The wound of the posterior wall of the stomach is found and made acces sible by inserting through the anterior wound a grasping forceps with which the posterior wall is seized at a point where, from the course of the bullet, the second wound is supposed to be located. Through a wound large enough to admit the index finger the greater part of the posterior wall of the stom ach can be made accessible to sight and touch, and the perforation can be lo cated and closed with the pu•se-string suture in a few moments. In doubtful cases inflation of the stomach should invariably be practiced for the detec tion of a second and possibly a third perforation.
The experiments demonstrated the safety of the circular suture in the treatment of gunshot and other pene wounds of the stomach. All of the animals operated upon in this manner recovered, and the repair of the injuries as shown by the specimens are ideal. The absence of adhesions over the posterior wound and their constant presence over the anterior wound indi cate that the presence of the silk liga ture and the needle punctures were the causes of the circumscribed plastic peritonitis which produced them. In none of the specimens could any indica tions be found of necrosis of any of the inverted tissues, and included in part by the circular suture.
In the course of three weeks the con tinuity of the mucosa at the seat of the injury was completely restored. The result of these experiments has, convinced the author that the circular suture compares favorably with the methods of suturing in general use, and besides has the great advantages over them in the ease of its application and. the saving of much valuable time.
Suturing of the posterior wound partial eversion of the stomach through the anterior obviates unnecessary hand ling of the organ and the necessity of interfering with the vascular supply in cident to exposure of the posterior wound, as is done by the methods now generally practiced. If extravasation into the retrogastric space has taken place, flushing through the posterior wound and a vertical slit, in the gastro colic ligament and gauze drainage through the latter are invariably in dicated. N. Senn (Brit. Med. Jour., Nov. S, .190.2).
The stomach and the transverse colon are best brought to view by an incision in the linen alba. In the case of the stomach hernia of the mucous membrane will facilitate recognition of the lesion.
The ascending colon requires lateral in cision on the right side, and the descend ing on the left. These also should be sufficiently long to facilitate the search for the injury or injuries that may be present in the organ itself and beyond.
The incision may he such as to inter sect the wound of entrance. This is de sirable at all times, the aim being, of course, to always avoid unnecessary solu tions of continuity. Such an incision can fortunately be made in many of the cases in which the hemorrhage is not formidable.
"hemorrhage. — When the abdominal cavity is opened and the hmnorrhage, which is usually more venous than arte rial, is marked, the blood rapidly accu mulates in the most depressed portion of the cavity from an invisible source. To mop out the blood with sponges is gen erally recommended; but such a proced ure does not cause the hamorrhage to cease,—the first desideratum. In these formidable cases an assistant should at once introduce his hand through the wound—hence the advisability of a long incision—and compress the abdominal aorta below the diaphragm. This proced ure immediately checks the flow. Care fully cleansed and disinfected sponges having been made ready in the mean time, the blood present is quickly, but not roughly, sponged out. When this is finished the source of limmorrhage is sought after. If any difficulty is experi enced, the digital pressure upon the aorta may, for an instant, be decreased, and a sudden gush will point to at least the direction from which the blood comes. The necessary steps are then taken to arrest the flow, and the abdominal aorta is released as soon as possible,—not sud denly, but by a gradual reduction of pressure.
The measures to be adapted in arrest ing haemorrhage vary according to the organ involved. Gunshot wounds of the liver are frequently stellate, and rents, radiating from the bullet-track in vari ous directions, greatly increase the bleed ing surface, the parenchyma in this organ taking part to a great degree in the emission of blood. To force resilient sponges into these tears is to increase their depth. If the wound be not very extensive, it may be sutured with catgut or cauterized with the actual cautery. If the wound is extensive it had better be packed with long strips of iodoform gauze, one end of which is brought out of the external wound.