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SECTION I
GENERAL SURGERY
CHAPTER XV
WOUNDS
OF
THE ABDOMEN
The man with an abdominal wound presents one
of the serious problems which the
military surgeon has to face. No other group of cases furnished
anything comparable to it in
testing the medical resources of an army or the technical skill of its
surgeons. Although gunshot
wounds of the abdomen comprise a small but indeterminate percentage of
the total wounded (in
the American Expeditionary Forces the relative frequency was 3.3
percent of those admitted to
hospital, no account being taken of the killed in action) 1 the severity of the lesions encountered
and their complex nature call for the highest surgical judgment in
diagnosis and treatment. The
problem is full of interest to every surgeon and challenges his best
thinking.
In
the war of 1914-1918, the attitude of surgeons with reference to
abdominal wounds
underwent a marked change. In the Spanish-American War and the Boer War
the expectant
treatment was followed,2 and few surgeons then had the
courage to argue for and practice.
operative interference in these cases. The occasional patient on whom
operations had been
attempted almost in-variably succumbed, chiefly because intervention
had been too long
delayed. This inevitably resulted from fighting over an open country
with a rapidly shifting line,
for properly equipped hospitals could not be placed near enough to the
firing line to be of any
service to the seriously wounded soldier.
During
the early months of the great war, conservative management of the
wounded
abdomen was still generally advised and practiced. This was due to the
open nature of the
warfare and the impracticability of establishing well equipped surgical
hospitals sufficiently near
the front line. On the other hand, early in 1915, after the battle
lines had become fixed, there
began to be evident a movement, both among the surgeons of the Allies
and German surgeons,
for surgical intervention, and this effort gained rapidly in favor.
The
reasons for this change in surgical attitude lay largely in the growing
appreciation of
the truth of three factors: First, that the man with a wound of the
abdomen, nonoperated, usually
dies. Gibbon 3 stated that in 19 months' active service
overseas he did not see a single instance of
recovery following nonintervention in penetrating or perforating
abdominal wounds. Second,
that the time factor is vitally important because of the frequent
presence of serious hemorrhage,
and, with a hollow viscus injury, especially the small intestine, the
rapid development of
spreading peritonitis. Third, that the intra- abdominal wounds in the
war just ended were
definitely more grave than in preceding wars because of the nature of
the projectiles used.
Machine-gun bullets and high-explosive shell fragments in particular
often caused extensive
lacerations of the bowel wall, sometimes completely severing it, and at
other times excavating
large areas. These lesions were in marked contrast to the clean-cut,
punctured rifle wounds of
former conflicts.
444
Before
proceeding with a detailed study of the wounds themselves, it is
important and
essential that consideration be given to certain subjects which are
vital in the proper care of the
abdominally wounded.
SPECIAL
PROVISIONS FOR THE CARE OF ABDOMINALLY WOUNDED
TRANSPORTATION AND THE TIME FACTOR
It
becomes evident at once that, whether with a fixed or moving line, the
abdominally
wounded man must be rapidly evacuated to the hospital where surgical
treatment may be
applied. Transportation, therefore, becomes an exceedingly vital
problem. The motor ambulance
made possible much of the advance in abdominal surgery by cutting down
materially the time
elapsing between the receipt of the injury and operation.
Various
factors, however, interfere with rapid evacuation, such as the severity
of the
fighting, the number of wounded men, the mobility or immobility of the
line, the terrain, and the
condition of the roads as to number, surface, and traffic requirements.
Wallace I found that in a
study of 1,200 cases of gunshot wounds of the abdomen most cases
arrived at a casualty clearing
within the first six hours. Only those evacuations accomplished within
the first six hours were
considered good; after that time the chances were against the patient.
Ambulances
should be provided with heating facilities, such as the British used,
that
patients may be evacuated in cold weather, warmed and, therefore, less
shocked and with better
chances of recovery following operation. The writer took many a dead
man from an ambulance
in which the other occupants were stiff and cold, with the firm
conviction that some of those lost
might have been saved had the ambulance been provided with a heating
appliance.
At
times horse-drawn ambulances have demonstrated their usefulness when
with roads
absolutely blocked and motor evacuations at a standstill the
horse-drawn vehicle has been able to
carry patients over an open country and bring the seriously wounded
where surgical aid was
available. A certain number of such ambulances should always be
included in a divisional
organization, that such special evacuation emergencies may be
successfully met.
A
well-organized front line evacuation is essential to the proper
surgical care of the
abdominal case. This effort is difficult enough when trench warfare
exists, but during an advance
it requires the best in organization and heroism in order to insure the
least possible delay. The
most capable surgeon and the best equipped hospital are of no avail if
the wounded do not reach
the hospital within 12 hours.
The
time factor is recognized as an all-important element. In general, the
patient must be
seen in the first 12 hours if a wounded hollow viscus is to be
successfully treated surgically.
Those operated upon within the first eight hours yield definitely
better results. No other
consideration compares in importance to the element of time; recovery
percentages are inversely
proportional to the time factor rather than to the organ involved or
the number of lesions
encountered.
445
THE NONTRANSPORTABLE HOSPITAL
Special
provision had to be made far forward where abdominal cases could
receive early
and adequate surgical care. With a fixed line small hospitals naturally
came into being, placed 6
or 8 kms. from the firing line. They were well housed, usually in
wooden huts or chateaux, with
completely equipped operating and radiological units and well organized
wards. A surgeon of
ability was placed in charge of such a unit and the staff requirements,
including a small nursing
quota, were limited. The French and the Belgians made this type of
hospital an integral part of
their organization, and as time went oneach sector of the line had its
advanced hospital for the
transportable wounded to care for men with wounds of the abdomen
especially, of the chest, and
for those suffering from shock or hemorrhage.
THE MOBILE UNIT
No
consideration of abdominal military surgery can be complete without
taking into
account the necessity for well-organized and equipped mobile units for
the care of the seriously
wounded, well up toward the front. When the war of movement began in
the spring of 1918 a
different type from the stationary nontransportable hospital had to be
evolved, so organized that
it could move with an advancing or retreating line and still provide
satisfactory surgical care for
the severely wounded. As told in Chapter V of Volume VIII of this
history, the French had
devised this type of advanced hospital, known as the auto-chir,
and, likewise, a lighter form, the groupe complementaire, and had made use of them on numerous
occasions. The American
Army adopted both these units, calling them the mobile hospital and the
mobile surgical unit,
respectively.5 They were controlled by a capable surgeon
with adequate assistants; the mobile
hospital had trained nurses. The bed capacity of the mobile hospital
was 120; upon its ultimate
standardization, 20 3-ton trucks were required for its transportation.6
Such
a hospital should be placed as far forward as is compatible with
reasonable safety to
patients and personnel, but no farther. It is very difficult to
maintain morale and surgical
efficiency when such a unit is under shell fire. Under these conditions
the patients become
terrified, it is exceedingly difficult to carry on any effective work,
and a hasty evacuation of all
patients may be imperative. Patients with abdominal wounds who had done
well after operation
in such a mobile hospital have been known to die following their
evacuation to the rear.
It
has been claimed that proper postoperative care could not be provided
by the mobile
unit if an offensive with an advancing line were in progress, as
military necessity would compel
the moving forward of the hospital and the evacuation of all
postoperative cases. The
organization of such a unit may include a rear echelon consisting of a
certain number of officers
and enlisted men who may be left behind with a portion of the tentage
and supplies to complete
the 8 or 10 days of postoperative care required for abdominal cases.
When such patients finally
are evacuated the echelon moves forward to join the major portion of
the unit. Another effective
way of dealing with this problem consists
446
in making use of a second mobile unit,
which passes the hospital already established and
establishes itself in a more advanced position, while the unit behind
completes the postoperative
care of the nontransportable cases.
INCIDENCE
The
true incidence of gunshot wounds of the abdomen among the members of
the
American Expeditionary Forces is not known nor can it ever be; many men
so wounded died
upon the battle field from shock and from hemorrhage. However, this
cause of a discrepancy in
our statistical data is counterbalanced somewhat by the fact that many
men, otherwise wounded
than in the abdomen, also died on the battle field. Since diagnosis
tags were used by medical
personnel in the trenches and at battalion aid stations, and since
these tags eventually became
more detailed medical records, thus including men with severe abdominal
wounds but who
perhaps died while being evacuated to a hospital, it is reasonable to
conclude that the relative
incidence of wounds of the abdomen may readily be determined from the
records so made. Thus,
of the 147,651 men wounded by gunshot missiles, 5,631 were wounded in
the abdomen
(including the pelvis),1 a relative frequency of 3.3
percent. Considering the incidence from
another viewpoint: Many of the men suffered multiple wounds, thus
making the total number of
wounds 170,841, and the relative frequency of wounds of the abdomen
among these 3.8 percent.1
MILITARY IMPORTANCE
At
first thought one would say at once that from the military standpoint
the soldier with
an abdominal wound is much less important than the man slightly
wounded. The latter may
reasonably be expected to return to the firing line at an early date
while the former may be
months in the rear or may never return to the front. Further, the small
proportion of intra
abdominal lesions encountered would seem to make them of decidedly less
military importance.
