three jiundredi pfrf(goiating4 wounds of the abdomen.

12 Pages·2008·4.72 MB·English

MARCH to, t9171 PEBFORATING WUN;I'D OP THE ABDOMEN.[ THUEr 32
A Vint'ral itnb fxptrtnunt-at-r-
fore appear that haemorrhage per se or combined with
intestinal infection is not responsible for subsequent
intestinal distension.
or
THREE JIUNDREDI PFRF(GOIATING4 WOUNDS
3. TWhat arfcthcrlatiL-c valucs of the diffcrent forms of
lateral anastomosis?
OF THE ABDOMEN.
There aretwo possiblewaysin wlicli lateral anastomosis
- BY ctan be accomplislhed. The ends of the bowel may bo.
J. FRA$S:ER,-M.D., F.R.C.S.E., CAPTAIN R.A.M.C., laid-side by side and the anastomosis so completed. (See
Diagram 1.) -Or
.AND. the two ends of
HAMILTON DrtUMMOND, M.B., F.R.C.S.E. thle bowel may 4
CAPTAIN R.AM.C.0. be brought so
(Recport to the Medical Research Committcc.' tbaktltetwoblind
[WITH SPECIAL PLATE. aepnpdo'ssi-tioan.re (Siene Di £sn 1.
Diagram 2.)
cSaOsMeEs otfimpeerfaogroatiwneg pwuobulnidsshedofatshteuambmdaormyuionfalsocamveitys.evenWtey ofTghrieeatsevcaolnude-mfeotrhoedxaomfplaep,prionxicamsaetsioinn mwlaiychlsoimtemtiigmlhetsboee
liave lhad an opportunity of inereasing oulr experience of itmpossiblo to secure thc first mentioned approximiation.
these cases, and the following article is an embodiment of A series of experiments was carried out to explore tho
tllat experience. We lhave been more especially induced values ofthesemetliods.
to puiblislh tllis furthier sumiiiary as increased experience Tle various anastomoseswere completed and the parts
hastaught usthat wetmlust alter certainopinionsexpressed examined at varyinglaterperiods. Nodifferencecould bo
in ourearlier ptublication. The paper is itntroduced by an detectedbetween the two methods-both did equally well.
ahctcavoeundotdnoefiansamtatelmliipatminn(ogunttootfhierxopwerliimghetntoanl cweorrtkaiwnlhiccllihnicwael Awlhfeutrhtehrerthseerrieeswaosf eaxtpeenrdiemnecLytiinwaeisthcearrroifedtheosuet ftoorpmrsovoef
pirblems wllich perplexed us. There follows a considera- anastornosis for intestinal
tion of various abdominal.wounds as they occur locally. contents to collect in tlhe
The paper concludes witha sumnmary of general renmarks. blind ends of the gut. For
t iese experimuents thel
EXPERIMEN-TAL SUMMARY.
animals were fed upon food
In tlhecourIse of carrying out the clinical work, pait of in whlichi small slhot were
wlhiclh is hiere suammarized, certain probleniatttical points mixced.
arose, anid it was witlh a view to tlhrowing liglit on tlhese It was fouind that in the
splohialnltssttihualtnatrlihzeeextlpheeriwmoernktalinwothrek fwoarsmuonfdeqruteaskteino.n aWned f(iDrsitagnrmaetmlho1d) ofthaenraestwovmaossias Diagram 2.
ainswer. greater tendency for arrest ofcontents to occur tllani in
tlhe second m6thod.-
1. Wthat are t7e rclatire vnalues of eiid-tv-crl ar1 tc'['--'lrfr7 Botlh forms of anastomnosisgiveexcellent results. As far
anastoniosis. as the arrest of intestinal contents in the blind ends of
Belgian hiares were used in these experiments. End-to- the gut is concerned, the second mnetlhod of anastomosis
end anastom-osis was unsatisfactory, as rabbits operated (Diagram2) iseven preferable to the first metlhod.
on in this way all succumiibed after an interval of from twvo Illustrations of th3ese experimnental anastomioses aro
to tljree days. Po8t nu0tenM there was found to be very showvn in thlePlate (Figs. 1 and2).
imiarked distension of thle intestinal canal above the site of
suture. 4. To whate.xtpntisdevasculari-cttion ofthe gutpossible
When lateral anastomosis was enmployed tlle resuilts wit/tout damaging the vitality ofthe gut/
were different-no complication developed, and thle This isa matter of great clinical importance, ra. in the
animals, witlhout exception, made good recoveries. One cases ofwounds of the abdomnen o'neisconstantly ineeting
niaturally askad onieself tllequestion, What was thefeature with examples of tearing of tllc niesentery, and it is
inw end-to-end anastomniosis wlhichi rendered its results so freciuently debatable whetlher or notresection should be
unsatisfactory? Thlere no complete obstruction, for, done.
both at operation and wianslater investigation, intestinal Delraseulariz-ation ofthe Colon.
contents could always be forced througlh the opening; it Inalargerabbit 1inchof colonwas devascularizedIbyliga.
iwmnvytauesGncosobuessleynrmvoeeemddi,ebmlraoatwneoevuessr;u,rrttohhuearntedfiionnrgeentadhetsleoir-nieeensdofoafnsauestxtuporemeroisbmieescnattmahele aotpumApreiannrlgteantueftmroluyerhxuvaanedamslsitecneloarstmedieo,ofsnbuudsptohp,wolnawy'secdftlrohsotoehmu,egthoadbteiohvnveapseercoduatgnledea(cIrtoiifszotneuh,dreracogouuplruto)d.nretditoontbhoeef
operations.were performed in whliclh the mucous membrane relatedboweel,
ulwsuaumsaelnsnwoiafpyp,teldlbeugtauwtfa.eyweTarlsleLcelamonrsebalesyrttoamsossuptoiussisriwebsalsetchaoarmnopulnuedstuetadhleinwoeptrehene cfoulIrIotnnnh..aea.rt,shLeiaarcntdodenardnfeiivaxmenaiamvnliemasnaslasettltiislholewnmedsorehrveo-eawlseeicxdgutlaenitiaoulrsriciezvdhae,atnciilogmneepvwlaiasinccsuatltchaiearnrLbgizoiawe1tedDiloa.inns.wtaeospf-
necessary. Whlen the anastomosis was performed in this performed. The colic artery was ligatureod just below the
way the animals invariably recovered. origin of the inferior mesenteric artery, and again all four
F'romuthese experiments one wvould draw the following vasc4lar loops:passing tothe bowel. The invo'led bowelat
creolnicalbulsdionpsr:oceLeadtienrgal tahnaasntomennodsitso-ies,ndonatnhaestwohmooles,isa;motrhee ceoaxnvcaiemtiybu,eecadan,mdea-tnohdefafw,oboulunudnisdnhoccrlomolsaoeiudr.i;nTiethvSrewerayerrdeeastypusercnltea.dtetrotthheeacbodloomniwnaals-
ftiah/ecestugoltrusytowifshceelnnidptptheoed-emanuwdacyoa.nuasstmotewmibosriasnaoreartentdlleereodpemnoree'ndsastiso.f ldiesvThahesesc-suaelacerolxilzpaaettreiiroamnlenmctiurssctus.lhoaoctiwcoeunrd,baetnfhdaotrtethhltaehtecaovlivtoeanrlyirtacypoiondfsliytdheeersatbaalbue-t:
2. TVhen di8tension of theinecstine occutrs afterresfcticn is interfered witl.
parn-(eIdsenacnealoSftobMloosoidSinoftheinptecrsittionen,caliscavitityinoflruebnycedVcer1i:tyonctahle :PyligattuDeeroafsetihlaeramie.rsleatnitoe;2-iccfves/tsheelSsiS1aliln.Iontfebstoiwnee-.l wascutoff
sifection? froniitsdirect blood supply. After somedays nochange was
gumiiAtethiswoedar)iseosrabonyfaslteaoxtupenreiarolismeadeenatsestiotlmwhoaesrsis.bpyerAffetonerrdm--etedoaceinndanwah(si(tcmhoolmdiofstiliehsde rsaeecpt.Itpuniaroarnteenndst.oefcionFbnootdrwhtee-yxe-prleeeitlrgahihtmeteed'nvhlteoosusore1pls.1silnoa.fteorwf-thghiuecthawreahasadwdbaeesveaensxcaulmiligaanrteiuLdzr.eedd TawJ'inasd
was comiipleted, a measured quantity of blood was spilt- foundsurroundedby tnomentalgraft.
iinntteosttihnee.peritoneal cavity togethier with contents of small foAuLnfdtertorebme;glaovnignrgetnhoiuss.g-r-atfhtetrheewiuansdearlcyeintnrgalsmpaelrlfoirnaitteisotnineabwosu-tas
In every case the animral made au uninterrupted re- wvidine..ii size surroun(ledt byan edge of gangrenious bowel in.
