Such is the operation with suture, which may occupy from thirty to forty minutes in performance, it takes a little longer than the methods either with the button or with the elastic ligature, but seems to be the method generally used. In this method, as stated at the outset, no special provision is made as against “vicious circle,” because it has been found that it is seldom that this unpleasant complication ensues. If, however, the anastomosis with the jejunum has been made at a point twelve inches or more beyond its beginning, there is a likelihood of finding that vicious circle will cause later complications, and perhaps necessitate the performance of a second anastomotic opening in the small intestine above and below the stomach opening.
Of course all the precautions mentioned previously for prevention of infection, such as washing out the stomach previous to the operation, and ensuring both its emptiness and that of the upper bowel, are a part of these procedures and cannot be safely neglected in any of them.
Many an ingenious device for effecting the same kind of communication between the stomach and the bowel, or between various parts of the alimentary canal, has been placed before the profession, though but a few will be considered more in detail when dealing with the operations upon the intestines proper. The most prominent of them, and the one which has found the most lasting favor in the eyes of the profession, is the Murphy button, or some similar expedient, by the use of which time is economized and the operations in some respects simplified. All devices of this character, however, depend upon a necrotic process for their eventual success, as the intent is that parts compressed between the halves of the button shall first adhere and then slough, the button falling through the opening thus made and passing on. But to rely upon a necrotic process is much like relying upon a criminal for the performance of a serious duty. The button, therefore, has gone out of general favor for purposes of gastro-enterostomy, although for other intestinal work it is still frequently used.
McGraw, of Detroit, has devised a different and equally ingenious method of keeping surfaces in contact with each other until adhesion shall have occurred, and then effecting a further necrotic process by which opening shall be finally accomplished. This is the so-called method with the elastic ligature. In many respects it is simplicity itself, and permits of ready and rapid employment. One needs especially a round rubber cord, about 2 Mm. in diameter, of the purest gum obtainable and sufficiently fresh to be reliable. The surfaces to be united are first approximated by a posterior row of silk or thread sutures which shall include their outer surfaces. Then a long straight needle armed with this rubber cord is passed into the intestine and out again at a distance of from 5 to 10 Cm. An assistant now holding the intestine, the operator stretches the rubber suture until it is very thin and then draws it rapidly through the bowel. This same step is repeated in the opposite direction within the stomach. A strong silk ligature is next passed across and underneath the rubber between the latter and the point where the stomach and the intestine are to come together and a single knot is then made in the rubber after it has been tightly drawn. Another silk ligature is passed around beyond the ends of the rubber ligature where they cross and is here securely tied. The rubber ends thus released are then cut off. The original silk suture is next continued around in front until the point of its beginning is reached. In this way the rubber ligature and the parts which it includes are surrounded with an elongated ring of silk sutures, and with this the operation is complete. Here it is the continuous pressure of the elastic suture which first shuts off the circulation and finally cuts its way through both coats, and permits the communication between the bowel and the stomach. This method is as applicable to other portions of the alimentary canal as to the stomach.
CHAPTER XLVIII.
THE SMALL INTESTINES.
CONGENITAL ANOMALIES OF THE SMALL INTESTINES.
The entire intestinal canal is sometimes too short and sometimes fails to develop sufficiently in caliber, or sections of it may remain undeveloped. None of these changes have interest or importance for the surgeon as such, save those which produce acute or chronic obstruction or conduce to acute inflammatory affections.
Intestinal diverticula are usually of that type described by Meckel and everywhere known by his name. Aside from these the others usually met are irregular sacculations or hernial protrusions which may be due to previous disease or to some congenital anomaly of structure. These are sometimes seen in multiple form, and in one case recently under my observation over one hundred of them were found scattered along the intestinal canal, but, inasmuch as the patient died practically of old age without a history of serious previous disease, it could not be ascertained whether the pouches were of congenital or acquired origin.
The genuine Meckel diverticulum is a relic of the tubular structure which leads from the primitive intestine to the vitelline or yolk sac, and which should persist until about the end of the second month of embryonic life. After this time it should be completely obliterated and disappear. When this does not happen there may result a fecal fistula at the navel, which is then usually referred to as persistent omphalomesenteric duct, and which implies a continuous passage-way between the skin and the interior of the bowel.
When the umbilical portion alone persists there results a small cyst on the posterior side of the navel.