But, as a matter of fact, the proper care of abdominally wounded men is
exceedingly important
from the side of the morale of the Army, for it gives its soldiers the
conviction that any man
badly wounded will receive the best chance for his life that surgery
can give him. Humanity
dictates that every combatant seriously hit by enemy fire shall have a
chance to live.
NONPENETRATING
WOUNDS
INVOLVING THE ABDOMINAL WALL
These
include gutter wounds; perforating wounds running tangential to the
peritoneum;
wounds, with the missile lodged in some portion of the anterior or
lateral abdominal wall or
posteriorly in the retroperitoneal tissues or muscles of the back. Any
type of projectile may cause
such a wound.
The
gutter abrasions make their own diagnosis. They call for complete d
ebridement,
with primary closure if the case can be held under the operator's
observation for at least one
week, during which time any symptoms of wound infection may quickly be
recognized and
promptly met. In times of great
447
activity, where a possibility exists of an
early evacuation of the case, the wound, after débridernent, should be
left widely open and treated with Carrel-Dakin dressings, a delayed
primary or a secondary suture being done at a later date. It is well to
remember that some
apparent gutter wounds are really penetrating wounds, the gutter in
these cases growing deeper
as the course of the projectile is followed. When any doubt exists,
X-ray diagnostic aid must be
made use of.
With
a perforating wound of the abdominal wall the shorter the tract the
less likely is one
to encounter a visceral involvement. With a through-and-through wound
the missile may change
its direction, after entering the soft tissues, without any impact with
bone, and travel along the
abdominal wall, emerging at some distance from the point of entrance.
Such a case may present
great difficulties in diagnosis, for the two most important local signs
of a visceral lesion-muscular rigidity and tenderness-are marked, as a
result of muscle traumatism, even when no
abdominal perforation has occurred. The patient's general condition,
with lack of pulse elevation
and gastrointestinal symptoms, is the important guide to a correct
diagnosis. It is well for the
surgeon to bear in mind that in visceral perforations seen very early
general signs may be absent.
The X-ray examination is of little aid in the differentiation. With
clean-cut rifle wounds no
intervention is necessary, but if definite doubt of abdominal
perforation exists it is necessary to
operate without delay. Wounds caused by shell or grenade fragments or
machine-gun bullets
should be completely dissected and the rule for or against primary
closure outlined for gutter
wounds should be followed.
The
determination of the true nature of wounds of the parietal wall, with
entrance only, is
at times as difficult as that when both entrance and exit exist. The
same local signs frequently
are present and the differentiation from cases of peritoneal
penetration must be made in a similar
manner. The radiological findings, however, usually make the diagnosis
for or against
peritoneal penetration, and too much stress can not be placed upon the
necessity for this type of
examination. Dissection of the tract with removal of the foreign body
is the course to be
followed. The rules for suture are the same as those outlined above.
SUBCUTANEOUS RUPTURE OF VISCERA
The
literature of civil surgery and of former wars has yielded many
examples of this sort
of abdominal lesion; that concerning the recent conflict has been
equally prolific. In the Medical
and Surgical History of the War of the Rebellion numerous types and
variations of subcutaneous
abdominal injuries are cited in great detail.7 In war, as
in civil life, injuries of this sort are
caused by the kick of a horse or a mule, by blows upon the abdomen
during a fight, or by falls
from a height, the man landing upon the abdominal wall. In military
surgery injuries of this type
are caused also by shell explosions in the immediate vicinity of the
soldier (the so-called "wind
injuries" of the Civil War); they may be caused by flying pieces of
wood or other solid objects in
connection with shell bursts; they may result from crushing injuries
from falling timbers or earth
incident to the bursting of a projectile.
448
Two
modes of injury which are especially important because of diagnostic
difficulties are
laceration of the abdominal wall by a missile without penetration of
the cavity but with sufficient
explosive force to rupture a viscus within, and visceral perforations
from flying bone spicules
without peritoneal penetration by a projectile.
The
former injury if unrecognized leads frequently to a fatal result; the
latter should
always be thought of in connection with rib fractures in or about the
hepatic or splenic areas or
with comminuted pelvic fractures where the pelvic portion of the small
intestine is the most
frequently injured viscus, while injury of the bladder, rectum, and
colon is less common.
The
organs most often ruptured are the liver, spleen, kidney, and small
intestine; the
mesentery is not infrequently torn. The colon, rectum, and bladder are
less often injured.
The
lesions encountered may be grouped under the headings injuries of
hollow viscera
and injuries of solid viscera. Hollow visceral lesions may include
contusions of the wall, minute
perforations, extensive lacerations or even complete division in the
case of the bowel or its
mesentery. Solid visceral lesions comprise subcapsular rupture of solid
organs, especially the
liver, with usually a small hematoma beneath the capsule, slight tears,
and extensive lacerations.
The
diagnosis of subperitoneal rupture of any viscus or of the mesentery
must be made
by a consideration of the site and mode of injury, the presence of more
or less anemia from
hemorrhage, especially with solid visceral and mesenteric lesions, and,
where a hollow viscus
has been opened, the usual signs of peritoneal irritation with
subsequent symptoms of a rapidly
advancing peritonitis. Patients with serious injuries frequently come
to the hospital
inconsiderable shock, particularly when the degree of hemorrhage is
severe or the small intestine
or mesentery has been seriously injured.
Rupture
of a hollow viscus calls for immediate intervention; the principles of
treatment
outlined under penetrating abdominal wounds should be followed. A torn
mesentery with signs
of hemorrhage requires immediate operation; resection is usually
necessary.
With
a suspected rupture of a solid viscus but without alarming symptoms or
hemorrhage, an expectant attitude should be adopted. Most of these
patients recover unoperated.
If the hemorrhage has been severe in such a case the best working rule
is to operate if the patient
is seen very early, but to watch and observe for a few hours if the
patient is seen six or eight
hours after injury. If then the anemia is not apparently progressive
one should not operate, for
the hemorrhage has to all intents ceased and laparotomy will cause a
renewal of the hemorrhage
with a probable fatal result. If there are signs of progressive
bleeding the abdomen must be
opened at once.
Control
of hemorrhage from a ruptured liver may be accomplished by packing or
by
mattress suture inserted with a large needle, blunt end first. Suture
near the diaphragm or far
back on the inferior surface of the liver is difficult and frequently
impossible. Packing with
sterile gauze should be resorted to when suture can not be effectively
carried out.
449
In
general a rupture of the spleen should be treated by splenectomy. The
objection raised
that, convalescence is hampered hy the impairment of the patient's
blood forming, mechanism is
practically unimportant.
In
all cases in which hemorrhage has been a serious symptom transfusion
should be
carried out as soon as possible after the bleeding has been controlled.
The ease with which this
procedure may have carried out, either with the aid of paraffin-coated
tubes or by the citrate
method, the prompt and striking improvement in the wounded following
transfusion for
hemorrhage, and the abundance of robust individuals among the slightly
wounded who may
serve as donors, should serve to make this operation a routine
procedure early in the treatment of
hemorrhage.
PENETRATING
AND PERFORATING WOUNDS
GENERAL CONSIDERATIONS
The
general principles of military surgery of penetrating wounds of the,
abdomen differ
but little from those employed in civil life. However, many factors
obtain to make the problems
of abdominal surgery complex and difficult, and each case must be
studied in the light of
accumulated experience in the war zone.
Before
the types of injuries involving special organs are discussed certain
general
principles influencing the diagnosis and management of abdominal wounds
must be considered.
As the patient is admitted the questions which arise are: (1) What is
the man's general condition
with respect to shock? (2) What is the diagnosis? (3) Is operation
indicated?
Several
factors contribute to bring the soldier with an abdominal wound to the
hospital in
a condition of shock. These are lack of sleep and food, exposure to
cold and wet, difficult
evacuation to the hospital, traumatism of abdominal and visceral walls,
hemorrhage, pain, and
infection, the latter being especially important in those arriving,
late. Hemorrhage, save in the
late cases, is the great factor in the production of shock, and the
degree of shock is usually
proportionate to the severity of the hemorrhage; undoubtedly many
combatants die on the battle
field from rapidly fatal intra abdominal hemorrhage. The abdominal
cases reaching the hospital
show most extensive hemorrhage when the mesenteric or pelvic vessels or
when the liver,
spleen, or kidney have been injured.
Hemorrhage
may also occur from the abdominal wall, the omentum, and from the
retroperitoneal tissues. In the latter case the loss of blood may
occasionally be alarming, and the
diagnosis very difficult. Since hemorrhages one of the principal causes
of fatal issue in the
abdominally wounded, it is therefore an important argument for the
earliest possible
intervention. Inactive hemorrhage from a solid viscus does not
constitute an indication for
operation.
Pain
is usually a distinct symptom. The pain in the wounded parts, increased
by
difficulties in evacuation, and the pain caused by an advancing
peritonitis both contribute to the
shocked state of the wounded. Moreover, the degree of shock found is in
approximate ratio to the
time elapsing before the administration of morphine.
450
Cases
with infection of the retroperitoneal tissues may show rather
pronounced shock.