covery, and nopareticdistonsionresulted. It woutld thcre Theexpeimentwasrepeatedin another animal ---a c-t.-the
C)
2 T.AIEIBRITISH
32'2' MTEIDICALJOURNALI PERFORATING WOUNI)S OF THE ABDOMEN. LMARCH IO, I9I7
|~~~~~~~~~~~~~
vshtimohtaeualrlclisetniyttnhrtoeeefsroteftilhnateetheewdinrabteseolsawdtteieelndveasgshucotouf.wleawrdhiizacehdc;omispaltneotttheoerious: 1gjafnogrtrye-neeitghhte acErxospse;rimienntot 3it.s-Tlhuemj9eenjausnhuro-tm4-ww^aa.ssbplr0aocuegdh,t0ao3sut)sahnoidwndiviindeJslkehtaclfh
thaFtrotlmle ctlojleosne beexapresridmeevnatsscuolnareizmaatiyondraw the deduction
trehaellsymaallveirnytecstoinnsei,dearnalbdltelhadtevbaostchulaproirztiaotmniosorneof Diagram 3.
podvbfieeetrlvcaiialoemsilvectoenuynilttabmalrelhaiacytzeoevmdi3bi(enlinewga.nifcftteaehofcofwtue4eectdtibenwgde.i.laitnoehfgvoFreuterthnoteehgmaastenmcngalesrilvuneleiinnnceagila,nrtegeeasrswxunetipldaitetntihreeniofrgeur.ntocmetheir t(thDheeiaalgocrocapom,emxp3)~aa.mniy~Fniienvdge;hsokteuhtrecshc0oln(atDte0e-ii-ran-tgtsrhaewmear4be).dfoomuennd reopsehnoedwnanid
Oniczt(l grafts. WVhat
awartenatfiIsaumcntsliaeuncldnaasitlsedafniiotwletohaseddy.,waointmdblelenilctneofutmaLimwnfergweeaeksmitonocraoremtetephntlea-hepnedtediaerrylisytum.osonrereseaemTlalonlvdeeycdavvailft-yru;eosmthe ewxlipAcesirhiimfneonlEltxopwielelrduistmthreeanttiesnj2tuhrDteyihaegctrrooaenmtslliwldea4e.sgruatbniloweealxaltr.rraevsatsation. This
corIunplaetesleycofnrdeedgrforuopm oiftseaxtptearcihmiumeennttss,tlle omentum it7a.grWeahteenrttheendweonuctnydItorulneaskhi?n the lontg axis of the gutt,7has
thwahwrbcoWatmuclinfpviwtiowtapas,ifbsgsbsneaotciIwhsfttaltfacolahsnTe6rtioofndndoerhirethhfernantlniimeoemuEehehnirnererenrseealI1fneeW6iLavrpaovtuxthfoSaOiiTtbswicedantnscerewofdfe.ertlxeensdeinittwfahreaseyhatfltiteumimmibec)aetahopseutcaaaete,ntttnorreorllhgaelgmrcpohaeasolmepthrputseylninlecesmeniiepprapitaowrluaenteelahtlwice,isoaeinwoeisdnbdlcaarsntit-twanlamsosthal-niurelwdtslnneereii-tooaifrywolDriihtrlatsdtisaienhenylshhwnngnmlmltlotalisonosetivieyea^lcietgaseetettspaeegeiehtatsadaagpitsohintoalscslthhledmnrihaeosxoocaottihote.odopadladstitscdtznordf;efetaedito;tdlTrcnmlerowtlsnltaaamttnirchmaaeoieohiblasieamtethwetenogaudevteielinlogouropdtsutleapaaiimmleypmlifadotrpehnrcymnreiphynebspoupatnlsdecoudeohtnogroalilwehapttbmneebeeeitaocnurlrisrlhtinifudfe.nhiuaeofnientoliiexL)rrtithyedgludncrwi(eiigldomrdfuniiiotupiw-sshenceatoieluhancyieoagieotseierCenntrnfsskagpiocpodennegdncmhttatdnooimeuiavs-iug,lvdoaoemntjatgnlhfral.oinaiLettntoflitenesraefmSwfsddv.hsFielhfusryoiteietgenttorniiarybrljurtenoreicla.taaxaae-atr)rantonee.aoboumtopgoIrliodcleeevtsdrwtpaasfdtmlrtd.osawrvauolewtrwhaptnnamerahsdeydepteiehseafhclnead-aeutelleToeadtemdsawyuhdellaiweentucilndeiaflsrTtraialrohsrnhbladudtsristuhodiGa.sctesneondwws.ehelrobacaaofheeupeedeaoetgncrlOviehhlgeidealfaleeartadsimbrmminatrrpucaomlNlaeutifndvifrieledlhvd.sgneneefsyuloeuooevitisiolitxgfshieyeeeeriTragsmtrrtbdipoasntaaovtiwcdammechoredtftmxtasdeaedwroeooihtevotsltetnsltlmyahaiefedewtyrcsflgfreefbensTaliatoielwytanetolblaetpghrsrse.vcnaneotoodobfhytlietosedeteysyaaetpftcooahraneiiuaofnotsbmeiuellrtwisfafirlvtsaphmhhwtwessuoloeGonneeyndloccrsttuiencsneaaereimemoaiohrhocslinssfwdstoxstehnoSrle.tealftamenemsdedutedaoreayhroteaohrefellvufeshhtta(apdlbdhydylafwodatlhweagrsleeetalaletitesdheepaypt.etoreaelaeifidrsaehepmesmrhrehhhbicSrhawpiohlrwrotisuesepfntnitedaretaedoiteaeoPpgflioogeayiweaeeainlliilislhoevluedxulteaidtrwgrffowatbininrzrntnlitonaesna.eaarnrcafeeenepeeeieento(trorelhatfdftksxopalguadidsdpmledethptleeleetaefheswsfop,tntyhs-aauyhbs,cedtodeieothfilettlretdobeolaennemriorhrsreFuNfwtiltsetrbnflseiionnhoteeots)eeeergeramtrrepiwlMsmmte.feleewnsieratnthyamindeiltaahlgotrtpltetahuIlevhislhonsoatptbtoieiaaaeb.syhennhanbwlcdecntecarltetsbyetxoidiaetrfviehceeuiddctnRimlwxioissatvlrn;otemfootverphsetnntlasgvineic,cepriimneiecenlctietderneaetdeadhutupnhrei.aareioaeaeeensae)dgdf-lherersdl;ld,t-anpwialeimwiiddaaEitafipotTtrnFtptiponlcewmlwcaevolnaaixninoesiphogfelxhitaihioiehrnhacuorehtxoseeEigmctavttsnuonlerapEteeWdrRlaiEvagaatmrtofaemdaxneTreaenlenrWttrhWsTtwnlftCifhEdesdxbuilaaptgs-evopxmfgsitnyshtopahhiedaeempolltlneti.ootaihlpsncmteeoieritertoenentpsavsetcnewlhii,eeydzulilhreursilapcaittnfeeserirrraeasthr.eiwde.ienewisnolieennexcornayatasleihrsaegxlatlseidenteirssadseeiaoewncmrdttiuiiytolehaeslytwdyi.atrTtgdmcmhbrnei,seo,eweiiolordsmhFemyhatehetnuietdesatahetneneaiasmbdotsntiepsloegutntietxabwhi,ndesotlvAria.tlnovneetuncilaiselnddeoueecorhnptduefoeTeovlad,marLoieiilaiostlues.eiwoipwxeoantfetemosiTyimnslwhadennlei,rmm.ntslno.csrdtewaotppttsrttaacmswahbetCt.ra-e9ivdpleyio8lsdnlhvosthathtee6oilvwuaeravlwmaed(eynolsdettnaefov.aol1eeaieewihem4raa(lenneeiluboaapiesrelBfedncsketoxroneaq)t-iretorneiyaivyirprte-lese7snieofonoarsupgodkisntrussiAhotcnirrebmaxnaaynicagls.dediwmeonevugiwcesropotuellgottt1eniditatotseatfgltl-rteon(ttuusllciflrnwamayahfghlnpfaoeeanre.lllcpodyioHcuteuihrituaaAeeouucnwpdlafslieectoxnaadnt;lrrohussrrosaromlanrorwabpseAlse,tanlsttrdi5dnslyjnet:wdneggnemso;eeeinrrnngcsavahiyeiusdeswhiiiHle.eeeyfsnadee.dtpeiellnmrteevtpiea.epsadsujvoht-ostnhsonotaedleetdatnciairetcaesBl.fate,uesoulosLenih.hociumlttedloettstrexn)eonidnmrieewanntlibnlafoefloecmaduyhtcieitelndpipdeamhttieanogso.gssidrrerhmlfsfenvlee.lkgtuceneShvmtdtdgmgn6tiSteeiohoewgiereee-.omihtwiriteieorropneniuotwailsrdrnamealfeomddaiebfneexilar-folLnsxntlcienomoli,vvakyitmitTrrtonewcae.,aoesmoleoaxmuuacttaeleatishvarhtntsac.maenhnabyhraluttntrlhuehnishigocdelitihoothophToascslnmlesaomsheebfewbfvituenanhsgnsrgoalunerlmhvtauirlteealanruati.egcdidkututtgruirtpemidgrotesieindoetsiokttoierohossssvrenenss.samsu-pemohgrsfuebd.xwionuntxoami.r,nwieltxenhaiafsoqfxussttevuagapufiner8tnndaiwamtateTwott.weiwrpulltornedieihrodtmsfgs.dtistrrfauhshaeIayhtrfehaeaksonwirsieosstleieeteteshoswarernedritscisdrWaanxvowehneusenr.bleltiiiatenlgtotsooktemtnastwardtooTadivtnvolledeenlyhmeuffheaigglr-iueitlalaiwyusuheatedufenewdrddoearntseieidtsanttirkensrnesetrnaoxassnleiveesnosshpoieimldtyxdeeido-hron,aeoeptmirndowtnadanptclddunmssmdaiistxuoyienumonssthvaraoesv:nsetn.aehnpppptcadafiaarwehaeethroslmitrcrteiensxesehhpelctglbirtfsitaatahoich;indardpulelieodldahoettmceodmeaevsitJotl.itklaiwlrreuntitxrodemapttcoinednitmhnaihaooengpmeimnlpevhgn.ce.naddanrntnmaipeeejerelegtsotenibteetiasiteuaterrld.egt.upariesmantw.tereiineo;xhnrnosestttafcnilitnoiodxmlpsoleiiltitaamnoqninoposoduemecamemca,uibniwiilaiwtnenyaontvrnianitiatorttnctnltoalencrntdenhaigsiatnhlelcdheecahuelyeiladilgssw-sjl;s:.eedl;sehr,etey--rll,-
omenitum was niolonigerover the wvound, butrathertoone side; recovered.
