WOUNDS OF THE ABDOMEN
Counting deaths on the battlefield, the percentage of wounds of the abdomen, according to Ferraton, is 13 or 14. That of the wounded received in the ambulances fluctuates between 7 and 10; a very small number of these cases are transported to the base-hospitals.
The proportion of penetrating wounds is 50 per cent. These statistics, which are partly of ancient date, require revising and completing.
The claims of diagnosis, and also those of categorical statistics, have already made an exact knowledge of the abdominal regions absolutely necessary to the surgeon; on the other hand, the relations the external orifices of the wounds bear to these regions constitute indications of the highest value, in spite of the displacements which, through respiratory movements or change in the position of the body, certain movable organs may undergo.
In planning out the abdomen, we divide it into three stories one above the other: the first or superior is situated between the diaphragm, the dome of which corresponds with a horizontal line passing through the fifth rib, and another line, also horizontal, which just touches the thoracic brim.
The second or middle. is contained between this last mentioned line and the horizontal plane between the two anterior superior iliac spines.
WOUNDS OF THE ABDOMEN
The third or inferior is situated below the iliac plane just mentioned, thus corresponding to the pelvis.
The upper space is thoraco-abdominal.
Two vertical lines starting from the centre of Poupart's ligament divide this space into three secondary zones : the right hypochondrium, the epigastric, in the centre, the left hypochondrium; these lines also divide the middle abdominal space into two lateral regions, the right and left lumbar, with the umbilical in the centre and finally divide the inferior story into right and left iliac and hypogastric in the centre. The following shows the organs contained in each of these nine regions:
Cul - de - sac of the pleura.
portal and inferior cava veins.
hepatic flexure, hidden under the liver.
Right lumbar fossa.
Anterior crural nerve.
The great omentum (posterior cavity).
Left lobe of the liver.
Coeliac axis. Aorta.
Stomach, when distended.
Mesentery. Small intestines.
Aorta. Inferior vena cava.
Cavity of Retzius.
Bladder, when full.
Inferior vena cava.
Thorax and pleura.
Anterior crural nerve.
Antero-posterior tracks, by far the most common, often affect but one region; transverse tracks go through several regions, either horizontally or obliquely. Vertical tracks are rare.
Cold Steel Wounds -These are deep, though they do not always wound the intestines (bayonet, lance), and superficial (cutting weapons).
Contusions, cul-de-sac wounds, parietal perforations, may be seen on the abdominal wall. In tangential firing the furrow or the seton made by the bullet is sometimes very extensive. Fragments of large projectiles make on the abdomen furrows or setons, especially very long furrows.
Simple penetrating wounds are exceptional. A bullet that goes through the wall produces always, so to speak, a penetrating wound with a visceral lesion.
Lesions of the Intestine -
In the small intestine, which is the more often wounded, and whose lesions may be regarded as types of wounds of hollow organs, we see contusions, tearing, or perforations. Perforations are very common; they are multiple in the intestine, frequently four in number, but as many as thirty have been seen. They are generally most numerous from transverse firing. The lesions are less from bullets which have but a small velocity; they increase in size with average velocity and more especially with great velocity; this is an important fact. Their size is in proportion to the calibre of the bullets, therefore they are larger when caused by shrapnel bullets or shell fragments than by ordinary modern bullets. They increase in size with flattened bullets, but they become much smaller with pointed bullets, whose wound resembles a puncture.
The orifices of the perforations are circular or oval, sometimes almost like a mere slit, punctiform, and more often with loss of substance. The aperture of entry looks as if it had been punched out, and gapes; the aperture of exit is everted, with the mucous membrane bulging, and is often larger than the aperture of entry. Sometimes the two orifices are quite near to one another, and only separated by a little bridge; more often, however, they are wide apart.
1. At a greater distance than 400 metres, the present bullets of small calibre generally leave very small perforations, which might almost be called simple punctures; they have a great tendency to close up spontaneously (Ferraton). Through these orifices, when they are larger than simple punctures, the mucous membrane is pushed out like a hernia; and it prevents to a certain extent the egress of solid or liquid intestinal material, but not that of gas. The contraction of the peripheral muscular fibres narrows the openings; when the contraction ceases, the localized inertia of the intestine prevents the escape of fluids.
