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 '^Qn ' 4-^ 
 
 END TO END ANASTOMOSIS OF INTESTINES 
 BY MEANS OF THE MURPHY BUTTON. 
 
 BY 
 
 JAMES BELL, M.D., 
 
 Surgeon to the Royal Victoria Hospital ; Consulting Surgeon Montreal 
 General Hospital ; Professor of Clinical Surgery, McGill University. 
 
 {Reprinted from the Montreal Medical Journal, Janvvry, 1895.) 
 
END TO END ANASTOMOSIS OF INTESTINES BY 
 
 MEANS OF THE MURPHY BUTTON.* 
 
 By James Bell, M.D., 
 
 Surgeon to the Royal Victoria Hospital ; ConsultinK Surgeon Montreal General 
 Hospital : Professor of Clinicir Jurgery Moflill [Iiiiversity. 
 
 I am able to ivport three cases in which I liave used tlie 
 Murphy liutton to securii end to end union of intestine 
 at'tei- resection. In two the results were conjpletely suc- 
 cessful and most satisfactory. In one thus made there was 
 non-union, slouginng of the apposed ends of the bowel, 
 escape of contents and death from peritonitis. Two of the 
 three operations were upon the same ])atient, and it was 
 the second operation upon this patient which proved fatal. 
 I am, therefore, enabled to present specimens showiui^ (1) 
 the union which had resulted from the first operation, as 
 well as (2) the sloughing of the bowel which resulted 
 from the second operatiori. This case is, moreover, a most 
 interesting and puzzling one from a pathological stand- 
 point, although I wish for the present to direct attention 
 specially to the use of the Murphy button. 
 
 The second case was one of femoral hernia, in which 39 
 hours of strangulation had produced complete gangrene of 
 the extruded loop of liowel. Until very recently such 
 cases were the hefe noir of the surgeon, and the question 
 
 • Read before the Montreal Medioo-Cnirurginal Societyt November 3()th , 1894. ' 
 
" Wluit shall l»e <lone with cases of" oiin^reiious hernia ;* ' has 
 Iteen much discussed. This case and othei's, now a jjfoodly 
 nund)er, of recoveries after resection of the bowel, indicate 
 the only rational treatment, and it is particularly in this 
 veiy class of cases, where rapidity of o|)erationisfre(|uently 
 such an important consideration, that artificial aids are, if 
 useful at all, of the greatest service. 
 
 Case I. — J. W. McC, male, ret. 40, had abvaj's enjced 
 good iiealth until June, 1893, when, while in Chicago 
 attending the World's Fair, he was suddenly seized with 
 severe and painful diarrhoea. The diarrhoea subsided in 
 four or five days, but pain remained, and he felt so badly 
 that he came home and was unable to work for six weeks. 
 His bowels had never been quite regular since this attack. 
 He recovered fairly well, however, until December, 1893, 
 when he had another attack of pain and a haemorrhage 
 from the bowels. Since that time he had never had a 
 natural movement of the bowels, without a purgative, and 
 he had suffered greatly from wind, which, after rumbling 
 i'.bout for some time, finally escaped in an explosive manner, 
 giving great relief. In Fel)ruary, 1894, he was seized with 
 faintness and some hours afterwards passed a large quan- 
 tity of blood per rectum. A similar attack had occurred 
 ( ice since. On the 14th June, 1893, he was admitted to 
 the Royal Victoria Hospital, with complete obstruction of 
 the bowels of six days .standing, and for which he had been 
 given various kinds of purgatives, as well as enemata, but 
 without any effect. His abdomen was greatly distended. 
 The principal distress was referred, vaguely, to the hypo- 
 gastrium, and bimanual examination, (with a finger in the 
 rectum), discovered an ill-defined mass in the middle line, 
 about midway between the umbilicus and the pubes. This 
 examination gave a good deal of pain and was followed by 
 the passage of a little flatus and soon afterwards by a liquid 
 stool. The symptoms were at once relieved and free 
 evacuation of liquid fseces continued for two or three days. 
 He remained well, with the exception of the wind and con- 
 ''tipation, which was relieved from time to time by purga- 
 
