HX64063852 RD540 M36 The surgical treatme RECAP WOUNDS AND OBSTRUCTION OF THE [NTESTTOS. MARTIN AND HARE. Columbia WinMvUit^ in tije Citp of Mfto |9orfe College of ^fjj'Siciang anb ^urgeonsf 3^ef erence l^ibrarp TPIE SURGICAL TREATMENT WOUNDS AND OBSTRUCTION INTESTINES. BY EDWARD MARTIN, M.D., INSTRUCTOE IN OPEEATIVE SURGERY UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE HOWARD HOSPITAL, ASSISTANT SURGEON TO THE UNIVERSITY HOSPITAL, /v. CLINICAL PROFESSOR OF DISEASES CTi CHILDREN AND DEMONSTRATOR OF THERAPEUTICS IN THE UNIVERSITY OF PENNSYLVANIA, PHYSICIAN TO ST/ AGNES HOSPITAL. liCl^l 'Mjs_ PHILADELPHIA: W. B. SAUNDERS, 913 Walnut Street, 1891. PHILADELPHIA : COLLINS PRINTING HOUSE, 705 JAYNE STREET. TO D. HAYES AGNEW, M.D., LL.D., PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PUILADELPHIA ; HONORARY PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, AS A TRIBUTE OF AFFECTION AND EESPECT BY TWO OF THE MANY YOUNG MEN HE HAS BEFRIENDED. PREFACE In presenting this essay upon the Surgical Treatment of Wounds and Obstruction of the Intestines to the Trustees of the Fiske Fund, it is proper to outline the scope of our work and to state briefly the facts and lines of original research upon which our conclusions are based. For over two years we have made experi- ments in the laboratory upon these subjects, and have carried out with every detail all the methods and modifications of operations that have been published, or which occurred to us in the course of our own studies. It is for this reason we feel some confidence that the opinions expressed by us in the following pages are not without a firm basis, and that they are stated with the positiveness of one who is sure of the ground on which he stands. In addition to the original work involved in studying so impor- tant a branch of surgery as the one before us, and which will be found represented graphically, in part at least, by a number of tracings, we have collected and placed before the reader what we believe to be the fullest statistics yet collected upon gunshot wounds of the abdomen. Our tables of intestinal obstruction fully recorded in the original manuscript we have summarized, appending to the various forms of acute obstruction the result of analysis of our own cases. CONTENTS. Introduction. Intestinal Obstruction PAGE Chapter I. II. III. IV. V. YI. YII. YIII. IX. X. XI. XII. XIII. XIY. Congenital Malformations 19 Intussusception 28 Internal Strangulation 40 Yolvulus 4Y Obstruction from Foreign Bodies 52 Intestinal Paralysis ~ 51 Chronic Obstruction 63 Peritonitis 66 On Diagnosing the Yarious Forms of Intestinal Obstruction 81 On the General Treatment of Intestinal Obstruc- tion 86 Special Treatment of Obstruction 90 Surgical Treatment of Intestinal Obstruction . . 107 Wounds of the Intestines 122 Rupture of the Intestines 140 Cases of Celiotomy for Gunshot Wounds of the Abdomen Summary of the Tables of Gunshot Wounds of the 145 Abdominal Contents 164 Index 167 WOUNDS AND OBSTRUCTION OF THE INTESTINES. INTRODUCTION. INTESTINAL OBSTRUCTION. Under the heading of intestinal obstruction are commonly classed not only such conditions as strangulation, Avhich by a direct primary effect i^roduces a mechanical impediment to the outward passage of the intestinal contents, but also certain pathological states, as peri- tonitis or enteritis, which, by engendering a paralytic condition of the intestinal walls, favors primarily stasis, with resultant fermen- tation of the contained matter and the development of the t}'pical symptoms of obstruction, accompanied by those of either inflam- mation or septic absorption. From the clinical standpoint all authors agree in classifying the cases of intestinal obstruction under the headings acute and chronic, though no sharp distinctive line can be draAvn between the two, and either is liable to merge into the other. The further general classification of conditions causing acute intestinal obstruction is as follows : — 1. Congenital malformations. 2. Invagination, or telescoping of one portion of the bowel within another. 3. Internal strangulation, by bands, diverticula, membranous adhesions, through apertures, or by means of the abnor- mal attachments of organs not in themselves diseased. 4. Volvulus, or twisting of the bowel. 5. Impaction of foreign bodies, gall-stones, etc. To these headings should be added still another, namely : — 6. Obstruction from intestinal paralysis and distention. 2 18 WOUNDS AND OBSTRUCTION OF THE INTESTINES. The caiiBes producing chronic obstruction are — 1. Stricture. 2. Neoplasms. 3. Pressure of tumors external to the boAvel. 4. Impaction of fecal masses. CHAPTER I. CONGENITAL MALFORMATIONS. Under this heading are considered anomalies or malformations of the bowel itself rather than of its environments, though upon a fissure or defect of the diaphragm, or upon abnormal persistence of the omphalo-mesenteric duct, may depend an occlusion no less abso- lute than that characterizing closure or absence of a part of the bowel. The obstruction is, in the great majority of cases, dependent upon malformation, or absence of the rectum or anus. In the rare cases of coarctation, or atresia (ira perforation), in the continuity of the intestinal canal, the lesion may be situated at any portion of the alimentary tract, though as a result of the study of many cases the seats of preference seem to be, in the small intes- tine, the duodenum, and the region of the ileocsecal valve ; in the large intestine, the sigmoid flexure. Apitz^ records a case of imperforation of the oesophagus, the lat- ter ending: in a blind cul-de-sac. Cases of atresia at or about the region of the pylorus are on record. Turner^ describes the autopsy of an infant in which there were two portions of the jejunum reduced to fine impermeable bands. Pied^ has observed the com- plete separation of the duodenum from the jejunum. The absence or stricture of portions of the ileum (Blat.,* Andrews,' Loblig- eois®), or colon (Cohen,' Thomas,^ etc.) has been occasionally recorded. Thomas notes the complete absence of jejunum, ileum, and the greater part of the colon. ' Allgemein. Deutsch, Hebammen. Zeitung, 1. 2 Edinburgh Med. Jour., 1863^, ix. 3 Jour, de Med. Chirurg. et Pharm., 1802, iii. * Bulletin Soc. Anat. de Paris, 1849, xxiv, 1856. 5 Peninsular Med. Jour., Ann Arbor, 1853-4. 5 De rOblit. Congen. des Intestines, 4°, Paris. 7 Med. Zeitsch., Berlin, 1838, vii. * Lancet, London, 1884. 20 WOUNDS AND OBSTRUCTION OF THE INTESTINES. At times the symptoms of obstruction can be traced to a stran- gulation, an incarceration, or a volvulus due to malposition. Price ^ gives an instance of transposition of the stomach and duodenum, with the colon placed behind the latter. As a consequence of this the colon was strano^ulatcd, the case terminating: fatallv. The cause of congenital coarctation, or atresia of the intestinal canal, is usually a pre-natal inflammation, either primarily inter- fering with growth, or by the deposit and organization of inflam- matory exudate, producing such disturbance in nutrition that wast- ing and contraction take place. It is of importance to bear in mind the fact that the stricture or defect is in many cases not limited to one part of the bowel.^ The more common congenital formative defects of anus and rectum are classified with reference to the method of development of these parts. The anal opening is continued upward until it finally unites with the rectum in its downward extension. From arrested development, or inflammation, there may be narrowing (partial occlusion), atresia (complete occlusion), or absence (imper- foration) of anus, of rectum, or of both these structures. Again, there may be a stenosed opening in an abnormal position. Good- man^ reports a case of imperforate anus and rectal atresia unsuc- cessfully treated by colotomy, in which, at the autopsy, the rectum was found to communicate by means of a minute orifice with the urethra at the base of the Caput Gallinaginis. The frequency of associated narrowings in other parts of the alimentary canal must be considered in dealing with these abnor- malities. A child operated upon by Darien * for imperforate anus was, at the autopsy, found to have a dilatation of the duodenum, imitating a second stomach; this was due to occlusion on the intes- tinal side by a complete spiral valve. Symptoms. — The symptoms of obstruction dependent upon con- genital stenosis, or atresia of the intestinal canal, are, of course, not developed until after birth, and the taking of food by the mouth. They do not difl^er from those of acute obstruction dependent upon other causes. There is no passage of fecal matter from the anus ; 1 Am. Jour. Med. Sc, 1853. 2 Gaertner, Jahrb. f. Kinderheil, 1883. 3 Medical Register, Feb. 25, 1888. * Bull Soc. Auat. de Par., 1881, Ivi. COXGENITAL MALFORMATIONS. 