certainly, aside from the time it requires, a valuable adjunct, as it serves to protect the Lembert stitches by keeping the intestinal contents away from them. When this suture is made with the Kürschner stitch for the first row it does not require much time.

Gussen hamer then thought of doing this all with one suture and made his figure-of-eight stitch (Fig. 5). This is an ingenious but complicated suture, and has the objection that should the lower portion ulcerate through, the whole stitch would become loosened and thus give rise to the escape of intestinal contents.

The Kürschner suture is a continuous one and (Fig. 6) is nade by tying the firs stitch and then proceeding as with any continuous suture, puncturing the intestine from within outwards, and fastening the whole when completed with a seamstress's knot. This is a very rapid and simple suture and closes the wound nicely. Nussbaum prefers it to all others, and says: "The simple interrupted suture like Lembert's is very much harder to make, the needle must be laid aside ten or twenty tines and the scissors taken in hand, while with the Kürschner suture this need be done but twice."

Fig. 6. The remaining methods of intestinal suture which I am to describe are of very recent date, and Lave been used altogether for uniting the ends of resected intestines.

First, we have the method of Neuber used in operating for the cure of artificial anus and made as follows: A circumscribing incision was made through the skin about the anal orifices. The skin was then dissected away from the fascia beneath, and the edges of the flaps thus formed united with a continuous suture so as to prevent the escape of intestinal contents. The ends of the intestine were then loosened and brought down (Fig. 7). The abdominal wound was now closed by provisional sutures, as recommended by Madelung, so that just enough room remained for the ends of the intestine drawn through the wound (Fig. 8). The intestine thus constricted closed the abdominal wound, and prevented the entrance of fecal matter into the field of operation. The bowel was now held by digital compression, and, after removing a sufficiently large piece of mesentery and tying the bleeding vessels, the ends were cut squarely off (Fig. 8). Neuber now sutured the ends of the bowel together over a piece of decalcified bone tube.

This tube was about two cm. in diameter, and turned so as to bulge in the central portion and have a deep groove in the middle line (Fig. 9). The sutures were made as follows: First, before inserting the tube, the ends of the bowel were united by two or three interrupted sutures, taken at the mesenteric insertion. The tube was then inserted

and the ends of the bowel drawn closely together over it. The ends were now united by a number of Lembert stitches (Fig. 10 a). The intestine was then drawn down into the groove by means of a constricting "suture" or ligature (Figs. 10 b and 9), and finally, in order to get a most exact union of serous surfaces, still another row of interruped Lembert stitches was taken about one cm. apart (Fig. 10 c and Fig. 9). Thus finally (Fig. 10 e and Fig. 9) there was, in the

Fig. 9.

depths of the groove the first row of interrupted sutures, then the constricting "suture" or ligature, and finally an outer row of interrupted sutures.

As advantages of this method Neuber claims, first, the ease with

which it is performed, it being much easier to sew upon a firm foundation than otherwise. Secondly, the wound of the intestine is protected by the tube from contact with the intestinal contents. Neuber, to obtain the best possible asepsis, powdered a little iodoform into the groove. Thirdly, the tube maintains a free passage for the intestinal contents, which is not always the case with some of the other methods, where at times the collection of fæcal matter above the wound owing to more or less stenosis forms a serious and even fatal complication.

b

Fig, 10.

The intestine has been united in this manner after resection at the Kiel clinic three times, twice by Neuber and once by Schlange, and each time with success. Experiments upon animals have shown that after from four or five days the decalcified tube disappears. In the cases at the Kiel clinic careful examinations of the dejections failed to give any trace of the tubes.

Professor Madelung, of Bonn, having in view the fact, well established in experimental pathology by Lister, Maas, Tillmans, Rosenberg and others, that pieces of living tissue or other substances, when made aseptic, could be placed in the peritoneal cavity, and there become imbedded or encapsuled, and gradually absorbed without causing suppuration, devised what he calls the cartilage-plate suture. This suture is made as follows: The costal cartilage of a young calf is first cut in thin slices, which should have about the thickness, Madelung says, "of sections made by beginners in microscopic work," and the circumference of a small lentil, from four to six millimeters. These slices are prepared in the same manner as antiseptic silk. The ends of the bowel are first united with a Kürschner suture. A No. 12 needle is now threaded so that its eye comes at the middle of the suture. The ends of the suture are then tied together in a double, or better, a treble knot. The needle is now passed through the centre of one of the cartilage-plates, and the same drawn through until the knot comes firmly against the plate. With the suture thus prepared, the needle is passed in the usual manner through the sero-muscular layer

of both ends of the bowel, and then through a second cartilageplate of the same size as the first (Fig. 11). The suture is now cut off close to the needle, and again tied in a treble knot firmly down to the second plate (Figs. 11 and 12).

With the use of this suture, Madelung claims that it is possible, with a much smaller number of stitches, to obtain sufficient contact of the serous surfaces. Circular cutting through of the tissues by the suture is here avoided. If the wound of the serous coat made by the needle is enlarged a little by drawing upon the suture, the cartilage-plate will cover in this opening. Madelung hopes that his suture will not be looked upon as too complicated, and affirms that it is simple and practical in its application.

Mr. Bishop, of Manchester, England, has recently devised a very ingenious suture, a full and illustrated description of which will be found in last year's January number of "Braithwaite's Retrospect." This suture is unnecessarily complicated, and presents no particular advantages. Besides, being made in a single row, it should not

involve the mucous coat, which it does. It has only been used in experimental operations.

So much for the different methods of suturing the intestine. From the first Lembert suture made with the single interrupted stitch, down to the most recent of the after-coming methods, which I believe to be those of Neuber and Madelung, all have been sufficient to secure, with varying frequency of success, union of the ends of a divided intestine, or the edges of transverse and longitudinal intestinal wounds. No method has yet been devised which stands preeminently above all others. That one is the best which secures and maintains the most perfect and undisturbed contact of the serous surfaces with the least reduction of the intestinal calibre, and it will be a matter of personal choice and experience in deciding which one best answers these requirements.

The various forms of intestinal suture may be applied to any part of the alimentary tract from the oesophagus downwards, but their most frequent application comes after resection of the pylorus, or some part of the large or small intestine. This may be for the cure of (1) anus-preternaturalis or fæcal fistula; (2) gangrene following incarcerated hernia or intussusception; (3) malignant growths; (4) where adhesions to an abdominal tumor are so firm as to necessitate removal of a portion of the intestine or ligature of its bloodsupply; and (5) stricture due to ulceration or other causes. Recently a new application has been found in Wölfler's operation of gastroenterostomy, a procedure similar to the method illustrated in the "Surgical History of the War of the Rebellion," for uniting two simultaneously-wounded knuckles of intestine, with Gely's suture. Wölfler's operation, suggested to him by Nicoladoni, during a pylorus resection, where, on account of too extensive disease, the pylorus could not be removed, consisted in taking the loop of small intestine nearest the stomach, and, after making a longitudinal opening in it, and a corresponding one in the stomach, a finger's breadth above the gastro-colic ligament, uniting the two by sutures, this being done instead of forming an intestinal fistula.

Let us now consider in detail the manner of making the intestinal suture. As there are now very few cases of intestinal lesion, which, if they lead to suture at all, would not be best treated by total resection of the affected portion, I will speak of the suture as applied in the latter operation. It is to be hoped that it is no longer