tivcs until th(> 14th of -Ttily, vvlien ho was seized with faint- 
 ness, and hccanie quite pah;. This condition histed all the 
 afternoon, and the patitMit stated that he knew fi'oni his 
 past experiences tliat he was about to have a haMuorrhaj^e, 
 and within a few hours a lai-ge quantity of chirk clotted 
 blood was passed per rectum. I now advised operation, to 
 wliich lie readily consented, and on the 19th of July 1 
 opened the abdomen in the n»iddle line below the uiid)ilicus 
 and directly over the part at which the mass had buen felt, 
 although it had disappeared with the free evacution of the 
 bowels and had not since been discoverable. Two loops of 
 small intestine, each acutely bent upon itself, were found 
 attached to a mass which overhung the brim of the pelvis. 
 These were carefully separated, when it was fou'id that 
 they both connuur.icated with a free cavity, bounded pos- 
 teriorly by the ina.'s altov o mentioned, and in which lay a 
 long irregular mass of inspissated f.iHcal matte)'. The ob- 
 struction was at the upper of the two acutely bent portions 
 of the ileum, and the bowel above this angle was three 
 times as large as it was l)el<)W it. Over a space of two 
 inches in length, and involving one-third of the circumfer- 
 ence of the bow(d the wall of the gut was entirely absent. 
 This portion was excised and the ends united by the 
 Murphy button. At the lower attached loop the destruc- 
 tion of the bowe) was less, being about one inch in length, 
 and involving a narrow strip along the mesenteric border. 
 These deficiencies in the wall of the bowel were apparently 
 the result of a destructive ulcerative process. It was from 
 this point that the hemorrhages had occurred, and a small 
 artery, which was ulcerated through, bled very freely. 
 The vessel was ligatured and the opening in the bowel 
 closed by a continuous Lembert suture running obliquely 
 from the mesenteric border to near the free border of the 
 bowel. This, of course, narrowed the lumen of the gut 
 somewhat, and gave me some, anxiety as to the possibility 
 of tlie passage of the button, which, it will be noted, was 
 on tlie proximal side of this suture. My only alternative, 
 however, was another resection and end to end anastomosis, 
 
and T tlrcitlfil to Icavo it, as it wiis, as T liml still to turn 
 niv attention to tlif i.iass ovrrlwuifjin;^ the pelvis, anil 
 wliicli lm<l IxM'n in sncli intinmte relation with the howcl 
 already o|>t'i'Hte< I upon, ('aret'nl examination of the mass 
 hd me to the conclusion that it \v»is sim))ly cicatricial, and 
 that it did not involve any other pai-t (»t' the intestinal 
 canal. 'I'lu; sul»se(|uent history shows that f was wrou"^^ in 
 till) conclusion arrived at, us to the chai'actcr of the mass, 
 hut ri^ht as to its not tlu'ii involving,' any other portion of 
 the bowel. The patient made an exoellent recovery, and 
 after a week or ten days his bowels moved i-eijfularly and 
 he pas.sed lar<ije well foi-mcd stools (showing that there was 
 then no obstruction in the rectum or sijrmoid flexure), but 
 the button never came away. With the exception of some 
 discomfort after an enormous dinner of coi'iumI beef and 
 cabbaj^e and several sunniun- ajtples, he continued well and 
 left the hospital on the 12th of August in first rate condi- 
 tion. (He wrote n\e the day after lea\ing the hospital, to 
 .say that we had not felt so well for two yeai's. ) On the 
 i 1th Septend)er he,returne<l, again suffering from obstruc- 
 tion. He had enjoyed good health for from one to two 
 weeks after leaving the hospital. Tnen diarrhrea set in 
 for a few days, after which it was succeeded by constipa- 
 tion and rundding of wind in the intestines, ending as 
 before in painful and exphjsive evacuations with temporary 
 relief This continued until September l.Sth at 4 p.m., 
 when obstructive .symptoms, (inability to pass even flatus, 
 vomiting, &c.), came (ni. These were attrilaited by the 
 patient to the arrest and impaction of the button (which 
 had never been found), in some portion of the ileum or 
 large intestine. In this condition he reached the hospital 
 on the night of the 11th of September, and on the following 
 day at 2 p.m., forty-six hours after the onset of the symp- 
 toms I reopened the abdomen througli the original median 
 incision. The button was found free in t\u\ spleenic flexure 
 of the colon and removed through a small incisi(m on its 
 free surface, which was closed by Lembert sutures. I had 
 
