THE PRESENT STATUS 
OF THE 
OPERATIONS 
OF 
INTESTINAL ANASTOMOSIS 
* ANl) 
ENTERORRHAPHY, 
AND 
THE COMPARATIVE MERITS OF THE VARIOUS “AIDS ” THAT 
HAVE BEEN RECENTLY SUGGESTED IN THE PER- 
FORMANCE OF THESE OPERATIONS.* 
Hy RUDOLPH MATAS, M. D., 
Visiting Surgeon Charity Hospital; Demonstrator oF'Anatomy, Medical Department Tulane 
University of Louisiana; Instructor in Operative and Clinical Surgery, 
New Orleans Polyclinic, etc. 
Reprinted from the August, i8go, number of the Neiv Orleans Medical and 
Surgical Journal. THE PRESENT STATUS 
OF THE 
OPERATIONS 
OF 
INTESTINAL ANASTOMOSIS 
AND 
ENTERORRHAPHY, 
AND 
THE COMPARATIVE MERITS OF THE VARIOUS “AIDS ” THAT 
HAVE BEEN RECENTLY SUGGESTED IN THE PER- 
FORMANCE OF THESE OPERATIONS.* 
By RUDOLPH MATAS, M. D., 
Visiting Surgeon Charity Hospital; Demonstrator of Anatomy, Medical Department Tulane 
LTniversity of Louisiana; Instructor in Operative and Clinical Surgery, 
New Orleans Polyclinic, etc. 
Notwithstanding the fact that Dr. Senn first acquainted the 
surgical world with the results of his numerous and important 
discoveries in the domain of intestinal surgery at the Ninth 
International Medical Congress, held September, 1887, it may 
be said that their full import and value was not generally 
realized until the conclusion of the memorable series of papers 
on thissubject, which appeared in monthly series in the Annals 
of Surgery during the first half of 1S88. It was only in the latter 
part of that year, after the enormous magnitude of the work 
done was laid in detail before the public, that distinct evidences 
of a thorough understanding of his ideas and methods, and of 
their clinical application by others, began to appear on record. 
So that it may be truly stated that the general work of clinical 
* Head before the Orleans Parish Medical Society, J une 30, 1890. 2 
and experimental corroboration was not seriously started until* 
the beginning of 1889. Since January, 1889, to the present 
date, May 20, 1890, a short period of only seventeen months, 
the interest developed in the subject of intestinal surgery has 
been simply extraordinary, and the work being done in the way 
of testing, comparing, and modifying Senn’s methods, both 
at the bedside and in the laboratory, is comparable only to a 
surgical revival which has hardly a parallel in the unparal- 
leled history of abdominal surgery. In fact, the published 
evidences of clinical as well as experimental confirmation’of 
Senn’s researches have accumulated in such rapid and impres- 
sive succession, that no better acknowledgment, no more 
eloquent tribute, to the solid and enduring merit of this inves- 
tigator’s splendid work could be desired. 
Of the new and revolutionizing ideas and practices which 
we owe to Dr. Senn, perhaps none have elicited more attention 
and have been productive of more fruitful results than his 
improved method of performing the old and formerly difficult 
operation of intestinal anastomosis* and enterorrhaphy. 
By the introduction of the decalcified bone plate, he has: 
reduced an unusually difficult and fatal procedure to the cate- 
gory of the simplest and most practical operations. It is by this 
eminently practical and useful turn that he has given to what was 
originally an unpractical and at best a hazardous procedure,, 
that the attitude of the general surgeon toward many formida- 
ble and hopeless pathological conditions of the intestinal tract 
has been revolutionized; it is mainly for this reason that we, 
who are actively engaged in the field of surgical labor, have 
* “ By an intestinal anastomosis we understand a condition of the intestinal canal 
where, on account of an obstruction or complete occlusion, the intestinal contents are directed 
into a segment of the bowel below the seat of the obstruction or occlusion, through a fistulous 
opening between the bowel above and below the seat of partial or complete occlusion. The idea 
of establishing such a communication between the bowel above and below the seat of obstruction 
originated with Maisonneuve, who, without testing the new procedure first on animals, oper- 
ated on two cases; but as the result in each case was fatal, he seems to have become discour- 
aged and abandoned the operation, and never published the communication on this subject 
which he had in preparation. In the Surgical Society of Paris, his proposition met with 
violent opposition from his contemporaries, who argued that the excluded portion of the 
intestine would become the seat of fascal accumulation, which, even if the operation Were a 
success, would subsequently destroy the life of the patient. For a long time the operation 
was completely forgotten, until E. Hahn, of Berlin, very recently alluded to it again in com- 
menting on his two cases of excision of the colon where circular enterorrhaphy could not be 
performed and where an artificial anus was established. Both patients recovered from the 
operation, but all attempts to close the preternatural opening proved futile.”—Senn, Annals oj 
Surgery, January- June, 1888. 3 
eagerly welcomed it as a new and powerful aid in our work of 
intervention against disease. 
Perhaps no illustration of the altered aspect of the surgical 
mind and of the improved situation brought about by the appli- 
cation of the new method of securing anastomosis could be 
offered than by instituting a comparison between the operation 
of gastro-enterostomy before and after the introduction of the 
Senn method. From the date of Wolfler’s first operation, on 
September 27, 1881, to May 14, 1889, a Pei'i°d of over eight 
years, Mr. Herbert Page, of London,* was able to collect the 
reports of thirty-eight cases, furnished by different operators 
and performed by the tedious and unaided Czerny-Lembert 
stitch. If we exclude two fatal cases from Page’s table, in 
which pylorectomy was done conjointly with gastro-enteros- 
tomy, thirty-six cases of pure gastro-enterostomy will remain 
to be studied. Of these thirty-six cases, fifteen were fatal, 
directly or indirectly, as the result of the operation. Collapse 
was the most frequent cause of death. The mortality, there- 
fore, by the old, unaided stitch method is 42.8 per cent. 
That this is the correct statement of the mortality of the 
old operation (by unaided suture), even when performed by 
the most experienced operators, is confirmed by the most re- 
cent contribution of Von Hacker, of Vienna.t This report 
embodies twenty-one cases of gastro-enterostomy, operated by 
Wolfler’s and Von Hacker’s methods. Of the eight cases 
operated by Wolfler’s method, four recovered and four died ; 
of the thirteen operated by Hacker’s method, seven recovered 
and six died. This amounts to about 47 per cent, and confirms 
the correctness of Page’s estimate, and, furthermore, proves 
the fatality of the old operation even when it is performed by 
the most experienced hands. On the other hand, I have not 
had much difficulty in procuring the records of eighteen cases 
of uncomplicated gastro-enterostomy, performed by different 
operators in this country and Great Britain, with a mortality of 
three cases, or about 16 per cent. These operations have been 
performed in the course of the last eighteen months, and all,. 
* Proceedings Royal Medical and Chirurgical Society of London. British Medical 
Journal, May 18, 1889. Vol. I, pp. 1114-15. 
j Transactions Imperio-Royal Society of Vienna, Correspondence Semaine Medica/a 
May 3, 1890. 4 
with the exception of four cases, with the aid of Senn’s decal- 
cified bone plates, the other four cases having been operated by 
the Senn principle, only that catgut rings were substituted for 
the bone plates. I have purposely avoided the cases of gastro- 
enterostomy which have been complicated with pylorectomy, 
as in Bull’s recent successful case and Tuholske’s fatal case. 
I have also excluded Rawdon’s interesting case, in which, after 
pylorectomy for malignant disease, this operator performed a 
direct gastro-duodenostomy, with the aid of decalcified bone 
plates, the case ending in complete recovery. The collection 
of gastro-enterostomies alone is large enough, however, to show, 
first, the increased confidence with which operators have at- 
tacked these otherwise hopeless cases, and second, to emphasize 
the immense superiority of the present improved and aided 
gastro-enterostomy over the old operation, when regarded from 
the standpoint of the immediate operative results alone. 
Furthermore, the present estimate of the mortality of gastro- 
enterostomy, as performed on the human subject, clearly con- 
firms the anticipations held out by the same operation as 
performed on dogs, the mortality of the operation in dogs being 
at present about equal to that in man. Thus, out of four dogs 
operated by Senn, two by Jessett, three by Brokaw, and two 
by Dr. Michinard and myself, in all eleven cases, there were 
two deaths, or a mortality of about 11.2 per cent. 
Without attempting to discuss in this communication the 
merits or demerits of simple gastro-enterostomy as a surgical 
expedient for the relief of pyloric cancer or other conditions 
of the stomach, I have endeavored to review, if only briefly, 
the work done in this restricted field during the last eighteen 
months, because it is thereby more convenient for me to illustrate 
the progress accomplished and to bring into relief the new life 
that has been introduced into the practice of intestinal opera- 
tions by the introduction of the new technical improvements 
due to Senn. To review the whole field of their application 
and the experimental work that has been done to test or con- 
firm the advantages of the Senn method would be to review 
the field of intestinal if not abdominal surgery, and to consume 
your time with considerations which would prove burdensome, 
since the work has been done ably enough by others, and, 5 
indeed, too recently, as a glance at the bibliographic index 
which is appended will sufficiently attest. 
Notwithstanding the fact that the consensus of surgical 
opinion, as gleaned from the preceding brief summary of the 
contributions of the past eighteen months in the restricted field 
of gastro-enterostomy, is unanimously favorable to, and con- 
firmatory of, the superiority of Senn’s method of performing 
anastomosis, there are still some points connected with this 
operation and with that of enterorrhaphy, in its general and 
special applications which are still open to discussion, and be- 
ing debatable can be profitably presented to this meeting for 
consideration. The points referred to mostly involve questions 
of technical detail and do not affect the fundamental feature of 
Senn’s method, which, in its essence, consists in securing 
extensive, and firm serous apposition of the confronted 
intestines with the aid of intra-intestinal decalcified bone 
plates which being held together in apposition, by sutures 
which transfix the intestinal walls, act in the manner of intra- 
intestinal clamps, which have the final advantage of being 
digested and absorbed. 
