Resurrection of the Murphy button

Publishingthe Trransactions AND

of THE NEW

YORK UROLOGICAL

SOCIETY; SECTIONS OP SURGERY, GENITOURINARY

ORTHOPEDIC SURGERY OF THENEW YORK ACADEMY

Editor:

THURSTON

SCOTT

OF MEDICINE;

WELTON,

EDITORIAL

M.D.,

Los

ANGELES

F.A.c.s.,

SURGICAL

NEW

SURGERY

SOCIETY, ETC.

YORK

BOARD

N.Y.; JAMES T. CASE, Battle Creek; A. C. CHRISTIE, Washington; W. B. COLEY, N. Y.; FREDERIC COTTON,Bosron; GEORGE W. CRILE, Cleveland; PAOLO DB VBCCHI, N. Y.; CHARLES A. BLSBBRG, N. Y.; C. R. G. FORRESTER, Chicago; EDWARD GALLIE, Toronto: JOHN H. GIBBON, Phila.; DONALD GUTHRIB, Sap, Pa.; A. E. HBRTZLER, Kansas City; c. GORDON HBYD,N. JAMES M. HITZROT, N. Y.: REGINALD H. JACKSON, Madison; A. F. JONAS, Omaha; WM. L. KELLER, Washington; A. V. S. LAMBERT, N. WM. S. BAER, Balr.:

SOUTHGATE MATAS,

ALEXIS

CARREL,

J. W. Y.; Y.;

LEIGH, Norfolk; H. H. M. LYLE, N. Y.; JEROME M. LYNCH, N. Y.: URBAN MABS, N. 0.; ROY D. MCCLURE, Detroit; RUDOLPH QUICK, N. Y.: HUBERT A. HARRY 6. MOCK, Chicago; F. R. PACKARD, Phila.: JOHN 0. POLAK, Brooklyn; DOUGLAS

N. 0.;

M. G. SBELIG, St. Louis; J. BENTLEY SQUIER, N. Y.; NORMAN E. TITUS, N. Y.; J. M. Gmnd Rapids; ALLEN 0. WHIPPLB, N. Y. Foreign C&borarorr-GREAT BRITAINJ. JOHNSON ABRAHAM, London: B. F. FINCH, Sheffield: ANDREW FULLERTON, Belfast; BASIL HUGHES, Bradford; GEOFFREY JEFFERSON, Manchesrer: SIR ROBERT JONES, Liuerpool: R. B. KELLY, Liuerpool; G. P. MILLS, Birmingham; 12. MAX PAGE, London; S. S. PRINGLB, Dublin; J, J. M. SHAW, Edinburgh: H. S. SOUTTAR, London: J. H. WATSON, Burnler. BA~T*AN~LI, ~~~~~ FRANCE -G. JBANNBNEY, Bordeaux. ITALY-RAFFAELE ROYSTER,

Raleigh;

WAINWRIGHT,

A. C. SCOTT,

Tern&.

Texas;

Scranton; F. C. WARNSHUIS,

II

II

III

’

II Ij

EDITORIALS’ RESURRECTION J.

W.

OF THE MURPHY KENNEDY,

M.D.,

BUTTON

F.A.C.S.

PHILADELPHIA

R

ECENTLY, that prince of teachers, John ChaImers Da Costa, reported* the discovery of an oId operating tabIe, a genuine antique of American surgery. This operating tabIe was the first used in Jefferson CoIIege in 1877. Professor Da Costa came across the tabIe in the basement of the hospita1 where it had been abandoned as a catcha for oi1 cans and various sorts of waste. In his opening remarks of dedication in resurrecting this oId friendIy tabIe, he says An oId wooden tahIe! It is not artistic or dainty but rather solid and capabIe. It was made for grim practica1 uses and not for show. It is not. Iike a ChippendaIe chair, a Sheraton sideboard or a HeppIewhite tabIe adorning a white coIonia1 drawing room or a parIor containing a hodge-podge of furniture of various makes and ages. It is not meant to be a part of + Facts concerning the oId operating table. Jefferson .Lledical

College Alumni

Bulletin,

hlay,

1928.

any society affair which wouId draw a crowd of the most uninteresting peopIe in the worId, herded by socia1 ambition, fear or menta1 vacuity to that last possibility of imbecility, an afternoon tea. I not onIy feeIingIy endorse Professor Da Costa’s remarks concerning the old tabIe but I further feel the same way toward the Murphy button. The Murphy button is certainIy not a device of fashion, it has not the commendation of popuIarity, it is IittIe understood and has been so modified in recent construction as to render unsafe some of its most sturdy principles. From the time the Murphy button was given the profession it has been used aImost excIusiveIy in our anastomotic work in the Joseph Price HospitaI. I recaI1 a conversation between Doctors Murphy and Price during which Dr. Murphy toId Dr. Price that he had done 293

