Part 54
July 5th.--The adnatæ have a yellow tinge; in other respects he is doing well. ℞.--Chlorid. hydrarg. gr. x; extr. colocynth. comp. ʒj: to be made into ten pills, one to be taken three times a day.
20th.--The wound perfectly healed; is cleaning his accoutrements, boots, etc. Was discharged on the 28th of July, perfectly recovered.
Owen M’Caffrey, aged thirty-three, first battalion 95th Regiment, was wounded on the 18th of June at the battle of Waterloo, by a musket-ball, which penetrated the cavity of the abdomen on the right side, about midway between the superior anterior spinous process of the ilium and the linea alba. When admitted into the Minimes General Hospital three days after, he was in the most deplorable state; the whole abdomen was tense and exquisitely tender; the pulse small and wiry; vomiting incessant, with hiccough and ghastly visage. From this period to the 24th, he was thrice largely blooded, and the strictest antiphlogistic plan was laid down and rigidly adhered to. Laxative injections were administered, the whole of the abdomen was frequently fomented, and opiates were administered to allay the irritability of the stomach, and to procure ease and rest. On the 25th the wounded intestine sloughed, and the feces escaped by the external orifice, _the adherence of the two surfaces of the peritoneum_ preventing any, even the smallest portion, getting into the cavity of the abdomen.
26th.--The high inflammatory action having been reduced, milk, rice, and sugar, and the farinaceous part of the potato were allowed.
July 1st.--No very alarming symptom remains. Half a fowl ordered for his dinner, and the greatest attention to personal cleanliness directed to be paid.
7th.--Strength slowly but gradually returning. The action of the large intestines is daily kept up by stimulating injections.
14th.--Progress to recovery satisfactory. The injections are daily repeated, and the discharge by the natural passage increases. The wound contracts and looks healthy. Is enabled to sit up, and has recovered his cheerfulness.
28th.--Still improving; ultimately recovered.
The situation of the ball was never ascertained.
A soldier of la Jeune Garde Imperiale was struck by a ball, which entered to the right and a little below the umbilicus and passed out on the left or opposite side, about two inches above the crest of the ilium. It was supposed to have passed along the canal of the great arch of the colon. Fecal matter, much tinged with bile, passed by both openings. The symptoms of inflammation were severe for the first few days, but gradually yielded to the means employed, when the bowels began to act regularly by the aid of mild injections, and the discharge from the wounds gradually lessened; the man was much reduced, but otherwise in good health, and was sent to France from Brussels, nearly well.
A soldier of the Third Division of Infantry was wounded during the assault of Ciudad Rodrigo, by a ball which entered and lodged in the left side of the back, about midway between the spine and a line drawn to the upper part of the crest of the ilium, from which opening the contents of the bowel were discharged. Left among the dead and those who were supposed to be dying at the field hospital, in the rear of the trenches, I sent him, with all those of different corps who were wounded, to my own hospital at Aldea Gallega, some ten miles off. Here, under a sufficiently vigorous treatment, of which bleeding, starvation, and quietude were the prominent features, he gradually recovered. On the fifth day the ball passed per anum, and on two or three different occasions afterward portions of his coat, flannel shirt, and breeches. Fecal matter passed readily through the wound, while the bowels were gently solicited by common injections for some time; but the wound gradually closed in, and the man regained his health, and was sent to the rear with a slight colored discharge from the wound, not quite free from odor.
Ensign Wright, 61st Regiment, was wounded by a musket-ball, on the morning of the 10th of April, at Toulouse. The ball passed through the abdominal parietes on the right of the linea alba, nearly half way betwixt the umbilicus and the pubes, and lodged. Sense of debility, tremor, nausea, small, feeble pulse, and pain in the lower part of the abdomen were the immediate symptoms.
