SECT. LII.—ON WOUNDS OF THE PERITONEUM, AND ON FALLING DOWN OF THE INTESTINE OR OMENTUM, WHERE GASTRORAPHÉ ALSO IS DESCRIBED: FROM THE WORKS OF GALEN.
How wounds of the peritoneum are to be treated is next to be considered. If then the wound be small, so that the prolapsed intestine being distended with air, cannot be restored to its place, it will be necessary either to evacuate the flatus or enlarge the wound. The former measure is the better, provided one can accomplish it. But how may this be most probably done? By removing the cause which occasions the inflation of the intestine. But what is this? Congelation of the surrounding air; so that the cure is to be performed by heating. Wherefore, having soaked a soft sponge in hot water, and then squeezed it out, foment the intestine therewith. In the meantime let hot austere wine be prepared, for it is more heating than water, and communicates strength to the intestine. If, after having had recourse to all these things, the intestine remain inflated, we must divide as much of the peritoneum as the prolapsed intestine requires. The straight instruments called syringotoma, used for operating upon fistulæ, are very proper for this incision. A recumbent position of the patient is the best when the wound is in the lower part; and when in the right side, he may lie on the left, and when in the left, on the right; and this is common both to great and small wounds. But the replacement of the intestine into its proper place when the wound is large, requires a skilful assistant. For he must take hold of the wound externally with his hands, and contract and compress it a little, so as to expose always a small portion to the sewer, and also must compress moderately what is sewed until the whole is sewed. What is the most proper mode of performing the operation called gastroraphé, we must next explain. Since the abdomen must be united with the peritoneum, we have to begin by passing a needle through the skin from without inwards; but when it has transfixed the skin and the whole rectus muscle, passing by the adjacent peritoneum, we must push the needle from within through the other part of the peritoneum, and so hence from within outwards, through the rest of the abdomen; and when it has passed out we must push the needle again from without inwards through this part of the abdomen, and, passing by the adjacent portion of the peritoneum, and beginning again from the opposite side of this membrane, perforate it from within outwards, and at the same time all the other parts of the abdomen; then beginning again from this, sew it with the opposite membrane, and afterwards transmit it from the neighbouring skin outwards; and do this repeatedly until the whole wound be sewed up. The space between the sutures required to keep the under parts together must be very small, but the interval between those required to keep the skin from falling asunder need not be so small. Excess in either respects must be avoided, and a medium chosen between the two extremes. And a medium is likewise to be observed as to the consistence of the thread, for that which is too hard breaks the soft skin, and what is too soft is itself first broken. In the same manner, passing the needle too near the lips of the wound, occasions often a rupture of the remainder which is too narrow. But if too much is taken in, much of the skin remains ununited. These observations apply to the treatment of all ulcers, but are more especially to be observed in gastroraphé; and, as aforesaid, we must act, forming a conjecture as to the adhesion of the peritoneum with the abdomen, from the circumstance that the latter being membraneous seldom adheres; or, as some do, by bringing together the parts of the same kind; that is to say, peritoneum to peritoneum, and abdomen to abdomen. Or, it may be done thus: in the same manner as above, we must pass a needle from the side of the abdomen nearest us, from without inwards, and through it above; then passing both lips of the peritoneum, we must again turn the needle from without inwards through both lips of the peritoneum, and again turning it from within outwards, pass it through the opposite part of the abdomen. This mode differs from the common and vulgar one, inasmuch as the needle is passed through the four lips at one perforation, and exactly conceals the peritoneum within the abdomen. The proper applications are those formed of the same materials as the applications for recent wounds; but in order that no vital part may be affected sympathetically, some tender wool is to be dipped in moderately hot oil, and the whole space between the groins and armpits wrapped in it. It will be better, also, to evacuate the bowels by a clyster of warm oil. But if any of the intestines be wounded, dark austere wine, in a tepid state, should be injected, more especially if it be perforated quite through. The large intestines are easily cured, but the small ones with difficulty, and the jejunum is utterly incurable, from the multitude of its convolutions and the magnitude of its vessels, and owing to its coats being thin and nervous; besides, it receives all the bile in an undiluted state, and is nearest to the liver. The under and fleshy parts of the stomach we may attempt to cure, for we may succeed, not only because these parts are thicker, but because curative medicines are more readily applied to them, owing to their situation. The parts, however, about the mouth of the stomach and œsophagus are affected by the medicines only in passing down; and the exquisite sensibility of the mouth of the stomach is an obstacle to the cure of wounds of it. When, from a rupture of the peritoneum, the omentum is prolapsed, and either becomes livid or black, the part anterior to the black portion may be included in a ligature, for fear of hemorrhage, and then the part behind the ligature is to be cut off, and the extremities of the ligature allowed to hang from the under part of the sewed wound of the abdomen, in order that they may readily escape when cast off by the suppuration of the wound.
Commentary. The description of gastroraphé here given will be sufficiently intelligible upon an attentive perusal. It is taken from Galen. (Meth. Med. vi, 4.) By abdomen, in this place, is to be understood the abdominal parietes, namely, the skin and muscles. Galen explains that ἐπιγάστριον is used in this sense.
Celsus gives a long description of a somewhat different method of performing gastroraphé. He uses two needles. (vii, 16.)
Several modes of performing the operation are minutely described by Albucasis. He relates the history of a case in which he practised gastroraphé. (ii, 87.)
Haly Abbas recommends the warm bath, to facilitate reduction. The method of performing gastroraphé which he directs, is similar to the suture now practised upon dead bodies after dissections. (Pract. ix, 43.)
Rhases describes various modes of gastroraphé. He speaks of performing the operation with the string of a harp. (Cont. xxviii.) That the strings of the ancient harp were made of the guts of a sheep is clearly proved from the following passage in the Odyssey of Homer:
ὡς ὁτ’ ἀνὴρ φορμίγγος ἐπιστάμενος καὶ ἀοιδῆς
ρηϊδίως ἐτάνυσσε νέῳ ἐπὶ κόλλοπι χορδὴν,
ἄψας ἀμφοτέρωθεν ἐυστρεφὲς ἔντερον οἶὸς.
Οδυσ. φ.
The modes of gastroraphé described by Galen and Celsus are explained and commented upon by Van Swieten (Comment. cccxi), and by Fabricius ab Aquapendente. (Œuv. Chir. ii, 53.) A complete history of the operation is given by Sprengel. (Hist. de la Méd. xviii, 21.) Ambrose Paré performed the operation exactly like Galen.