The technic of operations upon the intestines and stomach

Front matter

CORNELL UNIVERSITY.

xj^iv^

THE GIFT OF

Preface

Three years ago I began an experimental study of gastro-intestinal technic. The animals used for the experiments were mainly dogs, although cats were employed for certain operations.

The object of the experiments was to simplify, where possible, the best gastro-intestinal operations. After careful study of an operation upon animals, the method was tried again upon the cadaver, for anatomical corrections.

In this book, which is the result of three years of research, are collected certain of the standard operations upon the intestines and the stomach.

No pretence is made of giving all of the methods in vogue, and many well-known operations have been omitted to give more room for illustrating the methods which were chosen. It is believed, however, that a knowledge of the technic, here included, will enable the surgeon to meet practically all of the requirements of gastro-intestinal surgery.

I feel under the deepest obligations to Miss Florence Byrnes and to Mr. H. F. Aitken for the painstaking manner in which they have made their beautiful drawings. Certain of the drawings are modifications, or are copies of others already in print; credit is given to such drawings in the legends.

Through the generosity of my publishers I am able to add seven colored anatomical plates from Sobotta's "Atlas and Text-book of Human Anatomy," which illustrate certain important surgical landmarks.

The work on repair, in Chapter I, was done conjointly with Dr. F. B. Harrington, and is produced here with his permission. In fact, Dr. Harrington's suggestions have been so numerous and so valuable that the scope of the book has been greatly increased thereby. Prof. E. H. Nichols first suggested and then directed the experiments for the study of repair, a service for which I am greatly in his debt.

Through the kindness of Dr. F. T. Murphy I am able to reproduce his original microscopical drawings, illustrating repair following the use of the elastic ligature.

For the reproduction of the drawings upon the repair following the Murphy button I am indebted to Dr. J. H. Barbat, of San Francisco, who

6 PREFACE

obligingly furnished me photographs of his sections, from which the drawings were made.

The facts embodied in the discussion of intestinal localization are taken from the monographs of Dr. G. H. Monks, by whose courtesy I have been permitted to reproduce ten of his original drawings.

Dr. Mixter has been most obliging in allowing me to publish his technic on colostomy, before he has done so himself.

The interest shown by Professors Warren and Burrell encouraged me to attempt the task of writing a book, and their many kindnesses are gratefully acknowledged.

In the preparation of the manuscript, many works have been consulted, among the authors of which are : Tillmann, Bickham, Robson and Moynihan, Gant, Cheyne and Burghard, Poirier, Delamere and Cuneo, Hartmann and Cuneo, Terrier and Baudouin, von Frey, Binnie, Moynihan, Connell, Gray, Quain, Testut, Tillaux, Sobotta, Stohr, Piersol, and many reprints.

Personal communications from Doctors Finney, McGraw, W. J. Mayo and Connell have contributed valuable opinions which are embodied in the text, where they are referred to in detail.

I wish to thank Dr. William C. Quinby for his careful correction of the manuscript and of the proof.

48 Beacon Street, May, 1906.

TO

FOR SIXTEEN YEARS

PROFESSOR OF CLINICAL SURGERY

AT

HARVARD UNIVERSITY.

