 
ileum at its junction with the cecum as I had believed. 
It was impossible to reach the end of the segment. It 
at once became evident to me that nature in her attempt 
to circumscribe the original infected area about the head 
of the cecum had matted together the small intestines 
in such a way that what I believed to be the extern a 4 
portion of the ileum was only the point where it had 
entered into the formation of this wall. How much of 
it was involved I had no means of determining. On 
observing this condition I excised the cecum at the valve. 
I then proceeded to close the ileum by the same method 
that I had used for its other end, thus excluding that por- 
tion of the gut that lay between the point where I had 
cut it in the original operation and the ileo-cecal valve. 
I did not attempt to bring together the edges of the ab- 
dominal wound, but packed it with gauze and left nature 
to fill it up. The patient made an excellent recovery, 
and at the present time (January 20, 1895) is perfectly 
well. 
This case presents several points of interest. It adds 
another to the list of end-to-side anastomoses by the 
Murphy method. I cannot speak too highly of the 
mechanical ingenuity of this button, and the facility 
with which an anastomosis can be made with it. In 
fact, I believe that it is the only possible method that I 
could have used in this case, owing to the patient’s ex- 
tremely weak and depressed condition at the time of the 
first operation. Any prolonged procedure would un- 
questionably have terminated his life on the table. By 
this method, however, the anastomosis was effected in a 
very few minutes, and the operation speedily finished. 
So far as I know, this is the first opportunity in which 
the amount of contraction at the point of anastomosis 
has ever been observed in the living subject. Forty- 
two days had intervened between the time that the 
button was passed and the time of the second opera- 
tion, and as the opening was found to have a circum- 
ference of but two inches instead of three-and-a- 
quarter, which it necessarily must have had at the time 
that the button was passed, this brings up a very inter- 
esting question as to whether this contraction will con- 
tinue and where it will end. 
The case also furnishes an addition to the 104 cases 5 
of excision of the cecum tabulated by Magill.1 The 
article of Dr. Magill is a most exhaustive and admir- 
able one, but I am at a loss to understand why he 
should apply the term “resection” to an “ excision of 
the cecum.” It is certainly a misnomer to speak of a 
primary removal of the cecum as “ resection.” 
The second operation, I believe, furnishes the first 
example of a total exclusion of the portion of the intes- 
tine which has been performed in America. 
In the Centralblatt fur Chirurgie, 1894, No. 49, 
Obalinski discusses the case of total exclusion operated 
on by von Baracz, and reports two cases of his own. 
One of his patients suffered from a fecal fistula. The 
operation disclosed the fact that it communicated with a 
tuberculous appendix and cecum. Both of these struc- 
tures were excised. The surgeon was not able to ap- 
proximate the ileum to the ascending colon on account 
of the shortness of its mesentery; so he cut the colon 
at the junction of the hepatic flexure with the transverse 
portion and made an end-to-end anastomosis between 
the transverse colon and the ileum. He then sutured 
both ends of the ascending colon, totally excluding it. 
In the other case he first effected a partial exclusion by 
fastening both ends of the excluded gut in the abdom- 
inal wound. This gave rise to so much inconvenience 
from the discharge of mucus from the fistula that he 
operated a second time, making a total exclusion. Both 
of the patients made good recoveries. Obalinski con- 
tends that to Polish surgeons is due the credit for the 
first two cases of total exclusion of a portion of the in- 
testinal tract, and points out the fact that this operation 
has been confused with that of partial exclusion and 
simple excision. He cites Dr. Carmalt, of New Haven, 
1 William S. Magill: “ Resection of the Ileocecal Coil of the 
Intestine, its Indications, Results, and Modus Operandi, with a 
Review of 102 Cases and Two Yet Unpublished.’’ Annals of 
Surgery, December, 1894. 6 
as claiming in his article published in the International 
Clinics ior October, 1891, to have made a total exclu- 
sion. Dr. Carmalt’s case was simply an excision of 
he cecum, with an end-to-end anastomosis between the 
ileum and the ascending colon. He made no claim to 
having done an exclusion. 
Obalinski further objects to the term exclusion as ap- 
plied to this operation, and proposes in its stead “ elim- 
ination.” There can be no doubt that some confusion 
has arisen regarding the exact character of this opera- 
tion through the indefinite term “exclusion,” but to my 
mind “ elimination ” is no more definite. There is need 
of a term that will signify a shutting up of both ends of 
a portion of the intestine, thereby cutting it off from the 
fecal circulation and yet leaving it in place. I would 
propose for this operation the name “ entero-apokleisis.” 
This word in the Greek defines exactly the operation 
that is done, and if used the operation could be mistaken 
for nothing else. 
The invariably good results that have followed this 
operation of entero-apokleisis show that it has a dis- 
tinct and important position in modern abdominal sur- 
gery. It makes it possible to operate successfully on 
cases that without it would either be left with an artificial 
anus and its attendant horrors, or to die of the original 
disease. While on first thought it seems rather a rash 
procedure, its results show that it is not only justifiable 
but also to be commended. The Medical News. 
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