In order that these points may be brought out in a manner 
more favorable for discussion, I will draw up a series of prop- 
ositions which will be followed, whenever necessary, with ap- 
propriate commentaries, based on the evidence furnished by 
clinical and experimental work. 
In explanation of my personal opinions on this subject I 
will state that they are based largely on a series of incomplete 
experiments on dogs, whicn for some months past have been 
jointly conducted with my friend, Dr. Paul Michinard, and 
which have thus far enabled us to study most of the applications 
of the operation of anastomosis, as it has been suggested for 
the .relief of disease in man. While our experiments were not 
directed solely to test the value of Senn’s method or its modi- 
fications, still we have directed special attention to them, and 
we have obtained certain results which we believe will warrant 
the conclusions that we have arrived at. 
Proposition i.—The operation for securing intestinal 
anastomosis, as performed with the aid of the decalcified 
bone plate, is decidedly superior to the old and tedious method* 6 
which secures the same result with the unaided Lembert or 
Czerny-Lembert stitch. 
Proposition 2.—The superiority of Senn’s method of 
securing anastomosis lies (1) in the economy of sutures which 
it allows, thus saving time; (2) in the large serous surface 
which it brings in contact, thus facilitating rapid adhesion; 
(3) in the excellent basis which the intra-intestinal support 
affords for the ready application of the otherwise slow Lem- 
bert stitch. 
Remarks.—To any one familiar with the practical applica- 
tion of both the unaided Czerny-Lembert method of practising 
enterorrhaphy and the Senn method, the truth of these two 
propositions will appear too axiomatic to require further 
demonstration or illustration. In my “Remarks on Circular 
Enterorrhaphy, etc.,” published in the Louisiana State Medi- 
'Cal Society’s Transactions for 1889, p. 345 (vide this journal 
for 1889), I then stated : “The efficiency of Senn’s discs has 
now been too often demonstrated, both experimentally and 
clinically, to require for them more than a simple allusion as a 
most valuable and time-saving device in the performance of 
..intestinal anastomosis.” Since that time, April, 1889, the 
clinical and experimental evidence that has accumulated only 
serves to confirm this statement, and to emphasize the fact 
that the principle of intra-intestinal support, which is the most 
essential feature of the Senn method, has permanently thrown 
the weight of technical advantage on the side of this method 
over the old unaided method. The statistics of the new gastro- 
enterostomies already referred to in the preliminary remarks 
alone prove this. There are some new points however,which are 
connected with the manufacture of the bone discs and their mode 
of application which should be referred to under these proposi- 
tions, especially since the object of this paper is to compare the 
relative merits of this decalified bone plate with the substitutes 
that have been offered for it. In his latest paper, “Two Cases 
of Resection of the Caecum for Carcinoma, with Remarks on 
Intestinal Anastomosis in the Ileo-Caecal Region,” Journal 
American Medical Association, June 14, 1890, Senn states: 
“After having tried all kinds of material, organic and inor- 
ganic, absorbable and inabsorbable, for making the apposition 7 
•plates, I have finally settled on decalcified bone as the most 
suitable material. In preparing the plates the compact layer 
of an ox’s femur or tibia is cut with a fine saw into oval plates, 
]/x of aninch in thickness, to 3 inches in length, and 1 inch 
in width. The plates are then decalcified in a 10 per cent 
solution of hydrochloric acid, changed every twenty-four 
hours, until they have been sufficiently soft, so that they can be 
bent in any direction without fracturing. After decalcification 
they are washed and immersed for a short time in a weak 
solution of caustic potash, so as to remove the acid. Until 
quite recently I dried the plates between two pieces of tin, so 
as to keep the plates from warping during the drying process. 
The central opening and perforations for the threads were 
made after the plates were dry. Experience has taught me 
that it is unsafe to use material for plates which, when exposed 
to the fluids of the intestinal canal, will imbibe a sufficient 
amount of fluid to increase to two or three times in thickness, 
as such increase in the thickness of the plates may cause a 
-sufficient degree of pressure to cause gangrene of the parts 
included between them. This happened in at least two of my 
gastro-enterostomies. Since then I have not dried the plates, 
but keep them after decalcification in a solution of equal parts 
of alcohol, glycerine, and water, which keeps them in a plia- 
ble, soft condition, and such plates undergo no change in size 
after their introduction into the stomach and intestine until 
they are gradually removed by absorption and disintegration 
from the third to the tenth day. After the acid has been re- 
moved the central oval opening can be readily made with a 
sharp penknife, and the four perforations around it for threads 
are made with a fine drill, and after the plate is threaded it is 
kept ready for use in the solution first mentioned. 
“ Any one conversant with the manner in which the plates 
are threaded can keep them in the solution until they are 
needed. When the plates are to be used they are worked in a 
2 per cent carbolic acid solution and the threads or sutures at- 
tached by threading two fine sewing needles, each with a piece 
of aseptic silk, twenty-four inches in length, which are tied 
together, the knots become the ends of the end sutures, while 
the middle of each thread holds a needle and becomes the 
terminal part of the lateral or fixation sutures. The fastening 
of the threads upon the plate is done by the lock stitch by 
another thread passing through the perforations in the shape of 
a loop and fastened at the back.” 
Dr. Senn now uses three different sizes of the plates. 
The largest size is used in gastro-enterostomy, the second 
for intestinal anastomosis, and the smallest plates are in- 8 
tended to be used in operations on children in cases of 
congenital stenosis of the intestines, invagination, and other 
forms of intestinal obstruction, where it becomes necessary 
to make an intestinal anastomosis. As a rule the central 
opening in the plate should correspond to the lumen of the 
organ which has become partially or completely obliterated 
by the cause which has produced the obstruction. Thus in 
gastro-enterostomy the perforation in the plate should be as 
large as the lumen of a normal pylorus. In ileo-colostomy 
it should correspond in size with the lumen of the ileum. I 
have the pleasure of exhibiting to you the three different sizes 
of bone plates made for Dr. Senn, and which I have just re- 
ceived from the Messrs. Schorse & Co., 302 Chestnut street, 
Milwaukee, who make them after the directions given by Dr. 
Senn. These plates are preserved in a moist state, ready 
threaded, with four straight, self-threading Hagedorn needles 
to each pair. The price for each pair is $2.00, exclusive 
of express charges. The cost of these plates is, therefore, 
an item worthy of consideration, not so much in private prac- 
tice but in conducting experiments. Of course with some 
patience and practice they can be made almost as nicely as by 
the experienced manufacturer, and for practising the operations- 
ior which they are used, on animals, it is plain that ordinarily 
the operator must secure plates that will be less expensive- 
For this reason the suggestion recently made by Stamm, of 
Fremont, Ohio, is a good one, i. e., to cut out plates from the in- 
completely ossified scapula of the veal, which are very quickly 
decalcified and make very efficient substitutes for the bone 
plates made from the hard femur or tibia of the adult animal. 
I show you two plates made by myself after Stamm’s sug 
gestion, and which I can assure you have not given me much 
trouble to prepare. There are other considerations of a crit- 
ical character to be made on the Senn plate, but these will fol- 
low more appropriately after the following proposition: 
Proposition 3.—The decalcified bone plate is not indis- 
pensable to the successful performance of the aided (Senn’s), 
operation of anastomosis, and other organic material, especially 
catgut, can be safely used in its stead to secure the ready 
coaptation of the serous surfaces. 9 
Remarks.—This is probably the most debatable proposi- 
tion of the series. In order to appreciate the reasons for these 
differences, it will be necessary to review briefly the history of 
the substitutes that have been offered for the Senn bone plate. 
Abbe, of New York, was the first surgeon who criticised the 
bone plate as aid material, in an article in the New York Medi- 
cal Journal, for March 23, 1889. In this paper Abbe reported 
a case in which intestinal ■ anastomosis was successfully per- 
formed with the aid of the bone plates, and suggested the 
substitution of “rings made of the heaviest catgut, quite as 
firm and absorbable as the softned bone.” Abbe objected,, 
that (1) the plates can not be easily improvised and are not 
always readily procured; (2) that the size and lumen of the 
plates is constant, narrow, and can not be readily adapted to 
special cases, owing to the variable size of even the normal 
intestines; (3) the rings if not thoroughly decalcified may not 
be absorbed, and may give rise to obstructive symptoms like 
any foreign body. 
Notwithstanding the recent modifications of the bone 
plate, as described by Senn and already referred to under 
proposition 4, it is certain that Abbe’s objections still hold with 
as much force at the present moment as when they were first 
urged, and as simplicity, when combined with equal efficiency, 
is always a desideratum worthy of encouragement, we will 
at once inquire into the results accomplished with the Abbe 
substitute and those that were offered subsequently by others. 
The question as to the relative merits of the decalcified bone 
plate and its substitutes we shall reserve for a later moment,when 
Dr. Senn’s answer to the objections that have given birth to 
these substitutes will also be considered and commented upon. 
At present the question is, what are the substitutes offered for 
decalcified bone and what is the evidence in favor of their 
efficiency and safety? 
I now show you a ring made after the first Abbe model,* 
* The latest instructions given by Abbe to make his catgut ring (Medical News, June i, 
1889),are as follows: A moderately heavy catgut is chosen; taken from alcohol or juniper oil; it 
is wound loosely on a test-tube, and soaked in hot water. It soon kinks up, and were it not on 
a tube, could hardly be unraveled. After a while it is straightened out, allowed to untwist, 
wound again loosely, and soaked in hot water once more until it ceases to twist. It is then 
ready to make up into rings, which will lie perfectly flat. Eight or ten turns over two pins, 
stuck in a cork, two inches apart, will make a bundle somewhat smaller than a lead pencil. 
