be wise to disarrange the viscera as little as possible, when sponging out the exudates. Carefully inspect whatever parts present, and often the lesion will be revealed by this first search. If a median laparotomy is done, as soon as the cavity ts opened proceed to the site of the injury; cover the adjacent coils of intestine with compresses, thus preventing their possible infection. <Callout type="important" title="Inspect Thoroughly">The lesions are only rarely multiple or difficult of repair in this class of abdominal injuries.</Callout> (b) Extensive Incised Wounds.—These wounds are produced by instruments with a long cutting edge, or by the ripping cut of small knives. Horned animals occasionally produce them. The chief characteristic of these wounds is eventration, always present in some degree. If the case is seen immediately, the mode of procedure is very definite. But only too often the patient's efforts have augmented the hernia, or he or his friends have made untimely attempts to reduce it. Having cleansed the hands and the abdominal walls in the usual way, begin next a systematic cleansing of the eventrated mass. Cleanse it with warm sterile water, or normal salt solution, rubbing gently with the fingers, every inch of the projecting bowel or omentum. Only in the thoroughness of this step is there any assurance of success. If any visceral wounds are discovered in the cleansing process, they are to be repaired at this time. Once the cleansing and repair are complete, proceed to reduce the hernia. The wound may need to be enlarged; if this is necessary, slip a finger under an angle of the wound to serve as a guide, and divide the tissues with scissors. The other angle may be treated in the same way. Catch up the peritoneum with forceps along the whole length of each side of the wound, now lift on the forceps, and in this way create a sort of funnel with smooth sides, over which the bowel readily glides in reduction. Do not attempt to reduce by rough pressure, which may contuse the bowel. If it fails, there is a method which will surely succeed. Spread a large compress over the mass; tuck its edges well under the entire circumference of the wound; and, with both hands, make a gradual pressure on the mass enveloped in the compress, coaxing the refractory loops into place with the fingers, and at the same time pushing the compress further under the abdominal wall. The assistant, in the meantime, lifts up on the forceps attached to the peritoneum, raising the abdominal walls as the hernia recedes. When the reduction is complete, leave the compress in place, secured by forceps until repair of the peritoncum is nearly complete. Repair the abdominal wall; begin by suture of the peritoncum with small catgut. If the tension is great, it may be necessary to include the muscular plane in the suture. Next repair the muscular layers separately by continuous catgut suture; in the same manner, the aponeurosis, and finally the skin, with interrupted silkworm-gut sutures. Drainage is a question which always arises, but Lejars assures us that, if the cleansing is carefully carried out, drainage is in no wise necessary. If the case is seen late, but there exist only a few soft adhesions between the bowel and the walls of the wound, the same disinfection is carried out, the adhesions around the orifice gently broken up, and the mass reduced, as before. Drainage is quite indispensable, if there are already the signs of a beginning peritonitis. If the mass has become the site of a purulent peritonitis, the coils agglutinated by false membrane, and gangrenous, there is nothing to do except to keep applied moist antiseptic compresses, which must be frequently renewed. If the patient survives, whatever intervention is needed, may be undertaken later. (See also gunshot wounds of abdomen and laparotomy for traumatism.) WOUNDS OF THE SPINE, The whole gravity of the traumatism depends upon the medullary lesion. Treatment must of necessity be conservative; only when the cord is obviously compressed should active Intervention be considered. WOUNDS OF THE VULVA AND VAGINA, The chief danger in wounds of these parts is hemorrhage, especially when the vulva is involved and its venous plexuses torn. These wounds may be contused, lacerated or punctured, and more frequently occur from falls astride some object, and by that means the bulb of the vagina is crushed against the ramus of the pubes. Forcible pressure and ligation may be ineffectual to control the bleeding and often the only recourse is tamponade, first disinfecting the wound and the region adjacent, and afterward applying a T bandage and bringing the thighs firmly together. Perforating wounds of the vagina call for a most careful examination, for not only may the vaginal walls be involved, but the rectum, bladder or peritoneum as well. Careful suturing is here the best means of controlling hemorrhage. Peritonitis may result from such injuries or more remotely, fistula or astresia of the vagina. Any serious hemorrhage following coitus calls for an examination. It may ensue from a tear of the hymen, or of the posterior wall of the vagina. Cases are on record in which the tear penetrated the rectum. Deep suturing serves at the same time to control hemorrhage and to promote repair. WOUNDS OF THE PENIS, SCROTUM AND TESTICLE, The penis may be fractured; and, if the urethra is not involved, the hemorrhage will be subcutaneous. Unless the extravasation is very large and progressive, there is nothing to do but to bandage the organ and put the patient at rest. Otherwise it will be necessary to expose and suture the break in the corpus cavernosum. But with such a procedure one may expect a severe hemorrhage. Open wounds of the erectile tissues of the corpora cavernosa or corpus spongiosum may be expected to bleed freely, It is usually advisable to pass a sound to determine the integrity of the urethra, suturing it first, if involved, and then carefully coapting the erectile tissues. In the case of wounds of the scrofum merely the integuments may he penetrated, or more deeply the tunica vaginalis or the testicle as well. It must be remembered that any considerable wounding of the tunica of the testicle may result in hernia of the parenchyma. The scrotal tissues must not be roughly handled in cleansing, and <Callout type="warning" title="Gentle Handling">Bowel damage can occur if the tissues are mishandled.