Part 51
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.
28th.--So far recovered as to be able to be removed to Elvas.[5]
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.