Part 52
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the cavity as far as the enlargement of the wound seems to require, after which the director and the bistoury are to be withdrawn together.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to it, neither should it be spread out and cut off, as was formerly recommended, as it will gradually retract and be withdrawn into the cavity of the abdomen.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.
LECTURE XXVIII.
TREATMENT OF INCISED WOUNDS, ETC.