PUNCTURE OF THE BOWEL THROUGH THE RECTUM. 579 



the small intestine should not be overlooked, and, as Cadiot suggests, 

 puncture through the left flank should be reserved for special cases. 

 Frequently horses have been punctured in three and four places 

 in the right flank without any sort of adverse result. As long as the 

 cannula remains in position, the animal must be watched to prevent 

 the instrument becoming displaced. To prevent infective material 

 escaping into the peritoneal cavity when withdrawing the cannula, 

 some antiseptic fluid should be injected through it into the 

 bowel, and the stilette should be reinserted before the cannula is 

 removed. 



The wound is now cleansed, disinfected, powdered with iodoform 

 and covered with adhesive plaster or collodion. Both the skin and 

 intestinal wounds generally close by first intention, if antisepsis 

 has been carefully carried out. 



To prevent the bowel falling away from the cannula and the entrance 

 of intestinal contents into the peritoneal sac, Brogniez constructed the 

 enterotome, which consists of a trocar, whose cannula is provided with 

 projections capable of being opened by pressure after insertion. As 

 Brogniez's enterotome is of great diameter and its surfaces are not smooth 

 like those of the trocar, the instrument is not only inefficient, but positively 

 dangerous, on account of its favouring the passage of intestinal contents 

 into the peritoneal cavity and increasing the risk of peritonitis. In some 

 cases the wings of the trocar have refused to collapse, and removal of the 

 instrument from the peritoneal cavity has been attended with great 

 difficulty. 



The method proposed by Bourgelat, Chabert and others, and revived 

 by Fohringer and Imminger, of puncturing the bowel from the rectum, 

 is attended with the risk of infecting the peritoneum from the mucous 

 membrane of the bowel, a danger which cannot be entirely overcome, 

 even by careful antisepsis. 



In the case described by Imminger, rotation of the colon on its long 

 axis possibly existed, and after discharge of the gas, underwent spon- 

 taneous reduction. In such cases, reposition should certainly be first 

 attempted, and only when this fails does puncture of the colon appear 

 indicated, though even then the abdominal wall should be preferred to 

 the rectum, especially as the position of the colon can generally be discovered 

 by rectal exploration. 



If for any reason puncture through the rectum be considered unavoid- 

 able, the bowel should as far as possible be emptied, and most carefully 

 rinsed out with sublimate solution, as recommended by Imminger. The 

 left hand is then passed into the rectum, whilst the right introduces the 

 trocar (with the stilette drawn back), and, guided, by the left hand, places 

 the instrument against the pelvic flexure of the colon, which will be found 

 distended with gas. The stilette is then thrust forward with a slight jerk, 

 and the trocar caused to enter the colon. For this operation a curved 

 trocar is indispensable. The one used by Imminger has a length of nearly 

 9 inches, and a diameter of £ of an inch, and corresponds to Flourant's 

 instrument, except in being somewhat thinner. Further procedure is 

 similar to that in puncturing through the abdominal wall. 



pp 2 