Chapter I Page

The Repair or Intestinal Wounds 17

The Structure of the Intestines and of the Stomach 17

The Blood-vessels of the Intestines and of the Stomach -. 19

The Lymph- vessels of the Intestines and of the Stomach 19

Experimental Research on Repair 20

Experiments with the Segmented Ring 20

Experiments with the Plain Suture 22

Repair Following the Use of the Murphy Button 47

Repair Following the Use of the Elastic Ligature 63

CHAPTER II Suture Materials, Needles, Tying Knots, Sutures, and Clamps 65

Suture Materials 65

Needles 69

Tying Knots 70

Special Technic of Sutures 79

CHAPTER III The Anatomy of the Intestines 106

The Blood-supply of the Intestines : 106

The Lymphatics of the Intestines in

Intestinal Localization 1 14

CHAPTER IV Enterectomy 128

End-to-End Intestinal Anastomosis 130

Plain End-to-End Anastomosis 134

End-to-End Anastomosis by the Mattress Stitch 145

Formation of a Blind End , 158

Suture in Two Layers 158

The Purse-string Operation 160

Lateral Intestinal Anastomosis 162

Plain Suture 162

The Mattress Suture 164

IO CONTENTS

PAGE

End-to-side Intestinal Anastomosis *77

Colostomy 182

Left Inguinal Colostomy 183

Anterior Colostomy 186

Colostomy with the Rubber Ligature 188

Temporary Colostomy with Glass Tube 196

CHAPTER V Gastrotomy 201

Gastrostomy 202

Witzel's Gastrostomy 206

The Ssbanajew-Franck Gastrostomy 210

Pylorodiosis 211

Loreta's Operation 212

Hahn's Operation 217

Operations for Non-malignant Stricture of the Pylorus 218

Pyloroplasty 221

Gastroduodenostomy 222

Finney's Operation 225

Kocher's Operation 233

Gastroenterostomy 237

Posterior Gastroenterostomy 237

Anterior Gastroenterostomy 246

Pylorectomy 249

Partial Gastrectomy 269

Excision of Ulcer 276

Gastroplasty 281

Gastrogastrostomy 282

Gastroplication 293

Index or Names 295

Index 297

LIST OF ILLUSTRATIONS

FIGURE PAGE

i. Transverse Section of Human Stomach 18

2. Longitudinal Section of Human Jejunum 18

3 . End-to-end Anastomosis ; Three Days 25

4. Lateral Intestinal Anastomosis; Five Days 27

5. End-to-end Anastomosis; Eight Days 29

6. Gastroenterostomy; Twelve Days 31

7. End-to-end Anastomosis ; Fourteen Days 33

8. Gastroenterostomy; Twenty-one Days 35

9. End-to-end Anastomosis of Large Intestine; Six Weeks 37

10. Anterior Gastroenterostomy by Plain Suture; Seventeen Months after Opera-

tion 39

11. Peptic Ulcer of the Jejunum of a Cat; Proving Fatal Ten Months after Anterior

Gastroenterostomy 46

12. Cross Section of Peptic Ulcer of the Jejunum 49

13 . Repair Following the Use of the Murphy Button ; Three Days 51

14. Repair Following the Use of the Murphy Button; Thirty-six Days 51