*aotionnhiEtepderexsedrtpiiivtwenioaadinlsliimetecditmostnnho-ata2lep,nfne(dtBraseicn.1trofooinsiaisnnt.ttiessHtAapifrrnteeae)slr.encsioteTnvhteaeennndtjsejunuemscawpaesnd.o sign htwhahaIsettnthahettlelhh-aeerrgcdetoeougrrrrsetesemeaoolsffltteahixmetosnreuattnvrtaeasxtaopafteitrcoionmnttehenlnetatrs.gteiliyTehdehoeafpvsemneiodapllsenlroeatrutipitcioolemnndd
MARCII IO, 1971 PEIRF1IOATING WOLLNN4S OF THE ABDOMEN. [ I r__323
amount ofcontent thlC lesslilkelilhood is tllerc of an early seen it occur to any marled degt;ee. Apparently there is
extravasation. a conmplete inhibition of peristalsis for somiie titne sub,,
This observation is in keeping witlh the good results sequent to the injury. Furtlher, tlje less the dlegree of
.obtained in perforating wouIIds of tlle intestine in such damage to the gut and tlle fewer thle number of perfora-
*a campaign as the South Atrican war. tions tlle more likielihood is there of extensive peritoneal
soiling. We believe tlle converse holdsgood.
WOUNDS oF STOMACH. Wehave lad several examuples of cases in wlhiclh intes'.
Morbid Anatomy. tinal contents have escaped between the layers of the
Under thisheading thereareone or two observations to inesentery. Theyhave been cases in which tieprojectile
bemnade. hasnotactively perforated thegut, but,by passing near it,
Occasionally entranco and exit wounds of tlhe anterior has exerted suclh aforce tlhatthegut wall rupturesini tlhat
wallofthjostomachl arefoundwitlhanextraordinarilysmall portion which is unsupported by peritoneum-namely;
extent of stomach wall separating the wounds; it is between tlle layers of the niesentery. This is a serious
difficult tosurmise how suclh mechanically occur. type of injury, as it invariably necessitates resection of
We liave confirmted a former observation tljat wlile tlle-damaged area.
,entrance andexit wounds of the body of the stonmach are Whlen-thieblood vessels in the mesentery are damaged
very sinmilar in size, an exit wound inthetljicker miiuscula- the surgeon is faced with tle question wlietler thte
'ture of the pylorus is generally considerably larger than viability of the asiociated gutis oris not interferedwith.
.theentrance wound. We hiave carried out some experimiental work, noted
Wllile tlhe peritonitis whiclh results is, asarule, of slow above, to assist usin coming toadecision on thatpoint.
development and subacutecourse, ifbile has escaped from Experimentallyandclinicallyit wouldappear thattlhere
.thlestomacll wound theperitonitis ismuclh moreintense. must be a considerabledestruction of the vascular supply
beforethevitalityofthegut isinterferedwitlh. Thecolon is
Clinical Features. more liabletosubsequentnecrosis than the small intestine.
In addition tothesignscommon towounds ofanylollow Tile practical bearing of the point is that cases of
viscus thiere are certain distinctive featur;es. -mesenteric injury previously dealt-with by resection we
Sickness is usually more pronrounced than in wounds .of now treatby simple sutuireof the mesentery aiid ligature
the otlher abdominal viscera, and in the vo'mited muatter it of the divided vessels. Thle extensive injuries of their
israrely that one fails to'find tlhe presence of blood. The blood vesselsmust, of course, bedealt witlh by resection.
degree of collapse is less muarked than that found in intes- In this relation we lhave observed tlhat, wlile inter-
tinalinjuries, but wlhetherornot tlhis is ielatedtothe comi- ference with tbe mesenteric blood supplynmay notactually
parativelysmalleranmounit of haemnorrbage onecannot say. endanger the viability of the gut, that portion of gtut is
It is interestina to note tlhat, while the pulse and particularly liable to a subsequentdistension, whicl may
respiration rates are botli increased, the respiration rate pass toanactualparalysis.
has proportionately ineleased tmore rapidly than the pulse
rate. T1'he dlegree and the variety of the clinical features ClinicalFeatures.
are influenced considerably by thle situation of the lesion. The clinicalfeaturesaregenerally those of comimencing
-Pain would appeartobe miore intense wlhen tlle cardiac or peritonitis, coupled witlh the evidences of rapid and
pyloric ends of tlhe stomacli are involved; it iscorrespond- progressive haemorrbage.
ingly less so wlhen the woundis relatedto the bodyof the Under the influence of morphine, and sometimeswlhen
stomiiachl. tlhe intra-abdominal bleeding isprofuse, welhave seen tlle
Wounds of tlle curvatures of the stomachl, witlh the muscular rigidity of tleCabdominal wallalmostdisappear.
*greater destruction wlhich invariably accompanies themi,
are associated with severe symptom]s of collapse. The Treatment.
clinical features are alsoinfluenced by thecondition ofthe Laterthere are described measureswe havecarriedout
stomachl atthe time of injury; if tlhe stomaclh contains a preliminary to all abdominal operations for this class of
quantity of food, tlle wound is followed by more intense case-measures which are intended to antagonize the
clinical features than iftlle organ liad been emipty. shock and loss of blood which Occurs. As a preliminar4
tooperating for perforating wounds of the small intestine
Treatment. these precautionary measures are of the hiiglhest im-
We would renmark upon the importance of routinely portance, as the amount of sho6ck and tlho loss of blood
'examining theposterior-wall of the stomach. A wound of in thesecasesareoften exceptionallysevere.
tlhisregion is very apt to beoverlooked. To open the abdominal cavity we- lhave almost in-
- Wounds- may-occur- in the cardiac region wliichl are variably used a middle-line incision; it is importanttlat
almost impossible of access for suture- unless the tear there should be nohesitation in makingthe incisiononeof
be avery largeone. Such wounds maybe left witlh a fair considerable length. In localizing the sitesof injurywe
dogree of- certainty that natural healing Will OGCLIr with have followed a well-defined routine. After opening the
little or no leakage. . abdomen the caecum is identified,and from it thesmall
. .. Results.of StoMach Cases. intestine is traced upwards,beginningwiththelowerend
-:.. ... Totalcaa-s, 24. of the ileum. Aseachperforation of the guit isexposed, it
EBuolmlebtawnodunsdhesll wou.'..nds ...... ..... 1104 siswawbraaplpeendgtuhpoifn-taapsemailslstmitoeilshetd.swaTbll;istoisoslnioppseiddethorfoutgheh
8irhplc suithre ... ... ... 20 the mesenteryand doubled twice round the gut covered
CRSefusatesuctrtreioo-anedindtaengriadossgttarosiotY-reon-tecnrtocrs..of..sotmovn y.....-- ...;.... 111 tbhyerteheisslweasbs;chiannctheisofwamyasesaicvleh ipnefrefcotriaotniofnriosmmathrekeidn,juarnedd
Complicated woueds ... 22 gut. The whole lengtll of the small intestinc must be
Re'ults: examinedbefore anydecision astotreatmentis arrived at.
Recoveries ... . . ... 10 There is nDthing more disconcerting than to dealwitlh a
Died * ~......: .:...... 13 perforation by resection and to find that a few7inches
iTruoperatelo;n .. .. . 1 further on there is anotlher perforation wlicllcoulclhiave
been included in the same procedure.
