CHOICE OF METHOD.—Various posi tions for anastomosis have been advised by different surgeons, some preferring end-to-end, others end-to-side, and still others side-to-side junction. There is nothing to prove that lateral approxima tion is more successful in its immediate or remote results than end-to-end junc tion, and a good deal of time must be given to the closure of the free ends in case side-to-side anastomosis is per formed; this time is superadded to the methods of end-to-end junction. End to-side junction is the natural and pref erable method of joining the small bowel to the large bowel, and may be also used in case there is great contraction above the line of resection with enormous dis tension below. Lateral anastomosis is probably preferable to end-to-side anas tomosis in most cases in which consider able difference exists in the calibre of the proximal and distal ends of the same kind of intestine. Other factors which are considered by some surgeons to be of considerable advantage in lateral anas tomosis are that larger serous surfaces are opposed, giving greater likelihood of rapid and firm union and that there is less danger of stenosis at the site of anas tomosis resulting from this method.
Most surgeons consider the method of suturing without leaving mechanical de vices in the intestine the preferable one for the majority of eases. The use of Laplace's anastomotie forceps greatly facilitates the accurate and rapid inser tion of intestinal sutures, if it seems necessary to complete the operation with the least possible loss of time because of the weakened or collapsed condition of the patient. In certain cases in which union by suture would be inconvenient or impossible, junction by means of Murphy's button is the most rapid and convenient method. When lateral anas tomosis is considered desirable many surgeons prefer to accomplish it by the use of Senn's decalcified-bone plates or by some of the catgut rings, cartilage, turnip, or potato disks which have been devised as a substitute for them.
Enterotomy and Enterostomy.—"En terotomy" is the term used to designate the operation of making an opening into the bowel through which its contents may be discharged or temporary access to its interior is gained. The name should be retained for incision and evacuation of the intestinal contents with immediate or early closure of the opening. When the opening is kept
patent for a considerable length of time "enterostomy" is the better term. These names may be applied to operations in any part of the intestinal tract, but the names colotomy and colostomy are gen erally used when the operation is per formed on the colon.
— These operations are practically always performed for the re lief of some form of acute or chronic intestinal obstruction. They may be performed in cases in which there is danger of death from great intestinal distension, vomiting, or toxin poisoning, without relieving the source of obstruc tion. In other cases in which the cause of obstruction has been removed, the operation may be desirable because of the great intestinal distension. It may also be performed if there is doubt as to the vitality of the intestine. In malig nant disease it is often inadvisable to move the growth, hut necessary to re lieve the obstruction, and in some cases the operation is desirable to prevent the irritation of faeces passing over the growth, or the haemorrhage which occa sionally results from this source. As a curative measure colostomy has been performed in cases of simple ulceration of the rectum in which other means have failed. It has also been performed for the relief of excessive distension arising from atony of the walls of the intestine and for the cure of recto-vesical fistula. In case of imperforate anus the opera tion is indicated, provided it is impos sible to open the bowel from below.
OPERATIox.—The parietal incision is made over the obstruction. or as nearly so as possible. The intestinal coil is drawn through the wound and isolated by packing. In case of urgent necessity a simple incision about an inch in length is made at the free border of the gut. after sewing it in the abdominal wound to prevent peritoneal infection. If a case is not urgent, it is desirable to wait twelve hours or more in order that firm adhesions may form. If it is desired to make permanent drainage. a rod of some smooth aseptic material may be passed through the mesentery resting on the ab dominal wall, as in Mavdl's operation.