15. Repair Following the Use of the Murphy Button; Forty-two Days 53

16. Repair Following the Use of the Murphy Button; Sixty-three Days 53

17. Section Across the Mass of Tissue Enclosed within the Loop of the Elastic Lig-

ature; Five Days' Duration 55

18. Section at Right Angles to the Line of Union of the Stomach and Jejunum;

Twelve Days' Duration : 57

19. Section at Right Angles to the Line of Union of the Stomach and Jejunum;

Thirty Days' Duration 59

20. Section Across an Adhesion; Seven Days' Duration, Which Had Formed Be-

tween the Edges of the Jejunum after the Elastic Ligature Had Cut Out 61

21. Method of Holding Curved Needle; Point Toward Operator 67

22. Method of Holding Curved Needle; Point Away from Operator 67

23. Milliner's Needle No. 3 69

24. Moynihan's Curved Needle, as Modified by Scudder 69

25. Method of Tying a Knot; First Step 70

26. Method of Tying a Knot; Second Step 71

27. Method of Tying a Knot; Third Step 71

28. Method of Tying a Knot; Fourth Step 72

29. Method of Tying a Knot; Fifth Step 72

30. Method of Tying a Knot; Sixth Step 73

31. Method of Tying a Knot; Seventh Step 73

32. Method of Tying a Knot; Eighth Step 74

12 LIST OF ILLUSTRATIONS

FIGURE PAGE

33. Method of Tying a Knot; Ninth Step 74

34. Richardson's One-hand Knot ; First Step 75

35. Richardson's One-hand Knot; Second Step 75

36. Richardson's One-hand Knot ; Third Step 76

37. Seamstress Knot; First Step 77

38. Seamstress Knot; Second Step 78

39. Seamstress Knot; Third Step 78

40. A Surgeon's Knot as it is Usually Tied 79

41 and 42. The Seromuscular Stitch 80

43. Cushing Right-angle Continuous Stitch; First Step 81

44. Cushing Right-angle Continuous Stitch; Second Step 81

45. Cushing Right-angle Continuous Stitch; Third Step 82

46. Cushing Right-angle Continuous Stitch; Fourth Step 83

47. The Lembert Stitch 83

48. Lembert Interrupted Stitch, with Cross Section 84

49. Lembert Continuous Stitch, with Cross Section 84

50. Halsted Mattress Stitch 84

51. Gould's Mattress Stitch 85

52. Halsted Mattress Stitch, with Cross Section 85

53 . Gould's Mattress Stitch, with Cross Section 86

54 and 55. Use of Reversed Mattress Stitch for Burying Stump of Appendix 86

56. The Purse-string Suture 87

57. The Purse-string Stitch; Cross Section 87

58. The Purse-string Suture for Lateral Anastomosis 88

59. Murphy's Purse-string Suture, Used for Button 88

60. Glover's Continuous Stitch, with Cross Section 89

61. The Buttonhole Stitch, with Cross Section 90

62. The Buttonhole Stitch Doubled go

63. Penetrating Mattress Stitch; Cross Section of One-half of Stitch 91

64. Maunsell's Mattress Mesenteric Stitch g 2

65 and 66. Two Views of the Small Intestine g?

