position. In other words, the right forcep is the one having the teeth on the right side when held in an inverted position. This forcep is made to grasp the edge of the gut on the operator's right. When the edge of the opposing gut is similarly grasped by the left forcep, each forcep is rotated toward the other, describing a half circle. This motion inverts the edges of each gut, and now, by placing the two forceps together, the peritoneal surfaces are brought in direct contact, and, by holding both forceps with the left hand, the thumb resting on the top, the gut is held in accurate apposition, while the peritoneal surfaces are quickly sutured with a continuous Lembert suture followed by a second row if desired. The forceps are now released and placed further on, grasping the next section to be sutured and the suture may be continued without interruption, grasping new tissue, section by section, until the entire surfaces are united, save a small hole from which the forceps are withdrawn.

This, however, is of little forceps can be changed in When the wound is so near

In the case of anastomosis of small intestines, the forceps are not disturbed more than once or twice. importance, since the position of the considerably less than sixty seconds. closed that there is room only for the exit of the forceps, the edges naturally fall together and may be held between the thumb and finger while the suture is completed.

The writer prefers to make the suture doubly secure against leakage by re-enforcing it with a second row of Lembert sutures, which is now easily and quickly applied. Fine braided silk, threaded through a cambric needle, is most desirable. When the element of time is not of extreme importance, the lateral anastomosis of Abbe is preferable for the small intestines. However, endto-end anastomosis by suture is quickly and easily done by this simple mechanical aid.

No surgeon should undertake to do intestinal surgery until he has practiced the Lembert suture enough on the cadaver to be able to close a wound of the intestinal canal with such accuracy that it will not leak when tested by water or air pressure from within.

When he has accomplished this, he can, with the assistance of the forceps above described, quickly and safely unite by suture any part of the alimentary canal from the diaphragm to a point considerably below the brim of the pelvis.

For the writer's intestinal forceps and the Lembert suture, the following advantages are claimed: (1) Simplicity; (2) perfect inversion of edges, and absolute control of the tissues to be united; (3) the tissues can be held by one hand of the operator while being sutured without assistance if necessary; (4) by grasping the intestinal edges close to the border with the serrated edge of the forceps, a minimum amount of diaphragm formation is secured; (5) success is not dependent upon a slough; (6) no danger from any foreign substance left in the lumen of the gut; (7) rapidity and accuracy with which intestinal suture may be accomplished by any surgeon of moderate skill; (8) with properly placed sutures there is no danger of leakage; (9) they are highly useful in Abbe's lateral anastomosis of the intestines, which is an ideal method in nearly all intestinal cases where a few minutes' additional time is not of extreme importance; (10) their universal application to operations upon the stomach, small intestines, colon, gall and urinary bladder.

The use of my instruments is illustrated by the following case: N. J. N., married woman, age 46, Norwegian, came to Temple November 17, 1902, diagnosis of pyloric stenosis with dilatation of the stomach having been made during the previous week by my friend Dr. J. W. McLaughlin of Galveston. The patient gave a history of having suffered very greatly from some trouble which was manifested by dyspeptic symptoms, frequent vomiting and pain, beginning about twelve years ago and having then lasted with more or less severity for a period of nearly three years. Evidence obtained upon physical examination corroborated the diagnosis of Dr. McLaughlin. The patient was extremely emaciated and weighed only about eighty-five pounds. During the six months prior to her admission into the hospital she had suffered intensely at frequent intervals from attacks of vomiting, accompanied by

