Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE XXVII.

STRUCTURE OF AN INTESTINE, ETC.

372. If an intestine be divided circularly in any part, its walls will be found to be composed of three principal coats or tunics, which are—commencing from the inside—the mucous, the muscular, and the serous or peritoneal, each being separated from the other by a layer of areolar tissue. A diagram thus made would show a transverse division of the intestine, and eight distinct if not all different parts. Beginning from without, viz., serous or peritoneal, areolar or sub-serous; longitudinal muscular, areolar; transverse muscular, areolar or sub-mucous, and epithelial. The mucous coat in man has a peculiarity not observable in animals, of ledges or shelves projecting into its cavity.

When the mucous coat of the duodenum is examined with the naked eye, the first part of its course presents a tolerably smooth appearance, gradually, however, becoming irregular in transverse folds, which are so numerous, marked, and regular in the jejunum and ileum as to have obtained from the earliest times the name of valvulæ conniventes. They are most strongly marked in the jejunum, and gradually disappear toward the lower part of the ileum, the inner surface of the large intestines being still smoother than any part of the small, although large pouches or cells are formed in the colon by a peculiar arrangement of the muscular coat. These valves never extend completely round the inside of the intestine, and rarely more than half or two-thirds, although they sometimes bifurcate. They have a velvety appearance, which has obtained for this coat the name of villous as well as that of mucous.

Valvulæ conniventes are peculiar to man; none exist in the ourang-outang or chimpanzee. In the frog there are valvular folds, appearing, at first sight, like the valvulæ conniventes of the human subject; but, on a careful examination, they are found to be mere elevations, without villi. In the tortoise there are similar folds, running however in a longitudinal or opposite direction. In the rhinoceros the mucous membrane is raised up into villiform processes, somewhat like the valvulæ conniventes, or large villi; but they are not villi, as each process is covered with other projections which really are villi. A valvula connivens consists of two layers of mucous membrane and sub-mucous tissue, but the muscular coat is not continued into it.

373. When examined microscopically, the velvety appearance is found to consist of innumerable small processes which have been called villi, each villus being composed principally of a very thin, transparent basement or germinal membrane, forming a sheath or case, inclosing within it an artery, a vein, a capillary plexus, and an absorbent vessel termed lacteal. A nerve has not been discovered, although it is presumed to exist. These villi are longest in the duodenum, and gradually diminish in number and in size from 1/25 to 1/50 of an inch. Between these villi or projections, holes or openings are observable, termed the follicles of Lieberkühn, who first described them; they resemble inverted villi, being in some instances as deep as the villi are long. Unlike the villi, they are found throughout the intestines. The villi in every part in common with all mucous membranes are covered, and the follicles are lined by epithelium, which in this instance is the columnar, situated on the basement membrane, each column being attached by its pointed extremity. A layer of this epithelium extends between the villi, down to the lower part of each follicle, each column being, generally speaking, shorter and rounder than when covering the villi.

The office of the epithelium of the villi has been stated to be protective, that of the follicles to be secretive. A villus, when duly magnified, is seen to have a bulbous extremity without an opening, and to be covered by epithelium when the intestine is in a state of quiescence, uncalled upon for any purpose of digestion. When digestion commences, the epithelium, according to the researches of Mr. Goodsir, is separated and thrown off. As the chyme begins to pass along the small intestine, an increased quantity of blood circulates in the capillaries of the gut. In consequence of this increased flow of blood, or from some other cause, the internal surface of the gut throws off the epithelium of both villi and follicles, which is intermixed with the chyme in the cavity of the gut. The cast-off epithelium, forming 19/20ths of the covering of the villus, is of two kinds, that which covers the villi, and which from the duty it performs may be termed protective, and that which lines the follicles and may be termed secretive, each column having a nucleus situated at some part of it, and bulging out that part.

The villi being now turgid with blood, erected and naked, and covered by the chyme mingled with the cast-off epithelia, commence their functions. The summit of the villus becomes at first somewhat flattened and crowded under the basement membrane with a number of newly-formed and perfectly spherical vesicles, varying from 1000 to less than 2000 of an inch in size. Toward the body of the villus or the inner edge of the vesicular mass, minute granular or oily particles are situated in great numbers, and gradually pass into the granular texture of the substance of the villus. As the process advances lacteal vessels are shown passing up from the root of the villus, subdividing and looping as they approach the spherical mass, which in this stage has become more distinctly vesicular, although no distinct communication can be detected between them. The blood-vessels and capillaries shown in injected preparations are now seen colored red with their own blood, and running up to the basement membrane, looping with each other immediately beneath it, and ending in one or more venous trunks. The vesicles, quite distended and grouped in masses, push forward the membrane, and give to it by these inequalities an appearance resembling that of a mulberry.