67. Seromuscular Penetrating Mattress Stitch; Cross Section 95

68. Seromuscular Penetrating Mattress Stitch; Showing Stitch Pulled Tight 96

69. Straight Circumcision Clamp for Intestine gg

70. Rubber Tubing for Intestinal and Small Stomach Clamps 99

71. Maylard's Method of Using Forceps for Intestinal Clamps 100

72. Pean's Method of Using Hemostatic Forceps and Rubber Tube in Place of

Clamp 10I

73. Krause's Stomach Clamp IO ,

74. Gould's Stomach Clamp I0 ,

75. Scudder's Straight Stomach Clamp IO ,

76. Gould's Stomach Clamp I04

77. Harrington's Straight Stomach Clamp I04

78. Kocher's Crushing Clamp I04

79. The Blood-vessels of the Mesentery of the Small Intestine (Colors) 107

80. Showing Line of Mesenteric Root Traced on Abdominal Wall 115

LIST OP ILLUSTRATIONS 1 3

TIGURE PAGE

81. Showing Two Oblique Lines Drawn at Right Angles to the Two Extremities of

the Mesenteric Root 115

82. A Loop of Intestine, the Middle of Which is Exactly Three Feet from the End

of the Duodenum 119

83. A Loop of Intestine at Six Feet 119

84. A Loop of Intestine at Nine Feet 121

85. A Loop of Intestine at Twelve Feet 121

86. A Loop of Intestine at Seventeen Feet 123

87. A Loop of Intestine at Twenty Feet 123

88. Showing Monks' Method of Determining the Real Direction of the Gut 125

89. Showing How a Straight Instrument Passed into the Gut May Engage its Free

Border 132

90. End-to-end Intestinal Anastomosis 137

91. Showing Several Methods of Sewing Together the Cut Mesenteric Edges after

Resection of the Bowel 139

92. End-to-end Anastomosis; Mattress Mesenteric Stitch 139

93. End-to-end Anastomosis ; Sewing Mesenteric Third of Circumference 141

94. End-to-end Anastomosis ; Closing in the Last Third of the Circumference 141

95. End-to-end Anastomosis; Placing the Interrupted Lembert Stitches 143

96. End-to-end Anastomosis ; Suture Completed 143

97. Omental Graft 144

98. End-to-end Anastomosis, Connell Mattress; Showing Method of Placing the

Three Mattress Mesenteric Stitches 146

99. End-to-end Anastomosis, Connell Mattress ; Showing First Third of Bowel

Circumference Developed 147

100. End-to-end Anastomosis, Connell Mattress; Showing the Second Third of

Bowel Circumference Developed 148

101. End-to-end Anastomosis, Connell Mattress; Showing Closing in of the Last

Third of the Bowel Circumference 149

102. End-to-end Anastomosis, Connell Mattress; Showing Introduction of Last

Stitch 150

103. End-to-end Anastomosis ; Showing Introduction of Murphy Button 151

104. End-to-end Anastomosis ; Showing Button Halves Snapped Together 151

105. End-to-end Anastomosis ; Harrington's Segmented Ring 155

106. End-to-end Anastomosis, Harrington's Segmented Ring; Showing Purse-

strings and Mattress Mesenteric Stitch 156

107. End-to-end Anastomosis, Harrington's Segmented Ring; Showing Continuous

Seromuscular Suture 156

108. End-to-end Anastomosis ; Robson's Decalcified Bone Bobbin 158

109. Formation of Blind End; Inner Continuous Glover's Stitch 159

no. Formation of Blind End; Outer Layer of Reversed Mattress Stitches 159

in. Formation of Blind End; Purse-string in Position 161

112. Formation of Blind End; Invagination and Purse-string Tied 161

113. Formation of Blind End; Cross Section 161

114. Lateral Intestinal Anastomosis 163

115 an d II6 - Lateral Anastomosis with Jaboulay's Button 167

14 LIST OF ILLUSTRATIONS

FIGURE PAGE

117. McLean Needle for the Rubber Ligature 17 1

118. Lateral Anastomosis by McGraw Ligature; First Seromuscular Stitch Placed.. 174

119. Lateral Anastomosis by McGraw Ligature; Ligature being Drawn Taut 175

120. Lateral Anastomosis by McGraw Ligature; Showing the Three Stages of the

Technic *75

121. Lateral Anastomosis by McGraw Ligature; Cross Section 177

122. Lateral Anastomosis by McGraw Ligature; Showing Actual Opening 177

123. End-to-side Anastomosis, Gould's Method; Showing First Mattress Stitch 179

124. End-to-side Anastomosis, Gould's Method; Showing First Mattress Stitch Tied. 179

125. End-to-side Anastomosis, Gould's Method; Showing Suture Nearly Completed. . 179

1 26. End-to-side Anastomosis ; Cross Section 181

127. Left Inguinal Colostomy; Showing Line of Incision 183

128. Left Inguinal Colostomy; Showing Method of Placing Stitches 184

129. Left Inguinal Colostomy; Showing Coils Drawn Together by Mesenteric Stitch. 185