2. When the bullet has been fired from a less distance than 400 metres, when it has struck obliquely, and has undergone a deviation before reaching the intestine, when the projectile is a shrapnel bullet and a fortiori a shell fragment, the intestinal orifices are like the cutaneous orifices, the latter showing the extent de visu of the former, but larger and less likely to be closed by the mucous membrane. The stercoraceous effusion is then more abundant, more continuous than in the first case, in which it may be very small, especially if the wounded man was fasting.
At very short distances we see explosive effects: bursting of the intestine, large gaping wounds, especially if the bowel was full at the time of the wounding; nevertheless, severe disturbance, owing to pointed bullets, is less common than formerly. They would be frequent with bullets having a blunt extremity (Austrian and Russian). Contused sections are very exceptional (shell fragments).
These typical lesions of the small intestine are also seen in the large intestine. The large bowel is more vulnerable because it is fixed; but its perforations are less grave by reason of the solid nature of its contents and the absence of mobility, which prevents dissemination of contaminating products.
The same lesions are also seen in the stomach, the rectum, the bladder, and the gall-bladder.
In the stomach, whose walls are thicker than those of the small intestine, perforations are generally narrower, and with more tendency to close spontaneously. The vascularity of the organ makes the patient liable to intraperitoneal haemorrhage or to haematemesis.
The perforations are generally double, and involve at the same time the anterior and the posterior wall (effusion easily taking place into the large peritoneal cavity or into the posterior cavity of the omenta). Like the intestinal walls, the wall of the stomach may be contused or grazed.
The liver presents the typical lesions of abdominal parenchymatous viscera. They consist of contusions (exceptional with rifle bullets, more frequent with shrapnel bullets), furrows and grooves scooped out on the surface, cul-de-sac wounds, or total perforations.
The orifices and the tracks made by the bullets are generally narrow, rounded, not gaping, but prolonged byfissures whose depth, extent, and number are connected with the velocity of the bullet. These fissures are all the more numerous and deep the greater in general the velocity that is to say, the nearer the firing.
From a short distance we see explosive effects, with numerous subdivisions, both locally and at a distance, the apertures of exit much enlarged, gaping, and bleeding. The liver being a very vascular organ, it bleeds copiously.
In the spleen, which is just as vascular, the orifices and tracks are in general larger than in the liver, and more complicated, with extensive fissures.
The pancreas, whose traumatisms may be complicated by lesions of the stomach, the duodenum, the liver, etc., presents wounds analogous to those of the liver, though less severe by reason of the greater solidity of the pancreas.
To sum up, the principal cause of the gravity of abdominal penetrating wounds by projectiles is the frequency and copiousness of the immediate effusion, the vast effusion of blood furnished by the parenchymatous organs and the large vessels, but also, in addition, by vessels of the second and third class, from which the haemorrhage, though not so sudden, is none the less grave by reason of its persistence; and, again, there are the pourings out of food and secretions, both irritating and septic, giving rise to the very gravest local or general reaction, to peritonitis.
Poured out in large quantities, the blood, aided by gravity, invades the lower parts of the body, the flanks, the exterior of the colons, or more often the iliac fossa and the true pelvis. The effusion on the right side penetrates directly into the right iliac fossa; on the left side it descends into the left iliac fossa and into the true pelvis.
When less abundant, the effusion, instead of filling the peritoneum, may accumulate as a collection of pockets in the neighbourhood of the lesion in the wounded viscus.
The mixture of the blood with the septic products of the hollow organs gives rise rapidly either to the formation of adhesions, or to septic or purulent peritoneal effusions, sometimes circumscribed in the vicinity of the visceral lesion, sometimes multiple, sometimes generalized.
Peritonitis is the great danger in these wounds, and the higher the lesion the greater the risk of this complication. A well-known fact is that the power of absorption of the peritoneum is specially marked in the superior peritoneum above the transverse colon, and that it is reduced to a minimum at the level of the inferior peritoneum and in the true pelvis.