*WOUNDS.o SMALL INTESTINE. Whlen thedegree of damnage tothe guitlhas beenbrouglht
MotlbiclAnatoimzy. under review, there areth-ree varieties of operIative treat-
Whlen n bullotl passes thiroughi the pelvis it isniot un- nlent which ma,y be followved. These are: (1) Simple
commn' to find thje loop of intestine wlicil was lyinig in suture of tlle perforation; (2) resection of tho darnaged
the pelvis,atthetime of.injuty riddled withi holes over a intestine, followed bh a lateral or end-to-cnd anastomosis;
very limnited aroaw In -one case, wlhere the bulleteintered (3) resection of the damrragred intestiniew-itlh an accoinpani-
the sacrurn and-passed thirouglh tlhe pelvis,therewere eight mcnt of a temporary enterostoiny.
perforations, all of them withlin one foot of the caccuin.
We hlave observecd that wounds of tlle left flank, 1. SinmpZc Sutureof thePerforatinll.
damaging the descendiling colon and apparently out of the In a forrmer paper towlichli we contributed it wa1s leld
small intestine area, nmay wound coils of th-ejejununI. that cases suitable for suture of the perforation wverein
It is remarkable bio*i' seldoni tlhere is a muassive escape thle minority. It wacbelieved that awound tW besuitablk
of contents fromn tlhc lulmen of the gtut. Rarely hiave wve for suture slhould be small, without danagecd edges^,and
-
324 MEn.TI.ECABLiJnOiRT;TNsAHjI J PERFORATING WOUNDS OF THE ABDOMEN. L[ARCi 101 1917
withlian intact mesentery.. Furtlher experience has shown The gut appears to bepredisposed to the distension from
us that the range of possible suture is very muclh more ex- various causes: the general degree of nerve slhock, and
tensive than welhad at first imagined-there are very few more especially of,sympathetic nerve slhock; the paresis
wounds of the small intestine which,do not prove amen- of Auerbacli's plexus as a resultof the blow; tlle presence
able to suture. It maybe said that thereare three possible of blood in the peritoneal cavity, and the degree of the
contraindications to its use: (1) Extensive damage to the peritonitis which is invariably present. As a result of this
mesentery; (2) a wound which, when sutured, results in disadvantage we began to employ a lateral anastomosis,
marked narrowing of the gut, hnd the type of wound and from it we had undoubtedly greater satisfaction and
wlhichl most cormmonly results in this complication is oneo better results. At this point one must allude to the
running obliquely across the long axis of the gut; bearing whiclh experimelital work had upon.the featurQ.
(3) wlhen the perforation is associated with resulting End-to-end anastomosis of small intestines in animals was
necrosis of the surrounding bowel-a condition which is inevitably followed by distension of the gut above the
more common in the colon thlan in the sumall intestine. suture, witlh subsequent deatli of the animal. When'
The method of suturehas tlle advantage of speed (when lateral anastomosis was performed no complications arose,
the perforations are not too numerous), of simplicity of and recovery was invariably the result. The techlnique of
technique, and of lessened post-operative siock. tlle end-to-end anastomosis was then modified in so far as
There are, of course, distinct disadvantages. The suture the mucous membrane was clipped away around tlhe cut
may result in considerable narrowing of thle lumen of the edge of the bowel; a subsequent distension did not occur,
gut, and wlhere there are a number of similar sutures and recovery followed the operation.
withinasliort distance of each other the multiple narrow- The influence of blood and peritoneal infection was sub-
ing becomes a very real objection. The second dis- mitted to experimental investigation. After resection and
advantage is, that if the perforations are very numerous anastomiiosis of the gut, botlh end-to-end (modified method)
their closure would take considerably longerthan the time and lateral, a quantity of blood was placed in the peri-
whiclh would be entailed toneal cavity and a peri-
in, a resection of tlle ttoneal infection was
damaged guit. DESCRIPTION OF SPECIAL PLATE. started by allowing a
Inthesutureoperations rte). Smlalliztestueanastomosis. slight escape of intestinal
olwlfhlaivcetllhnleotwewexocluhinasdve,edtdahonendeedgwweees cLaLaanatsareesgrstaeol.lwa,shnoaewssriitetsohintoihfboelttiihnrcidessoeeptnceytdnpisieonnlgagiwaadvanesadplvafooerlnrtll-]iafgyoYgcfir(wmobmeul-diicnhdobnyeenbdeetsant.nioedtr-ltbori-eres.nudltRsaelstnehaacsttttniomoiinnosatitsh.de pcdoiosintnteetnnistnisgo;ntoonctolcluelrscrueobdns,celaquusfeianocntt
hfioraWvseetiultshcelaldvienga.frlionmentitmhereatdo LaanFtaiesGrt.aoli.2io.ws-iiEtsxhpoebflriitnmhdiesnetntadylspet(oBwgeeelrtgehiearne.vh,elIiaiTa9nrheb)ee.trteeSsrmualtlthslaoinfntrteehssotescietniedoaonnnaeosftwgoiumttohsaitnsh.de tldthheaaavvteelotlphhimtetussleeenthceooaolrf)pilntiiglciaacontilisotunlnbhs-o
timemade use of omental blind end_7s11-a1p1Ia.rAt.,vVaelsliininllFaig.1. I sequent distensionl.
graftstoreinforcedoubtful I imFpIlGa.nt3e-dExopnetroimnoernmtiaalls(mcaatl)l.inAfteisr3tebe:ieneo.mieTnhtealgrgarfatfti.sofinremlmyonutnhiiteodldt;o In point of time tlho
sutusruetulrienleisn.es TThhleemiaatttteerr theiiiesenteryofthegut,butison1lVyadherenttotheboNvel wallatthe lateral anastomosis takes
iisn dtehaeltexwpitelrhimmeiniotraelfuselcl-y poFiinet.s.4of.-sEuxtpureer.imentai. Free OIBleental graftapplied to theno t Saoffeawr amsomietnitnsvollvoensgerc,iosin-i
tion oftitoltnlhoiifssppapaerp.or.smiaglrafltwainstefsotuinned.toWbheenuiniievxearsmaililnyeda,(1A,["herenttotheunderlyinggut. ing, the open ends of tlez
2. RfD]oaelmlsoicwacvgetedidonbyInoLtfeasttirtnahele, pelxFettIeenGliyd6e.dd-iBovunildlteeodtthwteoheuponsdrtiegrohiftorsgmwaaaslltllrci3i0-nw-)fPE~et,tspehtiseptolivmoniieac.scchuaTsrwthafeelorlry.s,lpheacTalifnmidaiinieinitnlhicellel.uswtocroualti-eids- glpoolfoaustrtstg,iehebeiplbluirytrtxyooxiiviootmeafarllcaodpslimspssegeatsgreenmensenesnttiottlho.yne
omreiAtgsihan0oossarodltrlhola1Eysmonnofdsbfi-estate.vrtonooe.uaeertnspdemalidedn,tthw.iieens..perfmttomhhuFreeecrisafoGoeet.nxvuiattetseeIr76nrl.nlyym-ss.ieiT.nvmwg-eebTdldrhAavaaeemmnaaaapeingeg;nderetcidhytBcteoposineastreorhhifueeotmsowmmtnsne!eayasuplteanilcitiIib-t'r5ahttlio).iieligewpxbnretpuytpluoloowrlsi(heeeinttidlhtebceuaweihmsotm)iswseu.sisoenmsededioTndnsltehoaenfertwrthiyawege.tnnuohtdulseunsRegashedvavtmoeenalwrssigosshnrvoieoeatfodwnlh.niotrunheoosgeeff giioWnnupetget,ortcailhtanoaivntnooyonlwtvbhedeieesenyntlnoattltinehtllned.sdeemerteroeoxnfststeerincceotttlmnldeei-erd
preference to Multiple evertedmnucosa. lower end of the ileum,
sand extensive suturiDg. welhaveanastomosed the
We believed that the in- proximal bowel to tlle
dications for tlhe operation were the multiplicity of the centre of thle transverse colon. Slhort-circuiting, so to
perforations, the extent and degree of the perforations, speak, by aunilateral short circuit the caecum, ascending
and the involvement of the related mesentery; we now colon and liepatic flexure, there are obviouLsmecllanical
considerthat only the last constitutes a real indication. advantagesrelated tothis method.
Underexceptional conditions, such as lhave been already
stated, the first two indications may be entertained. TABLE I.-Resuilts of Smlnall Intestine Cases.