294

American

Journal

of Surgery

EditoriaIs

more to bring out the sterIing functions of the button than had its namesake. It needs no discussion to pIace it upon the list as the most rapid of a11 means of making an anastomosis. With a IittIe good management it is more easiIy accomphshed than any other method of bowe1 union. It is by far the freest method from hemorrhage of a11 efforts at intestina1 anastomosis. Its freedom from hemorrhage is due, of course, to the cIamp principIe of controIIing bIeeding, as no vesse1 escapes pressure from the cIamping shouIders of the button. A Iarger extent of bowe1 can aIways be removed by the use of the button than by any other method; this is important in its use for maIignancy. There is aIways Iess danger from Ieak at the anastomotic ring than from any other method; we have never seen such foIIow its use in the Joseph Price HospitaI. There is much Iess danger of failure of union in questionabIe bowe1 than in any other method. There is never any danger of stitch syphoning infection which may be of serious import as is seen sometimes in the stitch method. The button is entireIy void of damaging trauma to the bowe1 waI1, such as is too often seen in today’s cIamp method of anastomosis, either as end-to-end or IateraI union. The opening from the button is much less apt to contract than that made by incision. The opening produced by the Murphy button is accompIished by a sIough which is aIways Iess apt to contract or cIose than an incised wound. This principle is seen in a11 fistuIous openings. When the button is used as a IateraI anastomosis there is no need for any reenforcing sutures and there is thus no cause for any wide area of fibrous tissue which is incident to unnecessary suturing that might Iater cause contraction of the anastomotic ring. This is important and is one of the great virtues of the Murphy button. The cIamp and suture method which is so popuIar is predisposed to contraction on account of the excessive trauma of the

SEPTEMBER.

1928

technique and the great amount of stitching which must be done, a11 predisposing causes to infection, contraction, etc. The possibiIities of infection in the use of the button are reduced to a minimum as there is no exposure of the mucous membrane of the bowe1 in its use. The objections to use of the Murphy button on account of its being a mechanica means and a foreign body with the possibiIities of producing a postoperative bowe1 obstruction is iI founded and academic, as during the entire Iife of the button it has been used in the Joseph Price HospitaI without a singIe cause for any such contention. Its use is to be strongIy recommended in doing a gastroenterostomy foIIowing resection of a Iarge portion of the stomach for maIignancy, as the anastomosis can be made with rapidity and made more easily in the remaining smaI1 portion of the stomach. In a monograph entitIed Practica Surgery of the Joseph Price HospitaI, this function of the button has been discussed and iIIustrated and its importance in acute bowe1 obstruction emphasized. In peritonitic Iesions where a considerabIe Iength of bowe1 has to be removed on account of muItipIe injuries which have occurred from breaking adhesions and where there is necrosed bowe1, the button shouId be used. However, in muItipIe Iesions of the intestine from such surgery, an earnest effort shouId be made to repair the same, as these patients shouId be saved a resection if possible. We have many times reduced the Iumen of the bowe1 over one-haIf in repair and have never experienced obstructive symptoms. By a11 odds the button’s most important function is one which is rareIy, if at aI1, discussed and that is its distending and drainage function. This makes it the means par exceIIence of anastomosis where any Iength of bowe1 is to be resected for acute obstruction, and it is my opinion it is the onIy method which shouId be considered in these grave cases. Most surgeons today in operating on

NEW SERIES VOL. V, No.

3

EditoriaIs

these patients do an enterostomy or coIostomy proxima1 to the site of anastomosis in order to drain the distended boweI. Such is entireIy unnecessary if the button is used. The distending function of the button hoIds the anastomotic ring open from the moment of the operation, which permits gas and infected fluids to pass rapidIy on and the operator is often rewarded by a copious bowe1 movement within a few hours foIIowing the operation. This is, of course, to be weIcomed and means victory in nearIy a11 cases. I recentIy resected over 7 feet of gangrenous bowe1 in a man nearIy seventy. A Iarge bowe1 movement foIIowed within five hours, uneventfu1 recovery taking pIace. I have had thirteen recoveries in succession where not Iess than 235 to 7 feet of intestine had been resected for acute obstruction. Moynihan says in his Iatest work on abdomina1 surgery: “For every case reported as a cure from acute boweI obstruction five die and the mortaIity in any series of twenty or more cases wiII be I couId not have obtained 50 per cent.” any such resuhs in the above thirteen cases had I used any other means than the bottom. Mr. Moynihan in the second voIume of the eighth edition of AbdominaI Surgery gives an account of a Iarge number of recoveries which were conspicuous on account of the great extent of bowe1 which was resected. I find consoIation in this report for the reason that aIthough the button is Iittle used as a popuIar method of anastomosis, yet in this series of recoveries which were reported on account of the great Iength of bowe1 removed, the button had a Iarge per cent of recoveries. It is this distending function of the button which permits immediate drainage of the mucous membrane which gives the Murphy button its victories and which wiII eventuaIIy bring the button into popuIar use by the profession. on two Some years ago I operated doing a resection foIIowed by patients, end-to-end anastomosis, stitch method.

