372. If an intestine be divided circularly in any part, its walls will
be found to be composed of three principal coats or tunics, which
are--commencing from the inside--the mucous, the muscular, and the
serous or peritoneal, each being separated from the other by a layer of
areolar tissue. A diagram thus made would show a transverse division of
the intestine, and eight distinct if not all different parts. Beginning
from without, viz., serous or peritoneal, areolar or sub-serous;
longitudinal muscular, areolar; transverse muscular, areolar or
sub-mucous, and epithelial. The mucous coat in man has a peculiarity
not observable in animals, of ledges or shelves projecting into its
cavity.
When the mucous coat of the duodenum is examined with the naked eye,
the first part of its course presents a tolerably smooth appearance,
gradually, however, becoming irregular in transverse folds, which are
so numerous, marked, and regular in the jejunum and ileum as to have
obtained from the earliest times the name of valvulæ conniventes. They
are most strongly marked in the jejunum, and gradually disappear toward
the lower part of the ileum, the inner surface of the large intestines
being still smoother than any part of the small, although large pouches
or cells are formed in the colon by a peculiar arrangement of the
muscular coat. These valves never extend completely round the inside of
the intestine, and rarely more than half or two-thirds, although they
sometimes bifurcate. They have a velvety appearance, which has obtained
for this coat the name of villous as well as that of mucous.
Valvulæ conniventes are peculiar to man; none exist in the
ourang-outang or chimpanzee. In the frog there are valvular folds,
appearing, at first sight, like the valvulæ conniventes of the human
subject; but, on a careful examination, they are found to be mere
elevations, without villi. In the tortoise there are similar folds,
running however in a longitudinal or opposite direction. In the
rhinoceros the mucous membrane is raised up into villiform processes,
somewhat like the valvulæ conniventes, or large villi; but they are
not villi, as each process is covered with other projections which
really are villi. A valvula connivens consists of two layers of mucous
membrane and sub-mucous tissue, but the muscular coat is not continued
into it.
373. When examined microscopically, the velvety appearance is found to
consist of innumerable small processes which have been called villi,
each villus being composed principally of a very thin, transparent
_basement_ or _germinal membrane_, forming a sheath or case, inclosing
within it an artery, a vein, a capillary plexus, and an absorbent
vessel termed _lacteal_. A nerve has not been discovered, although
it is presumed to exist. These villi are longest in the duodenum,
and gradually diminish in number and in size from 1/25 to 1/50 of
an inch. Between these villi or projections, holes or openings are
observable, termed the follicles of Lieberkühn, who first described
them; they resemble inverted villi, being in some instances as deep
as the villi are long. Unlike the villi, they are found throughout
the intestines. The villi in every part in common with all mucous
membranes are covered, and the follicles are lined by epithelium, which
in this instance is the columnar, situated on the basement membrane,
each column being attached by its pointed extremity. A layer of this
epithelium extends between the villi, down to the lower part of each
follicle, each column being, generally speaking, shorter and rounder
than when covering the villi.
The office of the epithelium of the villi has been stated to be
_protective_, that of the follicles to be _secretive_. A villus, when
duly magnified, is seen to have a bulbous extremity without an opening,
and to be covered by epithelium when the intestine is in a state of
quiescence, uncalled upon for any purpose of digestion. When digestion
commences, the epithelium, according to the researches of Mr. Goodsir,
is separated and thrown off. As the chyme begins to pass along the
small intestine, an increased quantity of blood circulates in the
capillaries of the gut. In consequence of this increased flow of blood,
or from some other cause, the internal surface of the gut throws off
the epithelium of both villi and follicles, which is intermixed with
the chyme in the cavity of the gut. The cast-off epithelium, forming
19/20ths of the covering of the villus, is of two kinds, that which
covers the villi, and which from the duty it performs may be termed
_protective_, and that which lines the follicles and may be termed
_secretive_, each column having a nucleus situated at some part of it,
and bulging out that part.