These may be tied at four places, to secure the strands parallel while being wound around like 
a cable, with a continuous piece of the same catgut. The threads, armed with needles, are 
attached in the manner shown in the figure. 10 
and which is certainly not difficult to improvise. Abbe applied 
his ring in several experiments on dogs, and succeeded per- 
fectly in obtaining intestinal anastomatic communications with 
them. He subsequently repeated the operation in a successful 
case of enterectomy, substituting his catgut rings for the bone 
plates (Medical Nezvs, June i, 1889), thus securing clinical 
evidence in proof of the efficacy of his rings. Since that time 
the Abbe ring has been used by McBurney, of New York, in 
a gastro-enterostomy for cancer of the pylorus, the patient 
dying twelve hours after the operation (quoted by Abbe, Med- 
ical News, June 1, 1889). It has also been used in two suc- 
cessful gastro-enterostomies by Dr. Weir, of New York (one 
for malignant pyloric stenosis and the other as a substitute for 
Loretta’s operation, Medical Nezvs, December 14, 1889, and 
New York Medical Record, 1889). Once also, by Dr. Manly, 
in a colectomy for malignant disease, lateral enterorrhaphy hav- 
ing been performed with Abbe’s rings (New York Medical 
Journal, April 19, 1890), and more lately by Dr. Bull in a 
complete pylorectomy, in which the connections between the 
stomach and duodenum were permanently discontinued and 
communication between the stomach and intestine reestablished 
by performing gastro-enterostomy with Abbe’s rings (New 
York Medical Record, April 19, 1890). This case ended in 
the recovery of the patient. 
Therefore, if we sum up the cases recorded, we will find 
that the Abbe catgut ring has been used in the human subject: 
Once by Abbe, recovery. 
Once by McBurney, fatal. 
Twice by Weir, recovery. 
Once by Manly, fatal. 
Once by Bull, recovery. 
In all, six cases, with two deaths. 
It is thus clinically and experimentally proven that Abbe’s 
catgut rings can be effectually substituted for the bone plates. 
If I should adopt the order in which the various substitutes 
for the Senn bone plate have been presented to the medical 
public, I should next claim your attention with a discussion of 
solid catgut ring, made of the heavy commercial gut known as 
“ drum-snare ” material, which I thought of independently, 11 
and demonstrated to my classes in the Medical Department 
of Tulane University in i888-’89, and in the New Orleans 
Polyclinic, session of 1890, before the publication of Abbe's 
paper. Brokaw, of St. Louis, who published an account 
of his segmented rubber ring shortly after the appearance of 
my paper, claims that he had experimented with a ring made of 
solid catgut eight months before the publication of my paper, 
which would make the date of his experiments appear two 
months earlier than my own. Since his ring is widely and 
favorably known, and has been applied both experimentally and 
clinically next in point of frequency after the Abbe ring, I shall 
give it immediate consideration, reserving an account of my 
own ring for the end of this part of the discussion, in which I 
desire to refer to some criticisms that have been made of it and 
also to present some of the experimental evidence in proof of its 
practical utility, etc. The Brokaw ring, made of segments of 
rubber drainage tubing and threaded with catgut strands, is 
now well known, and will require no further description than 
the exhibition of the specimen which I have placed in the col- 
lection before you. Though this ring was devised originally 
and independently by Brokaw in a paper read before the 
St. Louis Medical Society, September 21, 1889 (International 
Journal of Surgery, November, 1889), ar*d even earlier, we 
find a suggestion of a similar ring in Abbe’s lectu:e on Anasto- 
mosis before the Philadelphia County Medical Society, May 8, 
1889, in which Abbe says : 
“I devised a ring ot rubber, made in segments fastened by 
catgut, which would fall apart after a few days, but abandoned 
that when I made a stiff one entirely of catgut,” etc. (vide 
Medical Nezvs, June 1, p. 590 L 
The credit of utilizing drainage tubing and of experi- 
mentally showing the utility and practical value of this ring is 
entirely Brokaw’s, however, and the experimental and clinical 
confirmation of its value gives it a distinct place as a worthy 
and really valuable substitute of the Senn plate; and as far as 
adaptability to clinical requirements and rapidity of construc- 
tion are concerned, I do not hesitate to say that it is equal, 
if not superior, to any of the substitutes that have been offered 
for the Senn plate. 12 
This ring has been used, according 10 Brokaw on dogs in 
fourteen cases of intestinal anostomosis, with three deaths; 
circular enterorrhaphy has been performed with it in fourteen 
cases, with seven deaths; duodeno-cholecystotomy, three cases 
and two deaths. In various other operations on dogs it has 
also been employed with perfect success. Dr. Benjamin P. 
Shimwell, of Philadelphia (Medical Nezvs, April 12, 1890), has- 
largely experimented on dogs with these rings, and decidedly 
prefers them to Abbe’s rings, which he considers to be theoreti- 
cally good, but practically imperfect The objection to them 
is that, like Senn’s plates, they can not be made quickly in an 
emergency.” In addition to this experimental proof of the 
efficacy of the Brokaw ring we find that two cases have been re- 
ported in which these rings were used in the human subject. 
One, a case of gastro-enterostomy for pyloric cancer, reported 
by Dr. Carson, of St. Louis (Brokaw, lnt. fournal of Surgery, 
November, 1889),which ended successfully, and another, a case 
of pylorectomy for cancer, in which, after closing up the py- 
loric end of the stomach and duodenum separately, a gastro-en- 
terostomy was performed. This patient died twenty-six hours 
after the operation, from causes which do not reflect on the 
merits of the ring used in the anastomosis (vide Tuholske, of 
St. Louis, Medical Nezvs, May 10, 1890). 
We may conclude from this evidence that, as in the case of 
the Abbe catgut ring, the claims for the Brokaw’s segmented 
rubber and catgut ring as a substitute for the decalcified bone 
plate are fully substantiated by experimental and clinical 
evidence. 
The ingenious catgut mats and solid catgut plates sug- 
gested and described by Dr. Davis, of Birmingham, Ala., next 
claim our consideration, especially since this observer has 
largely and successfully experimented with this material on 
dogs. This author reports seventy-nine anastomotic operations 
with the catgut plates and mats, though with what percentage 
of results I am unable to state, as I have not read the 
author’s original contribution to the Southern Surgical 
and Gynecological Society, which met in 1889, and this per- 
centage is not detailed in the author’s extensive article in the 
Annals of Gynecology for August, 1889, which I have con— 13 
suited. These “ mats ” have been tried clinically in a case of 
malignant disease requiring ileo-colostomy. Though the 
patient died of exhaustion twelve hours after the operation, 
the autopsy revealed nothing which could affect the merit or 
value of the mat. The mats have also been tried in a case of 
jejuno-ileostomy, which also ended fatally, and too early to 
permit judgment on the final efficacy of the mats. 
The mats are ingeniously made, and doubtless could be 
utilized as successfully as Abbe’s, Brokaw’s, or my ring, 
in cases demanding anastomosis; still the great objection to 
them is that they are not easily made in an emergency as the 
other more substantial catgut substitutes which have been sug- 
gested. The catgut -plates would appear a-priori to be espec- 
ially fitted for the work required of them. They are made of 
solid catgut sheets, and can be very quickly cut or punched out 
when the catgut sheets are at hand; furthermore, they present 
a large, flat surface for serous confrontation and adhesion, and 
in this way more closely" resemble the Senn decalcified bone 
plate than anything else yret suggested. They are at present 
open to the objection that catgut compressed into plates is not 
easily procured, as I know by my complete failure to obtain it 
notwithstanding my direct application to Mr. Snowden, Dr. 
Davis’s catgut manufacturer; but furthermore, as Senn has 
shown (in his paper on Resection of the Caecum, etc., 
loc. cit.), because the plate is so hygroscopic that it becomes 
rapidly" too soft and non-resistent to serve as an aid, and swells 
to such proportions that it endangers the vitality of the intestinal 
wall by exercising too much pressure at the suture points. 
In completing the list of substitutes that have been offered 
for the Senn bone plate, I need only mention the solid rubber 
discs which were successfully employed by Penrose, of Phila- 
delphia, in experiments on dogs (vide discussion following 
Abbe’s paper, Philadelphia County Medical Society, May 8, 
1889, Medical News), and the rings made of decalcified bone 
drainage tube threaded with catgut, and the prepared arteries 
also threaded with the same material that have been suggested 
by Brokaw, of St. Louis, in a paper in Philadelphia Medical 
News, for 1889. These substitutes have not been tried clinic- 
ally, but there is no reason to doubt their efficiency'. They' 14 
are certainly worthy of being counted -among the resources of:' 
the surgeon in cases requiring anastomosis. 
I have thus passed in review the different substitutes that 
have been offered by others for the decalcified bone plate;. 
now permit me, in justice to myself, to say something in regard 
to the solid catgut ring made of “ drum snare ” gut and already 
referred to as the ring originally suggested and demonstrated 
by myself before the Louisiana State Medical Society, at its 
meeting in this city on April io, 1889. 
The ring which is exhibited in the collection before you is 
the same as the one which Dr. Paul Michinard and myself 
have tried quite extensively in the experiments on dogs which 
we have jointly conducted during the last few months. It is 
quite different from the ring originally presented to the Louis- 
iana State Medical Society last year. While it is made of the 
same ‘‘drum snare ” material, it differs from very essentially 
in the fact that I now employ the catgut after it has been boiled,. 
and, consequently, the tendency to kink and twist which char- 
acterizes the original twisted material is permanently and effect- 
ually removed. At the time when I first demonstrated the 
technique of circular enterorrhaphy and of anastomosis, with the 
aid of these rings, before the State Society, I had only experi- 
mented with the rings on the cadaver, and had not had occasion 
to observe the effect which prolonged immersion of the thick 
catgut in a water}7 medium has in disfiguring the rings. For 
this reason, I am much indebted to Brokaw for this criticism 
with which he summarily disposed of the ring and put it,. 
metaphorically, hors de combat. This criticism led me to 
experiment and study considerably the hygroscopic properties 
of catgut, and on the conditions which modify them. In order 
to prevent the absorption of water, I tried the effects of pre- 
paratory saturation with various fixed and volatile oils, of 
varnishes, such as damar, copal, and gutta-percha; these 
simply retarded absorption, but in the end totally failed to pre- 
vent it, and with the failure came the inevitable coiling and 
distorting kink or twist; a tanning process was tried, chro- 
micizing, etc., but all this failed, until I resorted, finally, to 
the simplest expedient which is always effective with thread- 
catgut, and that was, to boil the gut in water until it had com- 15 
pletely uncoiled itself and had absorbed water to the fullest 
extent of its hygroscopic capacity. This result, much to my 
satisfaction, was accomplished by very few minutes’ immersion 
in boiling water, when the gut swells to three times its original 
diameter and is reduced to one-third of its original length. Thus 
three feet of drum snare will, after two or three minutes’ boil- 
ing, contract to one foot; and the cord which originally was 
about millimeters in diameter will swell to 6 millimeters. 
