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