 I 
 
I 
 
 i 
 I 
 
 pivviotisly <Hscnvor(Ml tlir olwtnirtion in tlio lower portion 
 of tlir ,siniiii)i,| tirxniv liy pnssinn- tlic liutton down throunh 
 tlir (liscfiKlinn' colon jukI iitt('ni|if inu' to expel it pei- nnnni. 
 'I'lie site ttf Mie previous reseeticMl could oldy I'e located l)y 
 the irre^rulurity in the mesentery, and the howel was of 
 uniform si/e nhove and lielow it. The mass overhuni'iiK'' 
 th«! Iirim ol* the pelvis was a])j)arently smaliei- iind was 
 certainly much more movable than at the previous opera- 
 tion. The site of the ohstruction having l>een located in 
 the lowermo.st portion of tlu' si<rmoi<l Hexure, I ])i'()Coeded 
 tt) remove it, together with the tuniour overhantrinir the 
 hrim of the pelvis, with which it was co.itintious. This 
 waw finally accomplished after .some difHcult;y owin<,^ to the 
 depth in the pelvis at which the manipulations ha<l to lie 
 cai-ried on. '{'he mass, which was <lense and hai-d, sur- 
 rounded the Itowel as a narrow hand, (ahout an inch in 
 width externally), and nearly elosei, its lumen, leaving;- 
 only a nai'i'ow slit aliout as lar^i^ as a waistcoat hutton 
 holi'. It was intilti'atini;- and was evidently either cicatri- 
 cial tissue or scirrhus cancer. It has since heen demon- 
 strated to he the latter. J)uring- the operation the howel 
 was occhuhMJ on either side hy a piece of hollow rubher 
 tuhin;;'. Alxmt three inches of tlu^ Viowel was removed, 
 and the ends united hy tlu- lari;e,st sized Murphy hutton. 
 The opei-ation lasted ahout two hours and was well horne. 
 Tliei-e was little lo.ss of hlood and no fouling of the peri- 
 toneal cavity. A <jflass drainagi; tube was carried down to 
 the bottom of the pelvis and exhausted from time to time. 
 A small (juantity only of odourless fluid — at first blood- 
 stained aud afterwards colorless — was all that was with- 
 drawn from the tube for forty-eight hours, during which 
 the patient <lid typically well in every respect. Several 
 copious evacutions of dark li(iuid fj^^ces occurred, the first 
 about three hours after the completion of the operation. 
 There was no vt)miting, the pulse ran from «!S to 94, and 
 the temperature from 98.5' to 99.')"F, and with the excep- 
 tion of the thirst and restlessness usually observed after 
 