Infection due to the presence of anaerobic microorganismsin badly
lacerated muscles of the
abdominal wall may be an important factor. The shock which accompanies
an advancing
peritonitis is readily recognized.
A
hurried examination having been made to assure the surgeon that no
progressive
hemorrhage is present and that no splint readjustments are necessary,
immediate treatment
directed toward the relief of shock must be instituted. The
preoperative ward of a hospital for
seriously wounded should be organized to deal particularly with this
condition. Since the subject
of shock and its treatment is covered in detail in Chapter VII of this
volume, no further reference
is made to it here.
Bound
up with the question of an accurate diagnosis are the questions of
abdominal
penetration and visceral injury. A tangential abdominal wound.
especially if the tract is a short
one, frequently gives no peritoneal penetration. With such wounds,
where peritoneal irritation is
lacking, the probability of abdominal entry is small. As demonstrated
by Wallace,8 a wound
above the pyloric level with entrance and exit to the right of the
median line seldom results in
visceral injury though the peritoneum may have been entered. Other
through-and-through
wounds mean certainly that the peritoneum has been penetrated but
occasionally without visceral
injury.
With
only a wound of entrance, diagnosis becomes more difficult, and under
these
circumstances the X ray may give the greatest aid to the surgeon.
Accurate information quickly
obtained by means of a roentgenological examination is often the most
important guide to the
character of the wound with reference to visceral injury and to the
exact situation of the missile.
SYMPTOMS OF VISCERAL INJURY
The
general symptoms are those of shock, hemorrhage, pulse acceleration,
and vomiting;
the local ones, abdominal pain, tenderness, rigidity, and distension.
The symptoms of shock are
well known and its causes in abdominal injuries have been already
enumerated. There may be no
symptoms of shock even in the presence of serious visceral injury.
Though
hemorrhage may produce little in the way of physical signs, the
cardinal
symptoms are a rapid, soft pulse, a low blood pressure, and obvious
anemia. Patients with
hemorrhage may exhibit excessive thirst and frequently show signs of
air hunger. With any
amount of bleeding intra abdominal fluid may be detected in the flanks,
and local peritoneal
signs may be moderately marked. The face is blanched and listless when
the degree of
hemorrhage has been considerable; it is anxious when infection in the
peritoneum is progressive.
Whether
there is hemorrhage or not, pulse elevation is the rule. With a
peritonitis in
progress the pulse rate steadily rises, and this sign is one of the
valuable guides in demonstrating
hollow visceral lesions. It is especially important in excluding a
parietal wound with
considerable muscle injury where local signs of peritonitis may be
closely simulated.
Vomiting
is usually present with a hollow viscus penetration and becomes more
marked
as peritonitis becomes more severe. Gastric wounds give earlier
vomiting, with a vomitus
frequently containing blood. On the other hand
451
wounds of the stomach sometimes occur with an
entire absence of vomiting, so that this
symptom can not be termed characteristic of gastric injury.
There
is a great variation in the degree of abdominal pain, and the surgeon
can not pass
judgment upon the severity of the visceral lesion from the amount of
pain the patient suffers. The
location of the pain usually gives little aid in the attempt to
localize the viscus injured. The most
important feature of the pain from a diagnostic standpoint is its
inception simultaneously with
the receipt of the wound. The soldier abdominally wounded may have
received a considerably
dosage of morphine prior to admission to hospital, and if this has been
promptly given his
complaint of pain may be absent, particularly if he is seen early.
The
local tenderness is the most pathognomonic sign of a ruptured hollow
viscus and is
the most constant physical symptom of peritonitis. It is always present
and is localized over the
region involved. It may be masked somewhat by morphine but it never
disappears completely.
Tenderness is also present with parietal wounds and contusions, but the
other signs of visceral
penetration are lacking.
Muscular
rigidity is a very important sign of visceral injury, but it is less
constantly
present than tenderness. Charles 9 has seen cases of
multiple
perforation with an entire absence
of muscular rigidity and again has encountered boardlike rigidity in
severe wounds of the
abdominal wall. Wallace 8 and many others have enumerated
certain injuries which may be
accompanied by marked rigidity without injury of an abdominal viscus.
The more important are
chest wounds with no abdominal lesion, wounds of the abdominal wall,
and hemorrhage into the
retroperitoneal tissues. The rigidity of an advancing peritonitis is
generally progressive and
increasing in intensity, while rigidity from introabdominal hemorrhage
is less marked, and
usually diminishes gradually if the hemorrhage has ceased. Muscular
rigidity as well as local
tenderness may be all important symptoms in diagnosing a visceral
perforation when the wound
of entry is in some remote region and the possibility of an abdominal
lesion seems very unlikely.
Abdominal
distension is not an early or important symptom of visceral
penetration. It
becomes more pronounced as peritonitis develops, but it is then of
little value in diagnosis.
INDICATIONS FOR OPERATION
Certain
groups of cases come to the hospital in which operation is
contraindicated and
these may well be considered here.
Moribund
patients should he made as comfortable as possible with morphine. A
so-called
moribund ward is practicable and fills a good purpose. The patients in
it must not be left
surgically unattended but should be followed through to the end.
Cases
with general peritonitis from a hollow viscus injury 24 or more hours
old are
generally hopeless subjects for radical treatment: Nearly 100 percent
mortality occurred among
such of our cases following operative intervention., The expectant plan
should invariably be
followed. Morphine in liberal doses, Fowler's position, heat, rest,
alkaline fluids, sugar solution
by rectum,
452
and saline solution beneath the skin are the
lines of treatment to be followed. These cases must
he carefully separated from the moribund class. Unless they are kept
under constant supervision
the rare individual whose peritoneal defense mechanism may bring him
into the operable class
may lose his only chance for life, because the psychological moment for
operation is passed
unnoticed.
Except
for the individuals in whom shock is due to progressive hemorrhage the
badly
shocked should be kept in the preoperative ward under the eye of the
ward surgeon, but the final
decision as to operability or nonoperability must rest with the
operating surgeon. When there is
no amelioration of the symptoms of shock, operation should not be
performed. As a working
rule, the patient who shows no tendency to reaction within two or three
hours never reacts.
Cases
with through-and-through wounds of solid viscera without progressive
hemorrhage
do well without surgical intervention: the chances of recovery are
better when no operation is
performed. The presence of hemorrhage in these patients is usually
differentiated from an
advancing peritonitis by the pulse rate of 80 or 90. Such a patient
should not be interfered with.
Intervention frequently results in a renewal of the bleeding when the
abdomen is opened and
disaster may follow. Fluids by rectum or by hypodermoclysis with
moderate morphine dosage
are the indications. If the loss of blood has been considerable,
transfusion may be resorted to
when a fair degree of certainty exists that hemorrhage has ceased.
Short
tangential wounds with unimportant abdominal symptoms, seen 8 to 10
hours after
injury, are best left unoperated, but no such patient should be sent
from the preoperative ward to
one of the postoperative wards. During the height of an offensive
military operation such an
individual may easily escape the eye of the ward surgeon and a case in
which operation may
have become definitely indicated may be overlooked.
The
basic indications for immediate operation are symptoms pointing to
progressive intrabominal hemorrhage or hollow visceral penetration.
Walters 10 and other surgeons speak of
the obvious necessity for operation in Cases with visceral or omental
protrusion; in cases with
escape of gas or feces through the wound: and in eases with
subcutaneous emphysema from the
escape of intestinal gas, usually from the large bowel, into the
tissues adjacent to the wound.
Emphysema of such origin appears shortly after the receipt of the
injury in contradistinction to
the emphysema of gas gangrene.
In
a time of great stress the problem of the seriously wounded may be a
difficult one to
handle. Practically it must be managed by first operating upon the best
operative risks. When the
stream of badly wounded becomes tremendous severe cases with wounds
other than abdominal
and with better hope of recovery must have the chance of life which
operation gives. A frequent
revision of the eases in the preoperative ward must be made that the
surgeon may assure himself
that no soldier with a fair chance of recovery with operation is passed
by.
A
good working principle is to operate if doubt of a hollow visceral
lesion exists, for the
mortality of such operation is exceedingly low when no visceral
453
penetration is found. In our evacuation
hospitals the mortality for this type of operation was 6.5
percent. 11 Exploration of the abdomen with negative
visceral findings is attended, therefore,
with little risk, compared to the uncertain possibilities of a serious
advancing peritonitis if the
man is left unoperated.
OPERATIVE TECHNIQUE
Since
no type of war wound presents such a complex problem as the penetrating
wound
of the abdomen, the details of surgical technique must be studied with
the greatest care.
There
is little doubt that nitrous oxide-oxygen is the least toxic and the
best borne of all
the narcotizing agents, but, unfortunately, it does not give the
complete muscular relaxation
which is essential to efficient abdominal surgery. Its administration
requires a skilled anesthetist
and a bulky apparatus.
Ether
is the agent universally employed and is by all odds the anesthetic of
choice for
abdominal cases. The ordinary open method of administration gives
reasonably satisfactory
results; the equipment required is the minimum. Marshall, 12 with an extensive experience,
found fewer complications when a warmed ether vapor was used, but in
the American Army this
method was not given a trial.
