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1847]

General Conclusions.

89

abstraction of blood, and by the early use of retaining bandages. 2. Abscesses in the muscular walls of the abdomen, from whatever cause they arise, should be opened early; for, although the peritoneum is essentially strong by its outer surface, it is but a thin membrane, and should be aided surgically as much as possible. 3. Severe blows, attended by general concussion, frequently give rise to rupture of the solid viscera, such as the liver and spleen, causing death by hæmorrhage. When the hollow viscera are ruptured, such as the intestines or the bladder, death arises from inflammation. 4. Incised wounds of the wall of the abdomen of any extent rarely unite so perfectly (except perhaps in the linea alba) as not to give rise to ventral protrusions of a greater or less extent. 5. As the muscular parts rarely unite in the first instance after being divided, sutures should never be introduced into these structures. 6. Muscular parts are to be brought into apposition, and so retained principally by position, aided by a continuous suture through the integuments only, together with long strips of adhesive plaster, moderate compression, and sometimes a retaining bandage. 7. Sutures should never be inserted through the whole wall of the abdomen, and their use in muscular parts, under any circumstances, is forbidden; unless the wound, from its very great extent, cannot be otherwise sufficiently approximated to restrain the protrusion of the contents of the cavity, the occurrence of which case may be doubted. 8. Purgatives should be eschewed in the early part of the treatment of penetrating wounds of the abdomen. Enemata are to be preferred. 9. The omentum, when protruded, is to be returned, by enlarging the wound, through its aponeurotic parts if necessary, but not through the peritoneum, in preference to allowing it to remain protruded, or to be cut off. 10. A punctured intestine requires no immediate treatment. An intestine, when incised to an extent exceeding the third of an inch, should be sewn up by the continuous suture. 11. The position of the patient should be inclined towards the wounded side, to allow of the omentum or intestine being closely applied to the cut edges of the peritoneum. Absolute rest, without the slightest motion, should be observed. Food and drink should be restricted, when not entirely forbidden. 12. If the belly swells, and the propriety of allowing extravasated or effused matters to be evacuated, seems to be manifest, the continuous suture or stitches should be cut across to a certain extent, for the purpose of giving this relief. 13. If the punctured or incised wound is small, and the extravasation or effusion within the cavity seems to be great, the wound should be carefully enlarged, and the offending matter evacuated. 14. A wound should not be closed until it has ceased to bleed, or until the bleeding vessel has been secured, if it be possible to do it. When it is not possible so to do, the wound should be closed, and the result awaited. 15. A gun-shot wound penetrating the cavity can never unite, and must suppurate. If a wounded intestine can be seen or felt, its torn edges may be cut off, and the clean surfaces united by suture. If the wound can neither be seen nor felt, it will be sufficient for the moment to provide for the free discharge of any extravasated or effused matters, which may require removal. 16. A dilatation or enlargement of a wound in the abdomen should never take place, unless in connexion with something within the cavity rendering it necessary. 17. When balls lodge in the bones of the pelvis, they should be carefully sought for and removed, if it can be done with safety and propriety. 18. In a wound of the bladder, an elastic gum catheter should be kept in it, until the wound is presumed to be healed-unless its presence should prove injurious from excess of irritation, not removeable by allowing the urine to pass through it by drops as it is brought into the bladder. 19. In all cases in which a catheter cannot be introduced, in consequence of the back part of the urethra or the neck of the bladder being injured, an opening for the discharge of the urine should be made in the perineum. 20. The treatment of all these injuries must be eminently antiphlogistic, principally depending upon general and local bloodletting, absolute rest, the greatest possible abstinence from food, and in some

cases from drink, the frequent administration of enemata, and the early exhibition of mercury and opium, in the different ways usually recommended, with reference to the part injured." P. 72.

Ventral Hernia.-This is the never-failing consequence of a musketball penetrating the walls of the abdomen, and it is also usually attendant upon the division of the parietes by a sharp cutting instrument. Moreover, the same result may follow a severe bruise without any rupture of muscular fibres being perceptible. Of this Mr. Guthrie relates two cases. In the one, a large flat piece of shell struck the left iliac region, producing a severe and painful bruise, the whole of that side of the belly becoming first black and then discoloured. The patient recovered with little or no treatment; but, upon examining the part some months after, Mr. Guthrie found that the whole of the muscular portion of the wall corresponding to the seat of injury had been removed by absorption, the tendinous portions having also become very thin, protruded on any effort being made, so as to constitute a circular broad-based ventral hernia, requiring the application of a bandage. In the other case, the belly was struck by the swinging round of the spanker-boom of a small vessel in the Tagus, and the same absorption of muscle and formation of hernia resulted. Mr. Guthrie suggests that, perhaps a more active treatment of the accident at first, and the earlier application of a bandage, might possibly have prevented this consequence.

