Part 53
392. When an incised wound in the intestine is not supposed to exceed a third of an inch in length, no interference should take place; for the nature and extent of the injury cannot always be ascertained without the committal of a greater mischief than the injury itself. When the wound in the external parts has been made by an instrument not larger than one-third or from that to half an inch in width, no attempt to probe or to meddle with the wound, for the purpose of examining the intestine, should be permitted. When the external wound has been made by a somewhat broader and longer instrument, it does not necessarily follow that the intestine should be wounded to an equal extent; and unless it protrude, or the contents of the bowel be discharged through the wound, the surgeon will not be warranted in enlarging the wound in the first instance to see what mischief has been done. It may be argued that a wound four inches long has been proved to be oftentimes as little dangerous as a wound one inch in length; yet most people would prefer having the smaller wound, unless it could be believed that the intestine was injured to a considerable extent. Few surgeons, even then, would like to enlarge the wound to ascertain the fact, unless some considerable bleeding or a discharge of fecal matter pointed out the necessity for such an operation. When the wounded bowel protrudes, or the external opening is sufficiently large to enable the surgeon to see or feel the injury by the introduction of his finger, there should be no difficulty as to the mode of proceeding.
393. A puncture or cut which is filled up by the mucous coat so as to be apparently impervious to air does not demand a ligature. An opening which does not appear to be so well filled up as to prevent air and fluids from passing through it cannot usually be less than two lines in length, and should be treated by suture. When the opening is small, a tenaculum may be pushed through both the cut edges, and a small silk ligature passed around, below the tenaculum, so as to include the opening in a circle, a mode of proceeding I have adopted with success in wounds of the internal jugular vein without impairing its continuity; or the opening, if larger, may be closed by two or more continuous stitches made with a very fine needle and silk thread, cut off in both methods close to the bowel, the removal of which from the immediate vicinity of the external wound is little to be apprehended under favorable circumstances. The threads or sutures will be carried into the cavity of the bowel, as has been already stated, if the person survive, and the external part of the wounded bowel will either adhere to the abdominal peritoneum or to one or other of the neighboring parts.
When the intestine is more largely injured in a longitudinal or transverse direction, or is completely divided as far as or beyond the mesentery, the continuous suture is absolutely necessary.
394. When the abdomen has been penetrated, and considerable bleeding takes place, but not from the intestine, it is necessary to look for the wounded vessel. When it comes from one of the mesenteric arteries or from the epigastric, the wound is to be enlarged until the bleeding artery be exposed, when ligatures are to be placed on its divided ends if they both bleed, the external wound being accurately closed. I have seen the epigastric artery tied several times with success.
A Portuguese caçador on picket was wounded at the second siege of Badajos in a sally made by some French cavalry. He had three or four trifling cuts on the head and shoulders, and one across the lower part of the belly on the right side. He bled profusely, and, when brought to me, had lost a considerable quantity of blood which came through a small wound made by the point of a sabre. This wound I enlarged until the wounded but undivided artery became visible; upon this two ligatures were placed, and the external wound was sewed up. The peritoneum was open to a small extent, but the bowel did not protrude; and the patient (not being an Englishman, and therefore not so liable to inflammation) recovered after being sent to Elvas.
A soldier of the same regiment, cut down at the same time, died as soon as he was brought into camp, having been severely wounded in the chest and abdomen. He was said to have died from hemorrhage, from a wound in the belly, two inches in length, made by one of the long-pointed swords of the French dragoons. I had the curiosity to enlarge the wound, and found one of the small intestines had been cut half across, another part injured, and that the blood came from an artery which had been opened by the point of the sword in going through the mesentery, which wound had caused his death.
395. When this operation cannot be done successfully or with advantage to the patient, whose life is in jeopardy from the continued drain, the wound should be closed by suture, and a compress laid over it and retained by a bandage methodically applied for the purpose of aiding the muscular parietes in keeping up that pressure on the viscera which may be useful in arresting the flow of blood from the wounded part. If the bleeding continue, or, having been arrested, should recur, and the belly become in consequence distended, the sutures being evidently so tense as to be likely to cut their way out, or if the blood should ooze out between the stitches, they may be in part removed in order to give immediate relief. When the belly becomes very painful, tense, and manifestly full after a punctured wound, and not tympanitic from the extrication of air or the distention of the bowel by it, the wound should be enlarged to allow the evacuation of the extravasated blood, which cannot be absorbed when in such quantity. The orifice of a small gunshot wound, which is not sufficiently direct to communicate with the cavity and to allow the issue of blood extravasated in the quantity alluded to, should be enlarged to such an extent as to effect that object.