The advantages of resection may be summarized as Totalcases,96.
ofmfoilzldeoadw,msa:tghleTehreefoisolpleloerwsaistnigloinkaeilsmiehcsooeomdnptleoefrtiesclaoinungdvhotilhnvogeroomfuegndhte,viitsthaemliirnziies-dk [BlC3ooumlmlpebltiacwnaodtuensdhdiwseoll.u..nwiodusnds....., ....... ......... ...... 448709]
intestine, and there is less possibility of subsequent Operations
strSiecvtuerrea.l disadvantages maybe quoted: The complexity ERSenutstueeroert:o_is-o.tnomy ..., .,.I.... ..,. .*....... 35187
of the technique, the time tlle operation takes, and the
iitn.tenTsheedfeigrrsteeanodftshehoscekcownldliacrheanlomroesatloibnjveacrtiiaobnls,ybfuotlltohwse ReRseuclotvse:ries . .. ... ... ... 37
third is a more potent one; it is the one feature wlich Analysis:
has led us to abandon the resection operation for the Sutureoperations ... ... ... ... 57
imiultiple suture. The degree of slhock is infinitelygreater Recoveries... ... ... .. ... 29
safutteurreaorpcesreacttiioonn.operation thanafter an extensive multiple ReseRcetcioovneroipeesr.a.t.ions ...... ..... ......... 388
nexHtavairnisgeswewilghelthleiderttheheclahnoaiscetoomfotshiesoipsetroatbieonl,attellrealquoersetnido-n BBuolmlRebetcaownvoedurnisehdses.ll.....woulnds...... ......... ............ ...... 414588
to-end. When we began thiswork, wefavoured and used Recoveries .. ... ... ... ... 22
aacnceonmdp-ltios-heendd iannaastsolmhoorstiesr,poenritohdeofgrtoiumned ttlhlaatnitthecolualtderbael LHiogwhResscmmoavalellrliienistn.et.set.sitniineeccaas.s.e.ess ......... ,..... ......... 415744
anastomosis. We discovered that this mnethod wasapt to
be followed bya certain degree ofparesis in tlleproximal Itis intReerceostvienrgietson..iote...thatin unicom.p.l.ic.a.te.dwou..n.(d2s1of the
segment, witl subsequent distension and eventual obstruc- smallintestinedemandilngasimplesutureoperationthere was
tion. On several occasions we have had to perform arecovery-rateof100percent.-
a second short-circuiting operatiou to overcome the Uncomplicatedwoundsofsmallilntestine ... 9
obstruction, Recoveries... ... ... ... ... 9
-I BIIIILI%H
M\tARCH Io, I9171
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MARCH IO, 19171 PERFOrtATING. 'WOUNDS OF THE ABDOMEN. I1METDIiCAcLB OUR33miu 2w3j'
1-1 =2I
WOUNDS DUODENUIMN. bosis, etc. Natutrally it is sutbsequent to wounds of tho
Wounds of the duodenuOmF lhave a veryhigh m-ortality, fixed portion of the colon that-this complication generally
andthe majority ofttie casesdie befpresuLrgicalassistance develop3. The clinical features associated withi such a
can be obtained. This is explained by tihe proximiiity of colonseptieaemia-are-diseussed-undertlenextheading.
the duodenum to sulch structures as theaorta, venacava, Colon woundsappear to bepeculiarly liable tosecondary
and portal vein, wounds of whicll wouLld necessarily be haemorrhage; in several instances'we havelost cases at
rapidlyfatal. varying dates after operation asaresult of this complica-
In the majorityof the cases we have seen tlhe second tion; The haemorrhage is the result of septicchange in
patt-of the duodenumhlas been wouncled-more exactlyat the guit, and it gencrally appears on the third and fouirth
the junction of first and second portions; in oneinstance daysafter operation.
wptnTUahihArlertigltgeeteroldhnnirrettedaidrulaalofpldacyrciastsvuieuutvomsyefuraetial;shnevdtienhdretysorumceoracedaliaeslsdiniouialnnmnyatlewtsleoatysriscnna,eoip.fanejnudHofrfoaetodehb.dmie;olerTwtrhiohhneuetanrogtedlehtihniiie-sss isdnpetrvTeeehsaltedoi.pnc:eliiSnnuiijcbauslreyfq;euaitetnuhtreeCysltioanraeirt,cielapelvreiiFrnmeyjaaurtisuirirylmeyitslha.artreleteaopsotst,shinobsoietlitsoiofeswsmimdaaely-l
uasually an associated wound of tlhe riglht kidney. In
-several instauces wehlavefoiund multiple tat necrosis. 1. Theeffuision and infection may remain localized.
2. Thleinfectionmayspreadandageneralperitonitis
result.
-Clinical Features.
The clinical features are similar to those of wouLndels of 3. Theinfection mayextend into the retrocolic and
small intestine; thei-c is generally intense slhock, and retroperitoneal tissties and the group of symptoms
sickness is usually pre- : whichl we havecalled
sent. - 0colon septicaemia"
SPECIAL PLATE. maydevelop.
Treat,ment. DESCRIPTION OF
Operative treatmiient FIc. 8---The mliddllethirdlof the bransversocolon,showing miiltiplo 1. In the first inistance
consists in suture of thie shell fragLment wvounds; in addiitbion to theperforation the bowel (if the effusion and in-
torn bowel; tlle p SSi. showedconsiderablebruising and i fection remain localized
hsbisliatynio.fcpteiri'fnormtaionrng'gaatbsotterihete woFFuinnm-.d.s910.o.f-GaSurmniafsllhelobtuilnwltoeetsntnairnIee.oafstTohuehtligg1iao:1pp1oebdcr'lttaibdOodlnleoron.feTgghtnulioiett rwsa.assnn1cloottiannnccdttulaC&l.lty tdihteiotpnatiisentg'osodg)entehriaelrecoanr-o
enterostomy must be con- pi.erced byabtullet, but it Layin ose proxinmity to tiopassing pro- slgns of a local inflam-
sidered. butum-e of tle' ijectile. The aretas markeCd A nnc r showedI an effutsion of infected matory focus and furthier
duLiodenum mijay result in oflfuitihdebeinuteeastthintebhea-dergiitveonnIewuMa.yeExXct1pmtintihaetpieornistohnoewuemnd.thiata11thecoats wnielgllecrtesoutfltthein coanbdsicteisosn
contraction anid ilatroxv-
iwno0"L'uannd-sd futahrfeler,esdpuetcoidaelilnayl pcm-nliFinLsmsaei.lse1p1w.ais-tspheodretxditooewnnnsoiftvhetehteioldueetcserarcteianosdiil,pier)lcee,tacuoosfleodtnhbesyhboaowwibeltlgulwltelvthirtewhe%ooguuatnndga.rcetnuoaTlthlleys floirshmlanteinotn aonfd tahe efsatcacba-l
bagl1gtodaiehae-asstvSOntbthaurlurtineiooottpi-tf-Eaeueo1nigSneetsrletrfleefseofeoarrassamo1cioearisnfanealtpaftiooo1attrmscvetanesorhtVieie.osbC(tldlOicedftddwudurhiboees-y-n'-aTs1...,o.c~~uf~iNFFNti-IItstnTGil-sr...eSneg1l1c13u2to4.,hn-.eMe---GrSBvchuiuopctnlalLolstllleshoit0wooooetffwutonrtwtuadhohnlueev(nkadIgicstudarotitnf.goiefhoyctA-notlloofitI01nh1gieeu-tyo.poecrAoalntftmeoinotstsn.-.1lo.icntovemheicrgPca.loneatgrertedineeoslutysreptaNlit.oroc;enhe th -fbap.oliigtnlseloi2tnii.rurtttmlilysharsT-e.ath-il;oslSefysaiecaagscnneogspcemeornapnaieicantrdunodatinleieptdsoipysaesisrnb.iidiy---s1
woundof exit.
the intestine is mobilized progressiveone.
in the iiianner stug,,ested stance th feat.u.oefsan 3. In the thlird in.
obtyitKerocshildeerobveyritulchiesriiognlhtofkitdlnieeyp.arietal peritoneum on the aSptaple1aCrC. tlTleE.hefesaitgunrsemsiiaoyfaiapnpeairnteenndsedleyverlaoppiwditsheptstihcratelmiinga
suddenness. Patients rrffering from this conidition lhave
TABLE. II.-S-n,zmz,a Cases Of oUndldsof Dm)dCe;iil. gtheineerroalhlavsabegerneyau,paelxlitdensaipvpeearlaosnsceo,f abnlododi,t bsuugtg_iensvtessttihgiaa-t
No. Positioniof Wcolnd. ccrciplications. TretLtm-lent. Rlesult. tion of the hiistbcy. will sblo-'that 'tlis has not been
the case. There is restlessness and great uneasiness.