21 there is obstinate and continued vomiting of all food taken ; this vomited matter is more or less feculent in odor and appearance, depending upon the seat of obstruction and the time which has elapsed since the symptoms developed. There is often violent peristalsis to be detected through the belly walls. There may be much tympany. Symptoms of pain, and straining efforts at defe- cation are common. Death is inevitable if the case is not treated surgically. The immediate cause of the fatal issue is inanition or exhaustion. Perforative peritonitis occurs at times, but is not so common as in acute obstruction of a more advanced age. "With such symptoms following hard upon birth, the diagnosis of obstruction from either congenital malformation or internal stran- gulation would be positive, and, as either would demand the same treatment, the differential diagnosis between these two is not abso- lutely essential. Diagnosis. — Since the most common seat of this form of con- genital malformation is about the anus and rectum, a careful search should be made in this region, the finger being carried into the anal aperture, if patulous, in the hope of finding the seat of occlusion. By means of a bougie, exploration can be carried some inches fur- ther than the finger can reach. It must be remembered that, the rectum and anus being normal, the next probable seats of obstruction are at or about the duode- num, the ileocecal valve, or the sigmoid flexure of the colon. In the new-born child the colon is a foot in length, and normally occupies the same anatomical region as in the adult. The sigmoid flexure is ten inches long, and lies mainly in the pelvis. The condition of the colon can readily be made manifest by means of injection of either air, hydrogen, carbonic acid gas, or any unirritating liquid, preferably normal saline solution (.7 per cent.). Neither gas nor liquid should be passed into the bowels by means of a force-pump, or any kind of injecting syringe. If gas is used it should be passed from a bag, and the pressure, not exceeding a pound and a half, should be kept under observa- tion by means of a manometer attached to the supply tube. The best way of introducing water is by means of gravity. The ordinary fountain syringe answers every purpose; the nozzle should 22 WOUNDS AND OBSTRUCTION OF THE INTESTINES. be wrapped tiglitly, an inch and a half from its extremity, witli a narrow roller bandage, thus forming a shoulder which can be pressed against the anus, preventing a premature discharge of the injected liquid. Tiie receiving bag should not be elevated more than three feet alcove the level of the patient. This gives a pres- sure of, approximately, one and a half pounds to the square inch, and is, in all probability, sufficient to overcome the resistance of the ilcocsecal valve, if steadily and continuously applied. By either gas or liquid injection the colon, if permeable, can be distinctly and unmistakably outlined, and by slightly increasing the pressure (three pounds) the ileocsecal valve may be made to yield, if healthy. If the colon is not permeable throughout its whole extent, the point where the injection is arrested is at once demon- strated. The quantity of liquid required to fill the extent of the colon permeable from below is also of diagnostic significance, since, if it be but an ounce or two, the obstruction must be low down, while if many ounces are received, this indicates a seat much nearer the ileocsecal valve. The character of the vomit would probably suggest the location of atresia at or near the pyloric valve. In addition to this, where the atresia is located in this region, the tympany is mainly confined to the epigastric region, the lower part of the bowel by contrast appearing to recede. The passage of the injection through the ileocsecal valve for the further localization of the seat of obstruction is not to be recom- mended in this relation, since the information to be derived from it is of little value, and it is a method which might produce serious results upon the delicate intestinal walls of children. Prognosis. — If the case is not treated surgically, the prognosis is absolutely unfavorable. That there is a possibility of nature effecting a cure, under certaiu circumstances, is shown by the remarkable case reported by Theremin,' which, though finally per- ishing, lived for six months. At the autopsy the upper part of the duodenum terminated in a blind pouch, the inner surface of which was so deeply invaded by an ulcer that a minute opening was 1 Dent. Zeit. f. Cliirur., viii. 3, 34. CONGENITAL MALFORMATIONS. 23 formed into a cul-de-sao of the ileum. Practically, death is certain, and usually occurs on the third day, though it may be postponed till the fifteenth or twentieth day. With a mortality of a hundred per cent., for expectant treatment there should be no hesitation in resorting to the knife, but even here prospects are gloomy, and the prognosis must be distinctly unfavorable. Of 49 cases, in 14 (28 per cent.) there was more than one point of obliteration. Of 37 more elaborately reported cases, malformation was so great in 4 that no operation could possibly avail. In 10 enterotomy and the establishment of an artificial anus would have been indicated ; in 20, as far as the anatomical relations were concerned, a lateral approximation might have been practised. Putting aside, for the moment, the risk attendant upon laparo- tomy as pei'formed upon such young children, the operation will, from these figures, be inevitably unsuccessful in 10 per cent, of cases, and can accomplish nothing more satisfactory than an arti- ficial anus in 21 per cent. Treatment.— Having located the seat of obstruction in the anus, the rectum, some portion of the colon, or, these parts being normal, somewhere in the continuity of the small intestines, the question of treatment arises. This should invariably be operative. Where the anus is com- pletely occluded or is imperforate the condition of the rectum, or even its presence, cannot be positively ascertained, though a bulg- ing in the ischio-rectal region, observed during straining or crying, would denote a eul-de-sac of bowel not far from the surface. It is universally agreed that in these cases, unless the cause of obstruc- tion be simply a membrane or a thin wall of tissue, a careful search should be made for the gut, carrying the incision into and through the anatomical region in which the bowel should lie. The obliquity of the pelvis in children must be borne in mind by the operator, and since it exhibits, compared to the size of the child, very small measurements, from the top of the coccyx to the pubic symphysis but little more than an inch, Verneuil has proposed resection of the coccyx in these cases as a means of giving room in 24 "WOUXDS AND OBSTRUCTION OF THE INTESTINES. the directiou in which the search should be carried, i. e., backward and upward. If the rectum is found, it should be brought down to the skin wound and stitched in place. Allingham distinctly advises against the latter procedure on the ground that it prolongs the operation, that the stitches cut out, as a rare exception only, effecting the object for which they are placed, and that the formation of abscesses is more common; but it not only has received the coucur- rence of Amussat, of Verneuil, and of the profession at large, but is more in the line of modern antiseptic work, seems rational, and has to its credit many brilliant successes. If the rectum cannot be found by this incision, followed by cai'e- ful dissection upwards and backwards to the depth of an inch, or an inch and a half, the cut for left inguinal colotomy should be made. If the finger, passed into the peritoneal cavity, shows that the perineal incision can be safely deepened, with a condition of the rectum which will allow of its being drawn through the opening, the operation first undertaken should be completed, and the peri- toneal incision should be closed. If, however, the conditions are such that an attempt to form a new rectum and anus is inadmissible, as, for instance, where there is complete absence of rectum and atresia of the sigmoid flexure, then left inguinal colotomy should be performed. The gut should be held in place, after suture of the skin to the parietal peritoneum, by a piece of rubber catheter passed across the wound and through the mesentery close to the bowel, or by a harelip pin, as described by Kelsey, used in a similar way, except that it transfixes each edge of the parietal wound. Stitches should, of course, be added. Before securing the bowel in this way a digital examination should be made in the region of the ileocsecal value and the duodenum, since these are the commonest seats of congenital malformation. Many cases have been illustrative of the danger of depending upon left or even right inguinal colotomy without making further exploration of the abdominal contents. Depault' formed, by means of colotomy, an artificial anus in the case of a child suffering, im- mediately after birth, from obstructive symptoms. After death the ileum was found to end as a cul-dc-sac a very short distance from the ileocsecal valve. Laborde^ performed a similar operation, but 1 Gaz. de Hopit., 1856. 2 Gaz. de. Par., 1861. CONGENITAL MALFORMATIONS. 