The villi being now turgid with blood, erected and naked, and covered
by the chyme mingled with the cast-off epithelia, commence their
functions. The summit of the villus becomes at first somewhat flattened
and crowded under the basement membrane with a number of newly-formed
and perfectly spherical vesicles, varying from 1000 to less than 2000
of an inch in size. Toward the body of the villus or the inner edge
of the vesicular mass, minute granular or oily particles are situated
in great numbers, and gradually pass into the granular texture of the
substance of the villus. As the process advances lacteal vessels are
shown passing up from the root of the villus, subdividing and looping
as they approach the spherical mass, which in this stage has become
more distinctly vesicular, although no distinct communication can be
detected between them. The blood-vessels and capillaries shown in
injected preparations are now seen colored red with their own blood,
and running up to the basement membrane, looping with each other
immediately beneath it, and ending in one or more venous trunks. The
vesicles, quite distended and grouped in masses, push forward the
membrane, and give to it by these inequalities an appearance resembling
that of a mulberry.
The minute vesicles above noticed fulfill the important office of
absorption, by drawing into their cavities through their walls, by a
process called _endosmosis_, that portion of the chyme necessary to
form chyle; when filled with it they burst or dissolve, their contents
being thus discharged into the texture or substance of the villus, fit
to be taken up by the granular vesicles interspersed among the terminal
loops of the lacteals, and communicating with their trunks, running up
from the root of the villus in their center. Absorption is thus shown
to be effected by closed vesicles, and not by vessels opening on the
surface of the villus.
The _débris_ and the contents of the dissolved chyle cells, etc. pass
into the looped net-work of lacteals, as in other lymphatics. When the
gut contains no more chyme, the flow of blood to the mucous membrane
diminishes, the development of new vesicles ceases, the lacteals empty
themselves, the villi become flaccid, and the cast-off epithelium is
reproduced, apparently from the nuclei in the basement membrane, in
the intervals of digestion, showing that this function should only be
induced at regular periods, the presumed special use of the epithelium
being to prevent, in a measure, the absorption of any effete or other
matters which might exert a deleterious influence oh the system,
the epithelium of the follicles now secreting a mucus which may be
considered protective.
In the large intestines there are no villi, but the whole surface is
covered with follicles which must be capable of absorbing as well as of
secreting, as it is ascertained that persons can be nourished and kept
alive for many weeks by nutritious enemata which do not pass into the
small intestines.
374. On examining the mucous membrane of the stomach, its follicular
structure is immediately seen, the follicles resembling much in
appearance those of the intestine; but in the stomach minute tubes are
found opening into the bottom of each follicle, fulfilling in all
probability a different office, the follicles being lined by columnar
epithelium, the tubes by spheroidal or glandular epithelium; it is
therefore presumed that the gastric juice is secreted by the tubes,
the mucus by the follicles. The tubes differ in the middle and lower
parts of the stomach, by being longer or more deeply seated, and more
numerous as they approach the pylorus, showing in all probability a
difference of function between the upper and middle, and the pyloric or
lower extremity of the organ.
The intestines are supplied with glands, not apparently for the
purposes of absorption, but of secretion; these require attention. They
are the duodenal of Brunner, the agminated of our countryman, Nehemiah
Grew, and of Peyer, and the solitary, which are found in the lower part
of the small and in the whole course of the large intestines.
The _glands of Brunner_ are situated at the commencement of the
duodenum, within an inch of the pylorus, and are not visible until
the serous and muscular coats have been removed from without. They
appear to the naked eye like the little white eggs of an insect. Under
the microscope each little gland is found to be lobulated, very much
resembling a small portion of a salivary gland or pancreas, each lobule
having an excretory duct, which unites with those from other lobules
to form one larger one opening on the mucous surface of the bowel. The
lobules themselves are made up of vesicles, within which the secretory
cells are discernible.
The _agminated_ glands of _Grew_ and _Peyer_, by the latter of whom
they were more minutely described, occur in oval patches at irregular
distances throughout the jejunum and ileum, and are situated on the
side immediately opposite the part where the mesentery is united to the
bowel. Each gland resembles somewhat a Florence oil-flask in shape, the
small end or mouth, which is more or less pointed, projecting through
among the villi or the follicles. They are composed of cells, supplied
by capillary vessels, which Mr. Quekett says have the peculiarity
of being unsupported by areolar tissue, and are termed by him, in
consequence, _naked_. These are the glands which are found more or
less diseased after phthisis and fevers which have terminated fatally.
The oval form of the patches is retained, although considerably raised
above the general surface of the mucous membrane, and when injected
the parts around are more vascular, the ulcerated portion being less so
than usual.