1 Jusnecctoiniodnpoafrtfsirstand Woundof liv'er Sututre DiedD.Itl pSuilgsnes iosf cdehlairraicutm^elr.i§atpipce:arfarnodm btheiceomneornemsatlablriastheied.it vTehrey
rapidly increases, so thlat in the course of a few liours
2 Jusnecctoinodnpoafrtfsirstanl Perftrationofcolon Sutture Died. it may have reachied a speed of 150 a minute. 'Tbo
3 Junctionof firsta-nd Pcrfo-titionofcoloni Suture Died. rmieisnpuitrea.tion rate increases uintil it reaches 40 to 50 a
secondinrts andliver .(colostollay'
The tem-perature behavesvariouLsly; in thlelmost intense
4 Codsmeleclnopnludem(tepadrilvuisoifc-d7ueoo-f Prk-citfodmonireaayctiiiao,nnrdutlopiftvueLtrrheed.Suitgteausritorresot-onacnlndy-. Died. ccaasseess iittrfaaplildslvtorisseusbntooramicaolnsaindedrarbelmeaihae.isghsiot,(i1t0l4e'stso1a0c5uct)e,
5 Peprofrotriaotnionofof tdhuier0c-d Pener.f-oyrationof kid- Suitutre Rtocoery iasndcosimomrotnly,bferfeoqrueiendtelaytlhinimtlfoaultllsifwuiltsl,h ualticrmiastise.lyVroemsnuilttiinnigg
denuin in acutedilatation of stomach. Beforedeaththedelirilum
6 Peprofrotriaotnioneof cond1 Pearnfd.ractoiloouniofliver' Suture Diedit(1. pgeansesre-salinpatlolcoormipslerteepllaocsesdofbcyonascsiloiugshintelsys,jaaunndditcheedeaxptrpeemaire-o
ance. Thle abcdominial signs are primarily those of
~~~~~~~~V -o.U OFC L._-K..................._ localized infection. Later thie abdomen becomiesmilarkedly
Effusion fronm a wWMooocurunNbrdiidsIofAos-ntthneaCtOtLcoOoyNl.;o.n hasa tenidenlcy to, pdmeiirsiuttseocnnuidltaeirds;.r.itgiiedrietyisasnootnethiaesssoacmieatdeesgrweiethofategnedneerrnaelsiszeodr
becomo slhut off an(l localized, miiore especially when the E'ost morteui the signsare thoseof an acute septicaemia,
W%ound occutrs in the ascending or tile descending colon. with marlked congestion of thie viscera; frequently tlhere
In latecolonwoundsit is com;lmontomeetwitlh a collection are iaemorrhages throughout the substance of thie
of fact.al and senmipturulent matter entirely shut off and spleen. TheBcacilluls perjringens has been isolatedfrom
opening into the uLnderlying colon. theblood antd( fromn tllCvisceral lesions.
Effusion from a wounud of tile colon too often extends
into the retrocolic and retroperitoneal tissues. WN'hen
Tr eazetwf-.
tthhieseoxctcruarvsastalhteedremsautlettiiaslfatpepqeuaernstlytofatal; avbesroyrptriapoindlyo,f WVelhave drawn attention to tle liability of wounds of
and an extremely virutlenit septicaemia,ocicsuerstablished. In the colon to become localized, and this facthias a bearing
fa-aonuwdronlhduanepdomsotrofrmhtaohgreetse;czoilntohnsepolefevnifiidcfettneicesnosuoelf,hoaurnvsl'uilndttiuperlnaestesieospnet,pictwietelarheoamnviio-ae pota-n-wteitnohtneyt--focopouermraethsiovu-erusntdteaeftattetmrrneetnahtte.merneTtcheiiaepttbaeoafrpietnrhgiioeidsinljtouhnragyt,eriitfthitsahnae-
326 MRITDuIxC,KBLnJzOTUrrstHNAL1j PERFORATING WOUNDS OF THE ABDOMEN. [MARCH IO, I1917
A
-wise principle, primarily at least, to enlarge the original If an intraperitoneal wound is discovered, it is suturedl
wound, on the possibility that the infection is becoming with aprimary layer ofcatgut and aseries oflinenthread
localized. At an earlier period than twenty-fourhours it Lembert sutures. Thequestionhasthentobeconsidered
isprobably better toopen the abdomen through aseparate whether or not a tem`porary col-ostomyis necessary. If
incision. thewound in therectu'm is severe, it is advisable to do a
We have been impressed with the risk run of over- temporarycolotomy. Theproblemofwhetheran inguinal
looking iinjuries to the colon; the risk is greatest when or a transverse colotomy be performed must be decided-
tlle wound lies inone or otlher of the flexures ofthegut. by such points as the situation of the surface wounds,
Thle actual operative treatment maybe summarized in and the degree of damage and position of the rectal
the followingmetlhods: (1) Simple suture; (2) sutuLre with wound.*
a proximal colotomy; (3) colotomy at the site of injury. T'ransverse colotomylhasthe advantages that itis more
Theoperation of resection maybe left out of account; it easily controlled, thatthe restoration of the continuity of
is rarely advisableto practise it in thistypeof surgery. thebowel is more easilyaccomplished when the need for
At first we followed thepractice of aproximal colotomy the artificial opening is past, and that should surgical
in combination withthe operation of suture. There are interference be necessary later in order to repair the
tlleobvious advantages that it increases the safety of the damaged rectum, the pelvic colon can be mobilized and
suture, wllile it obviates the passage of faecal matter brouglhtdownto theinjuredpart.
through the damiaged gut. At tllis time We were sus- Ifitis found tllat the wound of the rectum is extra-
picious regarding thie viability of the line of colon suture, peritoneal, the entrance wound is opened upand efficient
and we felt that the colotomy added greater security. drainage established; in fact,ineverycaseofwound ofthe
Later we recognized that the performance of proximal rectum it is advisable to open up tlleentrance wound very
colotomy was rarely necessary, and we lhave tlherefore thoroughly, as this diminishes the risk of a subsequent
almost abandoned its use. We now reinforce the suture pelvic cellulitis. Thei question of whether a colotoiny is
line by an omental graft. We believe that our results necessary in an extraperitoneal wound must be decided
have imnproved since wehlavealtered ourprocedure. by tlle clharacter and position ofthe wound.
Wlen tllewound of the colon isvery extensivecolotomy
at tlle site of injury is the only possible proceduie.
We believe tllat all wounds of tlle colonslhould receive TABLE IV.-Resi(lts of JVoid(Inns of Rectumit.
very thorough local drainage. In woundsoftlleascending Totalcases, 1I0.~~~~~
and thedescendingcolon wehave been impressed with the Bulletwounds... . .. ... ... 4
advisability of draining the retrocolic space by a tube Bombandshellwounds ... 6
passinig into tlle loin. Theestablishment of efficient local [Complicatedwounds ... -10 O. 9]
drainage is tlle means of lessening the likelihood of Treatment: ...... ~~... 32
development of infection of the retrocolic tissue and tlle -Suture... ... ..
establishmentof colon septicaemia. Simpledrainage ... 2
Drainageandcolotomy *-I... * ... 5
TABLE II1.-Resitlts of Colont JJVounids. Results:
Totalcases, 85. Diecl ... . ... 7
Bulletwounds... .. ... . 34 Recovered ... . ... ... ... 3
Re'volverbullet wounds ... .. . 2
Slellwounds -..-..-. ... .. ... 42
Bombandgrenade wounds 7. ... 7 WOUNDS OF THE BLADDER.
PCoumrpelcioclaotnedwowuonudnsds ... ... ~S.....@ 2614 The missile may Mr1eaocrlbhidtAhneatbolnamdyd.er laterally, antero-
rreatment: posteriorly, or froin above or belov; the relationslhip of
Simplesuture ... 55 the wound to tlle peritoneunmwvill varyaccording to the
~SCuotluorteomwyithproximalcolotomy * I2-5* portion of thebladderwlichl is injured.
..... 4 Complications are exceedingly common; gencerally the
Resectioii ..... I pelvis is fractured, frequently tlle lhollow viscera are
Results: injured-the small intestine orcolon.
Recovered ... .. ... ... 37 The missile may be arrested inside tlle luttnen of the
Died ... ... ... 48 blad-der, and thlis is iost likelytoocctirwhientlle projectile
That istosay,colotomyatthesiteofinjury. enters tlle full bladder. If the bladde- isem-ipty wlhen Iiit
there is more likelillood of tllere being entrance and exit
WOUNDS OF RECTUM . wounds.
MlIorbid Anatomty. We lhave seen a inon-peietLating btullet wound of the
Wounds of tlle rectum may be intraperitoneal, extra. abdominal wall, sustained by a man witlh a full bladder,
peritoneal, or a combination. Tlhe entrance wound is produce a large intraperitoneal ruptuLre of the posterior
generally in tlle buttocks. Of all possible types ofwound, wall of tllcbladder.
tllatmost commonlymetwith is thewound oftlleanterior
wvall of tlle rectum, low down and immediately above tlhe
floor of tlle pouclh of Douglas. Tlle wounds are nearly The clinical featureCslinaircealgeFneeartawlrleys.disauised by the fact
awloTwulanlydesrsecoofimsitlhpleliaibcsmia-ltlieatdlylbiytnotceosstmeipvneoeruoenrdbbllfeaied-ddabeitrnu.greforfotmhetpheelvilsarogre otthlahtertlwleoyunadreedcovmipslciercaa;tedoccbaysitohnealsliygntshearned hslyasmpbteoemnsaonf
pelvic vessels in close relatio'n to tlle rectum. Unless the opportunity of observinaan uncomiiplicated case.
