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posed. Separate the upper and internal connections of the gland.

Grasp the gland and draw it outward. Throw a ligature around the external connections, and sever the tissue distal to the ligature.

Extend the incision upward and outward to the middle of the axilla Tease out and separate by means of the fingers the stump of the gland, the areolar tissue along the inferior border of the pectoralis major, and in the whole of the axillary space.

If in the upper part of the axillary space any attachments require cutting, they must first be ligatured and then cut on the distal side of the ligature.

The axillary vessels are situated in the anterior third of this space. In the operation branches of the long and alar thoracic, intercostals, and internal mammary arteries are divided.

Puncture the lower flap through its most dependent part. Provide for drainage through this puncture and through the inner angle of the wound.

Suture the flaps together, using sutures of relaxation if there is any tension.

MEDIAN LAPAROTOMY.

Place the subject on the back. Evacuate the bladder. Stand on the right side, facing the abdo

men.

Make an incision with a scalpel in the median line of the abdomen from just below the umbilicus to a point about an inch above the symphysis pubis. Divide the integument and fascia to bring into view the linea alba. Cut in the linea alba, through its fibrous tissue and the underlying transversalis fascia, until the areolar tissue over the peritoneum is uncov. ered. Tease through this areolar tissue, or divide it on a director. Catch up very superficially the peritonæum and nick it near the end of the forceps. With a second pair of forceps seize the opposite side of the small opening, and tear it large enough to admit the finger.

Introduce the left index-finger, and apply its palmar surface to the peritonæum in the line of the incision. Introduce a probe-pointed bistoury flatwise along the palmar surface of the finger. Turn its cutting edge forward and divide the peritonæum.

The further division of the peritoneum is best made with a probe-pointed bistoury, cutting between the left index and middle fingers, which draw it forward and at the same time prevent the intestines slipping in front of the knife.

If the incision is not large enough, it must be prolonged upward. Divide the integument and fascia in the median line, avoiding the umbilicus by a curved incision around its left semi-circumference. The incision can now be completed by dividing the peritonæum and the remaining undivided tissues between the index and middle fingers in the manner described.

The contents of the peritoneal cavity are all accessible, and can be examined. To close the wound, bring together the divided peritoneum, apposing serous surfaces by means of the quilt or the continuous sutures. Draw together the recti muscles by means of buried sutures or silver sutures of relaxation. Provide for drainage from the superficial wound. Suture the integument and fascia, bringing them together, if necessary, by sutures of relaxation.

If the linea alba is obscure, and the sheath of the rectus is opened, remember that posteriorly, about midway between the umbilicus and the pubes, the sheath ends inferiorly in the semilunar fold of Douglas.

ENTERORRHAPHY.

Prepare the subject by stabbing through the abdominal wall or shooting with a revolver to wound the intestine.

Expose the abdominal contents by means of median laparotomy.

The different sutures considered in Chapter III for wounded intestine may be practiced to close the wounds.

Enterorrhaphy may be employed in cases where it does not reduce the caliber of the gut to less than one half of its normal size.

ENTERECTOMY.

Expose the abdominal contents by median laparotomy.

Remove the part to be operated upon out of the peritoneal cavity. Apply intestinal pincers two inches below the line of the proposed lower division of the intestine. Strip the intestinal contents upward and prevent their descent by applying intestinal pincers two inches above the line of the proposed upper division of the intestine. The gut to be excised, now being empty of any fecal contents, is divided by scissors.

The mesentery attached to the excised intestine may be ligated in sections near its attachment and then separated by cutting between the ligatures and

the intestine. A triangular piece of the mesentery may be removed, the base of the triangle being the border of the mesentery attached to the excised portion of intestine. The sides of the triangle are then joined by sutures.

A divided vessel may be found near the mesenteric border of the divided ends of the intestine.

Appose the ends of the intestine by means of the Jobert, Czerny-Lembert, or double interrupted suture if enterorrhaphy is proposed.

The division of the intestine may be made obliquely, and the mesenteric border of one end sutured to the free border of the other (Morris). This fulfills the requirement of good blood-supply to the ends of the gut. The division of the gut is ordinarily made near a loop of the mesenteric artery to meet this same demand.

Both ends of the intestine may be secured to the external wound, and a fecal fistula be established as is about to be described.

ENTEROTOMY.

Expose the intestines by median laparotomy.

Follow the mesentery downward to determine one of the lower loops of the small intestine. It is necessary to be guided by the mesentery, as Treves has shown that the long mesentery of the lower portion of the jejunum allows it to occupy the pelvic cavity.

Remove the loop selected for the operation from the peritoneal cavity. Open into its lumen by nicking a fold picked up by means of forceps.

Enlarge the wound by means of probe pointed

scissors, using the probe-pointed blade in the lumen of the intestine.

The wound may be closed by performing enterorrhaphy, or a fecal fistula may be established.

ENTEROSTOMY, WITH ENTEROTOMY OR ENTERECTOMY.

In this operation the loop of intestine is brought to the lower angle of the laparotomy incision, or a second opening is made in a line with the fibers of the external oblique muscle which will act slightly as a sphincter. An opening one inch and a half long through the abdominal walls is made to lead into the lumen of the gut.

After median laparotomy the loop of intestine is secured by piercing it with a ligature, both ends of which are brought out of the abdominal opening to which the gut is to be sutured.

Prevent the bulging of the intestines by inserting a sponge through the wound. Detach the peritoneum around the wound and draw it up, stitching it to the integument so that the walls of the wound will present a serous surface. Remove the sponge from the abdominal cavity and draw upon the ends of the ligature to engage the loop of gut in the wound. A quarter of an inch from the margin pass a needle into the wound through almost the entire thickness of the walls of the abdomen. Pierce a small fold of the apposed circumference of the intestine. Carry the ligature from within outward through the wall of the abdomen, and secure its ends by means of a knot. In like manner, at intervals of one quarter of an inch, stitch the intestine to the walls of the wound.

Open the intestine nearly to the extent of the

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