The _solitary_ glands are best seen in the cœcum and appendix
vermiformis. They are well developed in the fœtus, projecting slightly
above the mucous membrane. Each gland may be considered as one of
the agminated form much enlarged, and when the free surface is very
flat, an opening may be easily seen in the center. These glands also
are frequently the seat of ulceration in fever and dysentery, and
particularly in phthisis. The follicles partake of this disease, and
the whole mucous coat may be destroyed. In some cases there is an
attempt at healing, and the edges of the ulcers become more vascular
and even villous.
The sub-mucous areolar tissue--the tunica nervosa of Haller, the
_fibrous lamella_ of Cruveilhier--separating yet connecting the mucous
with the muscular coat of the intestine, is composed of the yellow
elastic and of the white or non-elastic fibers, the latter of which
predominate. It is more firmly connected with the mucous than with the
muscular coat, and in it the blood-vessels and nerves are supported
prior to their distribution in the mucous membrane. This sub-mucous
tissue or structure prevails also in the stomach, and is often much
altered by disease, becoming thicker, and assuming a more dense and
sometimes an almost gristly hardness. It is an important part in the
surgical treatment of wounds of the intestines, being firmer, stronger,
and more elastic in reptiles, and more distinct in carnivorous than in
herbivorous animals or in man.
375. The muscular coat of the intestines is in two layers, the internal
being composed of fibers running transversely, the outer fibers running
longitudinally; they are thickest in the duodenum and rectum. They are
of the _involuntary_ or unstriped kind, as opposed to the _voluntary_
or striped, which are of large size, and characterized by striæ running
transversely and longitudinally.
The involuntary fibers, on the contrary, are much smaller in size,
are always more or less flattened, and present no trace of striæ or
stripes, although the interior appears granular, with an occasional
nucleus. The heart is a remarkable exception to this rule, being an
involuntary organ, with striped fibers differing in size, resembling in
this respect those of a voluntary muscle.
The peritoneal coat is formed of the white fibers, under a
structureless or basement membrane, covered by tesselated epithelium,
constituting a serous and secreting membrane.
376. Wounds and injuries of the abdomen are essentially of three
kinds--1. Affecting the paries or wall. 2. Opening or extending into
its cavity. 3. Wounding or injuring its contents.
The wall of the belly is, when severely hurt, liable to a permanent
defect, as the ordinary result of a severe bruise. It is the formation
of a ventral rupture. A division of the wall to any extent by a
sharp-cutting instrument is usually followed by a similar consequence;
and it never fails to occur in the openings made by a musket-ball
penetrating into or passing through the cavity.
Captain Tarleton, of the 7th or Royal Fusiliers, was struck on the
left iliac region by a large, flat piece of shell, at the battle of
Albuhera, in 1811. The surface was not abraded, although the iron
caused a very severe and painful bruise; the whole of that side of the
belly became quite black, and the remaining part much discolored. Some
months afterward he drew my attention to the part, and I then found
that the whole of the muscular portion of the wall had been removed
by absorption to the extent of the immediate injury from the piece
of shell, the tendinous parts alone remaining under the integuments.
These protruded on any effort, constituting a circular-shaped ventral
rupture, with a large base, which required the application of a pad and
bandage for its repression.
Mr. Smith, a deputy-purveyor, received a blow on the side of the fore
part of the belly from the end of a spanker-boom, which knocked him
down, and gave rise for some time to much inconvenience. He showed the
part to me in Lisbon, in 1813, in consequence of the formation of a
ventral hernia to the extent of the spot originally injured. In neither
of these cases was such a result expected; no rupture of the fibers of
the muscles was distinguished at the time, and it was supposed that the
sufferers would recover without any permanent defect. The absorption of
the muscular fibers was therefore a subsequent process; whether this
result may or may not be prevented in similar cases by a more active or
a longer-continued treatment, with the early application of a retaining
bandage, is yet to be ascertained. It may be that some muscular fibers
were actually ruptured and others bruised in these cases; but the
extent of the absorption was greater than the apparent injury would
seem to have warranted.
Abscesses form from neglected injuries of this kind, and give rise to
the most serious apprehensions of their bursting into the cavity of
the abdomen, which, however, they very rarely do. The safety of the
peritoneum and its capability of affording sufficient resistance to
the progress of the matter through it seem to depend upon the strength
of the fibrous structure on its outer or muscular side; the inner or
really serous surface being very delicate, and offering but little
resistance to the application of any moderate degree of force.