Peritonitic and enteritic symptoms of considerable violence having begun to manifest themselves on the 11th, copious and repeated evacuations of blood were made by order of Mr. Guthrie, the Deputy Inspector-General in charge of all the wounded. Fomentations were applied to the belly; abstinence in food and drink was strictly enjoined, and the most rigid antiphlogistic regimen followed. The same practice was pursued during the 12th, 13th, and 14th, venesection being performed either two or three times every day, as the augmented state of the local and general inflammatory symptoms seemed to require. The bowels during the above period had continued perfectly free, and the dejections were tolerably natural in color, but rather dark, and extremely fetid. He had been frequently troubled with nausea and vomiting of bilious matter. Two small doses of castor-oil had been exhibited.
Toast and water, tea, boiled milk-and-water, with a little soft bread soaked in it, and mutton and chicken-broth in small quantities at a time, were all that was allowed him for food and drink.
April 15th.--Pulse above 100, weak and small; temperature natural; the tongue clean. Continued affected with a degree of nausea and vomiting, after drinks especially; and some diarrhœa was present.
17th.--Was bled last night to twelve ounces, in consequence of increased pain of abdomen and augmented pyrexia; to-day quiet and easy, and has had several stools.
18th.--Diarrhœa and tenesmus troublesome during the night; _ball voided with the feces at six_ A.M.; it is somewhat flattened, as if from impinging on a stone; has felt easy since. Continue antiphlogistic regimen.
19th.--Diarrhœa abated; but the abdomen is tense and painful on pressure. He is distressed with nausea and vomiting; pulse 100, and sharp; great thirst; tongue dry. Bleeding to sixteen ounces; abdomen fomented.
20th.--Bleeding was repeated last night from persistence of the symptoms of peritonitis. Blood drawn very buffy; has had several loose stools during the night. He is to-day easy; abdomen now scarcely painful. Fomentations continued.
29th.--This morning the abdomen was tense and painful on pressure; he was affected with nausea, and had had vomiting repeatedly during the night; thirst and pyrexia. Fomentations were applied from time to time, and yielded relief. Suspect that he has not observed the prescribed regimen.
May 1st.--Pain of abdomen and bilious vomitings during the night; has had three loose stools. Pulse 110, hard and small; thirst urgent. Blood let to fainting; fomentations continued.
2d.--Last night he was again bled to two ounces, when fainting supervened. He passed a quiet night; had two liquid stools; abdomen not painful, nor is he sick at stomach, nor thirsty. To keep himself warm, particularly the belly.
11th.--Suspect he has been rather irregular in diet. Passed a bad night, partly in delirium; has vomited much; has obviously pain on pressure of the abdomen, but appears studious to conceal it; pulse 112, small and not soft; temperature increased; tongue red; thirsty; three liquid stools. The stomach to be kept warm; ten drops of tincture of digitalis in half an ounce of mist. acaciæ, to be taken three times a day; diet of milk and farinaceous food; for drink, infusion of tea in small quantities. Eight o’clock.--Pulse 120, soft; feels easier, and has not vomited. Ordered a foot-bath.
13th.--Molested by pains, nausea, and vomiting during the night; pulse 110, not soft; skin cool, but is thirsty, and his tongue is of a vermilion color, and arid; confesses that he has hitherto disguised his feelings, as well as other circumstances connected with his case, particularly his manner of living. Digitalis continued; blister to be applied to the epigastric region, and the foot-bath repeated in the evening.
14th.--Bad night; pulse 112; skin hot; pain of abdomen not urgent; no vomiting, but is affected with nausea. Digitalis continued. Four o’clock.--Pulse 100; feels nauseated; no pain of abdomen. Digitalis occasionally.
16th. Eight A.M.--The tendency to vomit continues. One grain and a half of chloride of mercury with a grain and a half of opium, made into a pill, to be taken in the morning; to be bled. Seven P.M.--Vomits whatever he swallows in any quantity; skin hot; thirst great; tongue red; two motions; says abdomen is not painful; pulse 112. A blister to be again applied to the epigastrium; foot-bath in the evening; repeat the mucilaginous mixture for cough.
