. The Canada lancet and practitioner. s now performed. Theflushing out should be completed by douching every peritonealrecess till the saline returns perfectly clear. Finally the abdom-inal wound is closed. We have always left a large Keithstube in the pouch of Douglas, and have generally drained the•site of perforation with a Mikulicz tampon and drainage head of the patients bed should be raised about sixinches in order to favor the gravitation of any discharge fromthe dangerous absorptive region of the diaphragm towards theless susceptible pouoh of Douglas. 194 DOMINION MEDICAL MONT
. The Canada lancet and practitioner. s now performed. Theflushing out should be completed by douching every peritonealrecess till the saline returns perfectly clear. Finally the abdom-inal wound is closed. We have always left a large Keithstube in the pouch of Douglas, and have generally drained the•site of perforation with a Mikulicz tampon and drainage head of the patients bed should be raised about sixinches in order to favor the gravitation of any discharge fromthe dangerous absorptive region of the diaphragm towards theless susceptible pouoh of Douglas. 194 DOMINION MEDICAL MONTHLY Recovery is frequently uneventful. The chief factor affect-ing the issue is the nature of the organisms liberated within the-peritoneal cavity and the power of tissue resistance to the toxinsevolved. Fortunately we do not meet with organisms ofexcessive virulence within the stomach, and when there is no-stagnation or fermentation of the gastric contents, the highlyacid nature of the gastric secretion which we so frequently meet. Case 14.—Second perforation in Case 4, fourteen months after last operation ; markeii hour-glass contraction; omental bands adherent to vicinity of umbilicus A, and to lateral aspect of abdominal wall B. in such cases, inhibits the growth of most microbes. An addi-tional source of sepsis may be due to the damage inflicted bvthe gastric extravasation on the viscereal peritoneum permittingthe passage of intestinal organisms. Hence the value of aspeedy recognition of the serious nature of the lesion, and the-success which is likely to crown an early operation. DOMINION MEDICAL MONTHLY 195 Naturally the size and position of the perforation, the dateand the nature of the last meal, and the amount of materialwhich escapes into the peritoneum are obviously of moment. The chief prognostic is the pulse. A rate of 120 is to befeared, 130 and over to be dreaded. Temperature is of lessvalue. The course after operation may be full of anxiety,requiring the ex
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