Diagnosis-Although the symptoms of the traumatisms of the abdomen by the weapons of warfare are in a great degree like those we observe in similar lesions of ordinary practice, it may be as well to call to mind their chief differential characteristics.
Shock, pain (rarely acute), dyspnoea, nausea, vomiting, are all often absent; a small pulse is unreliable at first; disappearance of the liver dullness is a valuable symptom, but it is very variable, as also is dullness in the iliac fossa.
Escape of blood through the anus is a late symptom, and subcutaneous emphysema is rare. Primary diagnosis is based, in short, on rigidity of the abdominal walls, a wooden feeling oj the abdomen, absence of abdominal respiration, finally, by the relations of the external perforating wounds to the regions of the abdomen. We can assert that these lesions are always perforating under normal conditions of fire; therefore, if we cannot feel the projectile in the abdominal wall, we can practically say that a track exists in the abdomen formed by the projectile, and we therefore diagnose a perforating wound.
Haemorrhage is revealed by signs of acute anaemia and by the discovery of rapid effusion into the iliac fossa.
Peritoneal reaction, nearly always fatal after penetrating wounds, shows itself especially by peritoneal facies, dissociation of the Pulse and temperature, inguinal or rectal tenderness, vesical tenesmus.
Haematemesis would indicate a lesion of the stomach, but it is a rare sign ; radiating pains in the right or left shoulder are the only indirect signs to remember amongst those that are given for the diagnosis of lesions of the spleen and of the liver, for jaundice and escape of bile through a narrow wound are uncommon, and escape of splenic substance through the wound or hernia of the viscus are only seen in large wounds produced by shell splinters.
To sum up, a localized diagnosis, often very uncertain, large intestine, with the exception of the transverse colon, and, finally, still less with lesions of the rectum. Wounds of parenchymatous organs are less grave than those of hollow organs, and in order of their gravity we may mention the liver, the spleen, and finally the kidneys; and here again the question of active force and length of range comes into play. At reduced distances the tracks are wider, more gaping, more fissured, more likely to furnish a haemorrhage which is formidable, on account of its abundance and its persistence.
Absolute immobility is an important factor in making the prognosis less unfavourable. It is one of the best. In the Transvaal, at Spion Kop, all the wounded, being in a mountainous country, and having necessarily to be transported over very rough ground, succumbed; at Jacobsthal a great many men who were not moved recovered. We have seen quite a series of wounded cured by expectation, the soldiers having been obliged to remain on the field of battle for several days without being able to move from one spot, with nothing to drink or to eat.
Treatment-The treatment of penetrating wounds of the abdomen during a campaign has passed through three different phases - an old one, the expectant; an active one, extensive and early laparotomy; a third, the one of the present period, expectant, brought forward at first as a theory (Delorme, Chavasse, Haga, etc.), then confirmed by experience acquired in warfare. May the present war bring to light a fourth phase, in which treatment, more unvarying, more susceptible of generalization, and formations better adapted to circumstances and to the great variety of the lesions, will contribute to lower a mortality that is still excessive.
With regard to the treatment of perforating wounds, we will reproduce almost in full what we have already said in our "Advice to Surgeons."
Treatment of wounds of the abdomen, with lesion of the intestine, merits the undivided attention of surgeons, especially of the surgeons at the front. The treatment has been enriched by new methods, as yet not sufficiently known, the use of which will contribute to the lowering of the invariably dark prognosis of these wounds.
If we discuss the opportunities for extensive laparotomy in wounds of the abdomen and intestines in ordinary everyday practice, we find they are not at all the same in war surgery. As a principle, immediate laparotomy should be rejected. The most recent wars - Transvaal, Manchuria, Balkan-have shown its harmfulness.
In the Transvaal, although performed by eminent surgeons, under the best conditions for its success, it furnished many less cases of cure than did absolute abstention from operative interference, so much so that MacCormac was able to say: "A man wounded in the abdomen dies if operated upon; he lives if left alone."
