removed by sponging, and washing may be repeated as often as necessary.

In septic cases the writer has frequently performed such local washing with a bichloride solution (I: 2000 or I : 4000), followed by irrigation with plain water.

If the patient is horizontal and the gauze pads be properly placed, there is no danger of any of the fluid. entering the upper peritoneal cavity.

Closing the Abdominal Incision.-A variety of methods have been introduced for closing the abdominal incision. The simplest method, that is applicable to all cases, is the interrupted mass-suture, or the "throughand-through" suture. This suture passes through all the structures of the abdominal wall (Fig. 201).

Some

FIG. 201. The mass-suture for closing the abdominal incision: S, skin; F, fascia; M, muscle; P, peritoneum.

operators advise passing the suture to, but not through, the peritoneum. The writer includes the edge of the peritoneum in the suture. These sutures should be placed two or three to the inch, according to the thickness of

the abdominal wall.

Care should be taken to include all the structures in the embrace of the suture. A carelessly applied suture sometimes fails to include the retracted fascia and muscle. The needle should first be directed outward and then inward as it passes through the abdominal wall. It should not pass directly through, parallel to the sagittal plane of the incision. Thus when the suture is tied it forms approximately a circle, and the structures included in it are brought into a plane of apposition.

A long straight needle with a spear-point is convenient for introducing the mass-suture. A gauze sponge

If this

should be placed beneath the incision as the sutures are introduced, to prevent injury of the intestines and the escape of blood into the peritoneum. When the pad is removed, the omentum, if readily found, should be drawn down behind the incision. Before each suture is secured the sides of the incision should be drawn forward by traction on the ends of the suture, to ensure accurate apposition upon the posterior or peritoneal aspect. precaution is not taken, in a thick or rigid abdominal wall the cutaneous aspect of the incision may be brought into accurate apposition, while a gap will exist between the more posterior structures. Such imperfect apposition is a frequent cause of ventral hernia. The mass-sutures should not be removed for two weeks. The early removal of sterile sutures is of no advantage whatever, and may cause ventral hernia. The writer often leaves them in for three weeks.

After the sutures are removed the incision should be

strapped with adhesive plas

ter.

rupted suture.

The application of a buried suture of catgut or of silver wire, passed through the muscle and fascia, is a useful addition to the mass-suture and an additional preventive of hernia.

Various methods of uniting the tissues by sutures in separate layers are used. A very good method is to close the peritoneum by a continuous suture of fine silk, then to unite the muscle and fascia by a continuous suture of catgut, and finally to close the cutaneous edge with an

interrupted or a continuous suture of silkworm gut or silk. The subcuticular or the intra-cutaneous suture (Fig. 202) is very convenient for this purpose.

If the abdominal wall be fat, it is advisable to introduce a second catgut suture through the subcutaneous fat. When the structures are united in layers, a hematoma sometimes forms between two planes of suture, and, if not absorbed, the anterior portion of the wound may break down. This accident, which is caused by hemorrhage after the sutures are secured, may be prevented by employing, in addition to the usual dressing, a compress of gauze placed over the incision.

CHAPTER XLI.

TREATMENT AFTER CELIOTOMY.

THE after-treatment of celiotomy is usually very simple. A special nurse is required for the first three days. The patient should lie upon her back for the first two or three days; after this she may be moved partly upon either side, and a pillow may be placed behind her for support. The head may be supported by one or two pillows. Much comfort is experienced by raising the knees over pillows. The patient often complains bitterly of backache, which may be relieved by slipping a folded sheet or towel under the small of the back.

Thirst is always present after celiotomy, and is usually the symptom of which the patient complains the most. There is much diversity of practice in regard to the administration of water after celiotomy. The writer allows no water during the first twenty-four hours. During this time the lips and mouth are frequently moistened with a cloth wet in cold water or wrapped about a piece of ice. At the end of twenty-four hours small quantities of hot water or cold soda-water (I dram) are given every fifteen minutes or half hour, and gradually increased as it is found to be retained by the stomach. Hot water relieves thirst as well, and is not so likely to cause vomiting, as cold water.

The chief objection to the early administration of water after celiotomy is that it may cause vomiting. Some operators avoid this by administering the water by the

rectum.

Another reason, more or less theoretical, for withholding water is that the absorbing power of the peritoneum

is greatest when the tissues of the body contain a deficient amount of water.

Pain after celiotomy seems to bear no relation whatever to the amount of traumatism that has been inflicted. More discomfort may be experienced after ventro-suspension of the uterus than after a hysterectomy. In operations upon the generative organs the chief seat of pain is in the region of the sacrum. Pain is also felt in the ovarian region and in the abdominal incision. The pain begins to abate after the first fifteen or twenty hours. Opium should not be administered unless it is absolutely necessary to allay nervous excitement in a cowardly woman. In such a case a small dose (gr.) of morphine may be administered hypodermically.

The writer rarely finds it necessary to administer an anodyne. Most patients are able to endure the pain if they are properly encouraged by the physician and the

nurse.

There are several objections to the administration of opium. It increases the thirst and it diminishes the functional activity of the gastro-intestinal tract. It retards the passage of flatus by the rectum and causes tympanites, and it increases the difficulty of moving the bowels. It obscures and delays the recognition of symptoms that may demand immediate treatment. The patient who has had no opium is more comfortable at the end of three or four days after celiotomy than one to whom it has been given.

The patient should be encouraged to pass water voluntarily. The application of hot moist cloths to the external genitals sometimes facilitates urination. In many cases the use of the catheter is never necessary. If the urine is not voided about every eight hours, it should be drawn with the catheter. Catheterization should be done. with strict attention to asepsis. The former frequency of cystitis from the improper use of the catheter has already been referred to. Catheterization should never be performed under any circumstances by the aid of the