That a blunt instrument, like the small end of a ramrod, should be
forced between the loose viscera of the abdomen without wounding any
of them, may be easily conceived, but that balls or sharp-pointed
swords should do so, is not to be understood so easily. Ambrose Paré,
our own Wiseman, Ravaton, Lamotte, Muys, and others, however, have
related instances of this kind, in which the patients recovered in an
inconceivably short space of time; but these and other recoveries of a
similar nature must be considered as exceptions to general rule.
[Footnote 5: He marched with his regiment, in the summer, to
Valladolid, and was drowned in the Douro.--G. J. G.]
385. Wounds penetrating the wall of the belly, when made by cutting or
lacerating instruments, or by musket-balls, are usually followed, if
to any extent, by a protrusion of some portion of the contents of the
cavity, generally of the omentum or intestine, if not of both. This
may take place at the rounded orifice of entrance of a ball, as well
as at the more slit-like opening of exit, which, if the patient should
recover, becomes closed by a thin tendinous-like expansion, under the
cicatrix formed by the common integuments. These soon yield to the
general pressure on the abdominal cavity, and admit of the formation
at the part of a ventral rupture, requiring the application of a
restraining bandage.
386. When a piece of omentum only protrudes, the direction given by
the latest writers on surgery is, that it shall be returned into the
cavity of the abdomen whence it came, the finger following to ascertain
that it is quite free; after which the wound is to be carefully closed
by sutures applied close to the peritoneum, so that the omentum
may not again protrude through it. Having objected already to the
manner of employing the suture, I now object to the treatment of the
omentum, and do not approve of its being so dextrously returned by
the finger within the peritoneum to its natural loose situation. I
desire, on the contrary, that it may be retained between the cut edges
of the peritoneum, but without the slightest pressure or possible
strangulation, in order that by its retention it may more readily
adhere to these edges, and thus form a more certain barrier against the
extension of inflammation than is likely to take place when moving
at liberty in the cavity of the abdomen, however closely it may be
supposed to be applied to the inner surface of its paries.
It sometimes happens that a portion of omentum is altogether without
the cavity of the abdomen, and the opening through which it has
protruded seems too small to allow its restoration to the cavity.
The latest authors on this subject recommend a blunt director to be
introduced between the upper edge of the wound and the protruded
part, be it omentum or intestine, or both, upon which a blunt-ended
bistoury is to be passed into the cavity as far as the enlargement of
the wound seems to require, after which the director and the bistoury
are to be withdrawn together. I altogether dissent from this. It is
scarcely ever necessary to enlarge the opening in the peritoneum,
the obstacle to reduction being situated in the tendinous expansion
or aponeurosis of the wall of the belly, a slight division of which
will give sufficient space for the restoration of the protruded part
in almost every instance. I have unavoidably opened into the cavity
of the peritoneum, and have seen it done in other instances, but no
inconvenience follows small openings not exceeding a quarter of an inch
in length, when they are properly covered over by the healthy parts.
It is therefore important in all cases to have as small an opening as
possible in the peritoneum, and certainly no addition should be made to
the size of a small opening if it can by any possibility be avoided,
however indifferent half an inch, more or less, may be in the length of
a large one. All protruded parts, whether omentum or intestine, should
be gently cleansed with warm water, and the fingers of the surgeon
should be wetted in a similar manner, the mesentery being returned
first if protruded, then the intestine, and lastly the omentum; the two
former under all circumstances; the latter not so, if it be adherent
or inflamed, torn or jagged, or in a state of suppuration or gangrene.
It should in these cases be left to itself, and treated in the most
simple manner; a ligature should never be applied to it, neither should
it be spread out and cut off, as was formerly recommended, as it will
gradually retract and be withdrawn into the cavity of the abdomen. If
suppuration should take place in its substance, and the swelling of the
part lead to its constriction, or the formation of matter under the
integuments or between the layers of muscular or tendinous fibers,
these may be carefully divided.