The
shorter the period of anesthesia the less the degree of toxemia that
will be produced
and the better the prognosis for the patient.
Two
general rules may be followed to aid the surgeon in his choice of an
incision: (1)
Plan the incision to meet the visceral injury suspected; (2) avoid, if
possible, the projectile
wound site, and so diminish the liability to wound infection. Always
make the operative wound
sufficiently ample to insure a unhampered exploration. A wound of 8 or
10 inches usually
suffices. Some advise the paramedian incision as the one for general
use, while others favor an
opening in the median line either above or below the umbilicus,
depending upon the organ
probably injured. The latter is the incision of choice in most cases.
For the upper abdomen some
operators prefer a transverse incision or an oblique one parallel to
the costal margin. This gives
excellent access to wounds of the spleen, liver, kidney, or upper
colon. The greatest objection to
this type of incision is the difficulty in making a neat, rapid, and
satisfactory closure. With a
lesion below the umbilicus, and a wound in the flank, a transverse or
oblique incision should be
made. Such an incision affords good access to the retroperitoneal
tissues and wounds of the
posterior aspect of the large bowel. Transverse incisions in connection
with abdominothoracie
injuries are considered below under such lesions.
The
general principle of wound disinfection by careful dissection must be
as carefully
observed in abdominal surgery as in wounds of the extremities. Careful
excision of all soiled
tissues must alwavs be carried out if the patient's condition permits.
At times this is best done
before the abdomen is opened, and the instruments used should then be
discarded. Sutures may
be placed if the patient may be held for 8 or 10 days, but it is safer
not to close the skin. It may,
however, be wiser in very serious cases to defer the abdominal wall
dissection until the suture of
the operative wound has been completed. Failure
454
to carry out an efficient d ebridement
will result in an infected abdominal wall, with the
possibility of serious consequences.
Speed
is important, but no false moves should be made. It must be remembered
that an
operation of more than one hour's duration usually means a shocked
patient with little chance for
recovery. Try to determine what organs may be excluded from the
possibility of injury, but err
on the side of thoroughness and keep the surgical traumatism to a
minimum. Protect the skin
adjacent to the wound with towels and skin clips to avoid contact of
the cutaneous surface with
abdominal contents. Do as little as possible, at the same time making
the operation a thorough
one.
If
hemorrhage has been progressive or if upon opening the peritoneum there
is more
blood than was anticipated, seek at once for the source of hemorrhage
and check it by clamp,
packing, or suture. Considerable hemorrhage from the mesentery means
inevitable resection.
Throughout
the operation make the traction upon the abdominal wall as light as is
compatible with proper manipulation of viscera. The detailed treatment
to be applied in wounds
of the various organs may be found below, where wounds of these viscera
are discussed.
Closure
should be done carefully in layers except in cases doing badly on the
table, when
through-and-through sutures may be employed. If the wound by the
missile has crossed the line
of operative incision it is better to leave the skin without sutures or
but partially closed; and the
same precaution against infection of the abdominal wall should be
observed if a period of stress
prevails and the work is necessarily somewhat more hurried.
No
drainage should be employed in sutures of the small intestines, unless
a very active
peritonitis has developed. No drainage for stomach cases is necessary.
On the other hand,
drains of rubber dam (never gauze except to check hemorrhage) should
always be used in
wounds of the colon and rectum, especially those complicated by
retroperitoneal injury. Gauze
drainage for liver or spleen should be employed solely for hemostatic
purposes. Drains are used
to provide an outlet for leakage from the large bowel or to check
hemorrhage, but should never
be thought of as effectively draining the general peritoneal cavity.
POSTOPERATIVE TREATMENT
Practically
every one of these patients has suffered a loss of body fluids, and the
administration of fluid is the chief indication. For wounds of the
solid viscera, stomach, and
small intestines a Murphy drip of 5 per cent sodium bicarbonate
solution, with or without 5 percent glucose, is the method of choice;
or similar enemas at four or six
hour intervals may be
substituted. For wounds of the colon and rectum, hypodermoclysis with
saline solution meets
the indications. Saline infusion may be used in any case where
considerable hemorrhage has
occurred, but only as a temporary measure to tide over the man for a
few hours until blood may
be obtained. Transfusion in this latter group is frequently essential
to recovery, and it may be
necessary to repeat it. Blood grouping should always be done before
transfusion, as it takes but a
moment when Vincent's macroscopic test is used. Group IV
455
donors (Moss' classification) may be employed
for a recipient of any of the four groups. Citrated
Group IV blood may be collected at a distance and transported to the
hospital in sterile bottles,
and such blood may be kept for upward of 24 hours without fear of
clotting. If there is no
vomiting, water or very dilute alkalies may be given by mouth, but no
fluid food should betaken
for the first 24 hours. Restoration of the physiological activity of
the bowel probably requires a
still longer interval.
Pain
is a constant postoperative symptom and morphine is a very important
therapeutic
agent for its relief. It should be given freely during the first 24
hours, moderately during the
second, and sparingly or not at all during the third 24-hour period. If
the patient is doing badly
such a rule can not be adhered to and morphine should be given freely
to the end.
Distension
of the abdomen is a variable symptom, but is generally fairly marked
and
contributes much to the patient's discomfort. It is best treated by
colonic irrigation, pituitrin, and
local heat when the latter may be applied without discomfort to the
patient. Fowler's position is
particularly valuable in wounds of the lower abdomen, since it helps to
localize the inflammatory
process. It also helps to relieve the distension, especially when a
rectal tube is made use of from
time to time. The position may be maintained fairly continuously for
the first 48 hours or 72
hours.
Vomiting
is usually present and may become a distressing symptom. It is caused
by the
postoperative ether toxemia, the peritoneal traumatism incident to the
wound and the operation,
to an advancing peritonitis, or to a dilated stomach. If withholding of
fluids by mouth for a few
hours does not result in an early cessation of vomiting, gastric lavage
with warm water, with or
without sodium bicarbonate, repeated at two or four hour intervals,
is the most effective means
of treatment. In all the conditions named, except the advancing
peritonitis, lavage usually gives
effective relief.
The
length of stay in the hospital in which operation has been performed
and definitive
treatment given should be from 7 to 10 days, or longer if military
necessity will permit it. The
period named brings the average patient far enough along in his wound
healing and general
convalescence to permit a safe evacuation to the rear. A certain small
number of evacuated cases
may develop postoperative complications, but military exigencies will
usually allow the really
bad cases to be retained forward for a longer period than the time
used. Above all, careful
nursing and continuous care on the part of the surgeon must be
available, or many patients will
suffer and a certain number succumb who otherwise might be saved. The
dressing must be done
by the most experienced hands available, the operator or his assistant
doing this work whenever
it is physically possible. If a ward surgeon dresses the wounds the
surgeon himself must
supervise his work and personally direct the patient's convalescence.
POSTOPERATIVE COMPLICATIONS
The
more frequent and, therefore, important complications are infection and
the
development of fecal and urinary fistulae; secondary hemorrhage,
nephritis, and pulmonary
complications are less often seen.
456
Infection
is encountered in the form of local wound infection, as a localized
peritoneal
abscess, or as general sepsis. The wound healing is good or bad in
direct proportion to the
amount of infection present in the abdominal wall. The surgeon's first
effort, therefore, in
combating would infection is the prevention of it by painstaking
surgery at the time of operation. Careful débridement of the
abdominal wall and proper placing of the abdominal incision with
respect to the wound,
combined with the nonsuture of skin and subcutaneous tissues in
doubtful cases, are the most
important details to be observed. The surgeon must also carry out only
partial skin closure in the
presence of an active purulent peritonitis, as the parietal wall will
necessarily be more or less
contaminated. Very disastrous gas and streptococcus infection of the
abdominal wall may
develop, usually early in the postoperative course, and such a
condition calls for wide incision,
combined, where possible, with Carrel-Dakin treatment. Evisceration of
considerable intestinal
contents may occur with an infected abdominal wound, and such cases
usually do badly.
Immediate replacement of viscera must be accomplished with rapid
resuture of the peritoneal
muscular, and fascial layers.
Localized
peritoneal abscess is more often a later complication, occurring from a
few
days to two or three weeks after operation. It may complicate a fecal
fistula. It is the most
favorable outcome to be looked for in a case of diffuse peritonitis.
Considerable difficulty in
making a proper diagnosis of the location of the purulent collection
may be encountered. It may
be placed in practically any portion of the peritoneal cavity and may
point in the buttocks,
perineum, or flanks. Cases of infection following local leakage into
the retroperitoneal tissues
are the most difficult ones to diagnose and treat successfully. The
indication in all these cases is
drainage by the simplest possible procedure.
General
sepsis is relatively infrequent. The fatal cases of peritonitis usually
die within a
few days before sepsis has become general. It may occur in connection
with retroperitoneal
infection or with badly infected operative or projectile wounds. No
effective treatment has been
found to combat general sepsis successfully.