</Callout> The repair of these various structures must be conducted carefully. With the tunica vaginalis is opened up and the testicle herniated, it must be carefully cleansed and returned and the tunica sutured, with or without drainage, depending upon the probabilities of infection. If the tunica be destroyed, and the testicle remains sound, it must be preserved, covering it as much as possible with such serous covering as remains. Incised wounds of the testicle call for suturing of the fibrous coat with catgut. The tunica vaginalis is next repaired with a continuous suture (Fig. So), and finally the scrotal wound is sutured. If the testicle is lacerated, or seen late and manifestly infected, it must be removed without delay. Expose the spermatic cord as high up as possible, and at that level ligate the various elements separately and firmly, and resect. Trim away any infected tissues in the scrotum and repair, making drainage (Fig. 81). Cotton, of Boston (Amer. Jour, Urol., Nov., 1906), describes a case of injury to the testicle resulting from a blow on the scrotum by a batted base-ball. Shock and excruciating pain ensued, gradually subsiding coincident with the development of a large scrotal hematoma. The superficial tissues were infiltrated with blood. A rent an inch long in the tunica vaginalis, bleeding from the spermatic artery. The tunica albuginea was torn in shreds, the parenchyma destroyed. The testis bad evidently exploded under the swift impact, as a full bladder bursts under a blow.” After removal of clots and irrigation, the tissues were sewed up layer by layer with catgug and without drainage, and light pressure applied. Convalescence uneventful. WOUNDS OF RECTUM, Wounds of the rectum are rare. They are usually punctured wounds due to falling upon pointed objects, gunshot wounds, or tears accompanying fractures of the pelvis. The chief dangers are hemorrhage infection. Wounds of this region are usually self-evident, though their extent may be a matter of doubt, so that every such injury demands a careful examination. The examination calls for inspection. To depend upon touch alone may lead one into grave error. In every serious injury of this character, anesthetize the patient, dilate the anus, and by the use of retractors expose the wound. Douche with hot normal salt solution. If the hemorrhage persists, the bleeding points are to be clamped with long forceps and an attempt made to suture en masse, for at that depth it will be hardly possible to ligate the vessels. Sometimes in lacerated wounds, the oozing can be controlled only by tamponing the rectum firmly, packing around a large tube in the center. Suturing these wounds is not so desirable as one might at first think, for the sutures may conduct sepsis to the deeper tissues. Do not suture, then, unless the wound is easily accessible, recent and clean. If the sutures are used, frequent irrigations of normal salt solution must be employed and the bowels kept quiescent for several days. If the rectal wound has penetrated the peritoneal cavity, which fact may develop in course of the examination, or may be suspected from the tympanites and tenderness of the abdomen, the better plan is to proceed to a laparotomy. The abdomen is to be opened in the middle line, the patient put in the Trendelenburg position, the pelvis cleansed, and the wounds repaired by two tiers of sutures. If intestine should become herniated through a rectal tear, reduction is again indicated, reducing the hernia by traction from above. If the herniated loop protruding from the anus be gangrenous, in order to avoid infection of the peritoncum the affected segment should be resected and the two ends temporarily ligated before proceeding with the laparotomy. Once the abdomen is opened, the two ends of the bowel are to be pulled up and anastomosed.
Key Takeaways
- Thorough cleansing and repair of abdominal and genital wounds is crucial for preventing infection and ensuring successful healing.
- Proper handling of the peritoneum during laparotomy can prevent bowel damage.
- Suturing deep rectal wounds may introduce sepsis; drainage is often preferred.
Practical Tips
- Always ensure proper sterilization before performing any surgical procedures to avoid introducing infections.
- Use gentle and careful handling of tissues, especially in the scrotum, to prevent further damage.
- In cases where immediate medical attention is not available, prioritize controlling hemorrhage and preventing infection.
Warnings & Risks
Risk of Infection
Improper handling can lead to severe infections.
Rough treatment of the peritoneum can result in bowel damage and complications. Suturing deep wounds may introduce sepsis; drainage is often safer.
Modern Application
While many of these techniques are still applicable in modern survival scenarios, such as during a natural disaster or remote wilderness expedition, the use of advanced medical equipment and sterilization methods has significantly improved outcomes. This knowledge remains valuable for understanding basic emergency care principles.
Frequently Asked Questions
Q: How should extensive incised wounds be treated?
Extensive incised wounds should be cleansed with warm sterile water or normal salt solution, and any visceral wounds discovered during this process should be repaired immediately. The hernia can then be reduced carefully without rough pressure to avoid contusion of the bowel.
Q: What is the best method for controlling hemorrhage in rectal wounds?
For rectal wounds, tamponade with a large compress and packing around a tube may control oozing better than suturing. Suturing should only be done if the wound is recent, clean, and easily accessible.
Q: What precautions should be taken when repairing genital injuries?
Genital injuries require gentle handling to prevent further damage. The peritoneum must be carefully managed during laparotomy to avoid bowel complications, and deep wounds may need drainage rather than suturing to prevent sepsis.