LAPAROTOMY. 451 



little more being necessary than a simple laceration of the iutesti- 

 nal tissue with the fingers — there is little or no hemorrhage. The 

 openiag thus made admits the hand into the abdomen, and when 

 it is removed the fibres of each muscle having a tendency to come 

 together spontaneously, the openiag is more or less effectually 

 closed. 



Second step. — This varies, to correspond with the object of the 

 operation ; 1st, whether the extraction of a foreign body in the 

 abdomen or intestines, or 2d, the reduction of an iavagiaation or 

 of an iatemal hernia (diaphragmatic, mesentoric, epiploic, or pan- 

 creatic), and, 3d, the displacement or removal of a tumor involving 

 the intestraes. 



In the reduction of an internal hernia, it may be necessary 

 either to pull or to push upon the displaced organ. In some cases 

 the hernial ring must be enlarged, and if that cannot be done vyith 

 the fingers, the bistoury must be used. The reduction of an intes- 

 tinal invagination is obtained by the combined action of a slight 

 traction on the invaginated part and a steady extern9,l pressure 

 upon the enlargement formed by it in the portion of the intestines 

 in which it is enfolded. When the swelling of the organs or the 

 presence of abnormal adhesions prevent the reduction, the traction 

 must be increased and in opposite directions — the invaginated por- 

 tion in one, the enfolded portion in the opposite. 



If a stone, a calculus, or any foreign body is to be extracted, 

 the intestine is to be incised at some distance from the insertion 

 of the mesentery, on its lateral face, between the two curvatures. 

 On the removal of the body the intestinal suture is to be appUed. 



Third step, Closing the Parietal Wound. — "When the complex 

 incision has been made, a strong cutaneous suture is all that is re- 

 quired. When the division has been a simple one, the edges of 

 the muscular wound are brought together by ordinary interrupted 

 sutures, and the sMn is afterward sewed up. The drainage at 

 the lower part of the wound is always advantageous." 



As enteritis and peritonitis are common sequelae of this opera- 

 tion much care and watchfulness devolve on the surgeon in direct- 

 ing the regimen and nursing of the patient in order to prevent the 

 possibility of their access from becoming a certainty. 