!!3»'V«'rf ahdoininiil <»]i<>nitioiiSi he wmh perfectly ooiiit'ortalilo. 
 AltMut 2 pni., on the I4tli, (4S lioiirs after operation) the 
 patient was sei/,e»l with very se\ere j)ain which was jiot 
 sensildy lelievetl Ity a nKuh'iate »|uantity of Li^f. opil sed. 
 (hatth-y) injected hypodennically The dressinj;' was re- 
 moved and tlie j,dass draina^'e tiihe found tilh'd with licpiid 
 fa'cal matter. From this time lie sank rapi<ily and died in 
 aliout 18 hours. Post-mortem examination discovered a 
 •jonei'al peritonitis, with (piantities of li(|nid fmeal niatter 
 free in tl>e peritoneal cavity. The hutton remained in situ, 
 but the approximated ends of the bowel were coniplottdy 
 j^anj^renous in their whole circumference and had given 
 way just beyond the border of the button. I cannot otier 
 nny .satisfactory explanation of this unfortiuiate result. 
 Dr. Murphy states, in a letter to me, that " this is an ex- 
 ceptional case and has not «iccun'ed s(» far, except wdiere 
 there was infection from without, preventiii;^' the unio:i, 
 and wdiere the j)ost-mortem show^'d that there was no effort 
 at union at any poi'tion of the circutnfeivnce, as well as at 
 the point where the perforation occurred. This condition 
 was certaiidy sh(»wn by the post-mortem in this case, l)ut 
 1 cannot l)elieve that it was piimarily due to infection from 
 without. I caniu)t believe that with such .symptoms as I 
 have narrated in the liistory of the first forty-eight hours 
 after operation there could have been infection from with- 
 out. I am much more inclined to attribute it to one of two 
 things, either (1 ) impairment of the vitality of the ends of 
 the bowel by the use of the elastic ligature ; or (2) pressure 
 upon the wall of the l)owel between the end of the glass 
 drainage tube externally and the button internally, produc- 
 ing erosion and escape of intestinal contents, and then, 
 infection froni without. Finally, it is perhapj open to 
 question, whether the vitality of the bowel was not already 
 impaired by its great distension about the stricture, and 
 also whether, considering the thickness of the wall of the 
 bowel in this situation, the button may not have been closed 
 too tightly. 
 
 Case II. — Mrs. M., jet 49 ; strangulated femoral hernia. 
 
9 
 
 operation in tlu' Koyal V' ictiniii Hospital, Octolicr 2()tli, 
 1S!)4, jit II a.ni., tliirty-iiin«' hours after onset of symptoms. 
 The patient, a stoutly huilt woman, had always enjoyt'd 
 o()(((l health. Ahont fifteen years ap) a hernia first ap))enre»| 
 in the rij^lit femoral region. It luul always lu-en ri'ilneiMe 
 and had never ^iven hei- much trouhle. She had not worn 
 a trus.s. Symptoms of stran<fulation came on aliout S 
 o'clock in the evening (Octoher l.Sth), severe pain, swollin^r 
 of the ma.ss. which could not he reduced, <^reat tenderness 
 (a specially marked symptom), and fre(|uent vomitinji^ 
 whicli .soon became fiecal in character. On admission these 
 symptoms persisted, but in a modified degree. The pulse 
 was 90 and the temperature 100 F. The abdomen was 
 moderately distended. No attempt was made to reduce the 
 hernia. On making the incision through the skin and 
 fascia, brownish serum exuded from the cellular tissues hav- 
 ing a strongly putrefactive odor. The .sac was greatly thick- 
 ened, dark, (j'dematous and friable, and contained a couple 
 of drams of dark blood-stained .serum, which also gave off a 
 strong odoi" of putrefaction. The hernia consisted of about 
 three inches of ileum tightly caught and (|uite gangrenous. 
 When the opening was enlarged by incision of Oimbei-nat's 
 ligament and healthy bowel brought down, the gangrenous 
 part lay collapsed and empty, and was almost se[)arated 
 from the healthy gut at both ends where it had been con- 
 stricted. The bowel was emptied and compres.sed by the 
 fingers of an assistant, and six and a half inches removed 
 and the ends united by the Murphy button. The mesentery 
 corresponding to this portion had been ligated off at some 
 distance from the bowel through healthy tissue. In spite 
 of the greatest precautions, however, the mesentery stripped 
 itself away from the bowel at either end. There was no 
 great bleeding, but I felt that I could not leave the patient 
 in that condition, for fear of htemorrhage in the first place, 
 and secondly, for fear of sloughing of the bowel which had 
 been thus deprived of its vascular supply. I therefore 
 continued my incision upwards and outwards through 
 Poupart's ligament and opened the abdominal cavity. I 
 