130. Left Inguinal Colostomy; Showing Afferent and Efferent Coils Amputated 186

131. Mixter's Anterior Colostomy; Showing Line of Incision 189

132. Anterior Colostomy; Showing Flap of Skin and Subcutaneous Tissue 189

133. Anterior Colostomy; Showing Sigmoid withdrawn and Mesentery Incised 191

134. Anterior Colostomy; Showing Flap Fastened 193

135. Anterior Colostomy; Showing Sigmoid Resected 193

136. Cross Section of Anterior Colostomy (Horizontal) 195

137. McGraw's Colostomy with Resection; Rubber Ligature Placed 197

138. McGraw's Colostomy with Resection; Resection Completed 197

139. McGraw's Colostomy with Resection; Line of Original Incision 199

140. Gastrotomy 203

141. Witzel's Gastrostomy; Catheter Partly Buried in Stomach 207

142. Witzel's Gastrostomy; Eye of the Catheter Inserted in Stomach 207

143. Witzel's Gastrostomy; Stomach Fastened to Anterior Abdominal Wall 209

144. Witzel's Gastrostomy; Cross Section 209

145. Ssbanajew-Franck Gastrostomy; Lines of Incision 211

146. Ssbanajew-Franck Gastrostomy; Bridge of Skin Dissected Up 213

147. Ssbanajew-Franck Gastrostomy; Cone of Stomach Held in Place with Forceps . . 213

148. Ssbanajew-Franck Gastrostomy; Skin Closed Over Base of Cone 215

149. Ssbanajew-Franck Gastrostomy; Cross Section 215

150. Pylorodiosis, Hahn's Method; Steadying Pylorus 218

151 and 152. Heinecke-Mikulicz Pyloroplasty 223

153. Relations of the Posterior Abdominal Wall (Colors) facing 226

154. Mobilization of the Second Portion of the Duodenum 228

155. Finney's Gastroduodenostomy; Showing Application of Clamps 229

136. Finney's Gastroduodenostomy; First Seromuscular Suture 230

157. Finney's Gastroduodenostomy; Inner Continuous Through-and-through Suture 231

158. Finney's Gastroduodenostomy; Cross Section before Operation 232

159. Finney's Gastroduodenostomy; Cross Section after Operation 232

160. Kocher's Gastroduodenostomy 231;

161. Relations of the Great Omentum and the Stomach (Colors) facing 238

162. The Great Omentum Turned Up Exposing the Small Intestines (Colors) . .facing 238

LIST OF ILLUSTRATIONS 1 5

FIGURE PAGE

163. Transverse Colon Lifted Up Over the Thorax (Colors) lacing 238

164. The Small Intestine Cut Off (Colors) facing 238

165. Posterior Gastroenterostomy; Clamps Applied 239

166. Posterior Gastroenterostomy; Inner Through-and-through Suture 242

167. Posterior Gastroenterostomy; Completed 243

168. Gastroenterostomy; Cross Section 245

169. Diagram, Anterior Gastroenterostomy 247

170. The Blood Supply of the Stomach (Colors) 251

171. The Lymphatic Drainage of the Stomach, to Illustrate Cuneo's Division into

Territories (Colors) 253

172. Relations Around the Head of the Pancreas (Colors) facing 258

173. Pylorectomy; Showing Gastric and Pyloric Arteries Tied and Cut 259

174. Pylorectomy, Showing Section of Duodenum Between Clamps, Distal End

Partly Closed in 261

175. Sound Introduced Through the Foramen of Winslow (Colors) facing 264

176. Gastrocolic Omentum Cut and Stomach Lifted; Exposing the Lesser Peritoneal

Cavity (Colors) facing 264

177. Pylorectomy; Showing Extension of Growth 265

178. Pylorectomy; Showing Method of Holding the Scissors 266

179. Pylorectomy; Showing Distal End of Duodenum Wholly Closed in 267

180. Resection of the Middle Portion of the Stomach; Showing Harrington's Straight

Clamps in Position 271

181. Resection of the Middle Portion of the Stomach; Showing End-to-end Anasto-

mosis after Resection 273

182. Resection of the Middle Portion of the Stomach; Showing Suture Completed. . . 275

183. Resection of an Ulcer on the Lesser Curvature; Showing Clamps and Vessels Tied 277

184. Resection of an Ulcer on the Lesser Curvature; Showing Posterior Edges of

Wound Approximated 279

185. Gastroplasty for Hour-glass Stomach 281

186. Gastroplasty 283

187. Gastrogastrostomy for Hour-glass Stomach 285

188. Gastroplication ; Showing Method of Placing the Stitches 287

189. Gastroplication; Showing Anterior Wall Plaited 289

190. Gastroplication; Cross Section 291

THE

TECHNIC OF OPERATIONS

UPON THE

INTESTINES AND THE STOMACH

Chapter I. The Repair Of Intestinal Wounds

THE STRUCTURE OF THE INTESTINES AND OF THE STOMACH.— THE BLOOD- VESSELS OF THE INTESTINES AND OF THE STOMACH.— THE LYMPH- VESSELS OF THE INTESTINES AND OF THE STOMACH.— EXPERIMENTAL RESEARCH ON REPAIR.