396. Blood effused in moderate quantity, and circumscribed by the pressure exercised upon the contents of the abdomen by its parietes, may readily be evacuated by the wound, provided it be sufficiently open; and the patient may recover, if the inflammation which must necessarily ensue should not be communicated along the peritoneum throughout the cavity, or if it should be subdued in time. If the blood be in small quantity, it coagulates, and may be absorbed; but if in such a quantity as cannot be absorbed, or from any other cause which may prevent its removal by this means, it becomes after a time a source of irritation, and nature sometimes commences early to cut it off from the general cavity by surrounding it with fibrin--a result which, however desirable, can rarely be expected.
When extravasated blood is thus cut off from the general cavity, and cannot be absorbed or be by accident carried off through an opening in the bowel, a change takes place by which it ceases to be bland and harmless, and causes it to excite inflammation and its ordinary consequence, suppuration, if the patient survive so long. This occurs, for the most part, after the first inflammatory symptoms have subsided, from the tenth to the twelfth, or even to a later, day, when the renewal of irritation is accompanied by an increase of the general symptoms, by a more local pain, and by a circumscribed swelling of some part near the wound, in which fluctuation may perhaps be distinguished even during the existence of the general tenderness of the whole abdomen. Under such circumstances, when it is proposed to make an incision into this part, if it should be thought advisable to do such an operation, it may safely be preceded by an exploring needle or a very fine trocar and canula, which will demonstrate the fact of the purulent and sanious depot, without doing in such a case perhaps any mischief, if the expectations of the surgeon should not be realized. If the exploring needle should show that a bloody, purulent, or other fluid is really distending the abdomen, no doubt ought to be entertained about enlarging the original wound and making a depending opening.
Ravaton, in his twenty-fifth observation, relates the case of a soldier who was wounded five days before by the point of a sabre, to the right of the umbilicus. When the man was brought to him, the belly was swollen, hard, and very painful, with vomiting, hiccough, etc., announcing the approach of death. Believing that the abdomen contained a fluid, either effused or secreted, he made an opening into the cavity immediately above Poupart’s ligament or the outside of the internal opening of the ring of the right side, when, finding that nothing came from the cavity, he passed his finger upward along the iliac vessels, and, after tearing up some membranous adhesions, evacuated a pint of coagulated blood and fetid, serous fluid. He then introduced a dossil of lint into the wound to keep it open, fomented and oiled the belly, round which he applied a bandage, and placed the patient on his face. The bad symptoms diminished during the night, and the patient declared himself better in the morning. From the fifth to the tenth day of the wound he was in extreme danger. On the eleventh, the bed was inundated with a purulent matter of an almost insupportable smell. The cavity of the abdomen was injected and cleansed, the ordinary dressings applied, and the greatest cleanliness observed. He was subsequently dressed three times a day in a similar manner; portions of omentum were occasionally drawn away with the forceps. His strength was well supported by every kind of nourishment. The night-sweats continued until the thirty-third day, and on the seventy-second he was discharged from the hospital, cured. The discharge at first was serous, and only became purulent on the sixth day after the operation.
Thomas M’Mahon, 76th Regiment, aged twenty-two, was admitted into the Garrison Hospital, Portsmouth, upon the 13th of June, 1845, with all the symptoms of strangulated inguinal hernia of the left side, of two days’ standing, for which the usual operation was performed. Everything went on favorably till the morning of the fourth day after the operation, when he made a sudden effort to go to the close-stool, which was immediately followed by the descent of a considerable portion of intestine and omentum, accompanied with profuse hemorrhage from a small artery on the surface of the intestine, which was taken up and tied, and the parts returned into the abdominal cavity. The greatest excitement followed, with all the symptoms of acute inflammation. These were treated by general bleeding to the extent of fifty ounces, and sixty leeches to the abdomen, with other antiphlogistic remedies. On the morning of the seventeenth day from the performance of the operation, a piece of intestine came away with the fecal contents of the bowels, after which the patient experienced relief in all his symptoms, and appeared to gain health and strength, and after a time the wound seemed disposed to close, three weeks after the sloughing of the intestine. On the sixth day afterward the evacuations ceased, attended with acute tenderness of the abdomen, which began to swell fast. The means adopted had not the slightest effect, and the patient was considered past relief, unless it could be obtained by an external opening. I accordingly made an incision over the site of the former wound, and carefully opened the intestine, to the extent only to allow the tube of the stomach-pump to be inserted, when there was an immediate discharge of flatus and some feculent matter, and the patient expressed himself relieved. By the further use of the stomach-pump apparatus, I was enabled to extract a quantity of feculent matter by the artificial opening, and after some hours the patient was completely relieved from the dangerous symptoms he was suffering from. The artificial opening was left patent for two months, when the bowels again gave evidence of acting naturally. The artificial wound was not, however, closed till the 22d of August, 1845; a week after the bowels appeared to act freely and naturally.