An officer, whose name I forget, was wounded at the assault of Ciudad
Rodrigo, in 1812, by a musket-ball, on the left side and fore part of
the abdomen, near the crest of the ilium: it made a wound about four
inches in length, cutting away the muscles of the abdominal wall so
deeply as to lead to the exposure, and, as I feared, to the ulceration
of the peritoneum, when the sloughs should separate. Under these
circumstances, although not belonging to my division, I took him with
me from the field to the divisional hospital at Aldea Gallega, some ten
miles from the battlefield. Granulations sprang up, however, from the
bottom and sides of the wound, which gradually closed in and healed
without further difficulty.
377. It has been supposed theoretically, to be a matter of importance
to discriminate between the orifice of entrance of a ball passing
through the abdomen or its wall, and that of its exit. Practically
speaking, it is a matter of indifference; the part on which the ball
impinges is usually distinguished by a more circular and depressed
appearance, while the opening of exit more frequently resembles a tear
or slit, the edges of which are rather disposed to protrude.
A ball striking obliquely against the wall of the abdomen has been said
to run sometimes nearly round under the skin, or between the muscles
and the peritoneum, a proceeding upon the recurrence of which little
expectation need be placed. It may, however, do something of the kind
for a considerable distance, passing even over or between the spinous
processes of the vertebra behind. In such cases, when they actually
occur, the course of the ball will usually be marked by a line on the
skin, more or less of a reddish-blue color; and the constitutional
alarm, if it should occur at all, will subside early. A ball may,
however, pass under and between the muscular layers of the wall of the
belly, (or run nearer to the peritoneum for several inches,) giving
rise to great anxiety, until the sloughs have separated from the
openings of entrance and of exit, at which parts they prevail to a
greater extent than in the middle of the track of the projectile. In
some few instances an opening will require to be made in the middle of
this track or course of the ball, for the evacuation of pus or of other
extraneous matters which may be detained in it.
When a ball lodges in the wall of the abdomen and is deeply situated,
it sometimes escapes notice, and when found is often better left alone
unless it prove troublesome. When it approaches the surface, it may
be removed if it cause inconvenience. When removed after the lapse of
twenty or more years, I have found some dense cellular membrane forming
a sac around and adhering to the ball, which is usually more or less
flattened and irregular.
378. Injuries of the wall of the abdomen from cuts or stabs affecting
the muscular and tendinous parts are said to be frequently troublesome,
and even dangerous, from their giving rise to pain, vomiting, and
severe general derangement. This only occurs when suppuration takes
place, and, from some accidental circumstance, the matter does not find
a ready exit, but collects between the muscles, or within or under
their aponeurotic sheaths. This is indicated by the pain and swelling
of the part, proceeding sometimes to the formation of an abscess, which
ought to be prevented, if possible, by an early enlargement of the
wound, so as to remove the cause of irritation, and the obstacle to the
free discharge of the secreted matter. If the swelling should become
prominent in a more convenient situation than the spot of injury, it
should be opened at that part.
In these and in all other serious injuries of the abdomen, the
recumbent position, with a relaxed state of the muscles, should
be observed for several days at least. The antiphlogistic plan of
treatment should be fully enforced, especially by leeching, bleeding,
and spare diet, and in due time the part should be supported by a
proper bandage.
The late General Sir John Elley was wounded in the last charge of heavy
cavalry at Waterloo, by the point of a sabre, which entered nearer
the extremity of the ensiform cartilage than the umbilicus, causing
a wound about two inches in length, penetrating the stomach. From
this he recovered in due time without any severe symptoms, but with
a small hernia of that organ, which remained until his death, giving
rise occasionally to some gastric inconvenience when he did not keep a
gentle pressure on it by a retaining bandage.
379. Severe blows, or contusions from falls or from the concussion of
foreign bodies, may give rise not only to injury of the internal parts
of the abdomen, followed by inflammation, but to rupture of the hollow
as well as of the more solid and fixed viscera, and death.
