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skin in front, at a point about two inches from the median line and about three inches from the umbilicus.
The wound in the back was closed with adhesive plaster. Urine was drawn off with the catheter, but it showed no signs of blood. About thirty minutes after his admission, he began to vomit dark clotted and liquid blood mixed with food. Cracked ice by the mouth was given, and a hypodermic injection of Magendie's solution, Tv, and ergotin, gr. v, in water. He showed no signs of collapse and expressed himself as feeling well.
Within about three hours after the shooting, I removed the ball from under the skin; and I ascertained, by exploration with the point of the little finger, that the ball, a conical 32 caliber, had passed through the cartilage beneath. This fact, taken in connection with the vomiting of food and blood, showed that the ball had passed entirely through the stomach. Flaxseed poultices were applied over the anterior and posterior wounds, and he was ordered to have no food by the mouth, enemata of milk being given every four hours. During the day, he vomited blood four or five times, but showed no symptoms of collapse. the evening, he had a hypodermic injection of Magendie's solution, x. He was restless during the night, but had no pain. The temperature was 101° Fahr., and the pulse 120, full and strong.
February 13th, 6 A. M.-No pain, but restless. Magendie's solution, x, bypodermically. 9 A. M., pulse 120, respiration 23, temperature 101°. Had an enema of warm milk. At 1 P. M., the condition was unchanged. At 2.30 P. M., he vomited about of dark, fluid blood. Pulse 120 and strong. Ordered tinct. aconit. rad., ij, every two hours.
14th.-Slept most of the night after a hypodermic of Magendie's solution, π xv. At 3 A. M., vomited about a half-pint of blood. About noon, had a large movement from the bowels, consisting of fæcal matter with blood, looking like tar. Aconite continued. Evening, temperature 101°, pulse 107, respiration 20. Has had enemata of milk during the day.
15th, 9 A. M.-Slept about five hours last night after a hypodermic of Magendie's solution, m xv. Pulse 108, respiration 17, temperature 100°. Has slight pain in the anterior wound and tenderness in the iliac fossa, probably from flatus. To-day, beef
juice and eggs were added to his milk-enemata. Had a loose fæcal movement without blood. Tongue dry and covered with a brownish fur, but general condition very good. When the patient was first admitted, he was placed in a room on the north side of the hospital; to-day he was removed to a room with a southern exposure. 7 P. M., feels sore generally; thinks it due to the moving. Pulse 108 and slightly dicrotic. 10 P. M., pulse 110, respiration 17, temperature 102°. Complains of general abdominal soreness. Hypodermic of Magendie's solution, xv.
16th, 2 A. M.-Awake and restless, but has no pain. Magendie's solution, xv, administered hypodermically. 9 A. M., pulse 108, respiration 17, temperature 101.5°. No pain or abdominal tenderness. Both wounds discharging pus. Was allowed to-day, milk, j, and Apollinaris water, j, every hour. Loose movement from the bowels, without blood. 7 P. M., pulse 100, dichrotic; respiration 20, temperature 101-8°. 10 P. M., Magendie's solution, xv, hypodermically.
17th, 3 A. M.-Restless; can not sleep. Was given a hypodermic injection of Magendie's solution, π xv. 9 A. M., has had some sleep. Pulse 107, respiration 17, temperature 101.2°. Feels rather weak and complains of hunger. Was ordered strained bouillon in addition to milk, j every hour. General condition good. From this date on, the daily record gives a temperature of not higher than 103° to February 25th, when it is marked at 99°, with respiration 16, and pulse 86. He has had hypodermics of Magendie's solution in doses varying from xv to xx m, to induce sleep. Absorbent dressing was applied on the 20th inst. His bowels have moved spontaneously almost daily. The food taken by the mouth has been well borne. The nutrient enemata were discontinued on the 18th inst.
March 2d.-Sat up to-day for the first time. Has been doing well. Has had a hypodermic of Magendie's solution, x, each night, to induce sleep.
5th.-Doing well. Wounds not quite healed. Has slept for the last two nights without morphine.
15th. Since the last note, the patient has steadily gained strength. He has been up and about the hospital every day. The temperature, respiration, and pulse are normal. The wounds are not yet covered with epidermis. To-day he was permitted to go
out to walk. The weight shows a loss of about twenty pounds. The present weight is 1334 pounds.
25th. The patient continues to do well. The appetite and digestion are very good. He has gained ten pounds in weight within the last ten days. He makes no complaint and drives and walks daily. The wounds have completely healed, with the integument slightly attached to the tissues beneath but not enough to impede the movements of the body or to produce any discomfort. He left the hospital to-day, apparently well, and has remained well up to the present time.