After this result is obtained, the gut will remain permanently 
shortened, but will dry very rapidly and become as hard as 
wood. It may be then immersed indefinitely in water, and 
it will simply soften to the consistence of a solid rubber 
band, but will never show a disposition to become distorted 
by kinking or coiling. With a material thus prepared it is 
easy to make rings of any desired size, by simply cutting 
and shaping them; furthermore, they are made to retain their 
shape by simply inserting the free ends in a small piece of 
rubber tubing, which, acting as a clasp, is sufficient to keep the 
ring in shape; in order to secure the tubing permanently it will 
be safer to tie the ring to the tubing with silk thread. The 
ring is then ready to be mounted with the fundamental or per- 
forating sutures, which should consist of four threads six or 
eight inches long, each holding a round milliner’s needle of con- 
venient size, and tied at equidistant points on the circle. When 
the ring is to be used it should be placed in a towel previously 
wrung out of a hot carbolized or aseptic solution, in which it 
will rapidly soften and swell to its maximum dimensions, and in 
this condition will be made to slip easily through a comparatively 
narrow slit in the intestine. It is preferable to use the ring soft be- 
cause it then has attained its maximum hygroscopic diameter and 
there is no risk of subsequent swelling within the intestine; fur- 
thermore, while soft and of a rubber-like consistence, it is still 
sufficiently resisting to secure the ready coaptation of the op- 
posed serous surfaces. When thus softened, a large ring can 
also be used to secure coaptation after partial enterectomies of 
the intestinal convexity for multiple gunshot wounds, as Brokaw 
first suggested; though it appears to me that the application of 
aids in these cases is, if not superfluous, at least not essential. 
While studying the hygroscopic condition of catgut,! dis- 16 
covered that the only kind of heavy catgut that will stand 
boiling without disintegrating or spoiling, is the cheapest (five 
cents per foot) catgut first recommended by me, i. e., the crude 
commercial drum snares used for tightening drums, and not the 
heavy gut strings used for the bass violin, which Brokaw and 
others have erroneously regarded as identical with the above. 
The finer varieties of gut which are used as bass or violin 
strings are subjected to a sort of waxing process which totally 
unfits them for boiling, by‘disintegrating and making them 
totally worthless for any purpose. Not knowing this pecu- 
liarity, I recommended them in my first paper, owing to their 
apparent similarity to snare material, but since I have dis- 
covered my error I withdraw my recommendation and would 
warn those who should be tempted to try them against their 
use. 
Having thus modified my original ring, I believe that the 
objections against it have been removed, and the experimental 
evidence that I have secured in the operations performed by Dr. 
Micbinard and myself proves that they can be used as effec- 
tively as any of the catgut substitutes of the Senn bone plate. 
We have, used this ring twice in gastro-enterostomy after pylor- 
ectomy; once in entero-enterostomy ; once in ileo-colostomy; 
once in circular enterorrhaphv after colectomy, and once in 
circular enterorrhaphy after enterectomy. 
We have had a perfect success in one of the gastro-en- 
terostomies after pylorectomy, the animal living at this present 
date. In this case, a preliminary gastro-enterostomy was per- 
formed about two months ago; the secondary pylorectomy 
was performed over two weeks ago, the existence of a large 
and perfect gastro-duodenal fistula was verified, and an exten- 
sive resection of the pylorus and a portion of the duodenum and 
stomach performed; the stomach was completely isolated, and 
closed at the former pyloric end, and the pyloric end of the 
duodenum inverted and also closed. The animal made an ex- 
cellent and uninterrupted recovery, and is to-day eating like any 
other dog, and shows no dyspeptic or digestive disturbances. 
In the other gastro-enterostomy and pylorectomy, which 
was performed before a large class of students and under very 
disadvantageous circumstances, death followed twenty-four 
hours after the operation from hasmatemesis and hernial even- 
tration from the rupture of the abdominal stitches after vomiting. 
In this case, no extravasation was found in the peritoneal 17 
cavity ; the catgut ring in the stomach was found undergoing 
rapid absorption, and would soon have undergone complete 
digestive disintegration; the anastomotic communication with 
the jejunum was perfect in so far as coaptation was concerned, 
but the peritoneal exudate was scant. The hemorrhage came 
from the mucosa, which had been trimmed at the pyloric end of 
the stomach too far below the serous section, and consequently 
was not compressed by the sutures, 
In the entero-enterostomy, over four inches of intestine 
were removed; the two ends were inverted and closed into 
cul de sacs, and the continuity of the intestine restored by 
performing lateral anastomosis. The animal reacted well from 
the operation and appeared to be in excellent spirits and play- 
ful, when on the third day it died suddenly. Much to our re- 
gret, the animal was carted away in the garbage wagon before 
we could determine the cause of death by an autopsy. 
The ileo-colostomy was very interesting in its results, and 
ended in recovery. As the sequelae are given later on in the 
the paper, the details are omitted here. 
In the circular enterorrhaphy after colostomy, the resection 
was imprudently carried to excess. The whole transverse 
colon was excised; the ascending colon was united to the 
rectum directly as in circular enterorrhaphy, i. e., lumen to 
lumen, and coaptation effected with my solid catgut rings. The 
animal stood the operation badly and expired twenty-four hours 
after ; at the autopsy the rectum was found in a gangrenous 
condition from venous asphyxia, due probably to ligature of a 
hemorrhoidal or mesenteric vein; the circulation through the 
connected intestines was perfect and the joint showing no leak- 
age; the rings were in situ and showing no sign of disintegra- 
tion. The plastic exudate about the sutures was wanting, 
notwithstanding abundant scarification during the operation. 
In addition to the preceding we have performed various 
other anastomotic operations, over ten cases in which the results 
have satisfied us that solid catgut ring made of boiled drum- 
snare material can be effectually substituted for decalcified 
bone plate. 
Clinically, I have not had an opportunity of testing the 
value of my rings, and know of one case only, operated by Dr. 
J. D. Bloom, assistant house surgeon Charity Hospital, in 
which circular enterorrhaphy was performed with their aid 
after the resection of a large piece of gangrenous intestine, due 
to hernial strangulation. In this case the man was brought in 
an almost moribund condition to the hospital and the operation 18 
had to be performed simply as a matter of duty. The man 
died a few hours after the operation, too early to test the merits 
of the rings. 
We may now sum up in the order of their publication the 
various modifications that have been offered for the decalcified 
bone plate of N. Senn (International Medical Congress, Sep- 
tember 5, 1887). 
1. Rings made of catgut strands; Abbe, New York 
Surgical Society Proceedings, June 9, 1889. 
2. Rings made of solid catgut, drum-snare material; Matas, 
Transactions Louisiana State Medical Society, April 10, 1889. 
3. Solid rubber discs; Penrose, Transactions Philadelphia 
County Medical Society, May 8, 1889. 
4. Mixed rubber and catgut rings : segmented rubber rings ; 
Brokaw, St. Louis Medical Society, September 21, 1889. 
5. Solid catgut plates and catgut mats ; Davis, Proceedings 
Southern Surgical and Gynecological Association, August, 
1889 ; New York Medical Record, November 30, 1889. 
6. Rings made of decalcified bone drainage tube threaded 
with catgut; Brokaw, Medical News, 1889. 
7. Rings made of ox arteries threaded with catgut strands ; 
Brokaw, Medical News, loc. cit. 
We have now completed the list of substitutes that have 
been offered for the decalcified bone plates originally intro- 
duced by Senn, and we believe that the evidence here collected 
substantially proves the correctness of our third proposition. 
The important question that is now asked by the practical 
surgeon is: Do these substitutes constitute a real advance, an 
improvement, on the Senn plate ; are they really superior to it? 
Should they be preferred by the operator in all cases to the 
bone plate, or are they merely succedanea which should be 
utilized only when the decalcified plate is not ready at hand? 
Or are there special indications for the use of either the bone 
plates or the substitutes ? 
Senn himself has most recently answered, or at least par- 
tially answered, these questions at the late meeting of the 
American Medical Association, held at Nashville, May 21, 1889, 
n his important paper already referred to, “ Remarks on 
Intestinal Anastomosis, etc.,” loc. cit. Pie says: 19 
“ Objection has been made against the bone plates to the 
effect that they are not always at hand when needed. But like 
catgut, silk, drainage tubes, and other essential materials used 
in the treatment of wounds, they should be kept on hand, ready 
to be used in an emergency. The different kinds of rings de- 
vised by Abbe, Matas, and Brokaw, as substitutes for the bone 
plates, lack some of the most important advantages possessed 
by the plates. Catgut is a material which, when brought in 
contact with the alkaline secretion of the intestinal canal, be- 
comes, in a few hours, so soft and macerated that it can not be 
relied upon as a support. All ring supports bring into apposi- 
tion only a small area of serous surface, and the pressure is not 
equally distributed.* Davis catgut mats are superior to the cat- 
gut rings, but the material of which it is composed is so highly 
hygroscopic that, when acted upon by the intestinal contents, 
they swell up rapidly and become as soft as rag in a few hours. 
I immersed one of the plates which. Dr. Davis kindly sent me in 
a warm solution of common salt, and in three hours it had in- 
creased to three times its former thickness, and had become so 
limpid that in the same condition in the intestinal canal it would 
furnish little or no support in maintaining uninterrupted apposi- 
tion, The same objection applies to the catgut rings and cat- 
gut mats as to the dried bone plates, that when used in the dry 
state they increase rapidly in thickness from the imbibition of 
fluids, and, as the sutures are unyielding, the pressure thus pro- 
duced may become a cause of pressure gangrene. 