Th'e features arethose of aslowly developing peritonitis
wounid is large, it is unusual to find intestinal contents
escaping to anydegree. wgietnlehraaltafbirdsotmiloncaall ppaaiinn. ovIefr ttllllee pbaltaidednetr caannd avfotiedrwuarrindos
injTlulreyrteotalrhee aalbldotlmlieCnlfaielnaitcvuairlsecseFrewaalr;lailceilsnhest.lolneeeaarslsyocisattaegseswittheh mqlhuaaayenmtaibtteuyrtidhaiastcwhinllaolrngeepdirsoibpnaatbsolsyetdhbebeyppterhreeisteuonrntee.talliraUc.raivniet,y lihnowesvuecrh,
sriseycRmtvepouctimed.onemtds,lThahpareaeeirmneio'lrlrmidhsealfaycignoeebmdiepslauarnsieduntaeealndrlteyioolffnioaubionlnfedutterolsilcenbaee,prioeanvgnegidrolfnoriofookfmeudr.titlnhleee toaabhbnteWodulvlrheeoeasIwttcnoeharrepetaplfslbuoebbdrioyawsmmoteeulanlnlne.nddsicnittTialolstllieectreehxneitonirftsauicplpthetperreniairtdtnoietonrponenaaertslsthp,ser.oedafabunduldstlttnhrioeeincsgkstit,ldhlliaeitbpgyplypheeo,latvvheroier-ss
bladder.
In uncomplicated Wvounds of the rectum the degree of alonig tlle inguinal canal into the scrotum.
slhock is notsevere. disTtheensiuosneofofthtehevisccyusstocsacnonpoetibsenootbtoafindeida.gnostic valute as
Treatmiienit. Subjectively there is pain, tenesmus, andc frequent
It is necessary in every case to explore the abdomen. desire to' pass water with inability to do so; often afew
It is possible that beyond an infiltration of blood in the drops of blood are passed after muclh straining. Rectal
pelvic tissues, no wound may be found, In such a case spasm mayalso be present. Urine mixed withl blood may
the injury isprobably extraperitoneal, escapefromi thewyound.
mauu lot rqI7I MPERFORATING WOUINDS OF THE ABDOMEN. tiCaAsLBJOnUIRNAZ 3227
Treatncent. originallyremoved the kidneythroughananteriorinciAiol.
In the intraperitonealvarietythe abdomen isopened and We befieyetiat thisoperation isassociated with veryeon.
explored,the tearin the bladderwall sutured and drainage siderable shock, and that it isadvisablafirst toexplore tho
of the pelvis establislhed. Weafterwards tie in a uretlhral abdomen anteriorly, afterwards removing the damaged
catlheter-inorder to prevent overdistension of the viscera, kidneythrough a lumbar incisioi. -
andsoavoid strain ulpon the sutures.
Wheu the rupture is extraperitoneal a suprapubic in- TiBLE VL-P.suits cf Midney if'.(i)md.6
cision is made down tq the bladder and the anterior wall Total cases,29.
exaumined. If the rupturc is easilyaccessible the wound Bulletwounds... 8
is sutured anda suprapubic drain inserted in thebladder. Shellandbombwounds _ 040 0-0 21
Ifthe rupture is inaccessible, the bladder is drained supra- Purekidney wounds ... .. O" 0.0 12
pubically, and if necessary a counter drain is inserted in Complicatedkidney wounIds 0.0 G" 17
theperineum. ..6 0.0
Rightkidney tffected 16
TABLE V-.--%thslts of BladdIc,' JrnO1343. Leftkidneyaffected 0-0 so* 13.
T,illet wounds Totalcases,14. TrBeoatthmeknitd:neysaffected 0".a0 O6.... 2
Bombandshell..w.ounds ... ...I 11 Drailuage.operatious . ..21
tW + ., 3 Suturooperations. ..*".0 ... 2
[Complicated wounds ... ." ... ... 131 Ncphrectomy.... . ... .,. 6
Treatmeut: Results:
PSeSsuuuptlrutrasep:ubiccys.t.otom. ,v S."" 4... I...6...9...0~~~41440.,..1 WouRDneicdeodsv-eorf.i.teshe righlt kidney are more-f0....a.tal th'a.O..n.*w1127ou-nds
Recoverles .#. I4 of the leltkiducy. This is shown bythe following table:
Died ... .... .. ... .,.
.- ... Dlied.12cases.
WOUNDS OF KIDNEY ALND UrnETEV. PRightkiidney ...
Morbid Anatonmy. Leftkidney &,#,!p .. .. ... 2
A certain proportion ofkidney wouinds are slight, rwore Bothkidneys . .....0 . .. 2]
especially those in whliclh tle edgesorpoles areaffected. Drainageoperations; ... 21.
Wlhen the centre of the body ofthekidney is injured, the Die(d ... 7
tculraemdagiontiossseevveerraelapnodrtitohnes.kidBnuety tmhaeyapbpeafroennntdttroivibaelitryniopI. NephDrieectdomn-y.o..p...eration..s ......S" ..6
tlhe kidney wound is sometimes no guiide to the organic I
disintegration -which oeccurs; even in the slightest wounds WOUND OF URnETER.
the organ voften slhows extensive microscopical changes of WVe hiave had twoinstances of this injury, and wve offcs
minuite necrosis and haemorrhaae. nocomment beyond briefly describing the cases.
The bleeding is not as a rule excessive, unless somee of
thle larger vessels havo been divided; as a. rule it ceases Them-anwas shot at closeCArSaEngIe. bya machine gun bullet.
spontaneously.
Onoperationthere were found to bo eight perforations inthe
Generally blood is present in the urine; occasionally small intestine. In addition to blood, thie abdominal cavity
the pelvis of the kidney and the upperend of tLe ureter containedaquantityof fluid, apparentlyurine; thiswasfound
become-s blocked by blood clot and this sign is then in tohaveescapedfromawoundof theleftureter,whenitpassed
abeyanc. intothepelvis. As thepatient's general condition was grave,
Haemorrhage from tljh k.idney extends widely over the ndroaiantatgeemtputbewwaassnsiuatdueretdoinreppoasiirtiotnh,eaunrdetderraiwnoaugnedw,asbu-talsao
retroperitoneal tissues, and ifan infection develops in tllis- established in the flank. After the secoiid day there was no
Togiontlie result may ver easily be fatal. discharge- of urlile, and' the Patient made an uneventful
recovery.
Clinical Features CCAtSE II.
Thefirst indication thiat thle kidn-ey has been damacged 1)eAlomwfatnhewlaesftwaonutenrdieodr sbuypearsihorrapsnpiienlebouflltethewhiilciluhm.entTehreedenjtursyt
is generady got--from the position of the woundl. One totheperitoneal cavityu-asfoundon theleftlateralwallofthe
wouild reahonably expect'llaetnilturia to occur, but, as we truepelvisclosetothecommencementoftherectum.
lbthheaevaekbisdepnnoetiy.u:teadWlolnhoeue;tn,thtulenldepehwry,osuicnceardltaisisinguclnoscnaodrimetpiloitnchsaostteehdi,osfsiinagvnorlemvtiraony-g I atdnhaFeamosaturgoerecmtpooest-riovfseostrihwacoataislmoendpssooenwcuehei.btr.eerAyfoToushfhnerdtahipanenbegdtluhotemb.uiellnleReuetwmsaweswacisttcihloronescemoadonn,vsdeiaddnledarftaertbrohlameel
peritoneal injury; thegeneral condition is good, the ptlses entrywoundinthe left-sidewasdrainedwithalargetube.
rat6 beiug only sliglhtly increased. The local signs-are For the first two days following the operation clear urine
those ofpartial fixation.and rigidity ofthe adominalwall. cameawayiniquantity throughthewooundin the leftside. No
tendernesson palpationausually confined toone-halfof thle ucormiinieplwetaesrdeicsocvlehrayr.ged after tihis time,and the patient made a
abdonen, and occasionally thje presence of fluLid, demon-
strated by percussion in one or-otlerflanks. WOUNDS OF SPLEEN.
MorbidAnatomy.
Treetnicnrt. Wotunds of the body of the spleen pass tlhrouglh tlie
Generally spealking there are thiree possible 6pcrative organ without producing extensive datnage. There is a
procedures which one may be called upon to perform: smallcentral perforation withradiatingfissures.