THE STRUCTURE OF THE INTESTINES AND OF THE STOMACH.

(Figs, i and 2.)

In order to understand the repair of intestinal wounds, a knowledge of the histology of the gastrointestinal canal is necessary. A brief description of the histology of these organs is given below, which has been taken, chiefly, from Stohr 1 and Piersol. 2

The stomach and the small and the large intestines are composed of four coats, the serous, the muscular, the submucous, and the mucous. Although the characteristics of the individual layers change somewhat according to the digestive functions which they are required to perform, these variations are not of importance in the process of repair.

The external, or serous, coat is derived from the peritoneum, and "consists, principally, of fibrous connective tissue and numerous elastic networks; the free surface is covered by a simple layer of flat polygonal cells" (Stohr).

1 Stohr. Text-Book of Histology, p. 162. 3 Piersol. Normal Histology, p. 174.

i8

INTESTINAL AND GASTRIC OPERATIONS.

The muscular coat consists of a thick inner circular layer, and a thin outer longitudinal layer. In the stomach the arrangement is varied by the addition of a third layer of oblique fibers, which is derived from the esophagus. In the colon the longitudinal muscle-fibers are collected mainly

.Mucosa,.

Mascularls \ Mucosae.

} ouhmucosa-.

1 Inner circular layer of Mhele

longitudinal layer of muscle.

J Serosa-.

Fig. i. — Transverse Section oy Human Stomach. X 16. (After Stohr.)

Mucosa.

\ ouh/nuxosa.

I \ Inner circular \ Outer lo)iyitu.dinjLL

Fig. 2.

} Serosa,.

-Longitudinal Section or Human Jejunum, x 16. (After Stohr. 1 into three flat bands which are placed on the mesenteric, the anterior, and the inner borders of this portion of the large intestine.

The submucous coat is composed of loosely united connective tissuebundles, and elastic fibers, and occasionally contains small clusters of fat cells.

THE REPAIR OF INTESTINAL WOUNDS. Ig

The internal, or mucous, coat is soft, highly vascular, and covered with epithelium which varies markedly according to its situation in the digestive tube. In it are placed the glandular elements which take part in the digestive process. The glandular layer of the mucous membrane is separated from the submucosa by two thin layers of smooth muscle-fibers called the muscularis mucosa, and, from this layer, other muscle-fibers are given off which interlace among the glands of the mucous layer proper. The muscularis mucosas achieves its great importance from its tough structure, which is peculiarly adapted to resist the pull of a stitch. It is the only portion of the intestinal wall which has this valuable quality.

THE BLOOD-VESSELS OF THE INTESTINE AND OF THE STOMACH. 1

The blood-vessels of the stomach and of the large intestine have a precisely similar distribution, which is modified in the small intestine by the presence of the villi.

Upon entering the serosa of the stomach and of the large intestine the arteries give off small branches to the serosa, thence, piercing the muscularis, which they also supply, they pass to the submucosa to form a network which is placed within this layer parallel to the surface of the bowel. In the healing of intestinal wounds it will be seen later that the vessels which take the most active part in the process arise from the submucosa.

The small branches which arise from the submucous plexus ascend through the mucous membrane and from another network in the tunica ■propria at the base of the glands. The gland-tubules and crypts are supplied from this plexus.

The vessels of the small intestine which supply the crypts are distributed in the same manner as in the large intestine. The vessels are otherwise changed to adapt themselves to the special anatomy of the small intestine, — i. e., villi, glands of Brunner, lymph-nodes, etc.