Fecal
fistula is a frequent complication of wounds of the small and large
intestine, being
encountered most often after suture or resection of the latter. It also
follows operation for
inaccessible rectal injuries. It may occur at any time in the
postoperative course of the abdominal
wound, and the fecal discharge usually appears in either the operative
wound or along the
original wound tract where inaccessibility has made a careful
dissection impossible. Makins 13 cautions us to bear in mind that a bruised intestinal wall without
complete entry of the lumen
may at times break down with the formation of a fecal fistula. Such
instances have been verified
by the findings of a previous exploratory operation. Frequently a fecal
fistula will close
spontaneously, particularly one complicating operation. In a small
proportion of cases, however,
suture or resection may be required to relieve the condition. Every
precaution must be taken in
such an operation to isolate the general cavity from the operative
field; and adequate drainage,
preferably with rubber dam, should be provided. Such a type of
operation is usually done in the
base hospital when it has become evident that the fistula will not
close spontaneously.
457
Secondary
hemorrhage is rare as a sequel to abdominal injuries. It may occur from
septic
erosion of a large vessel or from a reopening of a partially healed
wound of a solid viscus. The
treatment is the same as for primary hemorrhage.
Any
of the inflammatory processes of the lung or pleura may complicate the
postoperative course of all abdominal lesion: they are, however,
comparatively infrequent. The
most striking pulmonary complications encountered by the writer were
four cases of pulmonary
embolism (diagnosis being made by symptoms, since no autopsy could be
performed) which
were fatal in from one-half to two hours after the intravenous
injection of gum solution. The
further use of this agent was discontinued by the writer and his
associates.
Nephritic
complications are comparatively infrequent. The indications for
treatment are
the same as in civil surgery.
TREATMENT
OF
VISCERAL INJURIES
In
a certain proportion of cases the peritoneal cavity is opened without
any injury of the
viscera. Practically this group may be considered in connection with
nonpenetrating wounds of
the abdominal wall. The possibility of an infection of the peritoneum
from the retained
projectile, or from foreign material carried into the peritoneal
cavity, makes them definitely
more serious than the nonpenetrating wounds. The missile, however,
usually becomes encysted,
when it may give no symptoms whatever. In rare instances a localized
peritoneal abscess may
result.
Cases
with short tangential wounds, and the occasional cases in which after 8
or 12 hours
no alarming abdominal symptoms have developed and in which the
patient's general condition is
excellent, are particularly the ones in which the question for or
against operation may arise.
When
any doubt of the wisdom of intervening exists it is better to operate.
As stated
above, it is far better to open every abdomen when there is question as
to visceral injury than to
abstain, for the mortality after operation where no visceral lesion is
found is very small and the
hazard is a tremendous one if a true perforation of a hollow organ is
left without operation.
Further, operation always furnished an opportunity to search for and
often to remove the foreign
body itself.
WOUNDS OF THE STOMACH
Stomach
wounds comprise about 7 percent of all abdominal injuries coming to
the
hospital for treatment. Two-thirds of all gastric lesions show no other
accompanying visceral
injury discoverable at operation. Wounds of other organs most often
encounterel are those of the
small gut. liver, colon, kidney, and spleen, in the order of their
frequency. 1
The
wounds are usually two in number and are most often situated on the
anterior and
posterior walls. If the anterior opening is small and the organ was not
distended at the time of
injury there may be no protrusion of mucous membrane and no escape of
gastric contents.
Leakage may, however, occur into the lesser sac when none is present
anteriorly. If but a single
wound is present it is usually of the anterior wall. Under the
conditions, great care must be
exercised in excluding a posterior wall perforation, for in comparison
with the
458
injury of the anterior aspect that of the
posterior may be much more difficult to detect. Lesions
of the borders and orifices are comparatively infrequent. Considerable
damage to the gastric
wall is more often seen with wounds of the lesser curvature and those
parallel to the walls of the
stomach. The more ragged and larger wounds are usually caused by shell
and hand-grenade
fragments and machine-gun bullets fired at close range.
There
are local signs of peritoneal irritation, but these are definitely less
marked than
with injuries of the small intestine. Only moderate shock is present in
most of the cases; where a
severe hemorrhage has occurred the degree of shock is profound.
Exceptionally, there is no
gastric leakage into the peritoneal cavity. The cardinal symptom is
early and persistent vomiting.
Rarely, however, vomiting may be absent. Escape of gastric contents or
gas may take place from
the abdominal wound.
Very
rarely recovery has been reported without intervention. The safe rule
to follow is
operation in practically every case. The best incision is the median or
paramedian. The
perforation of the anterior wall of the stomach is readily recognized.
The opening in the posterior
wall is best sought for through the gastrocolic omentum just below the
stomach. Pauchet's
approach, recommended by Eastman,14 is made through an
opening in the mesocolon, the line of
dissection passing just above the transverse colon. This frequently
gives good access, but it is not
recommended for general use, as repair work is more difficult when this
technique is used. A
ragged wound should be trimmed off rapidly before suture. The greatest
difficulty in
accomplishing a good closure of the stomach wall will be found with
wounds involving the
lesser curvature and those high up near the cardiac orifice.
Gastroenterostomy should be avoided
if possible, for a higher mortality results in the cases in which it is
performed. Drainage in gastric
cases should be employed only where a fairly well developed peritonitis
is present or if suture of
the stomach wound is difficult or impossible. The most important
precaution to be observed in
the postoperative care of these cases is careful feeding. Only water
should be allowed by mouth
during the first 24 hours and liquid diet for the following three days.
The
seriousness of gastric lesions is in no wise comparable to the grave
conditions
caused by wounds of the small intestine. A favorable outcome may be
possible even if the case
is seen a considerable time after receipt of the injury, as peritonitis
advances comparatively
slowly. Numerous cases have recovered where operation has been
performed from 24 to 36
hours after the receipt of the wound.
The
mortality of all gastric wounds is approximately 55 percent. 1 Uncomplicated
wounds of the stomach give a mortality varying from 25 to 50 percent.
WOUNDS OF THE SMALL INTESTINE
The
proportion of total small intestinal wounds, complicated and
uncomplicated, to all
abdominal lesions is approximately 22 percent.1
Wounds of the
colon are much more
frequently encountered than those of any other complicating visceral
lesion. The injuries next in
order of frequency are those of the stomach and bladder, while wounds
of the liver, kidney,
rectum, and spleen are still less often encountered.
459
Duodenal
injuries are fairly infrequent, comprising approximately 6per cent of
all small
gut wounds.1 Injuries to the jejunum comprise about 23
percent; to the ileum approximately 71
percent.1 Multiple lesions are almost universally
encountered, at times reaching the number of
15 or 20, but the average number to be expected is from 4 to 6. The
wound may be small or
large, depending upon the character of the missile, the velocity at
which it is traveling, and the
angle of entry into the gut. When the projectile strikes the intestine
vertically two perforations
are almost invariably found. As a rule there is a certain protrusion of
the mucous membrane, but
if the wound is a small one there may be no pouting and such cases may
show no leakage. The
more nearly parallel the wound is to the long axis of the gut the more
the damage to the visceral
wall and the larger and more ragged is the wound itself. Extensive
laceration of the intestinal
wall and even complete division of the gut are not so very unusual; in
such cases a considerable
tearing of the mesentery is frequently found. The mesenteric lesions
are especially important
from the standpoint of hemorrhage and because of the necessity for
resection with its added
shock and operative hazard.
It
is generally best to begin the exploration of the gut at the ileocecal
valve, but if the
wound is high up the duodenojejunal junction may be first examined.
Work rapidly upward, if
beginning at the ileocecal valve, or downward, if beginning at the
duodenojejunal angle, being
careful to replace within the abdomen every 8 or 10 inches of segment
after its examination. In
this way the entire ileum and jejunum with their mesentery are
carefully examined for
perforations. When a wound of the intestine is encountered clamp the
opening tightly, protect it
with a pad, and hold it outside the abdomen, and as each lesion is
discovered treat it in the same
way. It is a good general rule to refrain from repairing any
perforation until the entire length has
been examined. The writer has seen a small gut suture, requiring 15
minutes, performed upon a
segment of small intestine that later had to be resected because of
mesenteric injury. Exception
to this rule may be taken when normal bowel and mesentery are present
several inches to each
side of the lesion or where a large number of perforations with their
pad coverings would form a
serious obstacle to efficient technique.
Careful
search for complicating wounds of the stomach should then be instituted
and the
lesions appropriately treated. Other visceral injuries should be sought
for and the colon should as
a rule be the last one explored, as lesions here may necessitate
performing a colostomy. If,
during the course of an operation, a wound of the colon is encountered,
it is wiser to treat it
immediately if suture only is required.
The
vast majority of small intestinal wounds are satisfactorily closed by a
single purse-string suture of silk or chromic gut. Suture should always
be practised if possible, as resection is
attended with far greater hazard. With numerous small lesions close
together, suture is
preferable; if gut damage has been considerable, resection may prove to
be the better procedure.
The best rule is to resect only when it is impracticable to suture. A
double row of sutures should
always be employed when resection is done.
460
The
postoperative care of cases with small gut injury has been outlined
above under the
general discussion of penetrating abdominal wounds.