25 found at the autopsy a complete ocelusion of tlie jejunum nine and one-half inches from the pylorus, together with five other atresiie \ of the small intestines. \ If the obstruction is found to depend upon an atresia of neither anus nor rectum, the surgeon should advise an exploratory abdomi- nal section in the hope of finding the seat of trouble and remedying it by colotomy, enterotomy, or lateral anastomosis. Now that an exploratory abdominal section can be safely per- formed, it would seem rational in cases of imperforate anus, or rectum, or both, where there was no succussion or bulging to be detected in the ischio-rectal region during crying or straining efforts of the child, to at once enter the peritoneal cavity by an incision as for colotomy, and examine the condition of the sigmoid flexure and rectum. If the operation from below Avere then practicable, it could be rapidly and safely performed, the operator being guided by the knowledge obtained by his exploratory incision, and by the finger passed from above to the seat of operation. If colotomy were indi- cated, it could be performed at once. This would save the pro- longed and trying dissection necessitated by ignorance as to the seat and condition of the rectum or sigmoid flexure. The treatment of this condition by trocar and canula, with sub- sequent dilatation, has little to recommend it beyond the ease of its application. It is not devoid of danger. In at least one instance the iliac vein was wounded, and even if no viscera are injured, the outlet thus provided is insufficient. Though the mortality of abdominal section in children is high the operation is not, as is the disease it is intended to combat, abso- lutely fatal. In case of invagination the snrgeon has far more right to hesitate, since here there is a fair percentage of spontaneous cures or assisted cures Avithout operation. In congenital occlusion from malforma- tion, however, there should be no alternative. Nor is the statement that children are easily and profoundly shocked by operative procedures entirely true. Chilling and loss of blood they stand not at all, but any one wdth wide experience in the treatment of their diseases is frequently astonished at the rapidity with which they react from tedious and severe suro-ical operations, provided there has not been much hemorrhage, they 26 WOUNDS AND OBSTRUCTION OF THE INTESTINES. liavc n(*t been ehilled, and tliat the aneesthetic has been carefully administered. Griven then a case of congenital occlusion, which may be located in any pottion of the small or large intestines, the abdomen must be opened, and the sooner this is done the greater are the chances of success. There should be no waiting after the diagnosis is clearly established. If the constriction is in the colon and its seat has been recognized by the gas or water test, an incision in this region is indicated, since, should the obliterated portion of the bowel be of limited extent it could be carried out of the wound, in the method described for left inguinal colotomy, with a prospect of subsequently closing the arti- ficial anus thus created by a plastic operation. Or, should the con- dition of the child make a somewhat more prolonged procedure justifiable, the continuity of the colon could be restored by a colo- stomy. The incision for exploration, where the seat of obstruction is not known, should be in the middle line of the belly, either just above or just below the umbilicus. Bearing in mind that the duodenum and the ileo-csecal valve are the regions commonly affected, it is here that search should be made. If the cause of trouble is found at the duodenum, gastro- or duodeno- jejunostomy will be indicated ; if at the ileo-csecal valve the condi- tion of the patient must determine the choice between ileo-colostomy and enterostomy. If, however, there are multiple seats of atresia, if a large portion of the intestinal canal is atrophied or absent, all operative treatment must be abandoned. Chloroform should be used as an ansesthetic in these cases, because it is not followed by the vomiting which characterizes ether. The abdominal parietes and the exposed viscera should be kept warm by means of light, thin-ribbed, rubber hot- water bags at 110° F., and hot flannel cloths. Every endeavor should be made to hasten the operation. There is reason to believe that, should this method of treatment be adopted, some cases at least can be saved. A high percentage of cures cannot be hoped for, but each successful case is a triumph to surgical skill. "When no operation is undertaken, the withdrawal of all nourish- ment by the moutli, the administration of digested nutrient enemata by the bowel, and the subcutaneous injection of weak solutions of alcohol (10 per cent.) should be advised. CONGENITAL MALFORMATIONS. 27 SUMMARY. 1. The congenital malformations which cause intestinal obstruc- tion are mainly due to prenatal inflammation, and may involve any portion of the intestinal canal, 2. Excepting atresia or imperforation of the anus dnd rectum, the common seats of this malformation are at or near the ileocsecal valve; in the duodenum, or at the juncture of the duodenum with the jejunum ; in the sigmoid flexure of the colon. 3. In 28 per cent, of these cases the malformation is multi]:)le, and in over 10 per cent, is of such a nature (atrophy, extensive obstruction) that it is mechanically irremediable. 4. The symptoms are those common to obstruction (absolute con- stipation, fecal vomiting, pain, and tympany). If the trouble is in the colon, its seat can be located by gas or water injections ; if near the pyloric valve, by the peculiar epigastric distention and the character of the vomit. The prognosis is absolutely bad, death usually taking place on the third day, though life may be prolonged for Aveeks. 5. The treatment is surgical. For imperforate anus, the coccyx may be excised, and the bowel sought for by cutting upward and backward. If this fails, or as a first resort where there is absence of bulging in the anal region when the child cries, the incision, as for left inguinal colotomy, should be made with digital exploration of the regions commonly malformed. If the conditions justify it, an attempt to form a new anus and rectum in the normal position, of these structures should be made, the finger from above being used as a guide. Finally, if this is not possible, and no other seat of narrowing has been found, the surgeon should resort to left inguinal colotomy. 6. Where the seat of obstruction is unknown, exploratory abdominal section is indicated, followed by either gastro-enteros- tomy, entero-enterostomy, entero-colostomy, enterostomy, or colos- tomy, as indicated by the special lesion and the condition of the patient. With chloroform as an anaesthetic, attention to the preser- vation of the body heat, and rapidity of manipulation in complet- ing the operation, fair results may be expected. CHAPTER II. INTUSSUSCEPTION. By intussusoeption is meant the invagination or turning of one portion of the gut within the lumen of another part immediately adjoining. The invagination is made up of three layers of bowel. The intussusceptum is composed of the entering and returning layers, while the receiving layer constitutes the sheath or intussus- cipiens. The ring formed by the entering layer as it "is turned sharply upon itself to form the returning layer is called the apex. By the neck is meant the ring which results from the flexure formed by the returning layer as it merges into the sheath. Classification. — Intussusception is usually considered under the two general heads, acute and chronic. Bafinesque, for pur- poses of clinical study, has still further elaborated this classifica- tion into — 1. Ultra acute, death taking place within the first twenty-four hours. 2. Acute. The case terminating l^etween the first and seventh day. 3. Subacute. Lasting one month and upward. The invagination, if named from its seat, is termed — (a) Enteric, involving the small intestines only. (b) Ileocecal, in which the ileum and csecum, together with the ileocsecal valve, are turned into the colon. (c) Ileocolic. In this the ileum is prolapsed through the ileo- C£ecal valve, the latter retaining its proper position till, as a result of secondary changes, it, together with the cjecum, is more or less displaced. (d) Colic. The invagination involves the colon only. (e) Rectal. Here the seat qf trouble is situated entirely within the rectum. INTUSSUSCEPTION. 20 Usually the upper segment of the gut is received into the lower ; where the reverse condition obtains it is called retrograde intussus- ception, Kokitansky,* Harrison, Ulnier and others have reported cases. This was observed in 1,5 per cent, of Leichtenstern's 593 cases, and occurred in both the small and large intestines. As a secondary effect of a descending invagination there may be formed a retrograde intussuscei^tion which, involving the sheath of the former, surrounds the intussusception with five layers of gut. Spry^ and Stainet^ state that this' is due to a loose intussuscii)iens which becomes folded upon itself, Leichtenstern states that this is observed only in the colon. Double and triple intussusceptions have been occasionally noted. In these cases the intussusception plays the part of a foreign body, thus producing reduplications of its encircling sheaths. It must be remembered that these invaginations are double and triple only in a very limited portion of their length. Causes of Intussusception. — The cause of chief importance is irregularity in the nervous mechanism of the intestines, which allows of a sudden spasmodic contraction of a portion of the bowel, while its adjoining continuation may be entirely relaxed. This would seem to account for the intussusceptions so often observed upon the autopsy table, and which, there is every reason to believe, developed either during or immediately after the death struggle. These invaginations are frequently multiple and very limited in extent, and exhibit none of the effects of venous congestion, obstruc- tion, or inflammation. The facts that obstructive invagination occurs in children, is associated with colic, is observed after abdom- inal injuries, and sometimes follows typhoid fever or enteritis, would all strongly suggest, as a probable causative factor, disordered inner- vation. Nothnagle^ has elaborately studied this question from an experi- mental standpoint. By means of the faradic current he vigorously stimulated a small portion of the bowel. At the point of stimula- tion the bowel became so firmly contracted as to lose its natural color, this contraction was continued upward for some distance, and 1 Praktisclie Heilk,, 1S73-4, 2 Lond. Med. Journ., vol. iii, s Bull, de la Soc. Anat. de Far., 1850, p. 314. * Beitrage zur Physiologie niid Pathol, des Darm., p. 42. Berlin, 1884. 