pain and a great deal of gaseous distention of the stomach. These attacks had become so frequent that the patient appeared to be gradually starving to death. The patient was prepared for operation within a few days after admission into the hospital. An hour prior to the operation the stomach was well irrigated with solution of P., D. & Co.'s acetozone. By an incision four inches long in the median line, the stomach was soon exposed and inverted upon the epigastrium. An incision about three inches long was made in the posterior side of the stomach, through which the pylorous was readily examined with the index finger. The pylorous was found to be surrounded by a great deal of firm cicatrical tissue, and appeared to be almost if not entirely closed. It was at once determined to make a posterior gastro-enterostomy; accordingly a loop of the jejunum nearest the duodenum was picked up and drawn out through the abdominal opening. It was inverted in such a way as to leave it in its normal position, when ready to be returned with the stomach into the abdomen. Having sutured the jejunum with a double row of sutures to one border of the incision in the stomach, an incision was now made in the jejunum corresponding in length with that in the stomach wall and located very near the line of double sutures. The free margin of the intestine was now grasped by a pair of the writer's forceps described above, the free edge of the stomach was similarly grasped by the other forceps, and after proper rotation the double row of sutures above referred to was continued from one end until the other end was reached. The exposed stomach and intestines were then rinsed with normal salt solution and carefully dried with sponges, after which they were returned to the abdomen and the incision was closed. The patient vomited freely during the first twenty-four hours and two or three times during the first three succeeding days. She was sustained wholly by nutrient enemata for about seven days, after which she was kept upon liquid diet for three or four days, and she was then permitted to eat beefsteak, toast, light bread, rice, eggs, etc. The patient was dismissed from the hospital December 18th, with request to report in thirty

days. At the end of that time she presented herself at the office and gave a most satisfactory history of having been able to eat and digest with perfect comfort most anything she might fancy, and, as evidence of proper digestion, she had gained fifteen pounds during the first thirty days. The writer has heard from the patient within the last few days, and is pleased to note that she is enjoying excellent health, with the exception of a little rheumatism, which has recently affected one or two of her joints.

DISCUSSION.

DR. W. R. BLAILOCK, Dallas: My friend Dr. Scott is very ingenious in devising instruments. I will not attempt to rehearse the large number of instruments that he has invented that I know of, but shall confine my remarks to this one. I believe that in both end-to-end and lateral anastomosis, simplicity should be the governing principle. While this instrument is very ingenious, I do not think it simplifies, but rather complicates, the operation. It seems to me that he has sacrificed the simplicity which modern surgery demands. Now, from the incision which you must make in this operation, it seems to me that you run great risk of infecting the peritoneal cavity. We know that all that is necessary is a couple of little stitches, and these stitches will hold the ends in position as nicely as these forceps could possibly do. Then precisely the same suturing that is accomplished with this instrument is done. I am sure that this operation can be done in a shorter time by means of the Connell suture, and with less pressing on the tissues than would be the case with these instruments. I think these instrument would be quite awkward to the average operator in attempting an end-to-end anastomosis. With this instrument, you can only take hold of a portion of the gut, and, after this is stitched, must remove the forceps and take hold of a new portion; and I am inclined to think that this complicates the operation, at the same time increasing the danger of infection. I dislike to differ with my good friend Dr. Scott, because I know him to be very ingenious, but I can not avoid the conclusion that he has deviated from the simplicity which is the ideal of modern surgery.

DR. M. SMITH, Sulphur Springs: I was very much interested in this paper. I think with Dr. Blailock that the instrument displays a great deal of ingeniousness. These forceps, I think, will add largely to the usefulness of intestinal surgery. I haven't done a great deal of intestinal surgery in the living human being, but I have done a great deal of that in my dog work. I have done the various forms of anastomosis on dogs, and I think

that that is the place to begin. In experiments with the Connell suture, four out of my first five dogs lived. The first dog I operated on died. Now a very important point, sometimes, is as to which can be most advantageously used by the average man, the Connell suture or the Murphy button? If I were in a hurry, I would use the Murphy button. If I had plenty of time, I would make an end-to-end anastomosis. I saw Murphy apply his button in Chicago. He removed fourteen inches of the ileum, and adjusted the guts with his button. He did the operation in a very short time. He extended to me the courtesy of seeing this case occasionally. On the fifteenth day he brought up the case, and she said, "Doctor, here is the button." The doctor said that he usually had to keep the patient under morphine, or something similar, until the button is passed. They had just given her a grain of morphine during the twenty-four hours preceding the passing of the button. In the Connell suture, you do not have this trouble.

DR. BACON SAUNDERS, Fort Worth: The whole question of method is one that you must study out and become expert in its use. When you become expert in the use of some method, you will get good results in its use, and these remarks are meant to apply also to end-to-end anastomosis. DR. J. M. FRAZIER, Belton: I had the pleasure of seeing this operation. It is not only a beautiful theory, it is practical. It made a very fine impression upon my mind as being one of the very best methods of intestinal anastomosis. It is a very practicable instrument, in my opinion. The result demonstrates that it is a very successful thing in surgery.