wound, and pass a sponge into its lumen to prevent the escape of any matter. Suture the cut edges of the intestine and of the skin together, by means of the continuous suture.

If a fistula is to be established with enterectomy, the enterectomy may first be performed, and the two ends of the intestine brought to the abdominal wound. The lower end is sutured by means of the quilt suture to one side-wall of the wound, with its end flush with the integument. The upper end must be sutured as after enterotomy, no regard being paid to the presence of the lower end.

The lumen of the lower end may be closed by the Czerny-Lembert suture, and the end then allowed to remain free in the abdominal cavity.

COLECTOMY.

Follow the same rules given for the performance of enterectomy. It is best to establish a fecal fistula by attaching the upper end of the gut to the wound, the lower end being returned into the abdominal cavity after closing its lumen by the Czerny-Lembert suture. Colotomy is governed by the same rules as those for enterotomy.

LUMBAR COLOSTOMY.

This operation may be performed either on the right side into the ascending colon, or on the left side into the descending colon.

Place the subject midway between the side and prone positions, with a block under the loin to render tense and prominent the site of the operation.

Bisect a line joining the anterior and posterior superior spinous processes of the ilium, and one half

inch posterior to this point erect a perpendicular extending to the last rib.

Make an incision about four inches long, having the median point of the perpendicular line as its median point. This incision should extend downward and forward parallel to the last rib. Divide the integument and fascia, the outer edge of the latissi mus-dorsi muscle, and the posterior free edge of the external oblique muscle. Divide the internal oblique and transversalis muscles, and expose the external borders of the erector spine and quadratus lumborum muscles. Divide the transversalis fascia, and expose the areolar tissue lying posterior to the colon.

Retract toward the spine the quadratus lumborum muscle. Tease through the areolar tissue, and above feel the lower rounded end of the kidney.

Inflate the colon by forcing air by the anus through the rectum. The colon is felt immediately below and in front of the lower end of the kidney.

Divide slightly the outer border of the quadratus lumborum muscle. Tease through the areolar tissue until the colon is uncovered.

Draw up into the wound by means of forceps the posterior and inner wall of the colon. One inch from each angle of the wound pass a ligature deeply through the tissues to corresponding points on the other side of the wound. These ligatures will pierce the portion of gut engaged in the wound. Make a longitudinal opening, about one inch long, into the lumen of the gut. Hook up the ligatures as they traverse the lumen of the intestine and divide them, thus making four sutures. Secure these sutures, which will prevent the gut from receding.

Insert a sponge into the lumen of the intestine, and stitch the edges of the intestinal opening to the integument on each side of the wound. Appose the angles of the wound by sutures.

If the peritoneal cavity is opened, stitch the peritoneal wound, providing for drainage, and bring the abdominal wound together. The operation should be tried in the opposite loin. The ascending more often than the descending colon is attached to the abdominal parietes by a meso-colon.

The incision for colostomy, when prolonged into the quadratus lumborum muscle until the finger can touch the transverse process of a lumbar vertebra, is to be recommended in opening a psoas abscess. Tease a way with the finger along the anterior surface of the transverse process, where an opening into the sheath of the psoas muscle can be made.

NEPHRORRHAPHY.

Place the subject in the same position as for lumbar colostomy.

Make an incision, parallel and similar to that for lumbar colostomy, one inch nearer the lower border of the twelfth rib. The tissues are divided, and the fat enveloping the kidney teased through to expose the posterior surface of the capsule.

Press on the abdominal wall to engage the kidney in the wound. Divide on a director the capsule of the kidney and strip it from the organ to the extent of one half of an inch or more. Draw upon the capsule and stitch it to the sides of the wound.

Leave the wound open.

NEPHROTOMY.

Expose the posterior surface of the kidney as in the last operation.

Cut through the cortical substance as if to expose a calculus. The location of the incision is determined by systematic search with the exploring needle.

The pelvis of the kidney should be explored by dividing the organ parallel to the Malpighian pyramids.

NEPHRECTOMY.

Expose the kidney. Separate by means of the fingers the kidney from the surrounding areolar tissue. Separate the ureter from the vessels. With an aneurism-needle pass a ligature around the vessels and ligate them a little distance from the kidney. Divide the vessels distal to the ligature, and remove the kidney still attached to the ureter. Divide the ureter near the pelvis of the kidney. Invert the edges and close the caliber of the ureter by stitches, after which it can be returned into the wound. Ligate separately the vessels in the pedicle. Provide drainage, and

close the wound.

After the vessels are ligated, the kidney may be removed in halves if it is enlarged.

SYMPHYSIOTOMY.

Place the subject on the back. Shave the hair from over the pubes. Distend the bladder. Stand on the right-hand side of the patient.

Make an incision in the median line of the body from a point one inch above the upper margin to the level of the lower margin of the symphysis pubis.

Divide the integument and fascia above and all the tissues over the symphysis. By means of a periosteal elevator push aside the tissues on each side of the incision over the symphysis, clearing the bones to the extent of one half of an inch. Separate the pyramidales and recti muscles at their junction in the median line.

Evacuate the bladder. With the fingers clear the attachments above, behind, and below the symphysis pubis. Pass a chain-saw behind the symphysis. Protect the tissues behind and below by means of spatulæ while the symphysis is sawn through.

The diameters of the pelvis may be increased or the anterior vesical wall uncovered by separating the pubic bones.

The ligaments joining the ilia to the spinal column are stretched or partially ruptured when the pubic bones are drawn apart.

To close the wound, the pubic bones are to be wired, drainage provided, and the wound stitched (see Chapter IX).