William Fletcher, of the 18th Hussars, a healthy man, thirty-seven
years of age, received a kick from a horse, immediately above the os
pubis, on the 15th of April, 1810, (about a league from Cartaxo, on
the Tagus;) great tension of the belly soon followed, with excessive
pain and vomiting. The pulse rose rapidly. He was bled to syncope
twice during the day, to the extent of sixteen ounces each time. In
the evening he was removed to Cartaxo, and taken into hospital; the
pain continued, accompanied by retching, without much vomiting; the
abdomen was constantly fomented with hot water, and injection was
thrown up, and two ounces of infusion of senna with salts were given
every two hours. In spite, however, of the most active treatment, he
died on the 17th. On dissection, the peritoneum was found to contain a
large collection of fluid, partaking of a fecal character; the bowels
appeared to have suffered to the greatest extent, and a laceration was
discovered in the ileum.
A child, just able to walk, was placed under my care in the Westminster
Hospital, in consequence of its having received some injury on the
side of the belly, from having been tossed up into the air by its
father with his right hand, and caught in its descent in the crutch
formed by the thumb and fingers of the left, on the thumb of which it
unfortunately at last fell; this caused the child great pain, which was
soon followed by considerable swelling and inflammation of the belly,
of which it died. On examination after death, the small intestine was
discovered to have been ruptured by the end of the thumb, from which
extravasation of its contents into the abdomen had ensued.
The first effect of a rupture of the intestine must be the
extravasation of such gas as may be contained in or secreted from it,
giving rise to the sudden swelling, as well as to the sudden effusion,
of part of its contents, but which, from the support of continuity,
and of the general pressure of the abdominal parietes, is perhaps more
gradually poured out. The rapid swelling and tension of the belly is
perhaps then a distinguishing symptom of a rupture of the intestines.
A Spanish soldier was brought to me, near the conclusion of the battle
of Toulouse, in consequence of having been struck obliquely by a
cannon-shot on the right side of the abdomen and back, which appeared
to be badly braised, although no abrasion of the skin had taken place.
The shock was great, however; he was unable to move his limbs, and
appeared likely to die, which he did in fact, in the course of the
night, having passed bloody urine, but without any reaction having
taken place. On making an incision through the skin, which was then
quite a blue black, although not torn, all the soft parts were found
reduced to a state approaching to the appearance of jelly; the spine
was injured, the right kidney ruptured, and the cavity of the abdomen
full of blood.
A soldier of the 40th Regiment was struck by a ricochet cannon-shot,
on the last day of the siege of Ciudad Rodrigo. He saw the ball, which
destroyed his left forearm so as to render amputation necessary,
strike the ground a little distance from him, before he was himself
injured. He thought, from the sort of shock he received, that it had
also struck his belly; but this I should not have credited, if it
had not been for a bruise across the umbilical region without actual
abrasion of the integuments, on which account my attention was drawn
to him on the fourth day after the injury, at the hospital of Aldea
Gallega. He had been bled in consequence of complaining of pain, and
because of the quickness of pulse and the fever which had ensued, and
which were attributed to irritation after amputation. The belly was
swollen and tender under pressure. Calomel, antimony, and opium were
given: he was bled again, and blisters were applied. The stump took
on unhealthy action, and he died a fortnight after the receipt of the
injury. The abdomen, when opened, was found to contain a quantity of
opaque serous fluid, mixed with shreds of coagulable lymph. The omentum
and intestines were of a dark color, and loaded with blood, distinctly
indicating the chronic state of inflammation which had taken place.
If the injury should not destroy the patient, but prove sufficient to
give rise, after several weeks, to effusion into the cavity, the fluid
should be evacuated by the trocar.
When the fixed viscera are ruptured by severe blows, such as those
received by falls or from cannon-shot, the sufferers usually die from
hemorrhage and not from inflammation. The arm has been carried away,
and the liver ruptured without almost a sign of injury to the skin of
the abdomen, death ensuing from hemorrhage.
380. When an incised wound is made through the wall of the abdomen
to any extent, except perhaps in the linea alba, the muscular parts
are rarely found to unite in a more perfect manner than when they are
ruptured and bruised. In those cases in which I have tied the common
iliac artery by an incision on the face of the lateral part of the
abdomen, the patients recovering afterward, the incision through the
muscular wall did not remain united, although union appeared to have
taken place in the first instance, and a herniary protrusion formed in
the course of the greater part of the line of the wound.