THE LYMPH-VESSELS OF THE INTESTINES AND OF THE STOMACH. 2

The lymph-vessels of the stomach and of the large intestine take their origin in the mucous membrane as blind capillaries, and descend between

1 Stohr. Text-Book of Histology, p. 168.

2 Stohr. Text-Book of Histology, p. 169.

the gland-follicles. In the mucous membrane of the small intestine the lymph-vessels begin in the axes of the villi. All these vessels descend and join in a capillary plexus lying at the base of the glands. This plexus extends parallel to the surface and communicates by numerous anastomoses with a wide-meshed plexus in the submucosa. Proceeding from this network, the lymph-vessels penetrate the muscular coat, receiving tributaries from the plexus situated between the circular and the longitudinal muscular strata, the so-called intramuscular lymphatic plexus, which receives the lymph supply from both muscular layers. The vessels run beneath the serous coat to the mesenteric border, and pass on between its layers.

EXPERIMENTAL RESEARCH ON REPAIR.

The study of repair which follows was done with Dr. F. B. Harrington in the Laboratory of Surgical Pathology at Harvard Medical School. 1 The data was obtained from three sources:

(i) A series of twenty-two experiments upon fourteen dogs and four cats. In these animals the anastomoses were made with the assistance of the Harrington segmented ring.

(2) A series of experiments upon ten cats and three dogs. These experiments were not done primarily for the study of repair, but had in view the working out of certain technic in the operation of gastroenterostomy. These experiments were done without the aid of a mechanical device. Specimens taken from these animals were used for comparison with the first series.

(3) Sections of anastomoses done on human beings, kindly furnished by Dr. Nichols.

EXPERIMENTS WITH THE SEGMENTED RING.

The technic for introducing the ring and performing the anastomosis is briefly as follows:

(1) The cut bowel-ends are fastened over the ring by means of soluble purse-string sutures. These sutures perform the double duty of attaching the bowels to the ring, thus facilitating the introduction of the mesenteric

1 Harrington and Gould. Annals of Surgery, November, 1904.

THE REPAIR OF INTESTINAL WOUNDS.

and the peritoneal stitches, as well as of holding the segments of the ring together during the first four or five days succeeding the operation.

(2) The Maunsell mattress-mesenteric stitch is used to bring together the mesenteric borders, after tying the purse-strings.

(3) The peritoneum is approximated with a continuous Cushing right-angle suture. The suture material used for the purse-strings was No. 2 plain catgut; for the mattress-mesenteric stitch, No. 1 chromic catgut; for the Cushing right-angle stitch, No. 1 Pagenstecher's celloidin linen thread. A complete illustrated description of the three stitches mentioned above is to be found in Chapter II.

TABLE OF EXPERIMENTS WITH THE SEGMENTED RING.

End-to-end intestinal anastomoses 8

Lateral intestinal anastomoses 3

Gastrointestinal anastomoses 7

— 18 Gastrogastrostomies 4

End-to-end. (Dogs.)

Time Exp. elapsed after operation.

i day i day 3 days 7 days

7 days

8 days 14 days 42 days

Condition of suture at autopsy.

Slough of suture, too large ring 1

Segments found.

At site of suture.

At site of suture.

At site of suture.

Ileum.

Two in ileum, two in rectum.

Ileum and rectum.

Not found (passed).

Not found (passed).

S days 10 months 12 months

Intact Still alive Still alive

Lateral Intestinal. (Dogs.)

Near suture.

3 days 7 days 7 days 10 days 12 days 14 days 21 days

Gastroenterostomies. (Dogs.)

Intact Three in pylorus (stomach), one in small

Intact Ileum. [intestine.

Intact Ileum.

Intact Rectum.

Intact Large intestine and rectum.

Intact Three in large intestine and rectum.

Intact Not found (passed).

1 The intestine in this case was so stretched over the ring that it was anaemic. As it was an early case, the importance of breaking down the ring under such circumstances was not recognized.

INTESTINAL AND GASTRIC OPERATIONS.

Gasteogasteostomies. (Cats.) To determine how long ring remains in situ.