The numerous operations of late performed for the removal of ovarian tumours have shown that, when an incision, even of great extent, has been made along the course of the linea alba, the union of this part may be sufficiently firm to resist any hernial protrusion. Mr. Walne sent a woman for Mr. Guthrie's inspection, in whom he had made an incision 14 inches long, and yet at the end of as many months all was firm. In other cases, where adhesion had been prevented by the ligature from the peduncle of the tumour passing out between the edges of the wound, Mr. W. has found protrusion. So exact may the union of the divided peritoneum become, that a minute inspection after death has been required to detect the site of the incision. Dr. F. Bird states that, of 12 cases in which he had opened the abdomen, recently examined by him, the incision in five did not exceed three inches; in five it reached from 4 to 5 inches; in one to 8 inches; and in one to rather less than 12. With the exception of one case the incisions were made along the linea alba, without involving the muscular structure. Soon after the wounds healed in general, a very marked contraction of the abdominal walls took place; so that an incision of five inches mostly became replaced by a cicatrix of scarcely more than an inch. Whenever such contraction occurred, no tendency to hernia manifested itself; while in two cases, in which the incisions were from 8 to 12 inches long, little contraction followed, and protrusion of the cicatrix, or a hernia, ensued. In one case, in which a small incision was made transversely into the outer edge of the rectus and internal portion of the obliquus externus, hernia quickly followed. In all the cases the same mode of closing the wound was observed, viz. by the introduction of two interrupted sutures in every inch of incision, the skin alone being included.

1847]

Mode of applying Sutures.

91

"If it should be proved that incisions may be made with more confidence of success than hitherto has been supposed, and as these sections may lead us to believe, it will only confirm what I have constantly repeated from year to year in my lectures, that penetrating wounds of the abdomen, without injury of the viscera, when properly treated, are not so dangerous as they were generally supposed to be. In the sections made by other surgeons for the removal of diseased ovaries, ligatures have been sometimes used for the purpose of bringing the divided muscular and tendinous parts together, and although I forbid their employment as a general rule, I do not wish to imply that in very extensive transverse wounds they can be entirely dispensed with, if only to prevent the immediate protrusions which the suture through the skin might not be equal to resist in every case." P. 10.

Employment of Sutures.-The latter portion of the above extract leads us to Mr. Guthrie's views upon the mode in which sutures are most advantageously employed. His multiplied experience during the war, confirmed by what he observed afterwards in cases of ligature of the iliacs, having convinced him that the walls of the abdomen, formed of mingled muscular and tendinous structures, cannot be brought to unite permanently, save by the intervention of cellular texture, he disapproves of the endeavour to keep these parts in contact by means of sutures, which are of no permanent service, and may create much present irritation. Chelius, Graefe, Weber, and South, seem however to approve of this stitching the muscles together, although Chelius gives also directions for their immediate removal, if dangerous symptoms, such as inflammation, vomiting, hiccough, &c. supervene; but Mr. Guthrie believes that such accidents are much better obviated by avoiding the practice, which English surgeons have long discarded, as relates to other portions of the body. He brings the edges of the wound together by means of a small needle and fine silk, passing this only through the skin and contiguous cellular tissue, and employing the "continuous suture without puckering, precisely in the manner a tailor would fine-draw a hole in a coat or a lady a cut in a cambric handkerchief." This gives a certain degree of support to the parts beneath, which is also to be further afforded by strips of plaister extending for some distance around the body, a bandage being rarely of use, while, if it causes pressure, it will be mischievous. Great attention should be paid to the position of the patient inclining the body towards the wound, so as to keep the intestinal or omental peritoneum, if possible, in contact with the divided portion, until it has adhered to this. In such position he must be rigorously maintained without any change, until all hope of adhesion occurring has passed away.

Management of the Protruded Parts.-When omentum is the protruded part, the rule usually laid down in surgical works is to return it into the cavity of the abdomen again, and endeavour to retain it there by the application of sutures as near the peritoneum as possible. To this Mr. Guthrie demurs, believing that the best practice consists in retaining this substance between the cut edges of the peritoneum, without any strangulation or even compression however, its adhesion there forming the best barrier against the extension of inflammation. He believes, too, that the advice given to enlarge the opening into the cavity when this is insufficient

for the return of the omentum is bad, inasmuch as the obstacle to its reduction is not formed by the peritoneum but by the abdominal aponeuroses, the slightest division of which will almost always allow of the easy return of the omentum. Small wounds in the peritoneum, when covered over with healthy parts, are not usually followed by bad consequences, but the most disastrous ones may attend a large one; so that the greatest care should be taken not to augment the size of one already existing. If the omentum is adherent, inflamed, torn, jagged, or in a state of suppuration or gangrene, it should not be returned, nor should it be surrounded by a ligature, or cut off; but left to itself and treated in the most simple manner. It will gradually retract and become withdrawn into the cavity of the abdomen. Observation of several cases of neglected penetrating abdominal wounds during the Peninsular war, convinced Mr. Guthrie of the propriety of thus leaving the omentum between the edges of the wounded peritoneum, closing the integuments over it by the continuous suture. Larrey recommends leaving the omentum which cannot be returned in situ, and relates cases shewing the power which nature exerts in drawing it gradually into the abdomen. Mr. Guthrie has also seen such, but he has also seen fatal consequences follow both the leaving the part outside and the cutting it off. If, indeed, it be very much bruised or injured it may be cut off, but, as the general practice, he prefers returning it as far as the edge of the peritoneum, and bringing the skin over this.

