malignant disease where the patient is exhausted this would be a safer procedure, to be followed by enterectomy when the patient is in an improved condition.

The general mortality of these operations is about 50 per cent.

What are the three stages of the operation of resection of the bowel for any cause, followed by immediate suture to each other of the cut ends thus left?

1. Isolation of the bowel-loop that is to be excised;

2. Resection of the same;

3. Suture of the divided ends to each other, or circular enterorrhaphy.

Describe the method of isolating the portion to be resected.

Open the abdomen and draw the loop to be operated upon well out of the parietal wound, so as to bring a healthy portion of bowel into view. In a case of herniotomy, if this cannot be done through the original wound, a median abdominal section should be made, so as to give free access to the viscera.

Any recent adhesions should be separated with the finger. Firm adhesions fixing the portion to be resected to other loops and to the solid viscera are a contraindication to the operation.

In cases of malignant disease, if the mesenteric glands beyond the limits of the diseased portion are involved, the operation should be abandoned.

If the intestinal contents have been extravasated into the peritoneal cavity, this matter should be removed and the peritoneum cleansed before proceeding to the resection.

In case the gangrenous portion is very extensive or so firmly bound down as to be immovable, the operation is to be abandoned. Fix the limits of the part to be resected, draw this portion outside the abdomen, clear it of its contents by gentle pressure with the finger, place it on a warm sponge, and pack all around the abdominal opening with sponges, so that no intestinal matter can escape into the peritoneal cavity.

Describe how the diseased portion is resected.

Place some form of intestinal clamp on the healthy bowel above and below the seat of disease.

Many forms of intestinal clamps have been devised: Abbé's, Makin's, Brokaw's, and Newell's are all good. Senn uses a rubber band. Many surgeons prefer a ligature of tape or a strip of gauze

perforating the mesentery and tied in a single loop knot around the bowel. The fingers of an assistant will aid the constriction by the clamp, but they are not to be relied upon solely.

In cases of great distension of the bowel and accumulation of the intestinal contents the bowel should be incised and emptied of its contents away from the abdominal wound. The bowel above the resection area should also be emptied of any accumulation before the resection is made.

The bowel is then cut straight across from the free border to the mesentery. The mesentery of the resected portion may be divided close to the wall of the bowel, or a triangular portion of the mesentery may be removed with the resected bowel. The base of the triangle of removed mesentery is next to the intestine, and should be narrower than the length of bowel removed. This provides a greater vascular supply for the divided ends of the bowel that are left. It is claimed that division of the mesentery along the wall of the bowel involves less division of vessels, and therefore less risk of gangrene.

Bleeding vessels in the bowel should be picked up with pointed. forceps and clamped. Vessels in the mesentery should be clamped, and subsequently tied with catgut ligatures. Another method is to pass fine catgut ligatures around the vessels of the mesentery, and thus secure them before the triangular portion is removed.

The triangular gap in the mesentery should be closed with a continuous suture. If the mesentery is divided next to the bowel, the edges are united by a continuous suture and the redundant mesentery folded together by sutures transfixing the two layers at its base.

Describe the method of circular suture of the divided ends of the bowel.

Thoroughly cleanse the ends to be sutured by irrigating with a tepid salt solution (6: 1000). Then unite the mucous membrane by a continuous or interrupted suture, the needle punctures placed three-sixteenths of an inch apart. Then unite the serous surfaces by a second row of Lembert sutures placed one-eighth of an inch apart (Fig. 117). Unite the parts at each side of the mesenteric border first; here special care should be exercised to cover the bare portion of the bowel by a fold of peritoneum from the mesentery, using two or three extra sutures for this purpose.

The other sutures are put in place and tied, so as to unite firmly and securely the divided ends of the bowel.

The intestinal clamps are now removed, the parts are again irrigated, and returned to the abdominal cavity. Remove all sponges and close the abdominal cavity in the usual way. A drainage-tube is not used unless there is some special indication for the use.

To facilitate the insertion of the sutures various devices have been used to distend the bowel, such as a plug of cocoa-butter, the trachea of an animal, an inflated rubber bag, etc., but they are not essential.

What is the after-treatment of the patient?

The stomach and bowels are put at rest, and the patient is nourished by nutrient rectal enemata, and after a few days by artificially digested foods by the mouth. Large doses of opium are sometimes given to restrain intestinal movements.

The patient must lie absolutely quiet on his back.

What is lateral anastomosis?

It is the method of uniting two portions of the intestine by suturing together the edges of the openings made in them. Its indications are the same as for enterectomy or resection. There are two methods of performing lateral anastomosis :

(1) After resection it is used as a substitute for circular enterorrhaphy; that is, the cut ends of intestine remaining after the resection are each closed completely by turning in and suturing its edges, and then the two loops are placed side by side, the closed ends looking in opposite directions, and united by sutures after an opening has been made in each.

(2) There is no resection made, the affected portion is left in situ, and the parts of the intestine above and below this affected portion are united as above described. Malignant tumor, which on account of adhesions and size cannot be removed, is the usual condition for which this second method is used. "Short circuiting" is a term at times applied to this method.

Give the principal points of the technique of "lateral anastomosis.'

Place the loops of intestine side by side, and unite them by a continuous Lembert suture for a distance of five inches. This suture should be placed at about one-fourth of an inch from the

middle line of the free border of the gut. Leave the end of this suture long-that is, only one-half of it should have been used— and with the needle in place. Then apply another exactly similar suture close to the first one, but running in the opposite direction. The loops of intestine are now incised exactly in the middle line, the length of the incision in each being four inches. Another silk suture is now started at one corner of the openings, and unites by a quick overhand stitch the two cut edges lying next the first rows of sutures. The needle pierces both mucous and serous coats, and thus secures the bleeding vessels, from which the clamps, if it has been necessary to apply them, are removed as the needle reaches them. Each of the remaining two cut edges is similarly sutured. and each with its own separate suture. The portions of the intes

FIG. 118.

Diagram of Method of Using Decalcified Bone-Plates of Senn (Greig Smith).

tine beyond these last-mentioned cut edges, and at a quarter of an inch from them, are now united by the long ends of the original