The patient from this time got well and strong, and was discharged to his duty on the 10th of October, 1845, since which period he continued to perform all the duties of a soldier most efficiently, without experiencing any inconvenience to his general health or constitution, until the 6th of October, 1846, when he died of inflammation of the brain, at Fort George, in Scotland. On dissection, the abdominal viscera, including the intestinal canal, appeared perfectly healthy; but on a minute examination of the portion of small intestine (found to be the ileum) situated in the inguinal region of the side operated upon, directly opposite to the cicatrix of the external wound, it was discovered to be firmly attached to the abdominal parietes, by an adventitious membrane, to the extent of two lines, which then diverged, and formed itself _into a canal of a funnel shape for about five inches and a quarter in length, of a homogeneous structure, which united itself with the continuous intestinal tube_. By this wonderful provision of nature the healthy functions were uninterruptedly carried on, and permanently continued, without any pain or detriment to the patient’s general health. On appearance, Jan. 23d, 1847.
A. Maclean, M.D., late Surgeon, 76th Regiment.
Cases of extravasation or of effusion, terminating by the formation of a sac, pouch, reservoir, or _foyer_ surrounding it, while the rest of the cavity remains free from inflammation, are so rare in natives of our northern climates that I am indisposed to infer that they do take place, except as very accidental circumstances. The fact that such things do take place should be borne in mind, and surgery should not be wanting in giving its aid, under all well-considered and reasonable circumstances. It is easier to do nothing than to think and to act.
The general treatment to be pursued in the acute period of all these cases of inflammation has been sufficiently marked--antiphlogistic to the utmost extent consistent with propriety, by bleeding, leeching, and cupping; the repeated administration of enemata; the early exhibition of mercury and opium, and subsequently of gentle aperients.
397. Continental surgeons, and by pre-eminence Baron Larrey, who is followed on this point by most French surgeons, inculcate the necessity of enlarging the wounds made by a musket-ball in the wall of the belly, although the Baron is particular in confining it to the muscular parts; M. Baudens, one of the latest writers on the subject, points out the additional tendency this gives to the formation of hernia, and furnishes therefore the soundest reason for not doing it without an especial cause. When a slip of the muscular or tendinous structures interferes with the quiescence of the wound; when it is desirable to introduce a finger to make an examination; when it is necessary to divide a portion to allow the restoration of protruded parts, no one will doubt the propriety of the direction. But when neither these nor any other good or sufficient reason can be given for such an operation as that of enlarging the wound (_débridant la plaie_) simply because it has been usual so to do, at the risk of making a large hernial protrusion instead of a smaller one, it is unnecessary. It gives rise to some bleeding, but that is really nothing; it makes a cut instead of a hole, by which nothing essential is gained; and as this enlargement of the wound can always be accomplished when it may become necessary from a sufficient cause, such interference, especially on the fore part or the sides of the abdomen, may be safely omitted.
398. When a musket-ball, passing across the abdomen, comes out behind through the thick muscles of the back, with perhaps a slit-like opening in the skin, through which some urine, and perhaps fecal fluid or matter may also pass, such wounds should be enlarged both superficially and deeply. There is here an object to be gained, and the operation is necessary. There is no objection to its being done when it is even supposed that these fluids or matters are likely to be soon or ultimately discharged through it, as it is desirable that any secretions or effusions which cannot be evacuated by the natural passages should have every reasonable opportunity offered of making their escape.
399. When it is obvious, from internal hemorrhage, or from the discharge of fecal matter, or from the introduction of the finger, by which it can be felt, that a large hole or rent has been made in an intestine, the wound should then be enlarged so as to allow its being brought into sight, when the edges should, if required, be smoothed, and the continuous suture applied in the manner directed, Aph. 391.
400. When a musket-ball penetrates the cavity of the belly, it may pass across in any direction without injuring the intestines or solid viscera. It usually does injure one or the other, and it has been known to lodge without doing much mischief. The symptoms are generally indicated by the parts injured, although in all the general depression and anxiety are remarkable; their continuance marks the extent if not the nature of the mischief.
The following cases of the survivors of hundreds who died under similar wounds, during the war beginning with the battle of Roliça in Portugal, in August, 1808, and ending with that of Waterloo, in June, 1815, may be read with a melancholy interest, as showing what sometimes will happen in a few rare instances, and even then as more dependent on the wantonness of nature than on the united efforts of science and of art.
A soldier of the brigade of heavy cavalry, under General Le Marchant, advancing in line to charge the French infantry at Salamanca, on which occasion the general was killed, was struck by a musket-ball, which entered in front, between the umbilicus and the ilium of the left side and came out behind on the opposite side above the right haunch-bone, thus traversing the body. The bowel protruded in front, but was uninjured, and was easily restored to its place. He remained at the field hospital with me for the first three days and was rigorously treated, as well as afterward in the San Domingo Hospital, where he gradually recovered, and was ultimately sent to the rear.