The constant occurrence of this non-union, except by skin and cellular
membrane, led me to repudiate the introduction of ligatures through
other parts for the purpose of keeping them in apposition, as it does
not lead to the permanent cohesion of the parts, while it exposes the
sufferers to all the dangers which the irritation of sutures commonly
occasions, thus offering another instance of the improvement surgery
owes to the war in the Peninsula.
Chelius recommends “several flat ligatures to be introduced through
the skin and muscles, the needle being placed close to the muscular
surface of the peritoneum.” Graëfe (section 514) is declared to be of
the same opinion, he recommending, however, that a soft tape should be
substituted for a ligature. Reference is made to Weber in support of
this practice, to which Mr. South, the translator, does not raise any
objection.
381. In all simple wounds of the wall of the belly of moderate extent,
the edges of the wound should be brought together by means of a small
needle and a fine silk thread passed through the skin and the loose
cellular membrane only which is in contact with it, by a continuous
suture without puckering, in the manner a tailor would fine-draw a hole
in a coat. This gives a certain degree of support to the parts beneath;
and if proper attention be paid to maintain a well-regulated, relaxed
position of the muscles, no great separation takes place in wounds of a
reasonable extent, and little or none in a wound of smaller dimensions.
An effective support should be also given by strips of adhesive plaster
extending to some distance around the body; a bandage rarely does good,
and will assuredly do mischief, unless it be very carefully applied and
watched, so as only to give support and not to make undue pressure. The
position of the patient is of the greatest importance; its essential
object is to bring the edges of the incision, and especially of that in
the peritoneum, as nearly as possible in apposition, so that the space
between them may be more easily filled up by the opposing peritoneum
forming the anterior layer of the omentum, or by the outer covering
of the intestine if the omentum should not intervene. This is to be
effected by the gentlest inclination of the body toward the wound which
may be supposed capable of keeping these parts in apposition; for
although the omentum and intestines are often capable of undergoing
a considerable degree of motion from side to side, independently of
that peculiar wormlike movement on themselves which in the intestines
is called peristaltic, they very frequently do not wander from place
to place in the manner which has been sometimes attributed to them,
but remain, under proper care, so far stationary as to admit of the
cut edges of the wounded peritoneum adhering to the healthy peritoneum
opposed to them, when they will be retained in contact with it. The
serous surfaces of the peritoneum which are in contact with each
other soon offer on one part, and accept on the other, the process
of adhesion through the medium of lymph or fibrin deposited between
them. If this adhesion take place, it extends for some little distance
from the wounded part, which it thus closes up and cuts off from all
communication with the general cavity of the belly; the previous
admission of air--the bugbear of surgeons of the olden times--being
of no sort of consequence. The adhesive process is the effect of
inflammation extending to a certain point, and ending in the deposition
of fibrin. When it exceeds this, the secretion of a quantity of serous
fluid, together with threads of flocculent matter, marks the excess of
inflammation; it is diffused over more or less of the peritoneum lining
the wall of the belly, covers its contained viscera, and prevents that
adhesion from taking place which is the safeguard of the patient.
382. Absolute quietude is no less to be observed. It must, however,
be steadfastly continued; the slightest alteration of position should
be forbidden. Motion should not on any account, nor for any reason
whatever, be allowed, if it can by any possibility be avoided. In
the position in which the patient is placed he should be rigorously
maintained until adhesion has been effected or all hope of it has
passed away. The practice of the older surgeons was to purge such
persons vigorously, in order to remove from their bowels any peccant
matters that might be in them; in the same manner they recommended
persons should be purged who had undergone the operation for
strangulated hernia--both which proceedings the experience of the
war enabled me to condemn, as being not only contrary to the right
medical treatment of such cases, but to the physiological and surgical
principles on which it ought to be founded, a condemnation the accuracy
of which is now universally admitted, although the source from which it
is derived is not so universally acknowledged. No purgative medicine
whatever should be given to a person with a penetrating wound of the
abdomen. No food should enter his mouth; and no more water even should
be allowed than may be found requisite to moisten the lips and allay
any intolerable thirst which may ensue. This precaution need not be
carried out so strictly if it could be readily ascertained that an
intestine was not wounded; but as this knowledge, however satisfactory
it would be, cannot always be obtained, and ought not in the generality
of instances to be sought for, the restriction should be fully observed
if possible. In all cases of injury of the belly there is more or less
shock, alarm, and anxiety. It is sometimes remarkably great, even
when the mischief has not been considerable. When little or no injury
has been inflicted on the intestines, the natural and usual action of
expelling the contents is generally delayed beyond the time at which
in health it would in all probability have occurred. When nature shall
point out by the sensations of the patient an inclination to perform
this function, it may be assisted by an injection of warm water or
of any mild laxative which may facilitate the process and prevent
any unnecessary action of the abdominal muscles, against which the
patient should be cautioned. The attendants should be forewarned that
the position of the patient is not to be interfered with under any
circumstances, the necessary arrangements being made by bedsteads of
a proper construction, or by other simple means which are sufficiently
well known.
