421.--1. Severe blows on the abdomen give rise to the absorption of
the muscular structures, and the formation of ventral hernia, in
many instances; this may, in some measure, be prevented during the
treatment, by quietude, by the local abstraction of blood, and by the
early use of retaining bandages.
2. Abscesses in the muscular wall of the abdomen, from whatever cause
they arise, should be opened early; for although the peritoneum is
essentially strong by its outer surface, it is but a thin membrane, and
should be aided surgically as much as possible.
3. Severe blows, attended by general concussion, frequently give rise
to rupture of the solid viscera, such as the liver and the spleen,
causing death by hemorrhage. When the hollow viscera are ruptured, such
as the intestines or the bladder, death ensues from inflammation.
4. Incised wounds of the wall of the abdomen to any extent rarely unite
so perfectly (except, perhaps, in the linea alba) as not to give rise
to ventral protrusions of a greater or less extent.
5. As the muscular parts rarely unite in the first instance after being
divided, sutures should never be introduced into these structures.
6. Muscular parts are to be brought into apposition, and so retained
principally by position, aided by a continuous suture through the
integuments only, together with long strips of adhesive plaster,
moderate compression, and sometimes a retaining bandage.
7. Sutures should never be inserted through the whole wall of the
abdomen, and their use in muscular parts under any circumstances is
forbidden; unless the wound, from its very great extent, cannot be
otherwise sufficiently approximated to restrain the protrusion of the
contents of the cavity. The occurrence of such a case is very rare.
8. Purgatives should be eschewed in the early part of the treatment of
penetrating wounds of the abdomen. Enemata are to be preferred.
9. The omentum, when protruded, is to be returned by enlarging the
wound through its aponeurotic parts if necessary, but not through the
peritoneum, in preference to allowing it to remain protruded, or to be
cut off.
10. A punctured intestine requires no immediate treatment. An
intestine, when incised to an extent exceeding the third part of
an inch, should be sewn up by the continuous suture in the manner
recommended, _Aph._ 391.
11. The position of the patient should be inclined toward the wounded
side, to allow the omentum or intestine being closely applied to the
cut edges of the peritoneum. Absolute rest, without the slightest
motion, should be observed. Food and drink should be restricted, when
not entirely forbidden.
12. If the belly swell, and the propriety of allowing extravasated or
effused matters to be evacuated seem to be manifest, the continuous
suture or stitches should be cut across to a certain extent, for the
purpose of giving this relief.
13. If the punctured or incised wound be small, and the extravasation
or effusion within the cavity seem to be great, the wound should be
carefully enlarged, and the offending matter evacuated.
14. A wound should not be closed until it has ceased to bleed, or until
the bleeding vessel has been secured, if it be possible to do so. When
it is not possible so to do, the wound should be closed, and the result
awaited.
15. A gunshot wound penetrating the cavity can never unite, and must
suppurate. If a wounded intestine can be seen or felt, its torn edges
may be cut off, and the clean surfaces united by suture. If the wound
can neither be seen nor felt, it will be sufficient for the moment to
provide for the free discharge of any extravasated or effused matters
which may require removal.
16. A dilatation or enlargement of a wound in the abdomen should never
take place, unless in connection with something within the cavity
rendering it necessary.
17. If the epigastric, circumflexa ilii, or other artery in the wall
of the abdomen, be injured and bleed, the wound should be enlarged,
and the bleeding vessel secured by ligature. If the main trunk or the
external iliac artery be sought for and tied, the patient will in all
probability die.
18. When balls lodge in the bones of the pelvis, they should be
carefully sought for and removed, if it can be done with propriety and
safety.
19. In a wound of the bladder, an elastic gum catheter should be kept
in the urethra, frequently without a stopper, until the wound is
presumed to be healed--unless its presence should prove injurious, from
excess of irritation, not removed by allowing the urine to pass through
it by drops as it is brought into the bladder.
20. In all cases in which a catheter cannot be introduced, in
consequence of the back part of the urethra or the neck of the bladder
being injured, an opening for the discharge of the urine should be made
from the perineum into the bladder. It is essential to the preservation
of life.
21. The treatment of all these injuries must be eminently
antiphlogistic, principally depending on general and local
blood-letting, absolute rest, abstinence from food, and in some cases
almost even from drink, the frequent administration of enemata, and the
early exhibition of mercury, and especially of opium, in the different
ways usually recommended, with reference to the part injured.
422. As the operation for opening into the colon may be necessary,
after an injury of that part, as well as from disease below it, the
following method, recommended by Mr. Hilton, is briefly transcribed
from the Reports of Guy’s Hospital. A line drawn parallel to the
spinous processes directly downward from the angle of the seventh,
eighth, or ninth rib across the costo-iliac space to the crest of
the ilium, will correspond with the outer edge of the erector spinæ
muscle and the apices of the transverse processes. A measured inch
outwardly corresponds with the outer edge of the quadratus lumborum
muscle. A vertical incision, two inches long, made at the extremity
of the measured inch, should divide the skin, cellular tissue, and
the tendon of the internal oblique muscle, and expose the outer edge
of the quadratus lumborum muscle. Any bleeding vessels to be secured.
The last dorsal nerve, if seen lying across the upper part of the
incision, should be divided, to prevent the occurrence of pain from
its being engaged in the cicatrix. The transversalis abdominis muscle
is then to be divided vertically to nearly the same extent of two
inches, parallel to the edge of the quadratus, when a quantity of loose
lobulated fat will be seen, which should be partly removed and partly
displaced by the blunt end of a director, in the vertical direction
of the original incision, when the intestine will be brought into
view. Any bleeding vessels should be secured, and pressure made on
the abdomen, which will cause the intestine to become more prominent
at the bottom of the incision. A silk ligature is now to be passed
into the bowel and through the integuments at the upper part, so as to
fix the intestine above, when a second ligature is to be applied in a
similar manner below. The intestine is then to be opened between them,
care being taken to apply another ligature above and below it, if
the intestine should not appear to be firmly held in its place. If a
vessel in its wall should bleed, it must be tied. Inflammation, pain,
and restlessness should be obviated as far as possible by fomentations,
opiates, and diaphoretics, and strict attention paid to cleanliness and
the comfort of the patient, until the first symptoms have passed away,
and he is able to assume the erect position.
423. These commentaries are restricted to those points which
constitute, in a great degree, what the French call _la haute
chirurgie_. They are published that every soldier should have the
opportunity of knowing how he ought to be treated, when suffering for
a country not too grateful for the services rendered by her bravest
sons; and I have labored with the hope that some few of them, when
they find that their limbs, perhaps their lives, have been saved under
the precepts I have laid down, may acknowledge, when I am beyond that
bourn whence no traveler returns, that they owe them, under the will
of God, to those efforts I, more than any one else, have made, and
continue to make, for the adoption of that practice which led to their
preservation.