Evan Thomas, aged seventeen, was admitted into the Westminster
Hospital, Sept. 1st, 1828, having been stabbed with a dinner-knife
immediately above the umbilicus; the wound was three-quarters of an
inch long; the omentum protruded and could not be returned until the
skin, cellular membrane, and fascia had been divided; the opening in
the peritoneum was then distinctly seen, against the inside of which
the omentum was left, the wound in the skin being sewed up by the
continuous suture. In the evening he was bled to sixteen ounces, and,
as he had thrown up his dinner, an enema only was administered. On the
2d, the belly being tense and slightly painful, although he was not in
constant pain, the blood drawn before being buffy, twenty-two ounces
more were taken away, a purgative enema administered, and, as the bowel
was not believed to be injured, four grains of calomel and six of the
compound extract of colocynth were given, with a draught of senna and
salts every four hours. 3d. The bowels open; no pain and scarcely
any uneasiness on pressure; abdomen soft. No food; barley-water and
gruel; pulse 84. On the 6th the sutures were removed, the wound having
reunited. He was then made an out-patient, having a comfortable home.
A soldier of the Second Division of Infantry received several stabs
from a lance in different parts of the body, at the battle of Albuhera,
as the lancers rode past him, while lying on the ground, one only being
of any importance: it was on the right side and lower part of the
belly, and through it a portion of omentum protruded. On this being
reduced, the epigastric artery, which had been divided, bled freely; a
ligature was readily applied, and the wound closed by the continuous
suture. The patient, after undergoing a very rigorous treatment,
recovered.
A Spanish soldier was wounded in a scuffle in Madrid, in 1812, at
the gate of the British Hospital, near the Prado, into which he was
brought, with a wound on the right side of the abdomen, near and below
the umbilicus, through which a portion of omentum protruded about
the size of a small orange. As this could not readily be returned, I
carefully enlarged the wound at its under part, some three or four
hours afterward, by dividing the skin, and then found that it was
the aponeurotic or tendinous expansion of the muscles going to form
the sheath of the rectus, which prevented the return of the omentum
into the belly; on the division of this part it slipped back without
difficulty, but as it did not recede further than the peritoneum I
left it there, and closed the wound, which was about an inch long, by
sewing it up in the manner described. He was bled and starved, and was
delivered up to the proper authorities out of danger, with his wound
nearly healed, when the army evacuated the place.
A Spanish soldier was wounded at the battle of Toulouse by a
musket-ball, which passed in on one side and came out at the other,
carrying with it a portion of omentum which gradually became as large
as an orange, in which state I saw it four days after the accident.
Little had been done; he had not suffered much pain, although the
abdomen was tender; he had vomited; passed blood with his motions;
was feverish and ill. I visited this man every three or four days;
he suffered from privations of every kind, yet each time I found him
better. The protruded omentum gradually diminished in size, and was at
last drawn into the wound in the abdomen and covered by granulations.
He left Toulouse before me, nearly well.
If the omentum be greatly bruised or injured it may be cut off, and the
vessels tied if bleeding; but it should not be returned further than
the edges of the peritoneum, over which the external wound is to be
closed.
Ravaton wrote a hundred years ago: “The views of a surgeon must be
very confined who advises the application of a ligature to the omentum
when protruding from the cavity of the belly in a healthy state. It
is a cruel and deadly maneuver, contrary to reason and experience.
To restore it to its place is so simple, just, and reasonable, that
I am surprised it does not occur to every one. The reduction is
easily effected. It is sometimes difficult to retain the reduced part
except by sutures. I admit that when the omentum is strangulated,
gorged with blood, black, and about to become gangrenous, the result
of its restoration to the cavity may be doubted: yet experience has
demonstrated that it is the safest mode of proceeding, taking care not
to close the wound entirely, but to leave an opening at the lower part
to give vent to any effusion or suppuration that may take place.”