The
frequency of wounds of the small intestine an rid the high mortality
attending
operation for their relief make these injuries the big problem in
abdominal military surgery. The
mortality rate in cases of wounds of the small intestine in the
American Expeditionary Forces,
including the operated and unoperated, was as follows: 1 Duodenum, 80: jejunun, 78.8; ileum,
73; small intestines (not specified), 7.9. Resection gives regularly n
mortality 50 peraent higher
than does suture.
WOUNDS OF THE COLON
Wounds
of the colon represent about 22 percent of all intra-abdominal
visceral injuries.1 Perforating wounds of the colon are much
less often multiple than those of the small gut
because of the lack of numerous intestinal coils. The multiple lesions
that occur usually involve
the pelvic colon. Some of the smaller perforations may be due to minute
bone spicules
penetrating the bowel wall, and this type of lesion is much more
difficult to recognize than an
injury primarily due to a missile. Some of the wounds are large and
ragged and a complete
division of the bowel may be found, but less frequently than in wounds
of the small intestine.
Retroperitoneal
perforation with its consequent fecal leakage and cellulitis
constitutes
one of the difficult problems to be dealt with. The posterior
perforation may be a minute one
which is difficult to recognize. Injuries of the portions of the gut
which are without a mesentery,
the ascending and descending colons, are particularly liable to be
accompanied by a serious
retroperitoneal infection.
Retroperitoneal
injury of the transverse colon may only be detected when the lesser sac
is
explored.
The
symptoms and diagnosis of wounds of the colon have been considered
above in the
discussion of abdominal wounds under the heading of "Diagnosis." The
special factors which
make diagnosis difficult are the liability to retro-peritoneal
infection and the inaccessibility of
the splenic and hepatic flexures, particularly the former. A grave
acute sepsis may rapidly
develop in connection with retroperitoneal cellulitis. Further, the
type of peritonitis which the
surgeon encounters in connection with perforations of the colon is very
likely to produce more
aggravated local and general symptoms than that associated with the
involvement of the small
intestine.
No
one incision will satisfy all requirements with wounds of the colon. A
median or
paramedian incision is best used when a lesion of the transverse or
pelvic colon is to be dealt
with. The best incision for wounds of the cecum or of the ascending and
descending colon is a
transverse one in the flank, for this allows an easy access to the
posterior portion of the bowel
and a better chance of discovering a posterior perforation. The
incision of choice for either of the
colonic flexures is a subcostal incision on either side, prolonged
vertically downward if
additional space is required. This incision is particularly valuable on
the left side because of the
posterior position and inaccessibility of the splenic angle. The
general principles to be followed
are: Suture whenever possible
461
to secure a satisfactory closure, and always
employ a double row of sutures. Avoid resection;
colostomy is to be preferred. If a colostomy is performed are section
done at a later date
sometimes gives a satisfactory result. Colostomy is to be advised with
large ragged openings,
particularly those occurring in the cecum, descending colon, and
sigmoid. Drainage is a most
important factor with wounds of the large bowel. Always drain when any
doubt of the integrity
of the suture line exists and in every case of proved or questionable
retroperitoneal injury.
There
is a slightly lower mortality record with wounds of the large intestine
than with
those of the small bowel, the figure for the former being 59.6 percent. 1 The cases that do badly
die from retroperitoneal sepsis, which may be most acute, or from a
peritonitis secondary to fecal
leakage, preceding or subsequent to operation. The wounds that are
sutured do better than those
in which an artificial anus is employed; the latter group gives the
high mortality rate of 70 percent.1
WOUNDS OF THE RECTUM
Injuries
of the rectum are comparatively infrequent, constituting 2.4 percent of
the
lesions of abdominal viscera.1 Complication by other
injuries is infrequent. Associated lesions
which may be encountered are those of the bladder and pelvic colon, or,
less frequently, injuries
of the small bowel.
The
lesions vary in size from small perforations caused by a minute
projectile or a
fragment of bone to extensive lacerations. Wounds of the rectum often
show a wound of
entrance in the buttock or upper portion of the thigh or in the
perineum. If the wound is an extra
peritoneal one, fecal leakage posteriorly may occur. with the rapid
development of a grave
cellulitis.
Intra
peritoneal injury of the rectum gives rise to a rapidly developing
acute peritonitis
which is still more aggravated if complicating lesions are present. A
wound of entry through the
buttock or perineum in a patient exhibiting symptoms of peritonitis in
the lower portion of the
abdomen should always make the surgeon suspicious of a rectal injury.
Local tenderness in the
posterior rectal wall made out by the examining finger in the rectum
and associated with
evidences of infection in the perineum always suggests an extra
peritoneal rectal wound,
especially when associated with general symptoms of a septic type.
The
extra peritoneal injuries are best treated by careful d ebridement of
the buttock or
perineal wound, the dissection being carried upward and into the
rectum. It may be necessary to
open widely the lower segment of the bowl in order that complete
dissection of the tract may be
accomplished and that adequate drainage may be most effectively placed
in the retroperitoneal
tissues. Extensive lacerations of the lower segment may require a
colostomy. Intra peritoneal
injuries are treated by a median laparotomy with suture of the opening
wherever it is possible to
accomplish it. Drainage through the lower angle of the operative wound
should always he
practiced, rubber dam being the best material for the purpose. If a
suture can not be made, owing
to the depth of the rectal wound in the pelvis, a colostomy should be
performed.
The
mortality with wounds of the rectum is 45.19 percent.1 Usually death is due to a
rapidly advancing sepsis in the retroperitoneal tissues or to a severe
spreading peritonitis.
462
WOUNDS OF THE LIVER
Wounds
of the liver comprise 13.3 percent of all abdominal injuries.
Approximately
three-quarters of all liver lesions are uncomplicated ones. Associated
wounds to be considered
are, in the order of frequency, wounds of the colon, stomach, and
kidney; injuries of other organs
are much less often found.
Clean-cut
liver wounds are very unusual. There may be any type of lesion from a
small
perforation to a slit or a large ragged excavation, and in some cases a
loss of liver substance is
encountered. Whatever the type of projectile, a large wound of exit is
to be expected, and
lacerations in all wounds is the rule.
Hemorrhage
is always present, varying from a slight oozing to a severe and rapidly
fatal
hemorrhage. More often the bleeding tends to subside spontaneously.
Peritoneal symptoms are
to be expected from the presence of blood in the peritoneal cavity. A
dullness in the flanks,
particularly on the right side, may be made out if the amount of
bleeding has been considerable.
A case seen two or three days after the injury frequently shows a
slight degree of jaundice; late
jaundice usually means sepsis. Where the loss of blood has been
considerable the patient exhibits
a marked degree of shock.
The
diagnosis of liver injury is made from the position of the wound and
the symptoms
of intra abdominal hemorrhage. The early appearance of jaundice should
make one suspicious of
liver injury.
As
a general rule the expectant treatment should be followed. Operative
intervention
should be made when other visceral lesions are suspected, where the
hemorrhage is serious and
progressive, or where the foreign body retained is a very large one.
The incision best suited for
the management of liver wounds is a right subcostal one, though a
median or paramedian
approach may give adequate exposure. When the abdomen is entered, if a
small wound is found
without active hemorrhage, it should be left alone. A larger wound from
which the bleeding has
ceased should be packed or sutured, preferably the latter, for
secondary hemorrhage from such a
wound is not unlikely. In placing sutures use a large round needle,
blunt end first, the suture
being of a mattress type. This form of suture should not be drawn
tightly in order to prevent its
cutting through the liver substance. A properly placed suture will
effectively control a very
active hepatic hemorrhage. The retained foreign body, if of
considerable size, should be removed
in order to avoid the subsequent complication of liver abscess. The
shock present should be
combated with heat administration of fluids, and adequate doses of
morphine. When the loss of
blood has been considerable and the hemorrhage is no longer active
transfusion should be
performed.
The
mortality rate of liver wounds is 66.27 percent.1
A
considerable number of uncomplicated wounds of the liver treated
expectantly get
well. The cases of this type operated upon give a mortality of about 5
percent; 1 the mortality
rate to be expected if complicating lesions are encountered is in the
neighborhood of the
mortality rate for liver wounds as a whole. Certain of the cases with
retained foreign body in the
liver develop a hepatic abscess and may succumb to sepsis.
463
Wounds
of the gall bladder and bile ducts are so comparatively infrequent that
any
special consideration of them will be omitted. Records of but 9 cases
in the American
Expeditionary Forces exist, with a mortality rate of 77.78 percent.1
WOUNDS OF THE PANCREAS
The
cases reaching the hospital comprise about 0.2 percent of all
abdominal injuries.1 The proximity of the organ to the great vessels may give a rapidly
fatal result upon the field of
battle, so that a certain proportion of these cases never reach the
hospital.
The
accompanying lesions usually found are those of the stomach; other
organs are much
less frequently involved. The one important element to success is
adequate drainage.
At
least half of the cases prove fatal from an undiscovered or poorly
drained injury. The
writer had one case showing an anteroposterior wound in the
epigastrium. Operation revealed a
small shell fragment lodged in the head of the pancreas with an
associated contusion but no
penetration of the adjacent duodenal wall. The foreign body was readily
removed, and wound in the pancreas drained, and the patient when last
seen, seven days after operation, was
convalescing satisfactorily.