17th.--Rested ill; blister has not risen; cough has been severe and continues so; two motions; pulse 120, and not soft; cough augmented by deep inspiration, and pain produced. Take blood from the arm to eight ounces; foot-bath in the evening; continue pill.
18th.--Bad night; cough gone; respiration easy; pulse 100; skin cool and moist; no thirst; one motion of a natural kind. Repeat mucilage and the calomel and opium pill.
24th.--Has this morning experienced a severe attack of dyspnœa, attended by cough and pain of chest, both increased by full inspiration. Pulse 120; face flushed; says he caught cold from exposure to the night air. Bled immediately, and as much blood taken as his strength would permit; foot-bath repeated in the evening.
25th.--Six ounces of blood drawn; surface buffy; bad night; cough, pain, and pyrexia abated this morning; in the evening severe dyspnœa; cough and pain of chest have recurred; pulse 120. Six ounces of blood to be drawn, should strength permit; mucilaginous mixture to be continued; another blister to be applied to the chest.
28th.--In a fair way of recovery; was discharged for England in June, with little or no complaint.
John Murray, Surgeon to the Forces.
Sergeant Matthews, of the 28th Regiment, was wounded at Waterloo by a musket-ball, about an inch below the umbilicus, a little to the right side, which lodged. He walked to a village in the rear, where he remained for three days, having been bled each day to fainting, before he was removed to Brussels, where my attention was particularly attracted to him, in consequence of his having passed the ball (a small rifle one) per anum, three days after his arrival, or the sixth from the receipt of the wound. The wound was healed by the end of August; and he felt so well that he marched to Paris with other convalescents, to joint his regiment. After some weeks he got drunk, and suffered from an attack of pain in the bowels, in the situation of the wound, requiring active treatment. On attempting one day to have a motion, he found, after many efforts, that something blocked up the anus, and on taking hold of and drawing it out, he found it was a portion of the waistband of his breeches, including a part of the button-hole--a fact verified by Staff-Surgeon Dease, who wrote to me an account of this peculiar case. After this the man recovered without further difficulty, although, as in all such cases, there was a herniary projection. He was afterward subject to costiveness, to pain in the part after a copious meal, probably from the stretching of the adhesions formed between the intestine and the abdominal peritoneum, which inclined him to bend his body forward to obtain relief.
In all such cases, the extraneous substance having lodged, and mainly injured in all probability the vitality of the part which assists in the lodgment, the ball becomes covered with a layer of coagulable lymph or fiber, capable of retaining it in its new situation, whence it is gradually removed by ulceration, or by the sloughing of the injured parts into the cavity of the bowel; much in the same manner as an abscess in the liver is evacuated into the duodenum or neighboring intestine, to which it may become attached. It is always fortunate when the canal from the external wound is cut off by the deposition of lymph, as it expedites the cure, and renders the injury less formidable; but if this should not take place, the contents of the bowel are discharged through it for a greater or shorter length of time, until the canal between the parts gradually closes, and cicatrization takes place, in default of which an artificial anus may remain in addition to the natural one, the functions of the bowels generally being performed with more or less difficulty.
The two following very interesting cases of abdominal injury having been received while these pages were passing through the press, are here inserted:--
A man in the 19th Regiment was wounded through the abdomen, and survived nineteen hours, the ball entering near to the umbilicus, and passing out close to the sacrum. On the post-mortem examination, the small intestines were found to have been wounded no less than sixteen times by the ball in its passage. When wounded, he was stooping in the act of defecation.
T. Alexander, Deputy Inspector-General.
_5th August, 1855._
On the evening after the battle of Alma, as my regiment was halting on the brow of a hill, previous to bivouacking, a wounded Russian officer, apparently in great pain, was perceived on the other side of the ravine. Passing over to where he lay, I found that he had been wounded by a musket-ball, that had entered the lumbar region directly over the spine. As he was enabled in his agony to crawl on his hands and knees, it was evident there was no paralysis, and on passing a probe I found the ball had avoided the spine, but as I could not pass in the instrument more than an inch, I was left in uncertainty as to its further course.
