Part 50
The treatment of this wound, however, was most painful; the extraction of several pieces of bone was necessary at different times, during the three following years, before the wounds were finally closed. Considerable derangement of health followed, the deafness remains; and the general has ever since been subjected to attacks in the head of an increasing and most distressing nature.
369. Wounds of the lower jaw are perhaps more common, and are certainly more troublesome than those of the upper; they are more difficult of management, and, for the most part, end in greater deformity, unless particular care be taken to prevent it, and then only in very severe cases, by operations which were formerly not in use, but which the intrepidity of the surgeons of the present day have deprived of all their terrors. I mean the methodical division of the soft parts, the sawing off and removal of the broken pieces of bone, and the rounding off of those parts of the jaw which may remain irregular and pointed. M. Baudens has given two good examples of the success of this proceeding during his campaigns in Algeria. In the first case, the ball entered at the middle of the left cheek, and came out by the side of the spinous process of the seventh cervical vertebra. The ascending ramus of the lower jaw was broken into numerous splinters. M. Baudens divided the soft parts down to the bone, entering the straight bistoury four lines, or the third of an inch, below the articulation of the jaw with the temporal bone. He then carried it downward, and a little obliquely forward, so as to terminate it in the fibers of the masseter muscle, about half an inch below the base of the bone. This incision was begun below the seventh pair of nerves, and exposed the parotid gland divided vertically at its middle part. The splinters were removed, a part of the pterygoideus internus muscle was divided, and a projecting point of bone attached to it sawn off. He then separated the attachments of the buccinator, temporal, and pterygoideus externus muscles, divided the ligaments, and removed the coronoid and articulating processes, taking care to avoid the fifth and seventh pairs of nerves. The bleeding from two arteries was suppressed by twisting their ends; and the parts were afterward brought together by sutures, which remained for eight days. A month after the operation the patient ate solid food, and in six weeks was cured. In the second case, the ball entered near the left commissure of the lip, and came out behind on the side of the middle of the neck; three inches of the jaw were splintered, the ends of the bone being sharp and angular. In order to remove the splinters, and to prevent the evils anticipated, M. Baudens divided the lip from the angle downward and outward, below the base of the bone, as far back as the edge of the masseter muscle. He then separated the flaps, and sawed the jaw across, first near the symphysis, and then behind, outside the attachment of the masseter. The facial artery was twisted, four sutures were inserted, and the jaw duly supported. The patient was bled twice, and in six weeks was cured; at the end of that time he could eat solid food. After the healing of such wounds, mechanical means are often necessary to enable the sufferer to eat and to live without causing disgust to his neighbors and his friends.
It is said there are fifteen men in the Hôtel des Invalides, in Paris, wearing silver masks on the lower part of their faces, in consequence of injuries of this kind.
Colonel Carleton was an instance of a ball fracturing the jaw directly through its body, near where the masseter muscle is attached on both sides; the jaw was broken into three pieces, besides splinters; several teeth were knocked out, and the tongue very much hurt. By sawing off the splinters both from within and without, and by cleansing and supporting the parts with great care, he recovered after a length of time, the deformity after such a wound being much less than might be expected.
370. Incised wounds of the tongue do sometimes give rise to hemorrhage somewhat difficult to restrain, particularly if it occur a few days after the receipt of the injury, when the tongue is swollen and painful. It does not so frequently occur after gunshot wounds. As the vessels of one side do not communicate with those of the other, any bleeding which continues after the artery of one side has been properly secured, can only take place from a wound of the artery of the other, which must then also be tied. This should be done by drawing the tongue as far as possible out of the mouth by a flat pair of forceps, which may be easily effected at an early period, when it is not tender and painful. At a later date, and under difficult circumstances, various styptics, such as the mineral acids, nitrate of silver, etc., will be useful. The actual cautery has been recommended, but I have never seen it used in such cases.
371. One of the most curious instances of the lodgment of a foreign body in the face occurred in the person of Captain Fritz, at Ceylon; his gun burst in his hand, and drove the iron breech into the forehead, whence it descended into the nares, and, at the end of a year, part of it made its appearance in the mouth, through the palate. He died eight years afterward, having suffered much inconvenience from the offensive discharge it occasioned. When the iron was removed, it had obviously injured no part of any material importance to life. I have seen balls descend in this way into the throat and soft palate, and have removed them from both places with success, and from the hard palate with equal surprise and advantage to the patient. I have known a ball lodge in the superior maxillary sinus for months, and even for years, before it was removed, or the death of the patient proved the fact.
LECTURE XXVII.
STRUCTURE OF AN INTESTINE, ETC.
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.