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.