30 WOUNDS AND OBSTRUCTION OF THE INTESTINES. not infrequently slight temporary retrograde intussusception was observed, from the relaxed portion of the bowel, which was not influenced by the electric current, slipping down somewhat over the upper portion of the seat of contraction. From immediately below the seat of firm contraction the bowel was observed to ascend in the form of a sheath, thus producing a descending invagination M^hich progressively increased till the stimulation was removed, when nervous control being regained, the intussusception under- went spontaneous resolution. Nothnagle further asserts that stim- ulation of the bowel above the intussusception is without effect, but if the electric current, or any sufficient stimulus be applied below this point, the parts are promptly restored to their normal position by the ascending contraction. We have made repeated experiments on dogs to confirm I^oth- nagle's conclusions, but our results varied greatly from those he has published. We readily produced the firm ring-like contraction of the bowel segment to which the current was applied, but observed no attempt at invagination. To a Dubois-Reymond coil connected with two cells, and drawn out to twenty on the scale, were attached the electrodes. The segment of bowel stimulated was not upwards of a quarter of an inch in length. The current was used in all strengths, but without other effect than a local spasm so violent as to make the area involved resemble cartilage both in appearance and to the touch. As other causes of invagination, secondary or exciting in their nature, may be mentioned, ingesta (28 cases in 593), polypi (5 per cent, of Leichteustern's cases were dependent upon this cause), inflammatory affections of the bowels, traumatism (263 cases out of 593), and exposure to cold. Pathological changes. — Cruveilhier and Gorham have observed that there is strong reason for believing that in many cases of severe colic, especially when dependent upon imprudent diet, slight tem- porary invagination is of frequent occurrence. This form probably resembles that called by the Germans agonie invagination, and found so frequently upon the autopsy table. In the marked cases of invagination, profound pathological changes take place. As the intussusception increases at the expense of the intussuscipiens the mesentery is subject to constantly in- INTUSSUSCEPTION. 31 creased tension ; as a result of this, the whole of the involved gut and particularly the intussusceptum assumes a sickly-shapfjd curve, with its concavity toward the mesentery. The opening of the in- tussusceptum becomes simply a slit and is turned inward away from the lumen of the bowel. This incurvation involves the colon only slightly, and the rectum not at all ; when marked it is undoubtedly a factor in producing obstruction, with its attendant symptoms. That invagination, in itself, does not entirely occlude the lumen of the bowel is shown by the record of cases where life has been prolonged for weeks and months. The other causes operative in producing obstruction are; the lodgment of undigested food, of hardened fseces, or of a foreign body, and swelling of the involved area from venous congestion and inflannnation dependent upon the constriction at the neck of the sac. There is usually an extrava- sation of blood into both the mucous membrane and the mesentery ; inflammation is set up and the serous surfaces of the entering and returning layers become adherent to each other. Treves states that in acute cases these adhesions are more frequently absent than present. If they exist and are extensive, the best that nature can do is to strengthen the growth between the neck and upper portion of the intussusceptum, and discharge the lower portion of the latter by the process of ulceration. The sloughing of a portion of the intussusceptum is an exceed- ingly common termination of this form of intestinal obstruction. It is sometimes discharged as a tube, but more commonly in the form of irregular fragments. The extent of bowel discharged is at times extraordinary. Dampier* records a sloughing bowel seg- ment measuring 124 cm. and Bottcher,^ 112 cm. with a polyp as the causative agent. The discharge of the gangrenous bowel may be the first sign of a rapid convalescence ; if, however, the mortifi- cation has extended in the direction of the neck, perforation can be expected, with a resultant peritonitis w^hich is most frequently diffuse. This latter complication may arise without perforation, by extension from the inflamed and strangulated bowel, acute inflam- mation or sloughing of the mucous membrane so affecting the ^ Med. Trans., vol. iv. 2 Lobstein, Anat. Path., t. 1, p. 146. 32 WOUNDS AND OBSTRUCTION OF THE INTESTINES. remaining coats of the bowel that tliey are readily permeable to septic matter. Again, cases of intnssusception are recorded in which the condi- tion has lasted for ^^eeks and months without either producing obstructive symptoms during life or showing adhesions or marked congestion and inflammatory lesions after death. Frequency of occurrence. — In a total of 1652 cases of intestinal obstruction, hernia excluded, collected by Leichtenstern and Bryant, 657, or approximately 40 per cent., were due to intussusception. In regard to the age at '\^llich it develops all authors are agreed that it is most frequent in the first year of life. Of Leichtenstcru's 593 cases, 131 occurred before the age of twelve months and the great majority of these in the fourth, fifth, and sixth months. The statistics of Smith,^ Hansen,^ and Pitts^ absolutely confirm this. After the fifth year intussusception becomes comparatively rare till the fortieth or fiftieth year, when it again increases in frequency of occurrence. The ileocsecal region is the favorite seat of invagination at all ages. This is especially marked in the first year of life, when this form of invagination is more common than the combined sum of all the others ; the ileum invagination being exceedingly rare. If the invagination is in the ileum, the lower segment of this por- tion of the bowel is its common position ; if in the colon, it will generally be found at the sigmoid flexure. Symptoms. — Depending mainly upon the amount of constriction . at the neck of the intussusceptum, consequently upon the amount of congestive swelling and bowel obstruction, the intussusception is classed as either acute or chronic, and the symptoms of each form are to a certain extent diiferent. Also the symptomatology of in- tussusception in the infant is not identical with that of the adult or old man. In general it may be stated that the first symptom of acute intussusception is — Pain. — Sudden, violent, diffuse ; or, if localized, usually placed in the ileocsecal or umbilical region. After a few hours, in chil- dren, a much longer interval in the adult, the pain ceases, often as 1 Amer. Journ. Med. Sci., 1S62. 2 Dissertat. Iii-aug. Dorpat., 1864. 3 Jalirbuch fur Kinderlieil, 1870, Bd. 3. INTTTSSUSCEPTION. 33 suddenly as it eommcnccd, and there is an intci*val in which there is little to suggest that the pathological condition still continues. This is folloAved by a return of tlie pain, the paroxysms becoming more violent and prolonged, the intervals less marked as the disease progresses, or in the adult if it passes into the chronic form, intervals of even days may elapse between the paroxysms. Tlie pain is fre- quently accompanied by tenderness, but this is an exceedingly variabl'e symptom, and at times pressure seems to relieve the pain. Vomiting. — This is practically a constant symptom, occurring with the sudden pain, or, at times, even preceding it. In children it continues till shortly before death and is rarely feculent. In the adult and in the chronic form, there may be complete absence of vomiting, though this is certainly exceedingly rare. Leichtenstern takes exception to the statement that the seat of ob- struction is indicated by the period at which vomiting is developed. The ileum-invagination is most frequently accompanied by early vomiting, not because of its seat, which is usually but little re- moved from the ileocsecal valve, but because it is commonly ob- structive. The vomiting, both in time of development and in nature, will depend, not upon the seat of trouble, but upon the presence or absence of obstruction, and may be early, if the ob- struction is absolute in the sigmoid flexure, and feculent if the bowel is occluded in the upper part of the ileum. Blood-stained mucous evacuations. — This symptom is, in chil- dren, rarely wanting. Of 108 cases of invagination in the first year of life this symptom was absent in but four. It occurs within a few hours of the first attack. At first the discharge is of blood- stained feces ; later, if obstruction is developed, of blood and mucus, and is usually exceedingly oifensive. In children, diar- rhoea is common throughout the whole course of the case. At times, following complete constipation and feculent vomiting, there will suddenly appear copious evacuations from the bowel, mingled with blood, and in which may be found evidences of the necrosed