BY DR. LAUDER BRUNTON. 523 



so, the bundle of mesenteric vessels leading to the part con- 

 stricted by the ligature must be compressed between the finger 

 and thumb, while the constricted part is cut off. As it is 

 necessary that the serous surfaces should be in apposition, 

 the mucous membrane, which is turned outwards by the con- 

 traction of the muscular coat, must be first turned inwards, 

 and the closure affected by sutures, applied as shown in fig. 



318. The closed end is then replaced in the abdomen, and the 

 continuity of the intestine again restored by joining the cut 

 ends of the duodenum and jejunum. In doing this, the two 

 ligatures, with the parts constricted by them, must be cut off 

 in the manner previously directed. The ligatures applied to 

 the vessels should include a little of the adjoining intestinal 

 wall, so as to give them a firmer hold. The two cut ends are 

 now brought into apposition, and the ligatures firmly tied to- 

 gether so as to retain the ends in their proper relation, and 

 held in the hand of an assistant The first stitch is put through 

 the intestines in such a way as to include both bundles of ves- 

 sels, and should be drawn very tight and tied, so that it not 

 only unites the ends, but serves as an additional ligature for 

 the vessels. 



To prevent the ligature from cutting the intestine, it should 

 either be made of very thick soft silk, or of two or three fine 

 ligatures used together. Five or six similar stitches made at 

 a little distance from each other on each side of the first are 

 sufficient to join the mesenteric edge of the two pieces of in- 

 testine, which then lie with their axes parallel (fig. 318). To 

 complete the junction, the two ends must be brought into the 

 same straight line and sewn together. The application of the 

 final sutures is a matter of considerable difficulty, principally* 

 on account of the tendency of the mucous membrane to become 

 everted. The mode of applying the sutures so as to accomplish 

 this object, will be at once understood by a reference to fig. 



319. Several threads, each with a needle at each end, must be 

 prepared. For the first suture, one needle enters the intestine 

 from its serous aspect at a, and is brought out at 6, the other 

 enters at a', and is brought out at &'. The two ends, b and &', 

 are drawn tight and knotted together. For the second suture, 

 one needle enters at 6, and is brought out at c, the other enters 

 at &', and is brought out at c f ', and so on. To conclude the 

 operation, the wound in the abdominal wall is brought together 

 by sutures, and the open end of the cul-de-sac sewn into it. 

 It is also desirable that the junction of the divided intestine 

 should be secured to the wound by a suture, in order to pre- 

 vent the induction of general peritonitis by its locomotion. 



** 174. Artificial Intestinal Juice. Remove the small 

 intestine from a pig, dog, or rabbit, as soon after death as 

 possible ; put a ligature round its upper end, attach the lower 



