There is great ground for the objec tion to Senn's method, made by many surgeons, as regards its use for purposes of diagnosis prior to laparotomy, but, in the detection of perforations after the abdomen has been opened, it is of value, and may be used, at times, to great advantage.
The manner of closing the wound is that indicated for lacerations following blows. The stomach and intestinal per forations being treated in the same way, the margins of the wound are turned inward and the serous surfaces are united by a continuous, fine-silk Lembert suture or by interrupted sutures, including the serous and muscular coats and the sub mucosa. These are cut short and left in, being eventually discharged per anunz.
At times the tissues around a perfo ration are sufficiently contused to render an omental graft necessary.
Enterectomy is sometimes required, and not infrequently exsections of the intestine are necessary. In that case the intervening portion, if it is not too long, had better be resected, thus avoiding a double operation in the continuity of the gut.
Case with six intestinal perforations and wound in bladder 4 centimetres long. Resection of 62 centimetres of small intestine. Slight cystitis; recov ery uneventful. Rieder (Le Bull. 111&1., Jan. 3, '95).
After the active measures described have been carried out the extravasation of the contents of the stomach or intes tines may make it necessary to flush the peritoneal cavity. Warm, sterilized water should be used, but care should be taken not to handle the intestines roughly. By turning the patient on his side the fluid is poured out. The abdominal cavity is then dried with large sponges wrung out of warm, sterilized water. Chilling of the viscera should be carefully avoided, and the parts should be exposed to the air as short a time as possible.
Case of stab wound illustrating the value of salt solution. Within the abdo men, where only salt solution was used, no inflammation or trouble followed; whereas at the abdominal wound, where bichloride, etc., were used, suppuration took place. P. R. Bolton (Med. Record, July 31, '97).
Case in which cceliotomy for gunshot wounds disclosed fourteen perforations of the small intestine. Closed with con
tinuous and Lembert suture. Abdom inal cavity flushed with saline solution, drained with gauze; recovery. George Sherrill (Med. Record, Oct. 7, '99).
Drainage is sometimes necessary, espe cially for wounds of the solid viscera, such as the liver, spleen, kidneys, etc., in which active measures were not re sorted to early.
In abdominal surgery the weight of evidence stands in favor of dispensing with drainage whenever it is possible. Method of closing abdominal wound layer by layer has greatest number of advocates, and materials mostly used for sutures are catgut, chromicized cat gut, silk-worm gut, and silver wire. Causes of post-operative wound-infection ere unnecessary manifestations of wound, rough retraction of its edges and pro longed pressure with metal retractors, imperfect limostases, strangulation of large bits of tissue by ligatures, and un due tension of the sutures. A. C. Hef fcnger (Med. Record, Dec. 17. 'K.
Case of attempted suicide in which the intestine was wounded with a pair of scissors. The intestinal wounds were closed with silk, mostly by interrupted sutures, and a gauze drain was carried out of the median end of the wound and the walls of the abdomen closed. Recovery. Deiters (Munch. med. Woch., Sept. 4, 1900).
T.o summarize: we will say that imme diate exploration of the abdominal cavity is indicated as soon as it is suspected to have been penetrated or in any way in jured by a traumatism. The injury to its contents must then be repaired under strict aseptic precautions. The value of salt-solution flushing is emphasized by the results of practical experience.
Should no lesion be found, the mere exploration should result in no serious damage.
After-treatment. — Food should be withheld for thirty-six hours, but a little water and brandy, in teaspoonful doses, may be allowed, especially if there is any degree of shock. In that case it is advisable also to use stimulants by the rectum or subcutaneously. .1N utritive enemata of beef-tea and milk are neces sary to sustain the patient's powers.