intussusceptum. Where this slough is extensive it may be lodged in a lower portion of the bowel and cause fatal obstruction. Tenesmus. — In connection with the muco-sanguinolent evacua- tions the tenesmus or straining is a symptom so common that it is of some diagnostic import. That it is not dependent upon the character of the evacuation is shown by the fact that it is present 3 34 WOUNDS AND OBSTRUCTION OF THE INTESTINES. in cases of comjilctc obstruction. Brinton has shown tliat this symptom is seldom developed except in the ileocseeal and colon invaginations. A much rarer condition, and one which Leichtenstern ascribes to the secondary eflt'ect of intense tenesmus, is a j^^^'t^^fous condition of the anus due to paralysis, and dependent upon invagination of the descending colon and rectum. This is never produced by invagi- nation of the ileum. Tumor. — Leichtenstern' s statistics show that a tumor can be felt, either through the parietes or by rectal examination in 52 per cent, of all cases. In the first year of life this most important diagnos- tic sign was present in 63 per cent. The tumor is usually felt in the left iliac region, or by the finger passed into the anus. The ileocsecal invagination is most frequently accompanied by demon- strable tumor ; the ileum invagination exhibits this symptom with less frequency. Many authors have noted that the tumor varies in size and con- sistency from time to time, now, during an acute paroxysm of pain, being hard, knotty, and plainly perceptible shortly afterward eluding the most careful search. Duchaussoy has described two distinct movements which can often be perceived in the tumor, namely, the erectile and the vermicular motion. Distention of the abdomen is not of great significance, because so often absent. In children especially it may appear not at all, or just before death. In adults, where obstruction is more common, it may become as well marked as in obstruction from any other cause. Dance' calls attention to an inequality in the shape of the abdo- men dependent upon the meteorism, and in view of which he states that the seat of obstruction can often be inferred. But few authors, however, have been able to profit by his observation. In the chronic form of invagination the symptoms are less vio- lent in onset; there may be nothing more characteristic of the attack than recurring paroxysms of pain, meteorism, and obstruc- tion ; with symptoms of intestinal stricture constantly manifesting themselves. These cases terminate either in cure by reduction or by extrusion of a slough, or perish from exhaustion, inanition, or 1 Rept. gen. d'anat. et de pby. Path. bd. i. 1826, p. 206. INTUSSUSCEmON. 35 in the course of an acute attack. In over one-half the recorded cases a correct diagnosis was not made. Prognosis. — Leichtenstern places the general mortality of intus- susception as treated by the expectant method at 73 per cent. Pilz, Hansen, and Duchaussoy arrive at a similar conclusion. Our own statistics show even a higher rate of mortality (90 per cent.). In the first year of life this mortality is much higher, mounting to 88 per cent., and death commonly occurs between the fourth and sev- enth day. Between the eleventh aud fiftieth years the fatality is less (63 per cent.), and the duration of the disease is, when fatal, between eleven and fourteen days. In late life the mortality rate rises again. The sloughing and discharge of the intussusceptum must be regarded as a decidedly favorable circumstance, since of 408 chil- dren in whom the sloughing did not take place 345 (i. e. 85 per cent.) died, while of 149 children who passed the sphacelated por- tion of gut, 61 (41 per cent.) recovered. This discharge of bowel occurs very rarely in early infancy ; it is most common wdieu the ileum is involved in the intussusception, and is most favorable when it is observed in middle life. It usually occurs between the eleventh and twenty-first day of the attack. It must not be considered that after discharge of a sphace- lated bowel the danger is passed, since 41 per cent, of these cases perish at any time between a few hours and two years following the acute attack. In case there is no sloughing of bowel, the colic and ileocecal invaginations give a better probability of life than do those of the ileum. The cause of death is usually, in children, exhaustion and ina- nition. General or perforative peritonitis is exceedingly uncommon. In the adult, perforation and resultant peritonitis are of frequent occurrence. Diagnosis. — The diagnosis of intussusception is made upon the acute onset of colicky pain, and its intermittent character; passages from the bowels containing blood and mucus ; the presence of a tumor, commonly in the left iliac region, or felt through the anus; varying in size and consistency from time to time, with an erectile 3G WOUNDS AND OBSTRUCTION OF THE INTESTINES. or vermiform motion and the ordinary obstruction symptoms. The diagnosis is further confirmed if there are violent peristalsis and tenesmus, and if these symptoms occur in an infant. Treatment. — The diagnosis having been assured, the treatment will be either medical or surgical. And even in those hyper-acute cases, where death takes place in a few hours, apparently from shock, the first resort should be to those non-operative means to be shortly described, and which have many times proved successful. The pathology of the disease teaches us that disin vagi nation becomes more difficult in direct proportion to the length of time which has elapsed since the onset of symptoms ; hence every hour diminishes the chances of success. AVhatever the age of the patient or the seat of the trouble, provided the case is not of such long- standing that tight adhesions have probably made reduction impos- sible, or strangulation has produced a partial necrosis, ether should be administered to its full surgical extent, producing complete relaxation of the muscular system ; by means of a fountain syringe hot (105° to 108°) .7 per cent, saline solution should be slowly (4 ounces to the minute) forced into the rectum under a pressure of not over two pounds to the inch (elevation of the irrigating bag 4 ft.), the liquid being retained by a shoulder upon the injection pipe, readily made by wrapping it with a narrow bandage ; the abdomen should be thoroughly kneaded, the manipulations being so planned as to encourage disinvagination. This treatment should continue for thirty to forty minutes, the pressure being gradually increased by raising the bag till a pressure of not over eight pounds is produced, and may, if the tumor does not disappeai', be combined with inversion and shaking. This trial at forced reduction must be thorough and final ; there should be no idea that it is to be repeated with more care and at- tention to detail. If it fails, the surgeon must proceed to an abdominal section for the purpose of accomplishing disinvagination. If there is a distinct tumor, the probable success of the method above detailed will be denoted by its disappearance, the positive failure by the tumor occupying the same position as before treat- ment and retaining its full size ; in this latter case the surgeon may proceed to operate at once without letting the patient recover from the anaesthetic. Where there is anv doubt as to the effect of the INTUSSUSCEPTION. 37 treatment, however, and this will be in the majority of cases, the patient mnst be allowed to come out of his condition of anesthesia, when the progress of symptoms will quickly decide as to whether a cure has or has not been effected. It is true that the statistics of abdominal section for invagina- tion appear to be exceedingly bad, Ashhurst' giving the mortality percentage in 65 cases at 75.4 per cent. There can be but little doubt that the percentage is in reality even higher than this, since the natural tendency is to report favorable cases. Individual ex- perience will corroborate this, since every surgeon can recall unsuccessful and unreported cases of which he has personal knoMd- edge while the few successful cases have all been put on record. Heretofore abdominal section has been considered as a last resort to be attempted after days spent in repeated and ineflPectual efforts at reduction by small enemata, by air or gas insufflation, by in- version and shaking, by, at times, full doses of purgatives, or pounds of metallic mercury ; when the patient's strength was far spent, and inevitable and immediate death was staring him in the face. Under these circumstances it is obviously unfair to compare the statistics of operative cases with those treated expectantly, yet the mortality against the surgeon is but little higher (less than 2 per cent.). Given an equal number of cases treated on the one hand expectantly, on the other hand by immediate operation, it would be hard to find an abdominal surgeon who doubts but that his per- centage of success would justify his methods. Considering the class of cases in which section has been employed, any percentage of success would be encouraging; if resorted to when all condi- tions are favorable, that is, immediately after one thorough effort to accomplish reduction without operation, we believe that the per- centage of recovery will be so high that even the most conservative will be disposed to recommend it. While it is granted that there are certain cases in which disin- vagination cannot be effected, and in which nature frequently ac- complisiies a spontaneous cure by sloughing, it must be remembered that this form of cure is very rare in young children, and that over 40 per cent, of cases thus terminating subsequently perish from 1 Intei'iiat. Encyc. of Surg., vol. vi., p. 69. 