The minute vesicles above noticed fulfill the important office of absorption, by drawing into their cavities through their walls, by a process called endosmosis, that portion of the chyme necessary to form chyle; when filled with it they burst or dissolve, their contents being thus discharged into the texture or substance of the villus, fit to be taken up by the granular vesicles interspersed among the terminal loops of the lacteals, and communicating with their trunks, running up from the root of the villus in their center. Absorption is thus shown to be effected by closed vesicles, and not by vessels opening on the surface of the villus.

The débris and the contents of the dissolved chyle cells, etc. pass into the looped net-work of lacteals, as in other lymphatics. When the gut contains no more chyme, the flow of blood to the mucous membrane diminishes, the development of new vesicles ceases, the lacteals empty themselves, the villi become flaccid, and the cast-off epithelium is reproduced, apparently from the nuclei in the basement membrane, in the intervals of digestion, showing that this function should only be induced at regular periods, the presumed special use of the epithelium being to prevent, in a measure, the absorption of any effete or other matters which might exert a deleterious influence oh the system, the epithelium of the follicles now secreting a mucus which may be considered protective.

In the large intestines there are no villi, but the whole surface is covered with follicles which must be capable of absorbing as well as of secreting, as it is ascertained that persons can be nourished and kept alive for many weeks by nutritious enemata which do not pass into the small intestines.

374. On examining the mucous membrane of the stomach, its follicular structure is immediately seen, the follicles resembling much in appearance those of the intestine; but in the stomach minute tubes are found opening into the bottom of each follicle, fulfilling in all probability a different office, the follicles being lined by columnar epithelium, the tubes by spheroidal or glandular epithelium; it is therefore presumed that the gastric juice is secreted by the tubes, the mucus by the follicles. The tubes differ in the middle and lower parts of the stomach, by being longer or more deeply seated, and more numerous as they approach the pylorus, showing in all probability a difference of function between the upper and middle, and the pyloric or lower extremity of the organ.

The intestines are supplied with glands, not apparently for the purposes of absorption, but of secretion; these require attention. They are the duodenal of Brunner, the agminated of our countryman, Nehemiah Grew, and of Peyer, and the solitary, which are found in the lower part of the small and in the whole course of the large intestines.

The glands of Brunner are situated at the commencement of the duodenum, within an inch of the pylorus, and are not visible until the serous and muscular coats have been removed from without. They appear to the naked eye like the little white eggs of an insect. Under the microscope each little gland is found to be lobulated, very much resembling a small portion of a salivary gland or pancreas, each lobule having an excretory duct, which unites with those from other lobules to form one larger one opening on the mucous surface of the bowel. The lobules themselves are made up of vesicles, within which the secretory cells are discernible.

The agminated glands of Grew and Peyer, by the latter of whom they were more minutely described, occur in oval patches at irregular distances throughout the jejunum and ileum, and are situated on the side immediately opposite the part where the mesentery is united to the bowel. Each gland resembles somewhat a Florence oil-flask in shape, the small end or mouth, which is more or less pointed, projecting through among the villi or the follicles. They are composed of cells, supplied by capillary vessels, which Mr. Quekett says have the peculiarity of being unsupported by areolar tissue, and are termed by him, in consequence, naked. These are the glands which are found more or less diseased after phthisis and fevers which have terminated fatally. The oval form of the patches is retained, although considerably raised above the general surface of the mucous membrane, and when injected the parts around are more vascular, the ulcerated portion being less so than usual.

The solitary glands are best seen in the cœcum and appendix vermiformis. They are well developed in the fœtus, projecting slightly above the mucous membrane. Each gland may be considered as one of the agminated form much enlarged, and when the free surface is very flat, an opening may be easily seen in the center. These glands also are frequently the seat of ulceration in fever and dysentery, and particularly in phthisis. The follicles partake of this disease, and the whole mucous coat may be destroyed. In some cases there is an attempt at healing, and the edges of the ulcers become more vascular and even villous.