387. When a portion of intestine is protruded without being wounded,
it is to be returned, whatever may be its state, unless it be soft
and unresisting between the fingers, of a dull blue or black color,
and to every surgical eye deprived of life or mortified. At any state
previous to this (to Englishmen) almost certainly fatal condition, it
should be restored into the cavity of the abdomen. When a portion of
intestine is thus returned, three directions are given by most modern
surgeons, and especially by Chelius, section 517, on which his English
editor makes no comment; and which may therefore be considered to be
those which are commonly taught in London, but of which I entirely
disapprove. The first is, that the peritoneum is to be divided in cases
where an obstacle is interposed to the return of the intestine; this I
aver to be less necessary for the intestine than for the omentum. The
second is that, “after the reduction, the forefinger must be introduced
into the cavity of the belly in order to ascertain that the intestines
have not passed into the interspaces of the muscles”--a precaution
which is unnecessary, and may do much mischief. The third is, that the
patient is then to be placed “in such a posture as that the intestines
should least press against the wound,” to which direction I object. The
surgeon should certainly take care that the intestine does not pass
between the layers of muscle, nor anywhere else than into the cavity of
the belly. So far, however, from the intestines being pushed away from
the cut peritoneum, the most favorable position for it would be to be
applied against the edges of the cut membrane, and even rising up for
the least possible distance, without or above it, the great object to
be desired being to facilitate adhesion by as perfect an apposition of
these parts as possible, while the external wound is accurately closed
by the continuous suture, and duly supported by adhesive plaster,
compress, and a bandage, provided it be methodically applied. The next
best thing which can happen is that, every part being relaxed, and the
patient perfectly quiescent, the intestine should press so steadily and
yet so gently against the wounded peritoneum that it will be kept in
constant apposition with it without protruding through it.
A soldier of the Artillery was stabbed in two places, in 1812, with a
long knife, by a townsman, late in the evening, and was carried into
the hospital for the sick and wounded French prisoners in Lisbon. The
wound in the belly was situated somewhat more than an inch to the right
side of the umbilicus, and was about an inch in length from above
downward; through it a considerable protrusion of small intestine,
without any omentum, had taken place. This was distended by flatus,
and of a dark-brown color when I first saw it, some time after the
receipt of the injury. The bowel being constricted by the tendinous
expansion of the muscular fibers, the latter was carefully divided by a
blunt-pointed curved bistoury passed under its upper edge, and resting
on the back of the nail of the forefinger, by which the intestine was
guarded; the flatus having been pressed out of the intestine, which
was gently washed with warm water, it was restored to the cavity of
the abdomen. Of the part which had apparently first protruded, the
peritoneal coat and a few fibers of the longitudinal layer of muscle
were divided to the extent of half an inch, the remaining portion of
the gut being unhurt. The skin was then sewed up by a fine continuous
suture, and adhesive plaster and a compress duly applied. A good deal
of alarm was evinced, the pulse was very small, and the man faint.
The other wound was in the back, about half an inch in extent, and
near the inferior angle of the right scapula. It appeared to be a
penetrating wound, but not giving rise to any peculiar symptoms, he
was placed in bed on his back, with his legs raised, and the body
slightly bent. Early the next morning, the officer on duty found it
necessary to bleed him largely, to forty ounces, according to my
directions, on account of pain which had come on in his bowels and in
his back, accompanied by difficulty of breathing, the skin being hot
and the pulse quick and hard. The cellular membrane around the wound
in the back was emphysematous; there was a slight cough, accompanied
by an expectoration slightly tinged with blood. The bleeding removed
the essential symptoms, but the pain and difficulty of breathing
returning next day, it was repeated to eighteen ounces, with an equally
good effect. It was necessary to repeat it on the third, fourth, and
fifth days, when the pain ceased to return, and the pulse, instead
of being small and hard, became softer and fuller. The bowels were
open naturally on the third day, and the emphysema had gradually
disappeared, no food being allowed, and very little drink for some
days, and then only in small quantities of the simplest kind. The
threads were removed with scissors on the sixth day, and the man was
free from complaint, although very weak, at the end of five weeks.
Madame Doucet was applied to a hundred years ago, by a soldier, who
having been struck by a halbert, had a wound made across his abdomen
from above the ilium, through which a quantity of intestine protruded,
which he carried in his hat, enveloped in his shirt. Having had to walk
between three and four miles, in the heat of July, to the old lady, his
bowels were as dry as parchment by the time he arrived. She therefore
bathed them in warm milk and water until they became soft and natural
in appearance, returned them into the cavity of the belly, and sewed
up the wound with a well-waxed silken thread--thus setting an example
which ought to be followed in 1855. The man recovered.
388. When the protruded intestine is wounded, the case is complicated,
and much depends on the size of the wound. A mere puncture, or a
very small cut, is often of no consequence, and does not require any
treatment; the bowel should merely be returned to the cavity of the
belly, and the symptoms of inflammation closely watched, and, if
possible, steadily subdued.
