These cases may be considered exceptions to the general rule, which directs the return of all protruded parts. The retention of the part from which the piece was cut off within the divided parts of the wound was agreeable to the principles I have inculcated with respect to wounds of all the cavities.
407. Wounds of the stomach are usually fatal, although some persons escape when these injuries are confined to its anterior and upper surface, and do not penetrate both sides, in which case effusion into the cavity of the abdomen, and consequent inflammation, can scarcely fail to ensue. It is fortunate for the patient, when they occur, that the stomach should be empty. If it should not be so, the contents may possibly be ejected shortly after the receipt of the wound, but it is not advisable to excite vomiting by remedies, or by means adapted for that purpose. In a perfectly quiescent state, the general compression of the contents of the abdomen by its walls may prevent effusion under ordinary circumstances, and this state should be maintained as rigidly as possible. The apparent course of the wound indicates the probable mischief, which is especially confirmed by vomiting of blood, great anxiety, depression of countenance, a cold, clammy skin, pain in the part, hiccough, and by the discharge of the contents of the stomach, if the wound be sufficiently open to allow it; pulse low and sometimes intermittent. If effusion of the contents of the stomach should not occur, the external wound, if an incised one, should be closed by suture, and the patient kept in the utmost state of quietude, in a somewhat elevated position, the abdominal muscles being relaxed. Neither food nor drink should enter the stomach, although thirst should be allayed by wetting the tongue and mouth. The bowels should be relieved by enemata, and the belly fomented. Bleeding and leeching, as frequently repeated as the symptoms appear to require, must be carried to the greatest extent that can be permitted with safety.
When the external wound is so large as to enable the wounded stomach to be seen, the cut edges of the wound in it should be brought together by the continuous suture, as in the intestines; and the external wound should be closed in a similar manner, the end of the ligature on the wound of the stomach being cut off close to the viscus, that organ being left perfectly free, with the hope that the thread will be carried into its cavity, while the outside adheres to the peritoneum opposed to it.
When the stomach pours its contents through an external opening, too small to allow its being examined, it is desirable that the wound should be enlarged, if a doubt be entertained of the passage being free. It is a sufficient reason for such an operation to allow the opening in the stomach to be seen. It is very probable that effusion will take place into the cavity of the abdomen if it be not done, and the death of the patient will follow. It is very probable he will die if it be done, and therefore in such cases little has hitherto been attempted. I am of opinion, however, that in the case I have last alluded to, a blunt hook may be sometimes introduced through the wound into the stomach, so as to keep it stationary while the external opening is carefully enlarged, and that it ought to be done in such cases, and the wound in the stomach closed in the manner recommended. I have never had a case under my care in which I could have done this; but I have seen some die in whom it might have been done; and it deserves to be considered when surgeons shall be in sufficient numbers on the field of battle to attend to such recommendations, and to the after-treatment these cases require.
When the stomach is injured by a musket-ball, and its contents are discharged externally, the edges of the wound, not being in a condition to unite, must remain open for several days. The person should be placed in the mean time in the most easy and comfortable position which may enable the contents of the stomach to be readily passed out externally, if they show any disposition to be thus evacuated. The external wound should be dilated as far as the peritoneum, if it should be required, so as to admit of the passage being direct, and symptoms must be awaited and treated as they arise. If the patient should survive the first or inflammatory stage, he should be supported by clysters composed of strong beef-tea or veal broth, given five or six times during the twenty-four hours. When it may be expected that the wound in the stomach has closed, or that the injured portion has adhered to the neighboring parts, warm jellies and light broths may be frequently given in small quantities, but solid food should be forbidden until complete recovery has taken place. I have seen inattention to this precaution in more than one instance prove fatal.
408. Fistulous openings have been known to follow wounds of the stomach, and to continue for years. The case related by Dr. Beaumont of the American army, of St. Martin, who, in 1822, received an extensive wound in the stomach, which became fistulous, admitting of a variety of most interesting inquiries being made into the process of digestion, is remarkable.
