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.
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.