“ An extensive clinical experience and numerous experi- 
ments on animals have satisfied me that thus far no better ma- 
terial has been suggested for making approximation plates than 
decalcified bone. Decalcified bone plates kept moist in an an- 
tiseptic solution do not increase in thickness by imbibition of 
fluids when used in the stomach or intestinal canal, and they 
serve as an efficient mechanical support in bringing together 
and maintaining accurate coaptation of large serous surfaces 
which it is intended to unite in establishing an intestinal anas- 
tomosis. The decalcified bone plates can be relied upon in 
maintaining equable surface pressure upon the tissues inter- 
posed between them for at least three or four days, which is 
*The italics are mine.—R. M. 20 
the time required in obtaining a sufficiently firm union by cell 
proliferation from the apposed serous surfaces. Indestructible 
and unabsorbable material should never be used in the prepa- 
ration of the approximation plates, as such substances in the 
stomach or intestines, where they are used, may cause irrita- 
tion, or even ulceration and perforation; or the)’ may pass on 
and become impacted in the narrowed portion of the bowel. Dr. 
Stamm, of Fremont, Ohio, made plates of the thin portions 
of the scapula of a calf, and. used them in a gastro-enterostomy 
for carcinoma of the pylorus. The patient died forty days 
after the operation, and at the necropsy the plate inserted into 
the stomach was found unchanged in the viscus.” 
In reply to Dr. Senn we would state that the danger of 
pressure gangrene from secondary swelling of the catgut is pre- 
cluded by the rubber tubing in the Brokaw ring which does 
not materially increase in size, and by the fact that a prelim- 
inary immersion in a watery medium will also obviate this risk 
without seriously affecting the firmness of the material in my 
solid catgut ring; furthermore, the experimental and clinical 
evidence accumulated in favor of the Abbe, Brokaw, Davis, 
and the author’s ring would prove that these substitutes are 
really efficient, and can be successfully and advantageously 
utilized in practice. Still, the other points urged by Dr. Senn 
are well taken, in my estimation, and it would be unreasonable 
to deny (i) that the exceeding rapidity with which catgut is 
absorbed, and (2) the smaller surface that rings of all descrip- 
tions bring together for adhesion, make them inferior to the 
decalcified bone plate,* which should be regarded, if from these 
standpoints alone, as the superior material in all cases of en- 
terorrhaphy, excepting, perhaps, in those instances of circular 
resection of the bowel in which lumen to lumen enterorrhaphy 
is aimed at. It should be remembered that in the performance 
of intestinal suture, whether for anastomosis or for circular en- 
terorrhaphy by the direct method, the great merit and advan- 
tage claimed for the aided methods over the unaided, simple 
stitch procedures is in the greater rapidity as well as security 
with which the aided methods can be executed. The time- 
* As my colleague, Dr. Parham, has suggested, this objection can be partially overcome 
by nesting the rings into each other, thus forming a simple and substantial mat, which would be 
held together by silk or catgut threads. These mats would be easier to make and would be 
more resisting than the Davis mats. 21 
saving advantage rests on two points: (i) That a minimum 
number of stitches is needed when the aids are employed, and 
(2) that a firm basis is given the operator by the use of an intra- 
intestinal support which allows of a more rapid stitching than 
when no such support is employed. Now, the decalcified 
bone plate combines these advantages in addition to those pre- 
viously referred to in proposition 2 and elsewhere, and for this 
reason is the best material, when rapidity of execution as well as 
safety are the main desiderata, as by the use of these plates the 
surgeon need not be so particular in perfectingthe external serous 
suture once the apposition of the plates has been thoroughly 
effected hv the transfixion stitches. On the other hand, it can 
be urged that since this peripheral security (Lembert) stitching is 
needed in all cases, that the time lost in applying a few more 
stitches will not seriously affect the result in most instances, and 
that consequently the aids made of more digestible and absorb- 
able material can be advantageously employed as ephemeral 
supports in expediting the ordinary Lembert suture.* With this 
view I fully concur, and believe that by accomplishing this re- 
sult alone the technique of intestinal suture has been very much 
advanced by the introduction of the various aids referred to. 
As a result of the preceding considerations we may, 
therefore, draw the following propositions: 
Proposition 4.—While the various substitutes, Abbe’s, 
Brokaw’s, Davis’s, and the author’s, can be successfully sub- 
stituted for the decalcified bone plate, the latter is the pre- 
ferable material, the others being regarded in the light of 
succedanea, to be remembered in emergencies and special 
conditions. 
Proposition 5.—That where the digestive and absorbent 
surfaces are especially active, as in operations in the upper 
portions of the gastro-intestinal tract (stomach, duodenum, 
and jejunum), it is especially indicated to use less absorbable 
material—decalcified bone ; and 
Proposition 6.—Highly absorbable material (catgut) can 
* That the need for this intra-intestinal support as a basis for suturing has long been felt 
by surgeons is well demonstrated by the numerous devices which have been suggested ad hoc, 
and used by surgeons long before the introduction of the Senn plate. These cylinders of gela- 
tine, of dough (Hohenhauser), the trachea of animals, cartilaginous cylinders, decalcified bone 
cylinders (Neuber), Treves’s inflation rubber bag, etc., all emphasize this want. 22 
only be used with safety in the above-mentioned territory when 
the ring orplateis usedas a mere technical aid, not as a durable 
intra-intestinal support, but as a means of expediting and per- 
fecting the peripheral Lembert or continued stitch. 
Remarks.—That the absorption of the aid material bears 
a direct relation to the digestive activity of the region in which 
it is placed, is well illustrated in the operations performed by 
Dr. Michinard and myself. In one dog, twenty-four hours 
after gastro-enterostomy, the solid catgut ring in the gastric 
side had been almost wholly disintegrated and absorbed; in 
another canine, twenty-four hours after colectomy with circular 
enterorrhaphy, the two solid catgut rings used were found 
intact, and showed no trace of digestive action or disintegra- 
tion. 
Proposition 7.—That absolute reliance is not to be placed 
on fixed or definite periods for the formation of plastic peri- 
toneal exudation, and that while this protecting exudation takes 
place in two, four, and twelve hours, it may be very remarka- 
bly retarded. 
Remarks.—This is illustrated by the case of a dog (appar- 
ently in excellent health), in which we performed ileo-colostomy 
with the aid of my solid catgut rings. At the autopsy, one 
week after, no visible trace of plastic exudation could be dis- 
covered, notwithstanding the fact that the animal appeared to 
have recovered perfectly from the operation. In this case the 
anastomotic communication between the bowels failed to form, 
notwithstanding very thorough scarification of the serosa ; the 
incisions in the bowels having closed by muscular contraction 
around the everted mucosa and final agglutination of the serous 
edges. The rings had completely disappeared, and with them 
the transfixion sutures; the intestines were held together in 
confrontation by a few interrupted Lembert stitches, about 
which there was not the least appearance of exudation. 
This animal was reoperated to verify the anastomosis, and 
had it not been for this revelation we would have credited this 
case to the list of the successful anastomosis. In order to con- 
trol the operative results, it is important in experimentation that 
even after the apparently perfect recovery of an animal that a 
second examination be made in order to verify the result, 
which may be quite the reverse of the expectation. 23 
Propositions.—Gastrostomy: This operation is much 
simplified and expedited by the adoption of the ring principle, 
and, as at present modified, could be advantageously substituted 
for the older and unaided stitch methods hitherto adopted in 
its performance. 
Remarks.—This operation may be performed with the 
aid of one ring, as originally suggested by Prewitt, of St. 
Louis, Mo., and as it has been tried on dogs successfully by Bro- 
kaw. With the aid of two rings I believe the operation can be 
performed with as much rapidity and greater security. The 
stomach is drawn out through the usual abdominal incision and 
an incision made into it sufficiently large to admit a ring two to 
three inches in diameter. This ring should be made of rubber 
drainage tubing packed with catgut strands, or with solid catgut 
drum snare material, after my model; large decalcified bone 
plates (Serin’s) could also be used, were it not that the incision 
required to introduce them in the stomach would be too large. 
From six to eight apposition double threads, armed with one 
milliner’s needle each, should be attached to the rubber tubing, 
not to the catgut contained in the tubing, as in the ordinary 
ring, but to the rubber itself; strong silk should always be 
used. Each needle is now passed through the walls of the 
stomach, traction being made to see that the ring rests well in 
place, and the stomach is pushed back into the abdominal 
cavity. The needles are then passed through the whole thick- 
ness of the abdominal walls and tied as in the manner of a 
quill suture to an external segmented rubber ring or one made 
of solid catgut after my model. Finally, as suggested by 
Brokaw, the margins of the opening in the stomach should be 
stitched to the skin of the abdominal incision. By Prewitt’s 
method the transfixion threads are simply tied in pairs over the 
skin of the abdominal surface. In either case, the feeding 
may be commenced immediately after the operation. 
This operation has never been tried clinically, though it 
has been successfully performed on dogs. 
In cases of carcinoma of the stomach not fitted for gas- 
trectomy, Bernay’s operation by which the growth is curetted 
through an incision in the stomach, will be greatly expedited 
by resorting to this method of securing the stomach to the 24 
abdominal incision, where the organ will remain adherent and 
always accessible for secondary repetitions of the curetting 
treatment. 
Proposition 9.—The operation of pylorectomy has been 
much simplified by the introduction of Senn’s method, and 
judging by the present outlook the mortality of this most 
formidable procedure will be much diminished in future; the 
greater probability of operative success will in future encour- 
age the surgeon to earlier and more radical interference in 
these desperate cases. 