Hevin has related some of the most interesting cases of those who had swallowed knives, etc., by design or by accident, and whose stomachs were opened for their removal. The most ridiculous story of the whole is an instructive one, however. Some young students, desirous of punishing a young woman who had offended them, cut short the hair of the tail of a large pig, and when frozen hard, forcibly pushed it up her anus, leaving a couple of inches only hanging out of the small end or tip. The hairs having been cut short caught in the gut when attempts were made to draw out the tail, and gave her inexpressible pain. The most serious symptoms followed during six days, and every attempt having failed, Marchetti was applied to. He prepared a hollow tube two feet long, large enough to receive the thickest part of the pig’s tail, to the end of which he fastened a strong waxed cord, which he drew through the tube. This he carefully introduced into the anus, pushing it over the pig’s tail, until he drew the whole of it into the tube, which he then brought away, including the tail, to the great relief of the sufferer.
409. The necessity for an operation so grave as that of opening the stomach must be shown by the presumed impossibility of the foreign substances being dissolved, or of their passing out of it by any other means, while the continued distress they occasion more than equals the risk which is likely to be incurred. The offending substance ought to be felt through the wall of the abdomen, and the incision for its removal should be made between the recti muscles in the linea alba, unless the foreign body have actually pierced the stomach, and can be felt to the outside of the rectus muscle, at which part the incision ought to be made obliquely in the direction of the fibers of the external oblique muscle, all bleeding vessels being secured before the peritoneum is opened. This having been accomplished, the protruding body should be extracted by such an enlargement of the opening in the stomach as may be actually necessary. When the substance does not protrude, although it can be felt through the wall of the stomach, it will be advisable, if possible, to draw it toward the upper or smaller curvature of the stomach rather than to the lower, avoiding the coronary vessels, and taking a medium distance for the opening from the cardiac orifice, and thereby such advantage as may be derived from gravitation. The wound in the stomach should be united by the continuous suture, and the external wound should be closed in a similar manner. The patient ought to be kept in bed in an easy erect position.
410. Injuries of the spleen have been usually fatal, from hemorrhage filling the general cavity of the abdomen, especially when they have arisen from rupture of that organ, which I have several times seen occur in consequence of falls, or from blows from cannon-shot, which have not opened into the cavity or exposed the viscus. Wounds from musket-balls have for the most part destroyed the sufferers, either from hemorrhage or from inflammation. I have not seen nor heard, during the Peninsular war, of a wound in the abdomen through which the spleen protruded, the patient recovering. Instances have occurred in which this part has been removed in man after its exposure by injury. A case is said to have taken place after the battle of Dettingen, in which the spleen, covered with dirt, was cut off, and the patient recovered. In another case the spleen, found without the wound at the end of twenty-four hours, was cold, black, and mortified. The surgeon placed a ligature above this part, and cut off three inches and a half of the spleen; a large artery was tied, and the remaining portion of the viscus was returned into the cavity of the belly, the ligature hanging to it, and the patient got well.
Wounds from stabs with a bayonet, or a sabre, or long-pointed sword are frequently fatal, either from hemorrhage or from inflammation; but I have seen accidentally, after death, cicatrixes in the spleen corresponding to external marks, indicative of a former wound. The treatment, in all such cases, should be to encourage the discharge of blood from the part, in the first instance; then to close the external wound if an incised one, to place the patient on the injured side, and to subdue all unnecessary inflammation by bleeding, leeching, absolute rest, and starvation. The application of warm fomentations where an oozing of blood may be expected to take place cannot be recommended, and cold should be substituted if agreeable to the feelings of the patient. When the blow or wound does not cause the death of the individual by hemorrhage or acute inflammation, a chronic state of disease may supervene, which, if not duly combated, will ultimately destroy him. The early administration of calomel and opium, and the repeated application of blisters, will, in these cases, as well as in those of wounds of the liver, be of the greatest service. Effusion or suppuration may take place as well as in those cases which have been noticed, when other viscera have been injured; although instances of such terminations are not recorded, it does not follow that they have not taken place.