16 Sometimes the abdomen is penetrated by a stab of some sort, and it follows that intestines roll out. When this happens we must first examine whether they are uninjured, and then whether their proper colour persists. If the smaller intestine has been penetrated, no good can be done, as I have already said. The larger intestine can be sutured, not with any certain assurance, but because a doubtful hope is preferable to certain despair; for occasionally it heals up. Then if either intestine is livid or pallid or black, in which case there is necessarily no sensation, all medical aid is vain. But if intestines have still their proper colour, aid should be given with all speed, for they undergo change from moment to moment when exposed to the external air, to which they are unaccustomed. The patient is to be laid on his back with his hips raised; and if the wound is too narrow for the intestines to be easily replaced, it is to be cut until sufficiently wide. If the intestines have already become too dry, they are to be bathed with water
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to which a small quantity of oil has been added. Next the assistant should gently separate the margins of the wound by means of his hands, or even by two hooks inserted into the inner membrane: the surgeon always returns first the intestines which have prolapsed the later, in such a way as to preserve the order of the several coils. When all have been returned, the patient is to be shaken gently: so that of their own accord the various coils are brought into their proper places and settle there. This done, the omentum too must be examined, and any part that is black dead is to be cut away with shears; what is sound is returned gently into place in front of the intestines. Now stitching of the surface skin only or of the inner membrane only is not enough, but both must be stitched. And there must be two rows of stitches, set closer together than in other places, partly because they can be broken here more easily by the abdominal movement, partly because that part of the body is not specially liable to severe inflammations. Therefore two needles are to be threaded and one is to be held in each hand; and the stitches are to be inserted, first through the inner membrane, so that the surgeon's left hand pushes the needle from within outwards through the right margin of the wound, and his right hand through the left margin, beginning from one end of the wound. The result is that it is the blunt end of the needle which is always being pushed away from the intestines. When each margin has been once traversed, the hands interchange needles, so that into the right hand comes the needles which was in the left, and into the left the needle which was in the right; and again, after the same
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method they are to be passed through the margins; and when for the third and fourth time, the needles have changed hands the wound is to be closed. Afterwards the same thread and the same needles are now transferred to the skin, and stitches are to be inserted by a like method into this as well, always directing the needles from within outwards, and with the same change, between the hands. It is too obvious to need constantly repeating that agglutinants are then to be put on with the addition either of a sponge or of greasy wool, squeezed out of vinegar. Over this application the abdomen should be lightly bandaged.
17 Sometimes, however, whether from some blow, or from holding the breath too long, or from carrying a heavy weight, the inner membrane of the abdomen is ruptured, whilst the skin over it is entire. This often occurs too in the case of women from childbearing, and it particularly takes place in the iliac regions. But it follows since the overlying flesh is soft, that it does not hold the intestines properly in place and that the skin is stretched by them and forms an ugly swelling. And this too is treated differently by different surgeons. For some pass two threads through the base by means of a needle, and then tie on each side, as has been described for the navel and for staphyloma, in order that what is beyond the ligature may mortify; some excise the middle of the swelling by a myrtle-leaf shaped incision, which as I said is the method which should always be adopted, and then they unite the edges by stitching. But the best way is with the patient on the back, to try with the hand in which part the swelling is most yielding, for of necessity it is at
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that part that the inner membrane is ruptured, and where it is entire the swelling is more resistant. Where the rupture is seen to be, two linear incisions are made with a scalpel, so that when what lies between has been excised, the inner membrane has a wound freshly made on each side, because stitching will not unite a lesion of long standing. When on exposure any part of the membrane presents not a recent but an old rupture, a thin strip is to be pared away, which only just makes the margins raw. All the directions for stitching and further treatment have been given above.
Besides the above there are sometimes varicose veins upon the abdominal wall, and because there is no other treatment for these than what is usual for the legs since I shall treat of that part later, I will defer this too till then.