During the Russo-Japanese War, on the Russian side, laparotomy was abandoned because of its want of success (95 per cent.); on the Japanese side it had to be forbidden. After the Italian-Turkish War (1912) it was condemned, and also in the French campaign in Morocco.
On the other hand, mortality consecutive to operative abstention fell from 87 per cent. during the War of Secession to 50 per cent. Its mortality oscillates between one-half and one-third.
Delay in the patient's arrival, difficulty of finding anaseptic centre, length of operation, the absolute necessity of treating simultaneously hundreds of wounded men all arriving at the same time, etc., are, together with the operative mortality, the principal and valid reasons for the rejection of extensive laparotomy, which should be considered as only an exceptional method.
From the point of view of treatment, we have divided these wounded into two groups-those with narrow wounds, those with extensive wounds (Delorme "On Wounds in War: Advice to Surgeons." Paper read at the Institute, August 10, 1914.)
1. Narrow Wounds - As we have already seen, the German bullet, striking the abdomen point-blank, especially at long and medium ranges, makes in the abdominal wall a narrow aperture of entry, and does not carry with it infecting foreign bodies derived from the clothes. In the intestinal coils it only produces little orifices - very small perforations that have a tendency to close up spontaneously. Even in some cases it insinuates itself between the coils without perforating them. The immediate and valuable instinctive evacuation of both the intestine and the bladder, the fact of the wounded man remaining for hours on the same spot without experiencing the shock of transport, all these conditions prevent intraperitoneal suffusion, or, at any rate, circumscribe it, and promote recovery.
In this category of traumatisms the old treatment seems to suffice: absolute rest, no transporting to a distance, complete deprivation of food, and especially of drink, for several days - a regimen well borne, thanks to incessant rinsing of the mouth, rectal and intracellular injections of normal saline, finally to opium and Fowler's position.
2. Extensive Wounds. - When, on the other hand, the velocity of the projectile has been greater, the bullet has turned over in its course, or, in cases struck by shrapnel bullets, the circular or oval aperture of entry in the skin is bigger, the wounds also, as well as the intestinal lesions, are larger, and are less likely to become spontaneously obliterated; and complications resulting from shreds of clothing are frequent.
In these cases peritoneal infection is certain, but the surgeon is by no means disarmed. To the treatment already indicated he can add, if possible, the continuous drop by drop rectal instillations of Murphy, especially the Murphy's quick incision and drainage, and copious washing out of the peritoneum with ether (Souligoux).
Murphy's incision, that Professor Ferraton has highly recommended in France, consists of a small button-hole cut made in the abdominal wall above the pubic arch. Through this incision, done at an early period under simple local anaesthesia after a rapid disinfection of the skin by iodine, the cavity of the pelvis is drained, and here, thanks to Fowler's position, septic fluids have a tendency to accumulate. This incision, therefore, represents a safety-valve; it prevents dangerous tension, which would promote reabsorption of septic products.
In seventeen patients suffering from wounds by projectiles, with perforation of the bowel, Harris, by the use of Murphy's incision, had seventeen successful cases.
Murphy's conception and technique are well suited to the conditions under which military medical service is carried out in the ambulances and hospitals. It opens up for surgeons a path they should resolutely follow. Here is no longer the complicated operation of classical laparotomy which a number of skilled surgeons could not repeat at the outside more than three or four times in a day, and even then by neglecting the other wounded men ; a fatiguing operation, which increases shock, and is liable to destroy beneficial adhesions; an operation requiring a special armamentarium, minute aseptic precautions, and, after all, that ends by giving less cases of cure than abstention from operation. On the other band, Murphy's incision is a very simple and rapid affair, within the capacity of every practitioner.
At Nancy, Professor Rohmer, evidently struck by the advice given in our communication, carried out Murphy's incision on several wounded men whom we saw. Some were on the road to recovery. On the other hand, all the patients on whom Professor Weiss had performed laparotomy were dead. We also saw at Nancy spontaneous recovery from wounds of the abdomen in soldiers who had remained for several days lying on the battlefield, a hail of projectiles passing over them, and forced to fast all the time.
Wounds of the Lumbar regions and Kidneys