38 WOUNDS AND OBSTRUCTION OF THE INTESTINES. the direct effects of the invarovision slioidd be made for re- l)eatcd irrigation with hot (100-110° F.) sterilized salt .solution (sevea-tenths of one per cent.), several tubes being carried to the various parts of the al)dominal cavity, and the latter l)eing flushed out ever}: hour until the formation of adhesions prevents this. Nothing should be given by the mouth except intestinal anti- sejjtics such as naphthol, salol, or salicylic acid. As stimulants are most important they should be given freely, either by the rectum or, better, by means of hypodermic medica- tion, thus saving this portion of the bowel for the absorption of peptonoids and other nutrient enemata. For this purpose an ounce of brandy may be dissolved in eight ounces of sterile water and slowly injected by means of gravity into the subcutaneous or mus- cular tissues of the buttocks, abdominal walls, or other thick, fleshy region. For sudden prostration, hypodermics of ether, twenty minims pure, forced directly into the muscles, and re- peated six or eight times at short intervals, will be found most efiicacious. Progressive Suppurative Peritonitis. — The advice of Treves in the treatment of this condition, as developed by in- flammation about the caecum, that is to open and evacuate the purulent collections without breaking through the wall which separates them from the rest of the abdominal cavity, should dominate the surgeon in the treatment of this form of peritonitis, no matter what its origin or seat may be ; and it is to the neglect of this practice that many deaths must be ascribed. Mikulicz operated upon five cases of this character. On two of these cases he operated several times, opening each new accumulation of pus as it was discovered. The cavities were washed out ^vith salt solu- tion ; even if the gut was perforated, no attempt was made to suture it unless the wound was accessible ; drainage was provided for by iodoform gauze tamponade; a few sutures were placed in the parietal wound. The two cases thus treated recovered, while three treated in the usual manner perished. In these cases there is often no great urgency ; the course is one of weeks or even months. Suppuration is denoted by hectic or simply by night-sweats and by loss of flesh and strength. Sooner or later dulness on percussion, local pain or tenderness, and the PEEITONITIS. 75 signs of tumor, point to the seat of trouble. These cases, if gene- rally treated on the lines laid down by Mikulicz, are destined to present a far smaller mortality than heretofore. Intestino-peritoneal Septicaemia. — Although it is gene- rally stated that these cases are beyond hope and that, barring the medical treatment, nothing should be attempted, we are pro- foundly convinced that prompt abdominal section and washing out of the peritoneum, together with many incisions into the gut, and cleansing of it with mild antiseptic agents, will be of service. Thus will be removed the source of septic absorption, and even though a new supply be forthcoming the system will have had a respite in which to gather strength for the struggle against toxsemia. Stimu- lants forced to their extreme limits are indicated in these cases and are best given subcutaneously. Lavage of both stomach and colon should be employed. There remain many cases of peritonitis in which the knife can be productive of no good, cases without suppuration, and present- ing no evidences of bowel obstruction ; or possibly with symptoms of both these conditions, dependent upon intestinal paralysis. In all cases of peritonitis, except those which break out with virulent intensity, we believe that the first thought of the attendant should be a resort to medical treatment. Considering the disease from the standpoint of the therapeutist, an inflammation of the peritoneum, as in the case of any serous membrane, may be either sthenic or asthenic. The same rules hold, therefore, in this case as in all forms of inflammation, namely, that circulatory depressants are only to be used in the first type and followed, if needed, by stimulants ; whereas in the asthenic class the use of stimulants is called for at once and de- pressants are contra-indicated. For many years the profession has recognized opium and belladonna, particularly the former, as the most universally applicable remedies and best curative drugs for cases of peritoneal inflammation, and while a new school of treatment in this disease has arisen, it has only proved itself of value in certain cases. In so far as the treatment of the inflammation is concerned the course to be pursued is fairly plain. 76 WOUNDS AND OBSTRUCTION OF THE INTESTINES. AVhile the use of veratrum viride may be resorted to where the patient is strong and the pulse hard and ten.se, aconite may per- haps, in such cases, be better, for the double reason that vomiting is apt to occur of itself and may be induced by the veratrum viride, Avliile aconite decidedly prevents any such tendencies. This is im- portant in view of the fact that vomiting always is to be avoided, lest the retching increase the peritoneal inflammation. If vomiting and pain are present, they should be controlled by the use of full doses of opium and belladonna, say one-quarter of a grain of the extract of each to an adult, and the application of leeches to the abdominal wall in large number (from 10 to 30) or the use of counter-irritants. If the vomiting is too severe to take the drugs by the mouth, they must be given by the rectum in a half pint of starch-water, laudanum and the tincture of belladonna being employed in the proportion of half a drachm each, or the alkaloids may be given hypodermically. Opium is always well borne in full doses by those suffering se- vere pain, and it seems to be particularly well borne in peritonitis. The use of the drug here, as everywhere else in medicine, is not governed by the amount which has been used, but by the effects which it produces. Opium and belladonna, unlike the depressants and stimulants, may be used in all stages of peritonitis, if called for, but the leeches and counter-irritants are limited in their use to early periods of the attack. The use of calomel in peritonitis is highly praised by some and decried by others, largely because its proper sphere is not recog- nized. Mercury does good only in the severe acute forms of peri- tonitis where the disease arises from traumatism or other cause, and is not to be used except for the changing of a fibrinous exudate into one incapable of undergoing organization. Absolute rest and the administration of stimulants and food by the rectum till stomach becomes retentive must be enforced. Commonly in peritonitis the inflammation involves the muscular layer of tlie bowels. As a result of this obstinate constipation ensues, which is not always to be overcome by purges, which, if they are mild, will not act, and if severe are dangerous, but by the use of belladonna and opium already spoken of. The rationale of this treatment, in the light of our present physiological knowledge, is not far to seek. Belladonna acts as an antispas- PERITONITIS. 77 modic upon all unstripcd mnscular fibre, and in the large doses here given depresses the peri])heral ends of the splanchnic or inhibitory intestinal nerves. In this way the muscular fibres, which are in spasm, are relaxed and the peristaltic waves set free. The value of the opium also is apparent, for it allays and prevents the reflex muscular spasm and hence the pain and inflammation. Obstinate constipation after the ingestion of irritant foods, such as putrid meat, will often be relieved by opium and belladonna as effectively as if the patient was purged by an ordinary purgative. Very frequently in acute peritonitis tympanitis becomes not only a very painful, but even a dangerous symptom, the distention of the belly being very great. This may be greatly relieved by the employment of turpentine stupes, and in some cases by the rectal injection of the milk of asafoetida, or better still : turpentine, 1 drachm ; milk of asafoetida, 3 ounces ; and warm water, 4 ounces. Not content with having made a vast stride forward during the past few years, abdominal surgery brings with it not only new methods of treating disease in this region by the knife, but also has given us a method of healing peritonitis by the use of saline purgatives, which is certainly of greatest value in those sudden inflammatory conditions which occasionally spring into life after operations upon the abdominal contents. It will be remembered that Mr. Lawson Tait has been the chief advocate of this treatment for several years, and that the wonderful results which he obtained, the reputation of the reporter, and the complete reversal of all our ideas concerning the treatment of the disease, have called forth not only an enormous number of trials of the method in this country, but have also brought forth two opposing factions in the profession. The first of these is chiefly of surgeons; the second of persons who, in a long experience, have reached good results by older methods, and who are generally physicians. The first class dogmatically assert that the physician should turn over every case of peritonitis to the surgeon to be opened, searched, and purged ; the second class do not deny that saline purgatives do good in the hands of the surgeon, but