MULTIPLE LIGATION. 607 



united to one another, or at any rate not firmly adherent, there is 

 considerable risk of opening the peritoneal cavity when practising 

 this method. 



The simple cobbler's stitch is often recommended. A transverse 

 incision is made through the upper half of the protruded bowel, close 

 behind the anus, and the two layers of tissue in front of the incision 

 united by closely applied ligatures. The lower half is then divided 

 and the ligaturing continued until finally the protruded portion of 

 bowel is completely divided and removed. The simultaneous division 

 and ligation prevents the end of the bowel not yet firmly fixed by 

 sutures slipping back into the peritoneal cavity, and producing fatal 

 peritonitis. 



In dogs and pigs the following method can be employed. The 

 protruded piece of bowel is transfixed close behind the anus with 

 two needles arranged crosswise, and provided with two long threads 

 (Fig. 424). The prolapsed part is then cut through, about J to 

 f of an inch behind the threads, which are then drawn forward out 

 of the intestinal opening. By dividing these in the centre, one has 

 four threads (Fig. 425), which when united form four stitches, and 

 are generally sufficient. Should it be seen on cutting away the 

 posterior part of the bowel that union is still incomplete, two other 

 stitches can be inserted between each pair of those previously existing, 

 thus forming eight ligatures, which are sufficient even in large animals. 

 Savournin saw a horse in which the rectum had already become 

 necrotic, but by ligaturing it in two portions he effected complete 

 healing in twelve days. In the case of a mare, Grammlich gave 

 chloroform and then performed multiple ligation, cutting off the 

 prolapsed portion of bowel about half an inch behind the ligatures. 

 The bowels did not act naturally (i.e., without assistance) for six 

 weeks. It is scarcely necessary to add that, both in selecting the 

 ligature and in carrying out the operation and after-treatment, it 

 is necessary to practise antisepsis as far as possible. To facilitate 

 ligation Reuter recommends thrusting into the lumen of the pro- 

 lapsed bowel a conical piece of carrot, turnip, or even of soap, before 

 commencing the actual insertion of the ligatures. In swine Olivier 

 divides the prolapsed bowel in its long diameter and ligates the two 

 pieces separately. 



(4.) In old cases of prolapse, where union between the layers 

 of peritoneum is complete, and no chance exists of opening the peri- 

 toneal cavity, simple excision of the prolapsed part with suture of 

 the ends is sufficient. This method has been used in swine, but 

 caution is required ; simple or multiple ligation is greatly preferable. 



