GASTROCENTESIS 67 



rumen with one sharp blow of the palm. The operator 

 should stand at the right flank, performing these manipula- 

 tions by leaning over the body (Fig. 31) unless they are found 

 incompatible with the small stature of the surgeon or the 

 large stature of the patient. In this latter event the operator 

 stands on the left side, but well forward and at arm's length, 

 or else takes the precaution against injury by securing the 

 left leg with a rope held or tied backward. 



Fourth Step. — Evacuating the Gas.— The evacuation is 

 then effected by removing the trocar from the canula and 

 then occasionally replacing it to prevent choking of its lumen 

 with ingesta, which sometimes flows out in considerable 

 quantities. Before the operation is abandoned, the intra-ab- 

 dominal pressure should be reduced at all hazards, to prevent 

 large quantities of ingesta from flowing into the peritoneal 

 cavity after the canula has been withdrawn. If the rumen 

 remains stretched after it has been perforated, the opening 

 likewise remains stretched wide open, and gives free exit to 

 the contents. The warning already heralded in the descrip- 

 tion of enterocentesis in solipeds, to make frantic efforts to 

 diminish the intra-abdominal pressure once the evacuation 

 has been attempted by tapping, can not be too frequently 

 repeated. If evacuation is found impossible through the 

 canula, a rapid rumenotomy must be immediately performed. 

 In the urgent case a probe-pointed bistoury is passed into the 

 abdominal cavity along the canula, and an incision two inches 

 long made in the abdominal wall in the downward direction. 

 The rumen, which will then bulge into and even through the 

 incision, is then incised with a smaller incision. After the 

 first gush of ingesta, the edges of the incision in the rumen 

 are grasped with forceps, and held through the opening in 

 the abdominal wall until the flow ceases. Dependent upon 

 the cause, manual abstraction of the contents after enlarging 

 the opening of the rumen may or may not be necessary. 



Fifth Step. — Protecting the Wound. — The incision in the 

 skin made at the point of entrance should be protected by the 

 application of an antiseptic powder, — boric acid, iodoform, 

 tannin, etc. When larger incisions are made the rumen must 

 be closed with two or more Czerny stitches, and the abdomi- 

 nal wall with interrupted sutures. 



AFTER-CARE. — After ordinary tapping of the rumen an 

 antacid drench consisting of aromatic spirits of ammonia two 

 ounces in a quart of water and a saline purgative of magnesia 

 sulphate, are always indicated, but when the rumen has been 

 incised it is preferable that that organ be left dormant long 