The points which I wish to emphasize in the report of this case are that there was no meddlesome surgery or anticipatory drugging and that the patient was not overwhelmed with opium to prevent peritonitis. The stomach had entire rest for about four days, the system being sustained by means of nutrient enemata. Morphine was used only to induce sleep at night; and, beyond this, he had but a few doses of aconite tincture, and toward the end, two or three saline draughts. His food was carefully chosen, and he was allowed to take with it a little light wine. He was placed in a room with a southern exposure-a matter of great importance in the management of a grave case during the winter season.
There is not the slightest reason to believe that the ball did not pass through both walls of the stomach; but, the wounds being small and closing quickly, no food or blood passed into the peritoneal cavity. That we might in some wise imitate such an injury, I directed my house-surgeon to fill the stomach of a cadaver with water to about the quantity of an ordinary breakfast, and then to shoot it from behind. The ball entered the body at about the same place as in the case related above, and, by the dissection that followed, it was shown that it passed through both walls of the stomach and lodged in the anterior abdominal muscles. The posterior wound of the stomach was guarded by a valvular flap of mucous membrane, which prevented the escape of liquids. The anterior wound had no flap, as might have been supposed; yet the wound was almost
closed, which, in all probability, would be the case in living tissue.
Professor F. H. Hamilton, writing of such cases, says: "The recorded examples of recovery after this accident are very few.1 The case of Alexis St. Martin, on whose person Dr. Beaumont, of the United States Army, made his famous experiments upon the gastric juice, is well known to the medical profession.2
"Dr. De Witt C. Peters, U. S. Army, has reported the case of a soldier, wounded September 13, 1862, by a pistol-ball. For two months the stomach discharged its contents through the wound, but the opening finally closed without surgical interference, and the recovery of the patient was complete." 3 This case is also reported in the "Medical and Surgical History of the War of the Rebellion." I shall refer to it again hereafter.
Professor Hamilton also writes: "The fatality of these accidents is even much greater than that of similar wounds of the intestines. Probably not one in fifty recovers, perhaps not one in a hundred " ("Military Surgery," p. 358).
In the "Medical and Surgical History of the War of the Rebellion," Washington, 1876, surgical vol., second part, chap. vi, p. 44, is the following:
"Gunshot Wounds.-Not less than nineteen cases of recovery from alleged shot-wounds of the stomach were reported. The evidence in each instance has been examined, and the inferences are that in some cases the diagnosis had no foundation, and the erroneous returns were due to culpable carelessness or ignorance, the term stomach being sometimes employed by simpletons apparently as a euphuism for belly; that, in other cases, hospital-surgeons or pension-examiners have related and indorsed the narratives of patients, and described as facts events which, if they ever occurred, transpired long before the patients came under their observation, and are destitute of corroborative evi
1 "Treatise on Military Surgery," New York, 1865, p. 359.
"Experiments and Observations on the Gastric Juice and the Physiology of Digestion," Plattsburgh, 1833.
3 "American Medical Times," New York, April 4, 1863; quoted by Hamilton, "Treatise on Medical Surgery," New York, 1865, p. 360.
dence; that, in a few instances, recovery followed injuries which careful and competent observers pronounced to be shot-wounds of the stomach; finally, that, even in the latter small category, not more than one incontestable example of recovery was recorded. Careful investigation of the recorded symptoms and progress of the six following cases has failed to elicit any evidence in corroboration of the diagnosis of 'severe gunshot wounds of the stomach,' with which they were reported. None of the names appear on the Pension List."
Of Dr. Peters's case, referred to before, it says:
"The following case, reported by Assistant Surgeon D. C. Peters, U. S. A., has been adduced as an irrefragable instance of recovery from a shot-perforation of the stomach. It will be observed that there is no other evidence of the gastric extravasation and of the hæmatemesis than the patient's statement. It is noticeable that Assistant Surgeons Du Bois and MacKenzie, who successively had the patient in charge, made no note of these remarkable features."
Then follows Case 185, which is Dr. Peters's case.
Case 187 is that of Private Patrick Sweeney, 7th N. Y. Cavalry, aged twenty-one years, who was shot in a quarrel in Washington about midnight, January 4, 1862. This case (187) is, however, preceded by the following note: "The next observation (case observed) is important because the symptoms immediately following the injury were observed and recorded. Unfortunately, the reporter suffered an interval of four years to elapse before placing the case on record. It may be ungracious to deny the exactness of his diagnosis, which, indeed, furnishes the most plausible explanation of the phenomena, yet none of the symptoms related are inconsistent with the hypothesis that the visceral lesions might have been limited to the left lobe of the liver or to the duodenum."
It is either this case or Dr. Peters's case which is the "one incontestable example of recovery" referred to by Dr. Otis, the compiler; for the seventeen other cases are discarded as questionable or entirely valueless as cases in point.
From these remarks upon the so-called nineteen recoveries