The sub-mucous areolar tissue—the tunica nervosa of Haller, the fibrous lamella of Cruveilhier—separating yet connecting the mucous with the muscular coat of the intestine, is composed of the yellow elastic and of the white or non-elastic fibers, the latter of which predominate. It is more firmly connected with the mucous than with the muscular coat, and in it the blood-vessels and nerves are supported prior to their distribution in the mucous membrane. This sub-mucous tissue or structure prevails also in the stomach, and is often much altered by disease, becoming thicker, and assuming a more dense and sometimes an almost gristly hardness. It is an important part in the surgical treatment of wounds of the intestines, being firmer, stronger, and more elastic in reptiles, and more distinct in carnivorous than in herbivorous animals or in man.

375. The muscular coat of the intestines is in two layers, the internal being composed of fibers running transversely, the outer fibers running longitudinally; they are thickest in the duodenum and rectum. They are of the involuntary or unstriped kind, as opposed to the voluntary or striped, which are of large size, and characterized by striæ running transversely and longitudinally.

The involuntary fibers, on the contrary, are much smaller in size, are always more or less flattened, and present no trace of striæ or stripes, although the interior appears granular, with an occasional nucleus. The heart is a remarkable exception to this rule, being an involuntary organ, with striped fibers differing in size, resembling in this respect those of a voluntary muscle.

The peritoneal coat is formed of the white fibers, under a structureless or basement membrane, covered by tesselated epithelium, constituting a serous and secreting membrane.

376. Wounds and injuries of the abdomen are essentially of three kinds—1. Affecting the paries or wall. 2. Opening or extending into its cavity. 3. Wounding or injuring its contents.

The wall of the belly is, when severely hurt, liable to a permanent defect, as the ordinary result of a severe bruise. It is the formation of a ventral rupture. A division of the wall to any extent by a sharp-cutting instrument is usually followed by a similar consequence; and it never fails to occur in the openings made by a musket-ball penetrating into or passing through the cavity.

Captain Tarleton, of the 7th or Royal Fusiliers, was struck on the left iliac region by a large, flat piece of shell, at the battle of Albuhera, in 1811. The surface was not abraded, although the iron caused a very severe and painful bruise; the whole of that side of the belly became quite black, and the remaining part much discolored. Some months afterward he drew my attention to the part, and I then found that the whole of the muscular portion of the wall had been removed by absorption to the extent of the immediate injury from the piece of shell, the tendinous parts alone remaining under the integuments. These protruded on any effort, constituting a circular-shaped ventral rupture, with a large base, which required the application of a pad and bandage for its repression.

Mr. Smith, a deputy-purveyor, received a blow on the side of the fore part of the belly from the end of a spanker-boom, which knocked him down, and gave rise for some time to much inconvenience. He showed the part to me in Lisbon, in 1813, in consequence of the formation of a ventral hernia to the extent of the spot originally injured. In neither of these cases was such a result expected; no rupture of the fibers of the muscles was distinguished at the time, and it was supposed that the sufferers would recover without any permanent defect. The absorption of the muscular fibers was therefore a subsequent process; whether this result may or may not be prevented in similar cases by a more active or a longer-continued treatment, with the early application of a retaining bandage, is yet to be ascertained. It may be that some muscular fibers were actually ruptured and others bruised in these cases; but the extent of the absorption was greater than the apparent injury would seem to have warranted.

Abscesses form from neglected injuries of this kind, and give rise to the most serious apprehensions of their bursting into the cavity of the abdomen, which, however, they very rarely do. The safety of the peritoneum and its capability of affording sufficient resistance to the progress of the matter through it seem to depend upon the strength of the fibrous structure on its outer or muscular side; the inner or really serous surface being very delicate, and offering but little resistance to the application of any moderate degree of force.

An officer, whose name I forget, was wounded at the assault of Ciudad Rodrigo, in 1812, by a musket-ball, on the left side and fore part of the abdomen, near the crest of the ilium: it made a wound about four inches in length, cutting away the muscles of the abdominal wall so deeply as to lead to the exposure, and, as I feared, to the ulceration of the peritoneum, when the sloughs should separate. Under these circumstances, although not belonging to my division, I took him with me from the field to the divisional hospital at Aldea Gallega, some ten miles from the battlefield. Granulations sprang up, however, from the bottom and sides of the wound, which gradually closed in and healed without further difficulty.

377. It has been supposed theoretically, to be a matter of importance to discriminate between the orifice of entrance of a ball passing through the abdomen or its wall, and that of its exit. Practically speaking, it is a matter of indifference; the part on which the ball impinges is usually distinguished by a more circular and depressed appearance, while the opening of exit more frequently resembles a tear or slit, the edges of which are rather disposed to protrude.

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.

[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.

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.