WOUNDS OF THE SPLEEN
Wounds
of the spleen are much less frequent than those of the liver, 49 only
having been
recorded as occurring in the American Expeditionary Forces.1 Two-thirds of the splenic wounds
show complicating lesions.
The
injuries may be of all types, from a small perforation or moderate
laceration to a
complete separation of a considerable portion of the organ, or an
avulsion from its pedicle. The
visceral injury most frequently complicating a splenic wound is a
lesion of the kidney; organs
less often involved are the colon and stomach.
As
with wounds of the liver, hemorrhage is the chief symptom along with
the shock
resulting from it. The intra abdominal signs of hemorrhage described
under wounds of the liver
apply equally to splenic wounds. The fluid, however, is more apt to
accumulate in the left flank.
The diagnosis is made from the position of the wound and the
accompanying signs of
hemorrhage and shock.
The
best incision of approach is the left subcostal, but a left rectus
incision may give
adequate access. In some cases a liberal median or paramedian incision
may give abundance of
room. The incision for abdominothoracie injuries is dealt with in a
subsequent paragraph. Where
the hemorrhage is inactive and has not been of large amount abstention
is the best rule to follow in an uncomplicated case. A small wound
encountered at operation and showing no active
hemorrhage should be left alone. Suture in the splenic tissue is less
effective in controlling
hemorrhage than in liver tissue, and a continuation of the bleeding is
always a possibility.
Packing in cases of this sort is desirable. Splenectomy, though advised
by some writers, notably
Depage, 15 gave practically a 100 percent mortality in
the American Expeditionary Forces.1 The treatment of
hemorrhage and shock is the same as with liver injuries.
The
mortality rate is 63.26 percent.1 Hemorrhage is the cause
of death in practically all
the uncomplicated cases.
464
WOUNDS OF THE KIDNEY
Wounds
of the kidney constitute 6.3 percent of all abdominal injuries; 1 one-half of the
cases are uncomplicated. Wounds of the right kidney are complicated by
liver injuries in about
one-third of all cases, and wounds of the left kidney are attended with
splenic lesions almost as
frequently. The hollow viscera most often wounded are the small gut or
colon, while stomach
lesions are less frequently encountered.
Wounds
of the hilum include injuries to the renal vessels or to the pelvis
itself. Wounds
of the renal vessels are usually serious and often fatal because of the
severe hemorrhage. It is
well to bear in mind that an injury to any of the renal branches
results in necrosis of that portion
of the kidney tissue which the vessel supplies, as the anastomotic
circulation of the kidney is
very poorly developed. Injuries of the pelvis itself are comparatively
rare and require no further
discussion.
Wounds
of the parenchyma may be of any type from a simple perforating or
tangential
wound to a very extensive laceration or destruction of the organ.
The
X ray gives important aid in arriving at a correct diagnosis in this
group of eases.
Hemorrhage as well is an important symptom; the bleeding may occur from
the external wound,
it may appear in the urine, or may form a retroperitoneal haematoma.
Bleeding into the
peritoneal cavity may take place if the rupture has been
intraperitoneal. Under such conditions
one may expect a tender and rigid abdominal wall with dullness in the
flank. Under any
circumstance, if loss of blood has been considerable, the patient may
exhibit symptoms of shock.
Leakage of
urine is present when the pelvis of the kidney has been opened or the
ureter
has been torn. but seldom with wounding of the parenchyma itself.
Retention
of urine is seen in a certain proportion of cases. Sepsis is a later
complication,
which may develop where inadequate drainage has been established or
where hollow visceral
complications have resulted in a fecal fistula into the wound. Cases
with sepsis exhibit all the
symptoms common to this condition. Vomiting is frequently seen. Out of
42 cases reported by
Fullerton 11 arriving at a base hospital with kidney
lesions 9 suffered a secondary hemorrhages 1
on the third day, 1 on the seventh day, a between the tenth and
fifteenth days, and 2 after four
weeks.
Conservatism
should be the keynote in the treatment of lesions of the kidney. With a
penetrating rifle wound and where these is no evidence of intestinal
involvement rest and a
liberal administration of opium are indicated. Alarming, hemorrhage,
urinary leakage, advancing
symptoms of sepsis, or a large retained foreign body are the principal
indications for operative
intervention. A complicating hollow visceral injury requires immediate
operation. The incision
of choice is a transverse or oblique one, which may be extended as far
forward as is necessary to
give adequate exposure of the kidney or to treat other complicating
visceral injuries. If a small
lacerated wound with a retained foreign body is encountered the removal
of the missile and
drainage may be all hat is necessary for a satisfactory recovery.
Charles 9 advises under these
465
circumstances a débridement of the damaged
kidney tissues, followed by suture and drainage.
A rubber-covered clamp upon the renal vessels during this procedure
gives satisfactory control
of hemorrhage. If such dissection can be done with little sacrifice of
kidney tissue it is a
legitimate procedure. Nephrectomy should be avoided wherever possible,
for in the push of
advanced war surgery definite information as to the function of the
other kidney must of
necessity be lacking. Nephrectomy, however, must be performed where the
vessels themselves
are seriously damaged or where the injury to the kidney itself is
extensive.
The
mortality in uncomplicated cases varies from 25 to 30 percent.1 The fatal cases far
forward succumb to hemorrhage. In the rear areas sepsis and secondary
hemorrhage are the chief
factors leading to death.
WOUNDS OF THE URETER
Wounds
of the ureter are infrequent. A gross injury calls for nephrectomy.
Where a small
wound is encountered suture may be attempted, but, in general, ureteral
wounds will heal
spontaneously if left alone.
WOUNDS OF THE BLADDER
Injuries
of this organ comprise approximately 5 percent of all abdominal
lesions and
one-half of the cases are uncomplicated.
In
Fullerton's 17 series 70 percent of the cases were
complicated by intestinal or bone
injuries or both. A wound of the rectum may be expected in from 10 to
15 percent of the cases.
Injury of the prostate is comparatively rare.
Cathelin,18 in a series of 29 bladder wounds, found that the entrance was placed
posteriorly 18 times, anteriorly 7 times, and laterally in the
remaining cases. A wound of exit
was present in but 5 of the patients.
Bladder
perforations may be caused by either the projectile or by bone spicules
from the
fractured pelvis. The lesion of the bladder may be extra peritoneal or
Intra peritoneal and may
vary considerably in size. Legueu 19 reported 10 cases of
fracture of the pelvis associated with
bladder injury in which a vesical calculus was demonstrable. Other
observers have not so
uniformly encountered such conditions.
Hemorrhage
in connection with bladder wounds is usually not serious, but its
occurrence
into the bladder suggests an extra peritoneal lesion. With this type of
injury a considerable
haematoma is not infrequently found in the vicinity of the wound in the
viscus. Urinary
discharge through the entrance wound is fairly uncommon. An empty
bladder should make one
strongly suspicious of an intraperitoneal perforation. Leakage of
urine into the peritoneal cavity
causes a considerable degree of peritoneal irritation with definite
local signs.
Most
of the extra peritoneal lesions result in pelvic cellulitis. In the
long standing cases
associated bone necrosis and calculus formation may be expected, and in
most instances a
cystitis still continues.
Extraperitoneal lesions are best treated by
wide incision down to the
bladder wound,
which should be sutured if possible. Ample drainage of soft
466
tissues must then be provided. Suprapubic
cystotomy furnishes the best type of bladder drainage
and should generally be employed.
The
patients suffering from Intra peritoneal wounds, and especially those
with associated
visceral lesions, show such decided symptoms that little doubt exists
as to the wisdom of
laparotomy. Such lesions require operation with suture of the bladder
wound and rubber-dam
drainage down to the stitch line. A retention catheter or perineal
drainage, preferably the former,
meets the indications; suprapubic cystotomy should be avoided if
possible.
Retained
missiles are fairly frequent in the bladder. The projectile must always
be sought
for within the bladder, and if present removed.
In
the latter stages of bladder wounds one must consider the treatment of
persistent
urinary fistulae, calculi, and sepsis. Cathelin's method of dealing
with persistent fistulae is an
efficient one. He dissects a cuff of skin and in folds it by suture
down to the bladder wall, later
bringing muscle and aponeurosis over it. Calculi had best be removed by
the urethra, with or
without crushing, but a suprapubic cystotomy may be necessary. The
treatment of sepsis is
supportive but the cases usually result disastrously.
The
presence of complicating injuries may require considerable modification
in operative
technique. If a rectal or colic injury is so extensive as to make a
colostomy imperative a
suprapubic cystotomy should be dispensed with.
Very
variable statistics will be found in the literature concerned with the
mortality rate
following uncomplicated bladder wounds, but the average is about 50
percent. Where the
bladder injury is associated with a lesion of the small intestine a
much higher figure is reached,
running to 75 or 80 percent. The causes of death are sepsis, general
peritonitis, or, much more
rarely, a secondary hemorrhage from the pelvic vessels.
An important prophylactic precaution in the avoidance of bladder wounds
consists in an
invariable order that soldiers should empty their bladder before going
into action.