Remarks.— The continuity of the gastro-intestinal tract 
may be established after pylorectomy by either of the two 
methods recently suggested, viz: By direct gastro-duode- 
nostomy, with the aid of Senn’s plates ; or by the closure of 
the gastric and duodenal ends, thus severing completely the 
normal gastro-duodenal connection and creating an artificial 
pylorus by the formation of a gastro-enterostomy with the aid 
of Senn’s plates. The reason for preferring Senn’s plates in 
this operation has already been stated, and the conditions 
under which more absorbable material can be substituted for 
these plates have been already stated elsewhere. 
The recent case reported by Mr. Rawdon, of Liverpool 
(vide Bibliography, et supra),will illustrate the manner in which 
the decalcified bone plates are to be used when direct gastro- 
duodenostomy is aimed at after pylorectomy : 
“The patient, male, aged fifty-six, was admitted to the 
Royal Southern Hospital, Liverpool, with well-marked symp- 
toms of pyloric stenosis of some weeks’ duration, and a small 
tumor was felt in the abdomen under the left rectus, a little 
above the umbilicus. Mr. Rawdon opened the peritoneum by 
a median incision about four inches in length, commencing one 
inch below the ensiform cartilage. The tumor proved to be a 
mass of carcinoma involving the pylorus and pyloric end of the 
stomach. There were no abnormal adhesions, and the parts 
were drawn out through the abdominal incision, when it was 
found that a third of the stomach had to be removed. The 
vessels coursing along the greater curvature were secured at 
the point where the line of incision was required, and the duo- 
denum and the vessels immediately connected with it were 
compressed by a ligature of rubber tubing. The affected por- 
tion of the stomach was now excised, only one or two vessels 
in its walls requiring a ligature; the omental connections were 25 
gathered up, transfixed, and the rubber tubing constricting the 
duodenum was removed, and two or three arteries were secured. 
The stomach wound was closed with continuous sutures of fine 
silk, except one inch at the greater curvature, which was left 
open to admit of the introduction of one of Dr. Senn’s plates of 
decalcified bone. A second plate, cut circular, was passed into 
the duodenum and placed so as to lie across it, with the coats 
of the bowel overlapping the plate. The openings of the stom- 
ach and duodenum were now brought into apposition, and the 
corresponding ligatures on the two plates tied together, so that 
direct communication was established between the two viscera. 
The parts were returned into the abdomen, and the wound 
closed in the usual way. The operation was completed in less 
than an hour; the patient made an uninterrupted recovery. He 
was supported by nutrient suppositories during the first week; 
he was then allowed a little pancreatinized cow’s milk, and 
gradually returned to his ordinary diet. At the present time 
he is able to eat heartily without pain or other discomfort. 
The other improved method of performing pylorectomy 
with the aid of gastro-enterostomy is well illustrated by the fol- 
lowing successful case of Bull, of New York : 
The operation was performed on a woman aged twenty- 
nine, suffering from carcinoma of the greater curvature and 
posterior wall of the stomach. The abdomen was opened by a 
median incision, and the gastro-hepatic and gastro-colic folds, 
the tumor, together with the pylorus and about one-quarter or 
about one-third of the pyloric end of the stomach, were then 
removed. The cut end of the duodenum was sutured so as to 
form a blind pouch, the stomach treated in like manner, and an 
anastomosis made with the jejunum near its commencement, by 
means of Abbe’s catgut rings. The operation lasted three 
hours and a half. There was a serious fear of prostration at the 
end of the second hour, but at its close the patient rallied. All 
food by the mouth was withheld till the fourth day; no unto- 
ward symptoms were observed; on the seventh day the tem- 
perature and pulse were normal, liquid food had been taken 
freely, and the bowels had acted spontaneously. The patient’s 
subsequent progress was in every way satisfactory, and on the 
twelfth day, the day of the last report, she was considered to be 
out of danger. 
In regard to the special indications for these two operations 
it is difficult at present, in view of our very limited clinical 
experience with either, to formulate such rules as would assist 
the surgeon in deciding which should be accorded the prefer- 
ence in any given case. 26 
Mr Jessett (British Medical Journal, May io, 1890), has 
recently commented upon these two operative procedures. 
This investigator found, in his experimental work, that the 
portion of the duodenum that was surrounded by peritoneum 
was so very short that it would have been impossible to have 
done the operation successfully. 
The same difficulty would apply in most cases to the human 
being, as the first portion of the duodenum is only two inches 
long, and not more than two-thirds of this is completely sur- 
rounded by peritoneum, leaving, after allowing for a small 
portion which must of necessity be removed with the pylorus, 
only about one inch to deal with. This would be hardly enough 
to allow of a bone plate being introduced without putting a con- 
siderable drag upon the parts to be united. When, however, 
the pylorus becomes obstructed, and the stomach dilated, it 
seems to have the effect of elongating this first portion of the 
duodenum. “In such a case,” says Jessett, “the plan put 
into practice by Dr. Rawdon is undoubtedly, to my mind, the 
best mode of operating.” Should, however, this portion of the 
duodenum not be elongated, then the operation of invaginating 
and closing separately the divided gastro-duodenal ends, and 
creating a new pylorus by means of a gastro-enterostomy, as 
in the case of Dr. Bull, would be the preferable operation. 
The first method thus far has one case, Rawdon’s, on its 
list, and this was successful, The second method has two 
.cases, Bull’s and Tuholske’s, one successful and one fatal. 
Proposition io.—The operation of gastro-enterostomy by 
the Senn method is especially indicated in cases of cicatricial 
or non-malignant stenosis of the pylosus, as a more advanta- 
geous substitute for Loretta’s stretching operation, Hahn’s 
pyloric intubation, or the Heineke-Miculicz pyloro-plasty. 
Remarks,—This proposition has been made very plain by 
Dr. Weir, of New York, who, in a successful case operated 
with Abbe’s catgut plates (Medical Nexus, Philadelphia, vol. 
lv. 666, 1889), has proved this to be a most rational procedure 
in such cases. 
Proposition ii.—It is the opinion of the writer, based on 
anatomical examinations and experimental evidence, that in 
gastro-enterostomy, the method of Wolfler, which aims to 27 
secure the jejunum to the stomach, over the colon and great 
omentum, is a dangerous procedure which subjects the anasto- 
motic connections to unnecessary strain, and, furthermore, 
physiologically excludes an unnecessary length of most active 
intestine. The method of Curvoisier and Von Hacker, by 
which the jejunum is connected to the stomach directly, after 
tearing or cutting a passage through the bloodless area of the 
transverse meso-colon, under the meso-colic arch of Riolan, is 
more commendable from the anatomical, physiological, and 
operative standpoints. 
Remarks.—From experimental evidence and frequent 
•operations on the cadaver, I am convinced that the tendency 
to form an obstructing eperon in the attached bowel is greater 
by Wolfler’s method than the trans-meso-colic operation. 
Contrary to the opinion of several writers, this operation is 
very easily performed on dogs, and judging by my experience 
on the human cadaver, there is no reason to doubt that the 
anastomosis can be performed just as quickly as by the supra- 
colic route. It is easy to understand that when the mobility of 
the stomach is lost by excessive infiltration or adhesion, that 
Hacker’s procedure should be more difficult of execution. 
In such cases Wolfler’s method could be resorted to. The 
mortality by either method, as already referred to in the earlier 
part of this paper, is about equal, i. e., nearly 50 per cent; but 
this is by the slow stitch methods; the new statistics are not 
available on this point, but it will doubtless be proven when 
further reports accumulate that the immediate operative dangers 
of gastro-enterostomy will not be increased by Hacker’s trans- 
meso-colic method, whilst the post operative results will be 
much bettered.* 
United clinical and experimental evidence condemn em- 
phatically the method of Leucke, who, to expedite the opera- 
tion of gastro-enterostomy, unites the first presenting portion 
of small intestine to the stomach. The surgeon should always 
assure himself that it is the jejunum that he is attaching to the 
stomach, and not another intestine. Repeated practice on the 
cadaver, and a free exposure of the parts, are much better 
* Mr, Jessett, in his most recent contribution to the subject, Julj' 12, 1S90 {vide index), 
thoroughly concurs with this view. 28 
and more reliable than Hahn’s rules for finding the upper 
jejunum. 
Proposition 12.— Circular Enter or rhaphy.— The opera- 
tion of circular enterorrhaphy is, in the light of present ex- 
perimental and clinical experience, most promptly and secure- 
ly performed by the invagination and complete closure of the 
divided intestinal ends with the aid of a continued or inter- 
rupted Lembert siitch, the continuity of the intestinal canal 
being reestablished by the formation of an anastomotic open- 
ing with aid of Senn’s decalcified plates, or the catgut ring 
substitutes. (Senn’s method.) ( Vide plates, Nos. 7, 8, 9, 10, 
which illustrate the operation as performed with Brokaw’s 
rings or the author’s, and plates Nos. 16 and 17 [ileo-colos- 
tomy], with Senn’s bone plates.) 
Remarks.—This method is particularly indicated in all 
cases in which the opposed intestinal diameters are different, 
such as in cases of intestinal obstruction in which the £ut 
on the proximal side is much dilated and wider than on 
the distal side. The lumina being disproportionate, it would 
be difficult to unite the divided bowels mouth to mouth, 
and the onty practically good method of promptly restoring 
the intestinal circulation after enterectomy would be by the 
anastomotic method. On the other hand, in cases of circular 
resection in which the opposed bowels are symmetrical, and 
the lumina equal, the quickest and simplest method of restor- 
ing the continuity of the bowels would be by circular enter- 
orrhaphy by the author’s method. Vide plates Nos. 11 and 12, 
illustrating the application of the author’s catgut-snare ring. 
When the indications for this method are met (i. e., equal 
lumina in confrontation), it is difficult to conceive of an easier 
method of performing anastomosis. Certainly, it is the most 
rapid and secure method that the author has practised on the 
cadaver, and it is impossible to understand what would be the 
serious objections against its adoption on the living subject. 
Unfortunately this method can not be tested experimentally on 
dogs, unless very large animals are operated upon, though even 
in large animals of this species it is impossible to overcome 
the great anatomical obstacles in the way of its performance. 