383. The custom of directing a man to be bled forthwith, as well
as purged, because he has been stabbed, was another error much in
esteem by the older surgeons, but which experience did not sanction,
and it could not therefore be approved. The abstraction of blood
before reaction has taken place delays its occurrence as well as the
commencement of that inflammatory stage which is to be so salutary in
its result in favorable cases. It tends to prevent the agglutinative
process from taking place, and thus aids the diffusion of inflammation
over the whole surface of the peritoneum. The general abstraction of
blood is to be ordered, and regulated as to quantity by the symptoms
of inflammation which may accompany or follow reaction. The quantity
of blood required to be taken away in these cases is usually large,
particularly at an early period. With the army in the Crimea, the
abstraction of large quantities could not in general be borne and has
not been found serviceable, nor has it been found so necessary to
repeat the bleedings as in persons more favorably situated. It is,
however, often a nice point to determine when blood enough has been
abstracted with advantage, as too much may be taken away as well as too
little--the former being marked, after death, by the general diffusion
of a slight degree of inflammation, without the concomitant sign of
effusion of serum. Leeches applied in considerable number will often be
found more beneficial, particularly at a late period, when the sufferer
may not be able to bear a general abstraction of blood. The patient,
after leeches have been once applied and their good effect has been
ascertained, will often ask for them himself on the recurrence of pain
or on its increase; and from twenty to sixty, or even eighty, may be
applied in some instances of great danger with advantage.
The pulse is by no means a guide in the management of these cases; a
small, low, and sometimes not even a hard pulse being more strongly
indicative of an overpowering state of inflammation than is a quick
and full pulse; much more depends on the pain, the anxiety, and the
general oppression than on the apparent state of the circulation.
Before general and local bleeding cease to be employed with advantage,
calomel, antimony, and opium will render essential, nay, most
important, service.
The extensive incisions made of late years into the abdomen for the
removal of ovarian tumors, with fair success, confirm what I have
constantly repeated in my lectures for the last thirty-five years, that
penetrating wounds of the abdomen, without injury to the viscera, when
properly treated, are not so dangerous as they were generally supposed
to be.
384. In penetrating wounds of the belly, the offending instrument
frequently passes in for a considerable distance, sometimes separating
or pushing the viscera aside without injuring them, at others
inflicting upon them wounds more or less severe. In fatal cases of
stabs from knives and sharp instruments, the intestines have been
usually injured by the point, although when the lapse of three or four
days before death takes place, the small wound is not readily perceived.
W. Carpenter, private, 1st battalion, 43d Regiment, was accidentally
wounded, March 19th, 1812, by a comrade, the small end of a ramrod
entering about two inches below the navel, passing in a direction
upward, penetrating the second lumbar vertebra, and protruding an inch
and a half on the opposite side.
On examining the wound, the ramrod was found firmly fixed in the bone.
It was endeavored at first to extract it by a gentle turn, making
extension at the same time, but this failed. Force was then applied on
the opposite side, by fixing the broad end of a ramrod on the point of
the protruding one, which was laid bare by an incision, when by a smart
stroke with a stone it was driven back and removed. Bleeding to twenty
ounces.
March 20th.--Has slept several hours during the night; passed urine two
or three times; suffers slight pain occasionally on turning himself in
bed; has the perfect use of his lower extremities; pulse rather full;
skin cool; repeat bleeding to twenty ounces.
22d.--No evacuation since the 20th; pulse rather full; bleeding to
twenty-two ounces; sulphate of magnesia, one ounce. Seven o’clock A.M.:
Medicine operated three or four times; feels no pain in passing water.
23d.--Has passed a good night; wounds dressed; is allowed a small
proportion of bread with his tea.