are more conservative in their opinions concerning the general use of such, measured in all cases of peritonitis. Again, it would seem to be impossible at the present time to assert that peritonitis may be either idiopathic or traumatic with- out bringing upon one's head a storm of criticism, for on the one 78 WOUNDS AND OBSTRUCTION OF THE INTESTINES. side we have a number of pliysicians who believe that peritonitis may arise without any direct exciting cause, and on the other hand an equally large body of observers who assert that it is essentially a secondary inflammation brought about by direct contiguity with an already inflamed tissue ; or else that the inflammation is set up by the escape of foreign bodies into the peritoneal cavity, or by pathological changes in organs normally situated in these regions, as, for example, fibroid enlargements of the uterus with impaction in the pelvis, or pyosalpynx. As it is absolutely impossible for either side, at present, to prove that their opponents are wrong, and as both sides are not to be doubted in the integrity of their observations, the unbiased judge can but come to the conclusion that, as yet, we have a right to be- lieve that idiopathic peritonitis may exist. If those observers are correct who believe that no peritonitis arises save as the result of some one of these conditions, then the attempt on the part of the physician to treat such a case is crimi- nal negligence, and, as such, cannot be too severely condemned ; but too many cases of peritonitis are to-day walking examples of the value of the use of opium to permit of any one asserting that this treatment is useless, or that the knife of the surgeon is to be used in every case ; yet some of the more positive members of the profession would have us believe the abdomen should be opened solely for the purpose of making a diagnosis, and that this having been done and no intestinal complications found, salines should be given. Whether the inflammation be idiopathic or not has little to do, however, with the methods which we are to resort to in the medi- cal treatment of this condition. It cannot be gainsaid that the results obtained by surgeons in the use of saline purgatives have been startlingly brilliant, neither can any one deny that their methods may sometimes be employed in medicine as well as in surgery ; but there are several points to be recalled by both parties which, we think, so seriously modify the views of each as, after all, to somewhat harmonize their views. No one denies that the sur- geon does rightly when he uses salines to prevent peritonitis, after an operation, but the knowledge of the condition of the patient after he has been operated upon by the surgeon, and that possessed by the physician when called to see a case of peritonitis, are radi- cally different, for the surgeon has a right to believe that the PERITONITIS. 79 intestinal canal is patulous and dovoid of impactions and intussus- ceptions, while the latter knows not whether he lias before him an inflammation of the peritoneum without intestinal involvement, or inflammation dependent npon some abnormality in the primje v'lUi. As a consequence, it is perfectly proper for surgeons to administer salines which, to use their own words, not only deplete the abdom- inal bloodvessels, but also, by the increased peristaltic movements produced, prevent adhesions ; while the physician in the case of peritonitis from perforation, impaction, or intussusception, may do the patient an immense amount of harm by such a procedun; long before it is possible to decide what the cause of the trouble may be. It is evident, therefore, that the opium treatment must be ad- hered to, at least until the diagnosis is formed, unless at the first sign of pain an exploratory incision is made instead of using those remedies generally employed in ordinary attacks of abdominal dis- comfort ; and it should not be forgotten that pain and tenderness with inflammation are not only the symptoms of peritonitis after section, but also of many other states in the ordinary individual. It is also evident that other conditions may exist which render the administration of purges unjustifiable, and in which the use of the knife by the surgeon is not to be thought of. It is undeniable that the surgeon should be summoned the moment a suspicion of perfoi'ation arises, but in the case of a person in whom an enteritis has arisen, locally, by an old adhesion, increased peristaltic move- ment is equivalent to strapping the normal side of the chest in pleurisy, with the object of giving the diseased side more exercise. Again, it is of the gravest importance that both the physician and surgeon should distinguish very clearly between an inflamma- tion of the peritoneum in a strong healthy j)erson, and in one who is in a condition of vital depression, or exhausted from prolonged disease elsewhere. Depletion by means of purges is of course, in the first class, as much indicated as the application of leeches or bleeding, but in the second class, quite as strongly contraindicated. Ill the dynamic form of inflammation, there is danger of adhesions being formed by reason of the fibrinous exudate thrown out ; in the adynamic condition of inflammation there is already an enormous exudation of serum into the abdominal cavity, which purges cannot remove till they have drained oiF a large amount of liquid from the blood. 80 WOU^'DS AMD OBSTRUCTION OF THE INTESTINES. Again, there are some cases of peritonitis whicli are ushered in by an acute paroxysm of pain, but which do not continue during their whole course as dynamic cases, and in which depletion at first results in exhaustion later on. Until the profession have employed these two methods side by side, with an absolutely unbiased opinion for a long period of time, the only proper conclusion to be reached seems to us to be this, namely, that in acute peritonitis suddenly lighted up in a surgical case, and Mdiich is recognized almost at the moment of its inception by the surgeon, who is ever watchful for it, salines should be given ; in the case which the physician rarely sees till hours liave elapsed, and in which grave doubt must exist as to the cause of the trouble opium and external methods of depletion must be resorted to. CHAPTER IX. ON DIAGNOSING THE VARIOUS FORMS OF INTESTINAL OBSTRUCTION. Each of the comniou forms of intestinal obstruction has been considered individually, with the general appropriate treatment. It is now in order to discuss the differential diagnosis between the various forms of obstruction, and to treat in more minute detail the various therapeutic means which have been proposed in the treat- ment of this class of affections. In general, the symptoms caused by occlusion of the intestinal canal are the same : pain, ch'stention, obstinate constipation and vomiting, and systemic depression. Each form of obstruction pre- sents certain peculiarities, but these are unfortunately not constant. Hutchinson* states that an accurate diagnosis of the cause of ob- struction is not in four out of five cases possible. Obalinski^ says that a diagnosis cannot be made in more than half the cases. Depres,^ however, holds that the diagnosis of the cause can be made when the symptoms are well developed in 99 per cent, of all cases. With this statement there are few practical surgeons who will agree. $ At the very beginning of the question comes the difficult ques- tion of distinguishing between eases of obstruction due to mechan- ical occlusion of the bowel and those due to paralysis. Where the paralysis is the result of a frank peritonitis, the pain, tenderness, decubitus, characteristic vomiting, tympany, and absence of peris- talsis, with high temperature and rapid, wiry pulse, will at once suggest the diagnosis. Where it is attended with the minimum amount of inflammation, however, or where the septic symptoms predominate, it may be impossible to decide as to the nature of the case. Heusner^ reports two cases in which laparotomy for obstruc- 1 Archives of Snrg., Vol. 1, No. 1, p. 10. 2 VI. Langenbeck Arch. f. Chirur., xxxviii., 2. 3 Rev. de Chir., 1887. < Deut. Med. Woch., 1SS7. 6 82 AVOUNDS AXD OBSTRUCTION OF THE INTESTINES. tion was performed, the operation sliowing that the symptoms were ilependcnt upon a perforative ])aralysis. We liave an unreported case where the abdomen was opened for internal strangulation Avheu a paretic condition of the bowel dependent upon enteritis was present. Many instances of failure to determine between these two conditions can be cited, and it is well known that the men of greatest experience express least confidence in making a differential diagnosis. The history of the case is always important. A previous attack of inflammation would suggest bauds or adhesions. A record of typhoid, or other ulceration of the bowel, would suggest stricture ; a history of anomalies in the family would suggest a Meckle's diverticulum. An account of abdominal traumatism would suggest hernia through rents in the mesentery or omentum ; a history of stubborn constipation would suggest volvulus, impaction of feces, adhesion, or stricture. Age and sex must be considered — infants are prone to intussus- ception, young adults to internal strangulation, adult females' to fecal impactions. Males at about middle age or somewhat past it, to volvulus, this condition being exceedingly rare before the twenty- fifth year. Onset.