10 
 
 a<;aiii rostictcd ; tliis time Hvf inclics, fifi>iiii>- well witliiii the 
 lioidcr of tlic fittacht'd iiK'SL'nk'iy, united tin; ends with the 
 Murphy l)utt()ii, linjiturc*! tho nicst'iiteric vessels and hrought 
 the mesenteric horders tom-ther with catunt sutures close 
 up to the bowel. There were thus 11 inches of bowel re- 
 moved. The hernial sac was excised, and the peritoneal 
 woun<l closeil with matti'e.ss sutures of silk. The muscular 
 borders were next clo.sed with buried sutures of silk-worm 
 gut and t\ui pectineal fascia was attached to the i-(i-united 
 Foupart's ligament by three sutures (jf catout. Final)}^ 
 the skill was closed b}^ a separate layer of silk-worm gut 
 sutures, and a small tent of iodoform gauze introduced at 
 the lower angle of the wound. Tho operation lasted two 
 hours and was well borne. The patient never had a I>ad 
 symptom and made an uneventi'ul recovery. A liquid 
 motion, (with ^latus), was expelled at the end of twenty-four 
 hours, (after adminstration of an enema). A regular move- 
 ment occurred again next day, and on the fifth, sixth, ninth 
 and tenth days. The Itutton was found induMlded in a 
 well forme(l stool, which was passeil i\}. ].:]{) p.m., Octobei' 
 .'iOth, just ten full days after opei-ation. The wound was 
 perfectly healed and the patient allowed up on the 22nd. 
 Healing per primam. 
 
 My experience in these three eases leads me to the con- 
 clusion that the Murphy liuttou is a valuable aid in end to 
 end anastomosis of intestine. So nuiny artificial aids have 
 been introduced for this |)ui'po.se, have had theii" day 
 and have been discarded, that most suigeons are now 
 .sceptical about anyching of this kind. It is, of coui'se, not 
 to be assumed that union of intestine cannot be .secui'ed 
 without such aids, for it undoubtedly can, 1»ut the o-reat 
 desiderata, )-ai)idity of operation and accuracy and security 
 of co-aptation, are both admirably effected i)y this instru- 
 ment. I cannot agree with the view which has recently 
 been pi-onuilgated, that the Murpliy liutton is useful in the 
 hands of the tyi'o and is not neci-ssaiy to the experienced 
 suigeon. The actual union of the intestinal ends is but one 
 part of the operation, even if it be the culminating point, 
 
11 
 
 and the surge(in who is not possessed of the necessary skill 
 to unite the ends of the intestine by snhu'e, is certainly not 
 fitted to undertake iuiy such operatic u l»y any method. In 
 my experience the most difficult part of such opej-ations, 
 and the part which, most re(pn'rcs surgical skill, is that 
 which is preliminary to the intestinal co-aptation. Ajj;ain 
 the button may be used, (as in my second operation), deep 
 down in the pelvis where accui-ate union by suture would 
 be almost impossible. 
 
 The great want of intestinal surgery at the present time 
 is a suitable clamp, a damp which will occlude the lumen 
 of the bowel, without too much pressu)-e upon its delicate 
 walls, and without exercising pressure upon the arterial 
 supply at the mesenteric border. Dr. Murphy's ingenious 
 contrivance to exercise a unifoi-m spring [)re,ssure gives, 1 
 think, a clue which may be utilized to effect this purpose, 
 — 1 mean to produce a clamp to be locked like an ordinary 
 artery forceps (Pean), with smooth blades capable of being 
 armed with rubl)er tuliing, and upon a spinal spring which 
 will make the pressure indirect ratber than direct uniform 
 and capable of regulation. 1 know of no clamp at i)resent 
 in use which is not open to serious objection. The u.se of 
 rubber tubings is, perhaps open to less objection than any 
 (jther device, but it is not l)y any means satisfactory. As 
 it surrounds the bowel, the wall nui.st be puckered consi- 
 derably in order to occlude the canal— especially in the 
 large intestine — hence more pressure is reipiired than should 
 be necessary if applied so as to evenly appose the irnier 
 surfaces. It also cuts oft' the circulation for a time com- 
 pletely, and the proper regulation of the degree of pressure 
 is extremely difficult. If one could ahvays have the ideal 
 assistant, I believe that the best clamp is the thumb and 
 forefinger, but a serious oljection to this is, that at best, 
 the assistant's hands are greatly in the way of the operator, 
 and worse still, there is the constant danger that by ixdax- 
 ing or moving his fingers the contents of the bowel may be 
 allowed to escape and prove disastrous to the operation.