(1) Simpledrainage; (2) suturiing 0hekidney-; (3) nephrec. IWheneitherpoleof the spleen is wounded the damage
toSmiym.ple drainiage will bethe operation of choice in the eisntimroerlyeteoxrtnenosffi.ve, and sometimes one or othier pole is
majorityof cases; we would modifyany former remarks In one instance we have met with a curions type of
bysayingthat in manycasesin whicht formerly we would injuryto the spleen. The man was wounded by a rifle
have removed the damaged organ we now rely upon btullet in the lowest rib at the posterior axillary line,
efficient drainage, leaving a neplhjrectomy, if necessary, Upon opening thie abdomen the cavity was found to be
nntil a later date. To expose the viscus we employ a full ofblood, the spleenwas.disorganized into a mass of
vertical posteriorincision. Sutureof the damaged kidney bleeding pulp, the lower ribs were fractured and tth9ir
we hiave only employed in one instance-the viscus was shlarpends lhad been driven into the spleen, and the re-
almnost severed intotwo halves bya hiorizontal tear on its peated movementof respiration hadcontinned thedamage
posteriorsurface; -witha view to saving thborgan, and as thusbegun. The damagewas so extensive thit splenec-
the bleeding was notsevere, the two halves were stitehed tomy was necessary.
with interruptedcatgut sutures- The rbstfit was uinsatis- When the wound involves the hilum the bleeding is
factory, foirsepsisdeveloped w-ith disastrous results. intense; in other situations it has a tendency to cease
-Th indiestions for nephrectemy areextreme laceration spontaneously, and it is very reaffily-tontrolled.
of the kidney, and- haeorrhiage -from the, larger reiin Wounds-of thespleenare nearly always-comlicated by
vessels. As it is vervoften necessary"to examine the ab- wounds of one or moreof the neighbouring-viscera the
dominal viscera inadditiontodealing, with thekidne-y, we leftkidney, theleftplcural cavity, and thespleaic fexure
323288 BMTDiImWLBRJmOIUsRNALJ1 .PERFORATING WOUNDS OF TIIE ABDOMEI. [IvAttcn 10, 191,7
of the colon. Itis interesting tonote thatwounds of the post-traumatic jaundice isuncommon. There isgenerally
spleen and the stomach are very rarelyassociated. an escape of blood into the peritoneal cavity, and occa-
sionaally it can be demonstrated in the retroperitoneal
ClinicalFeatures. tissues.
The clinical features are best described byquotingthe We have onlytwo instances to record ofwounds of the
history oftwouncomplicated cases, one observed early,the ducts-acasein which thecysticduct wasdivided closeto
other late. The first case was observed about six hours itsentry intotlhe gall bladder, anda woundof the common
after the injurywas sustained. The general condition was duct. Duct wounds are so frequently accompanied by
wonderfully good, thepulse beingonly 88; there was somne injury to large vessels that the result is generally fatal
muscular rigidity alongthe left side of the abdomen; the before they can be given surgical assistance.
abdominal cavity.contained a quantity of free fluid; tlle We have on two occasions met with wounds of the gall
temperature was normal. These signs, together with the bladder-once with a wounld of the cystic duct, andonce
entrance and exit wounds, were the only clinical evi- witha wound of the comimon bile duct.
dences. The second case was different in so far as
forty-eight hours had elapsed since the receipt of the Clinical Features.
injury; during* that time haemorrlhage bad been con- The clinical features may be rehiarkably scanty. Iftlle
tinuous. When- admitted the patient was pulseless, wound has involved tlie lung and pleura the pulmonary
there were all the evidences of-intense haemorrlhage, the sigIns frequentlydisguise theabdominalfeatures. Generally
abdomen was distended, rigid, and contained a large pain is comlplained of ovor tlle liver and beneath tlhe right
amount of fluid. scapula. The pulse, temDperature, anidmore especially the
Treatbnent. respiration, are increased. There is usually somoerigidity
Thetreatment of .wounds of the spleen varies according ofthle upper partof thle abdominal wall; we lhave observed
to the degree of damage sustained. A small penetrating tllatthe rigidity isincreasied anidbecomesnmoregeneralized
wound unassociated with mucll bleeding is better left when there is a-considerable -effusion-of blood into tlhe
uninterfered with. Wounds accompanied by extensive peritoneal- cavity. By percussion an effusion can some-
destruction of the organ, orcomplicated by severebleeding times be demionstrated in the righlt iliac fossa. On1e would
-forexample, wounds -of tlle lbilum-are best treated by expect greater interference withi theexcretory funcetion of
removal of thle orgyan. Tlle mniddle groUp of cases are the liver tlhan is actually thecase. On only oneoccasion
those vithi a limLitecd wound of the region associated with lhave we seen a large effusion of bile into the peritoneal
mnoderate bleeding; the local treatment of these consists cavity. Post-traumatic jaundice is exceptional, and wlhen
in arrest of the hiaemorrhage and, if possible, closure of it occurs it generally indicates a septic clhange secondary
tllewounjdin tlie spleeu.; these desiderata can beattained totlhe wounid. Thjere is no alterationi in the bile contents
by theuse of suturesandpacking. of tlle faeces, andtlle urine is freefrom bile.
In gaininig access tothle spleen we have generally used
an incision parallel to the costal nlargin. Treatment.
We lhave only operated oln suclh cases as slhowed pro.
TABLE VII.-Riesiults of Spleen Wouids. gressive haernorrhage, or whichl, fron tlle clinical features,
Total cases, 14. we suspected to be comuplicated by wounds of othlerviscera.
BBFurolamlgebmteawnno(tudlosnfhdeselalr.w.t.ohunds ...0.. ...... 67 aIIcnncooaunnneoittihnloseftranticlnehsetvaaenccocepuemarualtaleatdtieofnoorpoaefrwaotbiiulonendwioanfstltlhneeeccyepsestrsiiactrodynuecaotln.-
Treatment: ... ,O 9 cavity.
ReSSsupultletuisri:eec..t.omy l.o." a-...b O..... .a...599 cainsgWiloeendshaihvnacevieseimogpnilvoreyenecodemxmcKe:olcehlnledenertd'sabcpcyaersMasac.yosotTahRletoibnoscpoiensr;iaotnbioootnrhhtilanls-e
Recoveries .. .8. generally been confined to investigation, pltugging, and
Died ... .. . ...* ... 5 drainage.
TABLE VII.-Resldts ofLivcer WToundllts.
WOUNDS OF PANCREAS. Totalcases,33.
We hiave liad only one instance of undoubted wound of Bulletwounds ... .. . 15
the pancreas, andwequote tlle case witlhout remark. Shell wounds ... .. 15
Shrapnelbulletwounds 2
There was a bomb wound of the left loin. The abdomen Bayonetwounds ... 1
showed all the signisof inijury to the abdominial viscera, the
spieTgrnshsiestbaeebnirtdnosgimcmekonnsetswsa.msaorpkeendediinnttlhleemuipdpdelrelaibnde;omtehnle;retwhaersesowmaes PCCooummrppelliwiccoaauttnee(dddswwoiifttlhhivwweooruunn.d.d.ssoofftah.b.o.droamxinialviscera 11815
free blood in the peritoneal cavity. Examining the stomach, Results:
thegastro-hepaticomentum wasfoundtobeperforatedandthe Recoveries ....t. 19
dleisvsiedredcuariviadtbulreeedoifnitg.he Tshtoempaocshtertioorrn;watlhle ocfortohnearsvtoarmtaecrhy-wwaass Died ... .. .. .. t ' 14
exposed butnoperforation was found. Therewas a quanitity
offree blood intihe lessersacofthe peritodfeum. Onexamining GEN-ERAL REMARKM.
thepancreasitwasfounid tobeperforatedthrough andthrough, We are conviniced that in tlle vast majority'of cases of
immediatelytothielateral si(leof the aorta; theprojectilewas penetrating wounds of ihe abdomnen operative measures
finallyfoundembeddedin theleftlobeoftheliver. offer the best clhance of success. Woe would qualify the
aniAdrbturbobuegrhttubteowtahsessuutrufraecdetoabtohveeanlttheeriosrtwoamlalcohftthheropuagnhcretahse statement by excluding from tlle category uncomplicated
gastro-hepaticomentum. No complications developedandthe wounds of the liver and certain wounds of the kiidney and
patientmadeagoodrecovery. spleen. Wlhen tlle wound affectsthle hollow visceraof thle
abdomen we are satisfied that it is only as tlle rarest
WOUNDS OF LIVER, GALL BLADDER, AND DUCTS. exception that a spontaneous recovery occurs. When
In discussing wounds of this region we slhall bring a thesecases arrive in hospital they are almostuniversally
series of cases under review, but it must be understood in a state of intense collapse. We lhavetherefore foundit
thatonly acertain proportion of these required operation. advisable to wait for a period of from one to twohours,
until the increased shockof thejourney has subsided. To
M11orbid Anatom211y. this rule we make one exception-thosecases which show
The close relation of the right pleura and lung to the evidences of rapid or progressive haemorrhage; in such
right lobe of the liver is responsible for the fact thata cases the risks attendant on immediate operation are
wound of tlle liver is very frequently accompanied by undertaken. We have occasionally found that tllese
damage to the overlying lung or pleura. TTisi'fact is patients arrive in hospital having beenvery heavily dosed
important, as the lattercondition is apt to be overlooked. witlh morphine, which greatly militates against their
We lhaveseen a case in which the lung wound hiad been eventual recovery; very rarely shouldthe amount of half
unnoticed until the degree of fluiid in the riglht pleura a grain be exceeded. Webelieve that this is an important
actually endangered the patient's life. It would appear to detail in thepre-operation treatmentof these patients.
be unusual tohave muchdestruction or disruption of the During the interval of waiting it is difficult to decide
liver tissue; probably for this reason the occurrence of whether or not active stimulant measures should be