The after-treatment should be based upon the necessity of insuring rest for the intestinal tract for a few days. This may be carried out by administering opiates. The patient's strength should be sustained, however, by means of nutrient, but small and frequently ad ministered, enemata.
Under all circumstances, an abdomi nal injury should cause the patient to be watched several days. After an uncom plicated injury he should remain in bed and be placed on a milk diet for a few days. Anodyne applications over the abdomen and a little morphine, inter nally, if there is pain, is all that is usu ally required in these cases. In the less fortunate the procedure to be adapted varies according to the organ involved.
probability of a rupt ure having been recognized, the abdo men should be opened by an incision through the linen alba, and any haemor rhage quickly arrested. The next step is to locate the visceral injury. Of im portance in this connection is the fact that in the majority of cases the rupt ure is due to compression against the spinal column. The spot over the abdo men upon which the blow carried being considered as the one end of an imagi nary line and the centre of the vertebral column as the other end, the probabili ties are that the rupture will be found near the linear axis.
In dogs with intestinal perforation there is constriction of the intestine above and below the point of injury, and swelling of the intestinal loop at the point of lesion. Lesions are always superposed in the direction of the spine; so that by going from injured portion of trail toward the spine the wounded loops are always found. F6vrier and Adam (Revue Int. de Med. et de Chir., Oct. 25, '94).
Four cases of abdominal sections for severe injuries without external wounds. One should make a careful exploration of viscera before closing parietal incision. Three of the cases reported terminated fatally and at the autopsy it was dis covered in two cases that a wound of the intestinal tract had been overlooked. A. M. Shield (Practitioner, Nov., '98).
Again, if the rupture cannot be read ily found, hydrogen may be insufflated into the rectum, as advised by Senn, and the spot from which the gas escapes will indicate the location of the rupture,— approximately, in the case of the small intestine, and accurately below the ileo meal valve.
Disorders, or lesions other than those sought after, are misleading conditions that should he borne in mind.
Lesions of the jejunum are sometimes difficult to locate.
Rupture of the jejunum. The patient was struck by the back rail of a barrow, across the upper part of the abdomen; severe pain, but not fainting. He was able to push the barrow a little further and to walk about a mile. No wound nor any bruising evident over the abdomen; very little tenderness, and breathing not markedly thoracic. Tem perature, 97° F.; pulse, SO and weak. On the day following peritonitis present, and laparotomy performed by Mr. Cheyne. At the upper part of the cavity, behind the liver and stomach, the peritonitis was most acute, and a rent was found in the upper end of the jejunum. Patient returned to bed very much collapsed and died nine hours after the operation. C. J. Hood (Brit. Med. Jour., Apr. 5, '90).
Stomach. — When the symptoms of complete tear are recognized, the pres ence of the organ's contents in the abdominal cavity render an immediate laparotomy imperative. The incision should include the tissues between the xiphoid cartilage and the umbilicus. If the tear cannot be quickly found, repe tition of the inflation with hydrogen-gas will help to locate it. As soon as located any bleeding vessel should be ligated, and the stomach evacuated and cleansed through the adventitious opening of any substance that may have remained in it. If the wound be a lacerated one, it may be necessary to pare its edges. This be ing done, the tear is closed, the mucous membrane being united with a contin uous or interrupted suture, cut short, and the muscular and serous coats by the continuous Lembert suture. Closure of the laceration having removed all danger of further extravasation into the peritoneal cavity, the latter must be flushed with warm, sterilized water and mopped out with a soft sponge. The cavity is then closed and a drain left if the peritoneal surfaces have been ex posed to contamination for some time.