If, after a stab wound, the parietal peritoneum alone is found incised or penetrated and there is no evidence that the organs behind have suffered injury. the tissues must be cleansed with great care and the peritoneal flaps brought to gether, the serous surfaces being kept in contact. A continuous catgut suture is used for the peritoneum: the muscles and skin are then united and the wound is closed. The measures already out lined to prevent ventral hernia are also indicated for the deeper wound.
When laparotomy becomes necessary the incision should be made in a spot affording the operator the greatest op portunity for a wide field of action, and should be sufficiently long. When performed for the arrest of dangerous limmorrhage, a long median incision will enable the surgeon to reach any organ with ease: an important factor, for the missile or blade inflicting the injury may have traversed harmlessly between sev eral coils of intestine and have caused a rent in the organ most remote from the point. of entrance. Again, the incision should be free, so as to make it possible to easily reach all parts of the abdomen to allow of a thorough removal of all extravasations which might otherwise ultimately cause complications.
Case eliding fatally through the fact that a too limited parietal incision had been made. A longer incision would have permitted more extensive irrigation and prevented peritonitis, which devel oped in the upper portion of the abdo men. Dubujadoux (Archives de Med. et de Phalli'. Militaires, Aug., '95).
In most eases of perforating wound when operation is decided on it is a good plan to make the incision through the point of entrance, and, when necessary, to apply silk-thread retractors. Charred tissue must be excised, and the part injured secured with fingers or forceps and drawn out, surrounded by gauze or sponges, and dealt with by suture or ex cision as the case requires. When flush ing is employed for the removal of foreign matter or extravasated some clean water left within the cavity often has a very beneficial effect. In hepatic injury often the chief difficulty is 'Hemorrhage. This. however, can be stopped by pressure with or without per chloride of iron or suture. Wounds of the intestine can be treated expeditiously by the aid of some sort of contrivance; but, of all the mechanical instruments introduced, Alurphy's button is the best. J. Ward Cousins (Brit. Med. Jour.. Oct. 21. '99).
One of the important elements of suc cess in the treatment of gunshot and stab wounds of the stomach is time. Unnecessary time lost in finding and suturing the visceral wounds is a source of immediate danger to life which should be eliminated as far as possible by means which enable the surgeon to make a quick and correct diagnosis, and by resorting to a method of suturing which closes the wound safely and se curely with the least possible delay, and which leaves it in a condition most favorable for speedy definite healing. It is well known that small penetrating wounds of the stomach often heal with out operative intervention. By contrac
tion and relative displacement of the different muscular layers of the thick wall of the stomach the tubular wound is contracted and obstructed sufficiently to prevent leakage until the canal on the peritoneal side becomes hermetically sealed by firm plastic adhesions which prevent extravasation during the time required for the repair of the visceral wound. If in larger wounds of the stomach the same degree of occlusion can he accomplished by the simplest mechanical means. then such a pro cedure should take the place of the more time-consuming methods of suturing now in general iise. This can be ac complished with the purse-string suture.
In gunshot injuries the defect in the stomach-wall is circular and the wound margins contused: hence the deep su tures could at best furnish a barrier to the escape of stomach-eontents only for a short time, as their hold in the neerosed tissues would be imperfect and only of brief duration. In short, round wounds the circular suture is the one which will bring and hold together in permanent uninterrupted contact the serous surfaces in the most efficient »tanner. In the treatment of gunshot wounds of the stomach the principal object of suturing should be to close the perforation in such a way as to guard securely against extravasation, and at the same time approximate and hold in apposition a maximum surface of intact healthy peritoneum. This is accomplished by making a cone of the injured part of the stomach, with the apex corresponding with the wound di rected toward the lumen of the organ. The purse-string suture, applied in a manner that will be described in the ex perimental part of this pa per, will main thin this cone until the healing of the visceral wound has advanced sufficiently to render further mechanical support superfluous. The cone on the mucous side of the stomach acts in the manner of a valve, which in itself is an effective barrier against the escape of stomach contents, while the circular suture con stitutes almost an absolute safeguard against leakage, and brings in contact the serous surfaces in the interior of the cone. For wounds of the posterior wall of the stomach the author recom mends a purse-string suture of heavy durable catgut to be applied through the anterior wound. The anterior wound is closed with a purse-string su ture of silk of medium size applied to the base of the cone on the serous side. It is desirable that the circular suture should cause no necrosis of the included tissues. By using an absorbable suture in closing the posterior wound in the interior of the stomach this object is gained, as only a small part of the thickness of the stomach-wall is sub jected to pressure, and the tension caused by the ligature is gradually lessened by softening of its material, and is entirely removed by the absorp tion and digestion of the ligature in less than three weeks.