In the dog the muscularis of the intestine is relatively much 29 
thicker and stronger than in man; so that immediately after 
circular division of the intestine the divided bowel contracts 
so thoroughly and spasmodically that it is even difficult to intro- 
duce a ring very much smaller than the intestinal lumen at the 
divided point. Furthermore, the elongated conical projection 
formed by the severed bowel end offers an insuperable barrier 
to the even coaptation of the confronted surfaces. After at- 
tempting this method on dogs, Dr. Michinard and myself 
promptly abandoned it as unpractical in this animal, in which 
even circular enterorrhaphy by the unaided Lembert method 
is extremely difficult and disadvantageous. It is not surpris- 
ing, therefore, that Brokaw, in his fourteen experiments, should 
have met with a mortality of 50 per cent, though this experi- 
menter, like ourselves, believes in the clinical excellence of 
this method. He very correctly says (St. Louis Courier of 
Alcdicine, p. 395, vol. ii, June, 1890) : “This is without doubt 
the most rapid method of performing circular enterorrhaphy, 
and while my experiments upon the dog, with this method, 
were not as satisfactory as I had hoped (50 per cent died), on 
man the results will be far better; the amount of stenosis would 
not be more than by circular suturing with the unaided Lem- 
bert or Czerny-Lembert. In man for anatomical reasons, the 
apposition threads can be passed nearer the cut margins of the 
bowel. In man there would not likely be any formation of 
enterolithis; a liquid diet for a time would do away with that 
danger, which was the cause of death in several of my experi- 
ments,” etc. 
The details of the technique of this method are made plain 
enough by the illustrations, so that no further explanation is 
needed; besides these, however, the descriptive text is fully 
given in the author’s “ Remarks on Circular Enterorrhaphy,” 
loc. c?V., April, 1889, in which this procedure was first presented 
to the profession fide this journal, July, 1889). While the 
value of the experimental test is denied this method, in dogs, 
at least, the author feels satisfied that it has a great future be- 
fore it, if is only tried in the operating room on the human 
subject. 
Proposition 13.—Enterorrhaphy after partial enterectomy 
for multiple gunshot and other injuries of the intestinal con- 30 
vexity, may be, in special cases, advantageously performed by 
the aided method. 
Remarks.— Brokaw and Davis have suggested that in in- 
juries of the intestines which permitted of the closure of the 
wound without producing obstructive stenosis of the intestinal 
lumen, but which could not be closed without a partial sacrifice 
of the intestinal wall, that a large multi-segmented catgut- 
rubber ring (Brokaw) or catgut plates (Davis) could be utilized 
to approximate the pared surfaces of the wound, as is shown in the 
illustration. Brokaw describes the method of suture as follows : 
“After trimming and enlarging the wound with scissors, an oval 
ring made of eight segments of tubing, with an aperture of two 
and a half inches, is placed in the bowel. Six apposition threads 
should be used with this ring, one at each end and two on each 
side, so arranged that when tied the ring is held bent upon 
itself. The ring is introduced into the bowel, the end apposi- 
tion thread passed, then the lateral; the ring is doubled upon 
itself, and the end thread tied first, next the lateral apposition 
threads. To prevent eversion of the margins of the wound, 
particularly at the point of flexure, a single provisional catgut 
suture is used in drawing the margins of the wound in the bowel 
together.” ( Vide fig. 13.) Davis tells us that the same result can 
be accomplished quite as readily with his catgut plates. On the 
cadaver I have tried a large, solid catgut “drum-snare” ring, and 
found that it could be just as easily used as the Brokaw ring, after 
previous softening in water. I onty once tried the method on 
dogs, but gave up the attempt because the spasmodic contrac- 
tion and narrowing of the intestine in this animal after irritation 
makes it absolutetyimpracticable to effect coaptation after par- 
tial enterectomy by the use of these aids. In fact, I am some- 
what astonished that other observers should affirm that their 
experimental work with this operation “ has been highly suc- 
cessful.” I must frankly confess that, in the light of my in- 
dividual experience, I think little advantage is gained by the 
ring aids in partial enterectomy of the small intestine. The 
indication for this method of suturing will be found in the 
wounds of the large bowel (caecum, colon), where, owing to 
the greater size of the bowel, the rings can be manipulated with 
greater advantage. For partial enterectomy of the small in- 31 
testine, the Lembert stitch will, as a rule, be found to be still 
the simplest and most expeditious method of suture. 
Proposition 14.—Linear Enter or rha-phy.—In simple linear 
incisions into the convexity of the bowel (stab wounds, enter- 
otomy), requiring suture, greater security and rapidity can be 
gained by the aided method. 
Remarks.—In wounds seriously compromising the mesen- 
teric attachment of the bowel, it is imperative (and the teachings 
of experience absolutely command this), that resection be prac- 
tised, but in incised wounds involving the free surface of the 
bowel the suturing can be quickly effected by the skilled appli- 
cation of the “aid” principle in the manner of a quilled suture; 
the aids representing the quills being made of decalcified bone 
(Brokaw) or bars of my solid catgut drum-snare material. If 
the last material is used, a piece is cut of the length correspond- 
ing to that of the wound in the bowel. Threads of fine and 
well chromicized catgut or aseptic silk are now attached to 
the solid catgut rod at half an inch or less distance from one 
another. These threads are now mounted each with a needle 
as small as can be used. With two rods thus pre- 
pared, the approximation is easily effected. After the rods are 
introduced into the intestine the needles are made to transfix 
the bowel by passing from within outward, about one-quarter 
of an inch from the margins of the wound ; the second mounted 
rod is applied in the same manner, traction is made upon the 
threads to see that the rods rest well in place, the central 
threads are now tied, and lastly the distal threads. A few 
extra Lembert sutures will add to the security of the suture. ( Vide 
figs. 14 and 15.) Brokaw, to whose ingenuity we owe the sugges- 
tion and technical details of this mode of application of the aid 
principle, recommends rods made of decalcified bone, or short 
sections of rubber tubing, the last being the most accessible ma- 
terial and possibly the safest in the upper digestive tract, where 
the disintegrating forces are most active. This modified “Bro- 
kaw ’’suture is a decided improvement on the suggestion made 
primitively some years ago by Beranger Feraud (vide Stimpson’s 
Operative Surgery, p. 353, 1885 ed.), who used rods or strips 
made of cork, which were mounted with pins. These cork rods 
were placed in the intestines, one on each side of the wound, and 32 
parallel to it and the pins forced through from within outward two 
or three millimeters from the edge. They are then turned so that 
the points face each other, and the pins of each driven into the 
other by pressure through the sides of the intestine. The cork 
rods and pins were to be eliminated with the fasces. The irritant 
effect of the pins fixed in the cork rods during elimination can 
well be imagined. The improved quill suture of Brokaw is 
therefore very noteworthy and should not be forgotten by 
practical surgeons, who will at one recognize its special advan- 
tages. 
Proposition 15.—Ileo-colostomy.—Intestinal anastomosis 
by making ileo-colostomy with perforated decalcified bone 
plates must now be accepted, not only as an established sur- 
gical procedure, but as the operation of election in the treat- 
ment of the following conditions: (1) Irreducible ileo-colic 
invagination without perforation or gangrene ; (2) cicatricial 
stenosis in the ileo-cascal region; (3) carcinoma of the caecum, 
with or without excision of the diseased portion of the bowel 
(Senn). 
Remarks.—In no other part of the alimentary tract do the 
disadvantages of the unaided stitch methods appear greater, 
and nowhere have the new methods proved more beneficial. 
Hitherto, in cases of malignant or other disease which fre- 
quently obstructs the ileo-cascal valve, the surgeon has been 
compelled to resort to the formation of an artificial anus, 
and only in exceptional instances have attempts been made to 
restore the freedom of the intestinal circulation at one sitting, 
and these as a rule have proved disastrous failures. Only those 
who have experimentally or clinically tried to restore the con- 
tinuity of the bowel tract after resection of the ileo-caecal re- 
gion can fully appreciate the difficulties and the dangers of the 
technique by the unaided methods, the results of which, in 
fact, forbid, as a chirurgia frohibita, the intervention of the 
surgeon. The aided methods have completely altered the face 
of this question, however, and the misery of the artificial anus in 
such cases will now, under the aegis of Senn’s innovation, be prob- 
ably consigned to the recollections of the past. With the pros- 
pects of a greatly reduced mortality the reluctance of the surgeon 
to undertake these formidable cases will cease and more cour- 
ageous aggressiveness will mark his conduct in the future. <PI.AT£ I ) 
Fig. i—Senn’s Decalcified Bone 
Plate. 
Fig. 2—Abbe’s Catgut Ring made of 
Heavy Catgut Thread. 
Fig 3—Author’s Solid Catgut Ring made 
of Boiled Drumsnare. 
pig. 4—Brokaw’s Ring made of Hollow 
Rubber Segments (Drainage Tub- 
ing) Threaded with Catgut 
Strands. 
Fig. 6—Davis’ Solid Catgut 
Plates. 
Fig. 5—Davis’ Catgut Mats. (PLATE 2.) 
Fig. 8—The Bowels Approximated and the Anastomotic Openings 
in Confrontation. 
Fig. io—Vertical Section Representing Anastomotic 
Connections and Intestinal Interior, 
CIRCULAR RESECTiOX (Illustrations after Brokaw) WITH “ AIDER ” AXASTOMOSIS, 
Fig. 7—Fixing Ring in Divided Intestine; the Bowel has 
been Previously Inverted at Cut End and Formed 
V4 into a Cul de Sac. 
Fig- g—Diagramatic Representation of Intestinal Circulation 
Afte- Completion of Anastomosis and Enterorrhaphy. (PLATE 3.) 
ClitCULAR RESECTION WITH “ AIDED ” CIRCULAR 
KNTERORRHAPHY. 
Fig. u—Circular Enterorrhaphy with 
the Aid of Catgut Rings. The Ring 
in Situ and the Intestines in Con- 
frontation , Author's Method). 