He was removed to my hospital tent, when I tried, but with little success, to remove the excessive pain from which he was suffering. In about two hours after he took my finger and placed it on a hard substance imbedded in the walls of the abdomen, and on cutting down on this I perceived a musket-ball. Previous to extracting it, however, I observed a white, glistening substance oozing from the wound, which, on carefully removing with the probe, proved to be a portion of tape-worm, about a yard and a half in length. I then extracted the ball, and again another portion of the worm presented, which measured about two yards and a half in length. It was now complete, though cut in two evidently by the ball, and the two portions, one containing the head and the other the tail, were soon writhing on the table.
The patient experienced immediate relief; the pain had ceased; he slept well, and on the following morning he was free from thirst, with a tolerably quiet pulse. Unfortunately the order arrived for all prisoners and wounded to be sent to the rear, and I lost sight of the case.
What was the cause of this agony of pain? Evidently the writhing of the worm, or why should it so suddenly cease on the worm’s liberation? The abdomen must have been entered by the ball, or how could the worm’s exit have been effected? Nevertheless, but for its presence, the patient was so free from constitutional symptoms on the following morning that a surmise might really have arisen that the ball had passed round the abdomen without injury to the peritoneum.
Rt. De Lisle, Surgeon, 4th K. O. Regiment.
_Camp before Sebastopol, August 8th, 1855._
LECTURE XXIX.
ABNORMAL OR ARTIFICIAL ANUS, ETC.
401. In some cases of wounds of the intestine the continuity of the bowel is not sufficiently re-established; the external wound remains open, and becomes indurated and fistulous, giving passage to the fecal matters, and rendering the sufferers very miserable. These cases are of rare occurrence among the hardy natives of Great Britain and Ireland, and comparatively little has been done or even recommended in this country for the relief of this misfortune.
When an intestine has lost a more or less considerable part of its substance at a particular spot, and an artificial anus is about to be formed, it adheres to the peritoneum around the inside of the external wound, although the adhesion is of little extent or width, and forms but a narrow barrier for the protection of the cavity of the abdomen. The upper end of the bowel is more open than the lower, the caliber of which is contracted in size, and is sometimes even difficult to find; while its opening is partially closed by a sort of septum extending across, or from where the two portions of a divided gut have come irregularly in contact with each other by their sides, without uniting in the first instance in their length; or from the falling in especially of the posterior part of the lower end, to which the upper has become united. The projection thus formed in the tube is called by the French _eperon_ or _promontoire_, valve or spur, ridge or septum; it directs the fecal matter through the external wound, while it obstructs its passage into the lower part of the bowel. There is generally great difficulty in ascertaining the fact of the existence and exact situation of this valve during life; in distinguishing the upper from the lower end of the intestine, as well as the nature and extent of the adhesions by which the injured intestine is retained in its situation. If the absence of such a valve can be satisfactorily made out--and it is sometimes wanting--the external opening may be successfully closed by compression, or by operation. If the valve should exist, its removal by a preliminary operation is necessary; it has been attempted in France with various but somewhat doubtful success.