ABDOMINOTHORACIC INJURIES
These
wounds comprised 4.6 percent of all the thoracic injuries coming to
the
evacuation hospitals, American Expeditionary Forces, for treatment. 11
The
lesions encountered are thoracic, diaphragmatic, and abdominal. Duval, 19 gives the
general rule that with a wound of entry in the chest the thoracic
lesions are more apt to be the
serious ones, while with entry through the abdomen the abdominal
injuries are more often the
graver ones. Frequently there are several wounds of the lungs and more
than one lobe is
occasionally involved. The types of lesion are the same as one
encounters in simple thoracic
wounds. A certain amount of hemothorax is always present, but the
amount is variable. In
approximately one-third of the cases a hollow abdominal organ is
penetrated. An uncomplicated
liver injury is more common than one of the spleen.
The
wound in the diaphragm may be made either by the projectile or by a
fractured rib.
The diaphragmatic wound may vary from a small puncture to an irregular
opening of large size;
the shape is often slit-like, in which instance it
467
is usually not more than an inch long. In
about 10 percent of the cases herniated abdominal
organs will be found in the chest cavity. The omentum is the structure
most often seen, and if
viscera are extruded into the thorax the omentum usually accompanies
them. Next in order of
frequency are the spleen, stomach, and transverse colon. Practically
all herniations occur through a wound in the left side of the
diaphragm.
Through-and-through
wounds involving both sides of the diaphragm are seldom
encountered in the hospital, for most of them die far forward before
evacuation can be carried
out.
The
pathognomonic symptoms of abdominothoracic wounds are dyspnea, the
breathing
being rapid and labored; sudden pain in the abdomen at the time of the
receipt of the wound;
hemothorax; abdominal rigidity over the corresponding half of the
abdomen, especially in its
upper part; and shock, which is partially dependent upon the degree of
hemorrhage and partially
upon the respiratory distress. Other abdominal symptoms such as
definite local tenderness and
vomiting may also be evident.
COURSE OF TREATMENT DEPENDENT UPON TYPE OF
INJURY
If
there are separate wounds of entrance for the abdomen and chest and the
latter one is
not a blowing wound, the abdomen should be opened immediately if a
hollow visceral lesion is
suspected, and the chest should be left undisturbed. With a wound of
entrance on the right side
of the chest authors vary as to the procedure to be adopted. If the
missile is a small one and X-ray examination localizes it in the liver
the wisest course is nonintervention. If the chest wound
is a blowing one it should be closed by suture in which the muscular
layer is included. No
blowing chest wound should ever be allowed to get past the regimental
dressing station without a
closure of the muscular layers of the wound by suture. This rule should
be adhered to even if
asepsis can not be maintained. Many advise operation in this group of
patients, the steps being
de bridement of the chest wall, and exploration of the diaphragm and
liver through an
intercostal or vertical wound after the chest lesions have been cared
for. The foreign body is
removed from the liver when possible, the diaphragm sutured, and
finally the chest itself closed
without drainage.
With
a wound on the left side above the level of the eighth rib and an
associated
abdominal injury which is high up a different problem is presented.
Excellent constructive
surgery has been developed by Duval 20 in cases of this
type. He uses a vertical incision upon the
chest wall, beginning near the thoracic wound. The ribs are sectioned
in order to allow access to
the thorax, and the prolongation of the wound downward opens the
abdomen; at times this lower
extension may be continued obliquely forward. Other surgeons employ a
transpleural approach
to the upper abdomen with an incision which is roughly transverse. A
rib may be resected, or
access may be had through an intercostal space with the aid of
Lilienthal's rib spreader. The
chest wound is carefully dissected out and any soiled rib or loose bone
fragments are removed. With fresh instruments the pleural cavity is
explored and any lesions encountered are
taken care of. The wound in the diaphragm is then sought for and
enlarged up to 5 or 6 inches;
this exposure gives a satisfactory
468
approach to the abdomen. Any abdominal injury
found is cared for and the diaphragm closed. It
is generally wise to obliterate the pleural space lowdown by suturing
the diaphragm to either the
lung or the lateral pleural wall. The chest should be closed without
drainage.
With
a wound on the left side and the point of entrance below the eighth rib
the lesion
within the abdomen is apt to be more serious. In this group of cases
the abdomen should first be
dealt with through a separate incision. At times it is possible to deal
properly with the opening in
the diaphragm from below. If the pulmonary injury warrants intervention
it may be explored
through an intercostal space. The closing off of the pleural cavity is
accomplished as described
in the preceding paragraph.
Duval
to the contrary notwithstanding, the mortality rate is principally due
to the lesion
in the abdomen, and is distinctly higher when a hollow viscus has been
penetrated.
LESSONS IN
CIVIL ABDOMINAL SURGERY GAINED FROM THE WAR
The
contributions of the war to civil abdominal surgery may be summarized
as follows:
(1) It has shown the types of tangential wounds which are not
infrequently without visceral
lesions. (2) It has taught the unwisdom in most cases of relying upon
the so-called expectant
treatment of abdominal wounds and the soundness of early radical
operation. (3) It has
demonstrated the wisdom of waiting an hour or so before operation is
attempted in cases with
severe shock. This rule applies, of course, only to those instances
where shock is not due to
active hemorrhage. (4) It has taught us the best methods of handling
abdominothoracic injuries.
(5) It has given an unusual opportunity to review the whole subject of
abdominal drainage,
strengthening our convictions that the general peritoneal cavity can
not be drained, but that it is
possible to drain a single focus within the peritoneal cavity. (6) It
has emphasized again and
again that speed, dexterity, simplicity of technique, and the minimum
of traumatism are essential
to success.
REFERENCES
(1) Based on Sick and Wounded Reports made to
the Surgeon General. On file, Historical Division, S. G. O.
(2) La Garde, Louis A.: Gunshot Injuries.
William Wood and Company, New York, 1916, 2d ed., 262.
(3) Gibbon, John H.: Treatment of Gunshot
Wounds of the Abdomen. Journal of the American Medical
Association, Chicago, July 19, 1919, lxxiii, 187.
(4) Wallace, Cuthbert: A Study of 1200 Cases
of Gunshot Wounds of the Abdomen. British Journal of Surgery,
Bristol, 1916-17, iv, No. 16, 679.
(5) General Orders No. 70, G. H. Q.
A. E. F., May 6, 1918.
(6) Organization and Operation of Mobile
Hospital Units, by Col. E. C. Jones, M. C., undated. On file,
Historical
Division, S. G. O.
(7) Medical and Surgical History of the War
of the Rebellion. Washington, Government Printing Office, 1876,
Surgical Volume, pt. 2, 3-208.
(8) Wallace, Cuthbert: A Preliminary Note on
the Treatment of Abdominal Wounds in War. Journal of the Royal
Army Medical Corps, London, December, 1915, xxv, 591.
(9) Charles, R.: Gunshot Wounds of the
Abdomen at a Casualty Clearing Station. British Medical Journal,
London, March 23, 1918, I, 337.
(10) Walters, C. Ferrier, Rollinson, H. D.,
Jordan, A. R., and Banks, A. Gray: A series of 500 Emergency
Operations for Abdominal Wounds. Lancet, London, February 10,
1917, i, 207.
(11) Based on reports of surgical
operations at evacuation hospitals, A. E. F., undated. On file, A. G.
O., World War Division, Medical Records
Section.
(12) Marshall, Geoffrey: Anesthetics for Men
with Wounds of the Abdomen. British Journal of Surgery,
Bristol,
1916-17, iv, No. 16, 733.
(13) Makins, Sir George: A Study of One
Hundred and Eleven Cases of Perforating Wounds of the
Gastrointestinal Canal which Occurred amongst a Consecutive Series of
Two Hundred and Two Perforating
Wounds of the Abdomen in which the Presence of Visceral Injury was
Certain. Journal of the Royal Army Medical
Corps, London, 1916, xxv, No. 1, 1.
(14) Eastman, James Rilus: The Question of
Operation in Gunshot Abdominal Wounds. Journal of the
American Medical Association, Chicago, September 28, 1918, lxxi,
1036.
(15) Depage, A.: Note sur les plaies
pénétrantes de l'abdomen traitées a l'ambulance de la Ocean a la Panne. Bulletins et mémoires de la société de chirurgie de Paris,
March 14, 1917, xliii, 691.
(16) Fullerton, Andrew: Gunshot Wounds of
Kidney and Ureter as Seen at the Base. British Journal of
Surgery,
London, 1917, v. No. 18, 247.
(17) Fullerton, Andrew: Observations on
Bladder Injury in Warfare. British Journal of Surgery,
Bristol, 1918,
vi, No. 21, 24.
(18) Cathelin, F. Blessures de guerre de la
vessie. Lyon chirurgical, 1918, xv, No. 1, 109.
19) Legueu, F.: Des calculs vesicaux chez les
blesses de la vessie. Bulletin de l’académie de médecine,
Paris, December 5, 1916, lxxvi, 445.
(20) Duval, Pierre: Plaies
thoraco-abdominales. Comptes rendus de la conférence chirurgicale
interalliée
pour l'étude des plaies de guerre, 3d session, November 5-8, 1917. Archives
de médecine et de pharmacie
militaires, Paris. 1918, lxix, 355.
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