Captain Slayter Smith, of the 13th Dragoons, being engaged at Campo Mayor, on the 25th of March, 1811, was shot by a pistol-ball, which entered at the left hip, three inches and a half from the junction of the ilium with the sacrum, an inch and a half below its crest, and came out about three inches below the navel, and one inch to its right side. He felt a terrible shock, but did not faint or fall from his horse.
“There was a protrusion of bowel from the wound in front of about three inches; but little blood issued from it. The hemorrhage from the wound in my back was very copious. A French officer, with three or four of his men, were so near me that he called out ‘Rendez vous, mon officier,’ to which I replied, ‘Pas encore, monsieur,’ and rode away with my bowel in my hand.
“I reached the field hospital shortly afterward, when the protrusion was returned without enlarging the orifice, and _no_ stitch was put into the wound then or afterward. It was dressed merely with lint and adhesive plaster. I begged earnestly for a glass of Madeira, which, after a little hesitation on the part of the surgeon, was given to me; but they afterward thought it necessary to bleed me; but little blood followed the insertion of the lancet. This was the _only_ time I was bled. In the morning I found the bed saturated with blood, which had trickled through to the floor, and had escaped from the wound behind.
“Before a month had elapsed I and all the wounded were removed to Elvas on _bullock-cars_, and a desperate journey it was.
“On my arrival, inflammation began in the wound in front, accompanied with great swelling and pain. The swelling was laid open and a quantity of matter was evacuated, followed by an angry-looking protrusion, which was carefully washed with warm water, and poulticed; when the inflammation had subsided, the wound was dressed as before, with lint confined by adhesive plaster. When the protrusion was touched by the hand I experienced a nauseous and disgusting sensation, to which in comparison the application of the knife or lancet was a flea-bite.
“I arrived in England in June, and in September went to Brighton. Soon afterward I felt terrible pains in the _right_ side of my back, in a line with the wound, through the ilium, or rather above it, where a kind of tumor formed. For several days I suffered agony from it; and one night, completely worn out, I fell into a long and deep sleep, and awaking late in the morning I found all pain and excrescence gone, and nothing remaining but a tenderness of the part on pressure with the finger. I underwent much from violent spasms in the stomach, which I never had before I was wounded. I recovered, however, sufficiently to rejoin my regiment the following spring in the Peninsula, and was soon afterward again wounded in a skirmish by a spent shot in the left shoulder, which, however, was of no moment, though I was compelled to return to England on sick leave, in October, 1812, as the spasms increased with greater severity, incapacitating me from doing my duty, and at times rendering me totally helpless.
“I now gradually recovered my health, and in the spring of 1815, accompanied the 10th Hussars to Belgium, and served at Waterloo.
“My health gave way again in 1821, and I certainly was in a precarious state for three or four years, but I gradually recovered, and by dint of great care and attention to diet I am now (1853) in robust health, and can take the strongest exercise with impunity.”
John Richardson, of the 1st Royal Dragoons, was wounded at the battle of Waterloo by a musket-ball, which entered two and a half inches above the umbilicus, and passed out on the left side, close to the lumbar vertebræ. He threw up a considerable quantity of blood, and the stomach was so irritable that nothing would remain on it. He complained of pain, which cut him right across, as he termed it; his eyes were suffused and face flushed; had headache; pulse 130. Thirty ounces of blood were taken from the arm, emollient injections thrown up the rectum, and poultices applied to the wounds.
June 20th.--Some blood came away with the injections during the night; great pain in the right side and shoulder; saline draughts are returned tinged with bile and blood; pulse 130. Bled to sixteen ounces; injections and poultices continued.
21st.--A draught was ejected mixed with blood, and a quantity of bilious fluid; diarrhœa during the night; the feces were mixed with blood; pulse 120; skin hot. Bleeding to twelve ounces; blood sizy.
22d.--Slept a little during the night; had several alvine evacuations of a bilious fluid mixed with blood. The tension of the belly is not so great. He still complains of pain. Tea remains on his stomach. Bleeding to twelve ounces; fomentations and poultices to the belly; chicken and beef broths; injections frequently.
24th.--Feels considerable relief from the tension of the abdomen having subsided; threw up his tea and a quantity of clotted blood this morning.
26th.--Had a bad night; pulse 125, and full. Complains of great pain in the hepatic region, and backward toward the spine. Bleeding to sixteen ounces. ℞.--Hydrarg. chlorid. gr. iv; conf. rosæ. gr. ix; to be made into two pills, one to be taken twice a day.
30th.--Vomiting in the night, mixed with blood; tea, etc. remain on the stomach this morning; pulse 108.