402. When a portion of small intestine has been lost by mortification or otherwise, and the patient has recovered with an unnaturally situated or artificial anus, the intestine, although at first in contact with the wall of the abdomen, is gradually, in many cases though not in all, retracted into the cavity--it has been supposed by the dragging of the mesentery upon it at the point of union of the divided extremities outside where the _eperon_ or valve is formed; and it is said that this dragging has even led to the gradual disappearance of the valve, admitting thereby of the contents passing more readily from the upper part of the intestine into the lower, and consequently laying the foundation for a cure. This dragging of the intestine, or its movements under the different motions of the body, in some cases cause an elongation of the membrane formed under the adhesive process, by which the intestine is attached to the inside of the wall of the abdomen in the same manner as adhesions are elongated between the pleuræ, and a sac or pouch is thus formed between the cut ends of the intestine and the fistulous external opening which Scarpa was the first fully to demonstrate and explain, and which he called an _entonnoir_, _infundibulum_, or funnel. If, then, in an old case, a small portion of the wall of the abdomen be removed in the form of a V, the internal opening at the apex of the V, if small, would be made into a sort of funnel, while the outer incision would remove all the hardened fistulous parts--an operation which is sometimes required to be done when the external opening is not free, and fecal matters have insinuated themselves between the aponeurotic parts, giving rise to abscesses and other small fistulous openings in different directions. It is necessary to bear the formation of this pouch in mind as well as that of the valve, in order to understand the operations proposed for the relief or cure of this complaint.
If simple compression fail in the first instance to prevent the passage of the feces, which never can be thoroughly controlled from the want of a sphincter and the uncertainty of pressure, the method of Desault may be adopted. This consists in gradually dilating the external wound so as to enable the operator to discover the open ends of the bowel, when a tent is to be introduced into the lower end, and afterward into the upper, being fastened by a thread passed around its middle. A pyramidal-shaped pad is then to be placed over the opening, and compression made by bandage upon it so as to press the whole inward. The size of the tent is to be gradually enlarged until the contents of the gut begin to pass downward with ease, when a well adjusted pressure is to be made on the fistulous opening only, to prevent all oozing from it until the internal parts have had time to close.
403. Dupuytren invented a pair of forceps, consisting of a male and female branch, to be applied separately, one on each side of the valve or _eperon_, to the extent of an inch or an inch and a half at most, when they were to be closed by a screw until they had compressed the part between them sufficiently to destroy its life. The separation of the valve included within the forceps would take place by the usual processes of ulceration in its immediate proximity, and by adhesion of the parts external to the bowels to those surrounding them. The inflammation, however, did not always stop at the adhesive stage, and death has been the result as well as a successful cure.
404. Mr. Trant has invented an instrument he calls a propeller, for pressing back the eperon, an account of which is given in the _Dublin Medical Press_, May 14th, 1845. He used this in one case with complete success. The instrument by its formation admits of being passed through the artificial anus, and of being placed on the _eperon_ at the bottom of the wound, where it can be retained for a considerable time without producing the slightest inconvenience. It does not, while in the intestines, offer any obstruction to the passage of the fecal matters flowing along the cavity of the tube. It acts as a forceps in retaining the anterior wall of the intestine in close contact with the posterior surface of the abdominal parietes, while the propeller is pressing back the _eperon_ toward the spine; consequently the danger of separating the delicate adhesions in this situation is prevented, otherwise a fatal extravasation into the cavity of the abdomen might ensue. The instrument was made by Mr. Reed, of Dublin, and merits further trial, being apparently less dangerous than the other methods recommended in similar cases. Whatever may be the method employed for the cure of an artificial anus by operation, it cannot be doubted that the patient must be exposed to all the dangers which may result from inflammation, for which he must be prepared beforehand, and the symptoms of which must be met and subdued as they arise; or, if this cannot be accomplished, the mechanical means, if any be used that can be taken away, must be removed, and quiet, if possible, restored by their abstraction and by the treatment adopted. In successful cases, a small aperture will frequently remain, constituting a fecal fistula instead of an artificial anus. This will sometimes become irritable, inflame, ulcerate, or burst, discharging the solid contents of the bowel, although, on the subsidence of the irritation, the part under pressure usually returns to its former state.
405. _Wounds and injuries of the liver_, whether incised or penetrating, occurring from blows or from musket-balls, are very serious, although not _necessarily_ fatal. Some few persons recover altogether, some few with more or less of permanent disability. The remainder die during the first or inflammatory stage, or in the secondary one, which follows from the twelfth or fourteenth day after the primary symptoms have in some measure subsided.