Fig. 12—Complete Approximation with the Continued 
Lembert Suture after Adjustment of Rings. Circular 
Resection of Bowel by Direct Lumen to Lumen 
“ Aided ” Enterorrhaphy (Author’s Method).  4.) 
Fig. 17—Ileo-Colostomy as seen after Resection 
of the Caecum, (a) Closed ends of the Colon 
and Ileum directed downwards; (a) Serous 
surfaces over Anterior Margins of Plates 
united by a number of Stitches of the con- 
tinued Suture. 
iLEO- COLOSTOMY (After Senlij. 
\ 
Fig. 16—Ileo-Colostomy without Resection of Caecum, 
showing Plates in position, one in the Ileum, the 
other in the ■ olon, (a) lateral or transfixion Sutures 
passed through the margin of the wound (a a) end 
Ligatures hanging out of Wound, (b) posterior row 
of Superficial or Lembert Sutures. (PLATE v) 
pig 15—Vertical Section of Intestine, Showing 
Catgut Rods in Situ; Transfixion Sutures 
through the intestinal wall. (Brokaw’s Modi- 
fied Suture for Linear Enterorrhaphy.) 
Fig. 14-Author’s Solid Catgut Rod, armed 
with Transfixion Needles. To be used as 
an Intra-Intestinal Quill Suture. 
Fig 13— (After Brokaw). Enterorrhaphy 
with Aid of Single Ring after Partial 
Enterectomy. 33 
The aided methods which are at present offered the sur- 
geon are (i) lateral implantation and (2) lateral apposition 
by means of absorbable perforated plates or its substitutes.. 
Lateral implantation may be done by Senn’s original method, 
or by Brokaw’s method, but both of these are inferior to the 
operation of anastomosis by means of the bone plates as illus- 
trated in Figs. 16 and 17. This method is unquestionably the easi- 
est, most rapid, and secure. Itisthe method adopted by Senn in 
his two recent and remarkable cases of resection of the cascum 
for carcinoma (one recovered completely and the other suc- 
cumbed six days after the operation from peritonitis, caused 
by deep ulcers of the excluded portion of the colon). The 
anastomosis here is, in principle, effected in precisely the same 
manner as an aided anastomosis in other portions of the intes- 
tine, only that when it is coupled with resection, additional 
and special precautions as to drainage and anchoring the 
sutured bowel and mode of closing the abdominal incision, 
which is here lateral and not median, are required. All the tech- 
nical details have been so thoroughly and recently described 
by Dr. Senn that I will limit my reference to them by simply 
pointing to the excellent illustrations furnished by this writer,, 
which gives a clear idea of the operation. 
Finally, I would add that the experimental work by Dr. 
Michinard and myself completely confirms the experience of 
other operators: first, on the value and necessity of serous 
scarification to obtain prompt exudative reaction in the part of 
the peritoneum; second, on the value of omental grafting, 
though we believe that the valuable influence of the epiploon 
in securing the suture joint after enterorrhaphy is not as readily 
procurable in the operations on man as it is on the dog. 
CONCLUSION. 
In the preceding propositions and accompanying remarks 
much has been said which is doubtless well known to the in- 
vestigator and special reader who is an fait in all the details 
and developments of intestinal surgery. But the new art or 
school of aided enterorrhaphy, which has been founded by the 
imperishable labors of Senn, has not yet celebrated its 
fourth anniversary, so that it can scarcely be called old. 34 
The modern rapid “aided” method is quickly superseding 
the old; in this country and in England no progressive surgeon 
could admit his ignorance of the methods without blushing. 
In conservative Europe it is otherwise, though a crisis is im- 
pending which will end in a reaction that wdl be equivalent 
to a revival in continental methods of intestinal surgery. In 
the meantime, the work is ever progressing, and the finale 
has not been reached ; new indications, modifications, and details 
in the technique must be perfected before they finally crystal- 
lize ; hence the work of the reviewer who surveys the field, 
confirms or rejects the modification and the methods, is still in 
■order, as his work serves to strengthen and diffuse progress, if 
only by the ventilation of the most advanced ideas and results. 
This has been the aim of the author, and he will be amply 
satisfied if his efforts have aided in accomplishing this last 
result. 
BIBLIOGRAPHY. 
Index of contributions on intestinal surgery, which have 
appeared since the publication of Dr.Senn’s first paper, and in 
which special reference is made to his methods of enterorrhaphy 
and anastomosis: 
Senn, (N.)—An experimental contribution to intestinal surgery, with special 
reference to the treatment of intestinal obstruction. Transactions of Inter- 
national Medical Congress, Washington, 18S7, vol. i, pp. 435-4S6. Also, 
Annals of Surgery, St. Louis, 1888, vol. vii, pp. 99, 171, 264, 367, 421. 
Senn, (N.)—Intestinal surgery. Chicago, 1889, W. T. Keener, p. 276, 1889. 
Senn, (N.)—The surgical treatment of intestinal obstruction. Transactions 
Congress American Physicians and Surgeons, Washington, September 18, 
1888. 
Abbe, (R.)—Complete obstruction of the colon successfully relieved by using 
Senn’s plates; a proposed substitute of catgut rings. New York Medical 
Journal, 1889, vol, xlix, pp. 314-317. 
Jessett, (F. B.)—Observations on intestinal surgery; results obtained from an 
experimental investigation into a novel mode of operating. British Medi- 
cal Journal, London, 1SS9, vol. i, p. 590. 
Ransohoff, (J.)—Gastro-enterostomy; a clinical lecture. Polyclinic, Phila- 
delphia, 1SS8-9, vo*- v*> PP- 229-231. 
.Matas, (R,)—On circular enterorrhaphy and its rapid performance with easily, 
improvised catgut rings. New Orleans Medical and Surgical Journal, 
1889-90, N. S. vol. xvii, pp. 1 -15. 
JPage, (H. W.)—A case of gastro-enterostomy; together with the table of 
cases hitherto recorded. British Medical Journal, 1S89, vol. xii, pp. 1, ir, 
14; also, Lancet, London, 1889, vol. i, p. 986. 
Brokaw, (A. V. L.)—The use of segmented rubber rings in intestinal anasto 
motic, and other operations. International Journal of Surgery, New York 
1SS9, vol. ii, pp. 251-256. 35 
Clarke, (T. K.)—Case of gastro-enterostomy with the aid of decalcified bone 
plates. British Medical Journal, London, i88g, vol. ii. p. 1089. 
Brokaw, (A. V. L.)—An experimental study of intestinal anastomosis, with 
some practical suggestions as to a modified technique. Weekly Medical 
Review, St. Louis, August 12, 1889, vol. xx, pp. 121-125. 
Davis, (J. D. S.)—Ileo-colostomy in which Davis’s catgut mats were used for 
approximation. New York Medical Journal, 1889, vol. i, p, 296; also, 
Virginia Medical Monthly, Richmond, 1889 90, vol. xvi, pp. 454-460. 
Jessett, (F. B.)—Results obtained from an experimental investigation into a 
a novel mode of operation, suggested by Professor Senn, of Milwaukee. 
British Medical Journal, London, 1889, vol. ii, pp. 169-180. 
Curtis (B. F.)—Knots, ligatures, and sutures. Medical Record, New York, 
1889, vol. xxxvi, pp. 449-456. 
Standfield, (G. S.)—A successful gastro-enterostomy with Senn’s plates. 
British Medical Journal, 1890, vol. 1, p. 294. 
Standfield, (G. S.)—Sequel to a case of gastro-enterostomy with Senn’s ap- 
proximation plates. Correspondence British Medical Journal, p. 1300, 
f vol. 1, 1890. 
Ravvdon.—A case of pylorectomy and direct gastro-duodenostomy with the 
aid of Senn’s decalcified bone plates. Liverpool correspondence British 
Medical Journal, p. 323, vol. 1, 1890. 
•Stamm, (M.)— A case of gastro-enterostomy after Senn’s method for cancer- 
ous obstructions of the pylorus. Medical News, Philadelphia, 1889, vol. 
lvi, pp. 112-117. 
Mayo-Robson, (A. W.)—A successful gastro-enterostomy after Senn’s method. 
Correspondence British Medical Journal, p. 1167, vol. 1, 1890. 
Rrokaw, (A. V. L.)—Intestinal anastomotic operation with segmented rub- 
ber rings; with some practical suggestions as to their use in other surgical 
procedures. Medical News, Philadelphia, 1889, vol. iv. pp. 634-637. 
Weir, (R. F.)—The treatment of simple pyloric stenosis by gastro-enteros- 
tomy (by Abbe’s rings) rather than by Loretta’s operation. Medical 
News, Philadelphia, 1889, vol. iv, p. 663. 
Davis, (J. D. S.)—An experimental study of intestinal anastomosis. Annals 
of Gynecology, Boston, 1889-90, vol. iii. pp. 150, 157. 4 plates. 
Weir. (R. F.)—Gastro-enterostorm with catgut rings (AbbeL). New York 
Medical Record, February 22, 1890. 
Siiimwell, (B. T.)—Intestinal surgery. Medical News, Philadelphia, 1890, 
vol. lvi., pp. 3S9-393. 
Tuholske, (H.)—Gastro-enterostomy and pylorectomy. Medical News, Phil- 
adelphia, vol lvi., pp. 503-6. 
Bull, (W. T.)—Gastro-enterostomy and pylorectomy. Note in New York 
Medical Record, 1890. 
Brokaw, (A. V. L.)—New methods of performing pylorectomy, with remarks 
on intestinal anastomotic operations. St. Louis Courier of Medicine, vol. 
ii, 1S90, pp. 355-367. 
Senn, (N.)—Two cases of resection of the caecum for carcinoma, with remarks 
on intestinal anastomosis. Journal American Medical Association, June 
14, 1890. 
Jessett, (F. B.)—Remarks on pvlorectomy. Correspondence British Medical 
Journal, p. 1105, vol. i, 1890. 
Jessett, (F. B.)—Two cases of gastro-enterostomy for pyloric carcinoma, 
Lancet, London, pp. 68-69, vol. 2, 1890 (July 12).