It is advisable, in investigating this subject further, to consider the
abdomen as devoid of cavity during life and health, the contained parts
being so gently pressed upon by the containing and retaining muscular
parietes around as to enable them all to carry on their ordinary
functions, unless suffering from some derangement, exclusive of that
which might arise from a deficiency of the pressure usually exercised
upon them; but that this pressure can, or generally will, prevent the
effusion of the contents of a bowel when ruptured, if the wound be half
an inch in length, or that it will prevent the extravasation of blood
from an artery or vein of moderate dimensions, if torn, is contrary to
facts now considered indisputable, as I have frequently had occasion
to verify. That a mere puncture of the intestine does not allow the
effusion of air, much less of the contents of the bowel, is not
doubted. When the contents of the bowel have been poured out, without
an external opening in the paries through which they might escape,
inflammation and death have ensued at no long distance of time. When
blood is poured out from the great vessels, as in rupture of the liver
or spleen--of which instances will be adduced--the general cavity may
be filled; but when the injury is less extensive, or the lesion less
important, the blood usually gravitates toward the back or sinks into
the pelvis. It is possible that blood may be effused in small quantity,
and be then confined, under the general pressure of the wall of the
abdomen and the resistance offered by its contents, to a particular
spot, whence it may be absorbed after coagulation; or, by commencing
decomposition, give rise to irritation, and be discharged through the
external wound, if one exist, or through the bowel with which it may
happily be in contact.
A soldier, belonging to the Second Division of Infantry, was wounded
by the Polish Lancers at the battle of Albuhera, in several places
slightly, and in the abdomen severely, a penetrating wound having been
made an inch long, between the umbilicus and the crest of the ilium on
the left side. Brought to me the day after at Valverde, the edges of
the wound were stitched together and dressed simply. He said it had
bled freely at first, and was then painful. Treated antiphlogistically
and sharply, the inflammatory symptoms gradually subsided. The bowels
were relieved by gentle aperients, there being no reason to suppose
they had been wounded. A small, oval swelling was soon perceived under
the wound, which was tender to the touch, indicating mischief of some
kind. The edges of the wound, which did not unite fully, although
they were retained in contact, at last separated, and allowed about a
wineglassful of bloody matter to pass out, which reduced the swelling
and removed the uneasiness and pain of which he complained. After this
he gradually recovered, and was discharged to Elvas, and thence to
Lisbon.
389. Whenever large effusions of blood have occurred, the sufferers
have usually been lost, from the occurrence of peritoneal inflammation.
That small ones may be absorbed, cannot be doubted. I have seen
instances of their having been discharged by the bowel, although I have
never been so fortunate as to see a general formation of matter from
effusion, and to have opened the abdomen for the evacuation of its
contents with success; nevertheless, I do contemplate that such cases
may occur, and surgery may come to their relief with good effect.
The important conclusions to be deduced from the observations of
those who have made experiments on the intestines of living animals
are--First, that wounds not exceeding four lines in length, (or the
third part of an inch,) no matter what their direction may be, are not
so apt, as might be supposed, if left to themselves, to be succeeded by
extravasation of the contents of the intestinal tube; and that, in the
majority of cases, nature, properly aided by art, is fully competent to
effect reparation. Secondly, that wounds of the bowels to the extent
of six lines, whether transverse, oblique, or longitudinal, are almost
always, if not invariably, followed by the escape of the contents of
the bowel, and the consequent development of fatal peritonitis. It may,
therefore, be concluded, from experiments made on animals, as far as
they can be relied upon with reference to man, that every wound in the
bowel, of such an extent as shall not admit of its being temporarily
filled up by the protrusion and eversion of its internal or mucous
coat, which always takes place as an effort of nature to close the
wound, ought, if possible, to receive assistance from art, and that can
only be given with advantage in the first instance.
Mr. Travers tied a thin ligature firmly round the duodenum of a living
dog; the ends were cut off, the parts returned, and the external wound
properly closed. On the fifteenth day, the cure being completed, the
dog was killed. A portion of omentum, connected with the duodenum, was
lying within the wound, and the folds contiguous to the tied part of
the intestine adhered to it in several points. A slight depression was
observed around the duodenum, the internal or mucous surface of which
was more vascular than usual; a transverse fissure marked the seat of
the ligature. “The lymph,” Dr. Gross observes, “which is effused upon
the external surface of a bowel, consequent upon such an operation,
gives the part at first a rough, uneven appearance; but, if the animal
survive several months, it is generally no easy matter to determine
the seat of the injury from the external appearance of the part.