The intestine, in any condition short of that of mortification, should be returned to the abdomen, but the directions given for this purpose by Chelius are objected to by Mr. Guthrie. These are, that the opening of the peritoneum should be enlarged when the reduction is difficult, the finger introduced to feel that the gut has not passed between the muscular interspaces, and that the patient should be so placed as to prevent the intestines pressing against the wound. The two first of these are unnecessary and mischievous, and the last erroneous, since the very best thing that could happen to consolidate the union would be to bring the intestine in contact with the divided peritoneum. When the protruded intestine is wounded, if it be a mere puncture or a very small cut, the bowel may be returned just the same, the pressure of the containing parts preventing effusion, the development of inflammation being closely watched. Wounds, however, sometimes of apparently the slightest appearance, give rise to terrible consequences, while others proceed favourably, in spite of every aggravating circumstance.

Wounds of the Intestine.-In his second and third "Lectures," Mr. Guthrie furnishes us with an elaborate view of this subject derived from his own observations, and those of preceding writers. After describing the experiments of Travers and Gross, he observes upon these latter :—

"The important conclusions to be deduced from his experiments, 1, that wounds not exceeding four lines in length, 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. 2. 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 es

1847]

Wounds of the Intestines.

93

cape of the contents of the bowel, and the consequent development of fatal peritonitis. It may, therefore, be concluded, from these experiments made on animals, as far as they can be relied upon in reference to man, that every wound of the bowel, of such extent as shall not admit of its being temporarily filled up by the protrusion and eversion of its internal or mucous coat, ought, if possible, to receive assistance from art, which can only be given with advantage in the first instance." P. 18.

That this last conclusion; founded as it may easily be upon experience in the human subject, is a correct one, may at once be admitted; and, indeed, experiments upon the lower animals might induce a fallacious security, since Nature seems in so many instances to have endowed them with the power of resisting an extent of lesion to which man succumbs; and as, in them, the third tunic of the intestines, (the fibrous lamella of Cruveilhier, and the membrana nervosa of Haller), the most important of the tunics, that in which hypertrophy has its seat and in which adhesion after division readily takes place, varies much in strength and elasticity in different animals. Mr. Quekett has shown that it is most developed in reptiles, and more so in the carnivora than in man and the herbivora.

After describing the various ingenious modes by which surgeons have endeavoured to maintain the divided edges of the intestines in juxta position, Mr. Guthrie quotes the following observations from Dr. Gross' "Critical Enquiry into the Nature and Treatment of Wounds of the Intestines."

"Of the four methods, that of introducing the suture through the cellular fibrous lamella is the least objectionable, as it enables us to bring the serous surfaces into more accurate apposition. When the needle is conveyed through all the tunics, there must necessarily be some degree of puckering, whereby the mucous lining will be forced between the lips of the wound, if not beyond the level of the peritoneal membrane. By such an arrangement, the adhesive process would be retarded, and if the stitches were to lose their hold, or if the bowel should not become glued to the neighbouring parts, fæcal effusion might occur, followed by its whole train of evil consequences.

"In making the continued suture, I would, therefore, recommend, that the needle be carried through the cellular fibrous lamella, or between the muscular and mucous membrane, and not across all the tunics, as is generally advised by authors. The lips of the wound should be held parallel with each other, and the stitches, drawn with considerable firmness, should not be more than one-twelfth or one-eigth of an inch apart. The needle is to be introduced a short distance, say half-a-line, from the peritoneal edge of the opening, and brought out at the corresponding point at the opposite side. The first stitch should be one line from one angle of the wound, and the last about the same distance from the other, care being taken to secure each with a double knot, and to cut off the extremities of the suture close to the surface of the tube. The instrument which I prefer, and which I employed in nearly all my experiments, is a long slender sewing needle, armed with a waxed, but strong and delicate, silk thread. The operation should be performed as expeditiously as is consistent with safety, and the bowel handled in the gentlest manner possible." P. 26.

These conclusions have only their foundation upon experiments upon animals, and Mr. Guthrie at present demurs to their practical adoption. "The continuous sutures of Bertrandi, of Travers, of Dupuytren, of Lembert, of Jobert, of Gross, and of Nuncianti, appear to resemble each other so much as to be essentially alike; the object of all being to close the bowel effectually. The

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