American

Journal

OF Surgery

295

These patients continued their distention, and on the third day I reopened; the anastomosis was in perfect condition. No evidence of IocaI infection appeared but in each case immediateIy above the anastomotic ring the bowel was distended, for gas had not passed through the opening. I irrigated the bowe1 with hot saIine soIution and made gentIe manipuIation and the gas passed on. Both cases recovered but I am sure I wouId have Iost both had I not reopened. This taught me a very vaIuabIe lesson; such wouId not have occurred with the button and I now use nothing eIse. In a11 methods of intestina1 anastomosis there exists at Ieast a temporary period of paraIysis of the bowe1 at the site of union and peristahic movement does not readiIy pass the Iocation of the anastomosis and thus the bowe1 is not immediateIy drained. Yet drainage is essentia1 and determines the outcome of the operation in a11 acute obstructions. In the Murphy button operation this temporary paresis of the bowe1 may, of course, occur but the mechanica distention of the bowe1 at the anastomotic ring permits the gas to pass on without assistance of the peristahic wave and therefore the bowe1 is immediateIy drained and distention reIieved. Another redeeming feature of the button is that there is no temporary distention of the bowe1 at the site of the anastomosis. Therefore, there is no tendency toward a Ieak or rupture of the sutured end of the boweI, since no force by distention upon the anastomotic ring has occurred as does in a11 suture operations. The button is idea1 in resection of the cecum and ascending coIon and Iast few inches of the iIeum, in resection of the peIvic coIon where anastomosis is required with the rectum, and in any Iocation of the Iarge or smaI1 bowe1 where manipuIation is diffIcuIt. The operator naturaIIy works out his If the two haIves of the own technique. button can be pIaced within the intestine

296

American

Journal

of Surgery

EditoriaIs

or stomach and then pushed aIong to Iocation where the anastomosis is to be made, this is desirabIe, but such cannot a1way.s be done. I usuaIIy pIace on four cIan-ps, cut between with cautery, remove section to be discarded, then open one of the clamps which has within it the end of the goad bowe1, drop in one-haIf of the button, replace the cIamp, then overwhip cIamp with the suture which is to cIose the end of the bowe1. There wiI1 be no escape of infected bowel contents if, before one opens the cIamp in order to drop in onehaIf of the button, another cIamp is pIaced on the bowe1 2 inches from its resected end, the gas being first pressed back of the forceps which are pIaced to prevent escape of gas as the button is being inserted. The construction of the button today is so fauIty that we seIdom use it in an end-to-end anastomosis. The diameter of the cyIinder has been increased to such an extent that the shouIders of the button have too IittIe cIamping space and therefore if it is used as an end-to-end anastomosis the mucous membrane of the incised bowe1 everts between the cIamping shouIders of the two haIves of the button and a Ieak is apt to take pIace. When it is used in a IateraI anastomosis this does not take pIace, as a puncture may be made over the cyIinder of the button and the bowe1 waI1 which tightly hugs the cylinder is pushed over the same, preventing any eversion. When the button is used as a means of a

REDUCTION

IateraI anastomosis it is passed several days earlier than when used as end-to-end anastomosis. The serous surfaces are heId in such perfect apposition with uniform pressure from the shouIders of the button that the sIough takes pIace earIier than wouId occur in an end-to-end union where very often some tags of mucous membrane may prevent perfect apposition and thus hold the button in stationary position for some time. I operated on a man of ninety years, doing a Murphy button anastomosis between cecum and sigmoid for extensive malignancy of the transverse colon. This patient passed the button on the third day and Iived over two years, dying from pneumonia. As I enter my second quarter of a century experience in abdomina1 surgery, I find that a11 intra-abdomina1 procedures which are primariIy the most finished and are not anticipating a second operation as an auxiIIary, have by far the best results. The Murphy button wiI1 again come into its own when the profession Iearns the vaIue of its drainage virtues through its distending function, which stamps it by all odds the best method of anastomosis in a11 acute bowe1 obstructions where there is a Iarge extent of bowe1 to be removed, in the oId and feebIe patient, in peritonitic bowe1 and where the circuIation is questionabIe, as union wiI1 take pIace in such bowe1 by the Murphy button when trouble wiI1 often foIIow the use of any type of suture method.

OF FRACTURES AND DISLOCATIONS LOCAL ANESTHESIA

UNDER

C. R. G. FORRESTER, M.D. CHICAGO

F

OR a number of years, in folIowing so-caIIed traumatic surgery, I have found that the fear most patients suffering from fractures or disIocations entertain is the necessity of taking a

genera1 anesthesia and not the setting or reduction of a bone condition. I have experimented aIong the Iines of nerve block for the purpose of reductions. It is rather dif%cuIt to carry out a program