Internally, the cicatrization is almost as complete, the continuity of
the mucous membrane being everywhere established, leaving scarcely even
a seam at the original seat of constriction. The rapid manner in which
the ligature cuts its way from without inward obviates the evils which
might arise from the occlusion of the passage. In an experiment, in
which the dog was killed upon the eleventh day after the application of
the ligature, the canal of the bowel was completely restored, and the
bond of connection between the divided parts was firm and organized.”
Similar effects are produced when a small ligature is applied around
the edges of a wound from two to three lines in diameter, provided
it be drawn with sufficient firmness not to slip off. The process of
reparation is not, however, so speedily completed, owing to the breach
being much wider than when a ligature is simply placed around the tube.
The mucous membrane requires a longer period for its reproduction, and
the quantity of lymph deposited around and inclosing the ligature is
proportionally greater.
390. The idea of sewing together, and thereby restoring the continuity
of a wounded bowel, is attributed to four master surgeons, as they were
called, of Paris, in the thirteenth century, who, having united their
efforts for the relief of the sick poor in that city, procured, it is
said, a portion of the trachea of an animal, one end of which they
introduced into the upper part of the divided bowel, and the remaining
piece into the lower, and then brought the divided ends into contact,
and retained them by as many sutures as appeared to be necessary. Their
writings, in which this operation is described, are lost. Peter de
Argelata, who lived about the middle of the fifteenth century, says
that Jemerius, Roger, and Theodoric supported the intestine by a canula
of elder-wood, while Gilbert de Salicetti condemns both the use of the
trachea and the elder-wood tube, and recommends, if anything be used,
that it should be the dry and hardened bowel of some animal. These
ancient surgeons believed that a transverse division of the intestine
was necessarily a fatal injury, and only resorted to the methods they
recommended when the division was less complete. Duverger de Maubeuge,
in the beginning of the eighteenth century, apparently unaware of what
had been done before his time, brought forward this method of the four
masters as an invention of his own. He cut off a portion of mortified
intestine in a case of strangulated hernia, introduced a piece of the
trachea of a calf, brought the divided intestine over it, and fastened
it by a suture. The trachea was passed on the twenty-first day, and the
external wound was closed by the forty-fifth, the patient recovering.
Ramdohr, a German surgeon, who lived in the early part of the last
century, seems to have been the first to join the ends of a divided
bowel by introducing the upper end within the lower. He removed two
feet of mortified intestine in a case of strangulated hernia--performed
this operation on the ends of the bowel, retained the parts by
stitches, and his patient perfectly recovered. Heister says the
mortified parts were in his possession. (Haller, _Disputat. Anatom._,
vol. vi., _Observ. Med. Miscel._, 18.) Since his time, many of the
most eminent surgeons of France, Italy, America, and Great Britain
have turned their attention to this subject; but the conclusion at
which I have arrived is that the continuous suture is, in all cases of
serious injury, the most simple and the best.
391. In making a continuous suture, a fine needle and a waxed silken
thread should be introduced through the gut, beginning on the inside
close to one end of the cut part, and bringing it out on the peritoneal
surface a little more than a line distant from where it entered. The
needle is then to be carried to the opposite side through the bowel
from without inward, and the sewing thus continued until completed,
each stitch being about the sixth part of an inch asunder, and about
that distance from the edge of the cut. The threads or stitches
should not be drawn close until the whole are inserted, when, on
being drawn moderately tight one after another, the cut edge of the
intestine should be turned inward by a blunt probe, so that the
peritoneal surfaces shall be in contact under the stitches and in the
best situation for union, the mucous coat forming a ridge within, the
outside being perfectly smooth, the stitches not being too tight, while
the end may be secured by a knot made by a turn of the thread over the
needle. This done, the intestine should be returned into the cavity
of the abdomen, and events awaited. Recoveries more frequently follow
wounds of the colon than of the jejunum or ilium; but the result must
always be doubtful, being dependent on many causes which the surgeon
can neither foresee nor control.