— This will serve to distinguish the acute from the chronic forms of obstruction. If it occurs suddenly in a j^erson of good health, not presenting previous bowel symptoms, and especially if dependent upon some sudden or violent muscular exertion, the chances are greatly in favor of internal strangulation being the causative condition. Frequently, however, a violent outbreak with fulminant symptoms is found to depend upon a chronic form of obstruction. Pain and shock. — These symptoms are usually best marked in cases of internal strangulation. They both, however, depend in the beginning upon the amount of constriction to which the bowel is subject, and they may be, exceptionally, well marked from the first in volvulus or invagination. The seat of pain should be care- fully considered, since, if it is correctly referred to the position of the obstruction, and this is occasionally the case, it may be a valu- able diagnostic guide. 1 Treves, London Lancet, 1887. DIAGNOSING VARIOUS FORMS OF INTESTINAL OBSTRUCTION. 83 Temperature. — This makes no great departure from normal till peritonitis sets in, when it may be moderately elevated. In disten- tion with septic absorption a subnormal temperature is frequently noted. Pulse. — In acute obstruction the pulse is quickly and profoundly affected. It becomes exceedingly rapid and weak, thus markedly contrasting with the normal or subnormal temperature. Of all single symptoms this is the one which is most constant and most significant as to the vital condition of the patient. As a means of differential diagnosis it is of no value. Meteorism and abdominal configuration. — If the patient is seen early, the meteorism may suggest the seat, if not the nature, of the obstruction. With a stojipage at the sigmoid flexure, first the colon, then ultimately the small intestines become distended, giving the belly a quadrilateral shape. When the small intestines are involved there is primarily a bullet-shaped enlargement of the central part of the belly, with flatness in the region of the colon. The amount of distention is dependent upon the absoluteness of the obstruction, the presence or absence of vigorous peristalsis, and the amount of fermentable matter in the bowel. So long as the muscular walls of the gut retain vigorous contracting power, there is constant re- gurgitation of liquids and gases into the stomach, whence they are quickly vomited. When paralysis allows wade dilatation and con- sequent kinking, the contents of the gut cannot escape, and meteor- ism reaches its extreme limit. An irregularity in the abdominal distention is of diagnostic value ; in both volvulus and strangulation the constricted loop is the first to become inflated ; this loop, if of any length, Avill pro- duce a local tumefaction preceding the general swelling. Invagi- nation usually gives but little meteorism. In general, the distention is proportionate to the suddenness and acuteness of the process. Peristalsis. — This, in peritonitis and paralysis of the bowel from other causes, is absent. In mechanical obstruction it is violent and long continued, and can be perceived by palpation and auscultation. Urine. — Though much has been written upon this subject, there is little here to guide us. In amount, it probably depends upon the frequency of vomiting. In strangulation it has often been observed to contain albumin, while in pure obstruction iudican in large quantities is always found. We have made a number of personal 84 WOUNDS AND OBSTRUCTION OF THE INTESTINES, observatious upon this test, but find indioan so frequently present in other pathok)gical conditions, or even Avhen tlie urine is in all respects normal, that the finding of it in any given case is without value. Vomiting. — In strangulation, vomiting comes on early and be- comes fecal rapidly. In other forms of obstruction the vomiting may be slight, or even wanting altogether. In peritonitis it is bilious and at times takes the form of an outpouring from the stomach with scarcely any eifort on the part of the patient, and with all the symptoms of a cholera-collapse. In both volvulus and invagination the vomiting is rarely fecal. Constipation. — Excepting invagination, there is constipation in all of the forms of obstruction. Volvulus sometimes gives one or two passages, and at times the onset of peritonitis is denoted by watery alvine evacuations. Tenesmus. — This is peculiarly characteristic of intussusception involving the descending colon and sigmoid flexure, thouo-h it has been noted in volvulus of this part of the gut. When combined with the discharge of blood and mucus it practically makes certain the diagnosis of intussusception. Palpation and i^ercussion will detect the tenderness of perito- nitis, the sausage-shaped erectile tumor of intussusception, the doughy masses of fecal impaction, the central tympany with peripheral dulness of exudative peritonitis, the hard induration of cancerous stricture, the localized tenderness and resistance of circumscribed jDcritonitis, and more rarely, the tender tympanitic swelling of strangulation or volvulus. An examination of the rectum should never be omitted, since invagination, occlusion by malignant growth, and impaction of feces or foreign body have many times been diagnosed by this means. Auscultation. — The loud borborygmi dependent upon the increased peristalsis of mechanical obstruction are readily heard ; at times they can be traced to the point of obstruction, where they are replaced, according to Auffret, by a peculiar click resembling that of the water-hammer. By using gentle palpation the friction sounds of a beginning peritonitis may occasionally be perceived. Injection. — Gas or water can be used and either will be of diag- nostic value in the early stages of obstruction. The colon, if per- vious, can by this means be clearly outlined and percussed ; if not, DIAGNOSING VARIOUS FORMS OF INTESTINAL OBSTRUCTION. 85 tlie imiiossibility of forcing over a quart of water into the bo-\vel would at ouee suggest an occlusion about the sigmoid flexure. It must be borne in mind that the amount of water which the rectum can hold varies greatly, depending upon the condition of its muscular coat, and that at times its capacity for distention is very great. In a case reported by Miller^ the test of the capacity of the rectum, and its perviousuess to water injection seems to have failed, since, although the strangulation was in the small intestine, only a very small amount of liquid could be forced into the bowel by the injection pipe. The report of this case is so meagre, however, that it is impossible to discover how thorough a trial was made of the method. Prognosis. — It is almost impossible to justly decide as to the average chance of life in a case of acute intestinal obstruction. On the one hand the statement is made that " nearly all cases of acute mechanical intestinal obstruction die unless relieved by surgi- cal interference,"^ on the other it is within the experience of every practising physician that cases of this nature do get well under careful medical treatment. As to the probability of relief to internal strangulation, or confirmed volvulus by palliative means this is open to doubt, since an autopsy is necessary to confirm the diagnosis, but that paretic distention and invagination frequently yield to the physician's manipulations cannot be questioned. Curschmann^ places the mortality of obstruction from all causes at about 65 per cent. Our own tables give a considerably higher death rate. 1 Edinburg Med. Jour., 1890. 2 Fitz., Boston Med. & Surg. Jour., Nov. 15, 1888. 3 Therapeut. Mouatsh., May, 1889. CHAPTEE X. ON THE GENERAL TREATMENT OF INTESTINAL OBSTRUCTION. On this question the surgeon and physician are arrayed against each other. The extremist of one party rejects all the ordinary therapeutical agencies and advises immediate recourse to the knife, while his opponent cites the appalling mortality of operative cases, and trusts to measures which, if not successful, at least do not hasten death. In so far as statistics can be relied on, the surgeon certainly has the best of the discussion. In another place we have alluded to some of the reasons which make conclusions founded upon reported cases of doubtful value. Under intussusception it has been shown that the mortality of the operative cases was practically the same as that of cases treated expectantly, although as a rule only the desperate cases were subjected to the knife. It may be safely assumed that the mortality of cases of acute intestinal obstruction treated medically lies somewhere between 65 and 75 per cent., our own statistics give 73.2 per cent. Obalinski,^ of 38 cases treated by laparotomy lost 60.5 per cent. In his last series of nineteen the mortality was 52.6 per cent. Schramm gives a mortality, since the aseptic wound treatment, of 58 per cent. Curtis^ reports 328 cases of acute intestinal obstruction treated by section with a mor- tality of 68.9 per cent., 62 cases treated by enterostomy^ gave a mortality of 43.3 per cent. Far more conclusive than statistics, which are decidedly favorable to operation, are the records of the autopsy room, which show that so many of the fatal cases could have been relieved by operation. It is now very generally conceded that, provided a patient is in good general condition, an exploration of the abdominal cavity, if quickly performed, is attended with very little danger to life. When tympany is enormously developed such exploration becomes 1 V. Langenbeck, Arch. f. Chirur., xxxviii. 2. 2 Annals of Surg., May, 1888. 3 Med. Rec, Sept. 1, 1888. GENERAL TREATMENT OF INTESTINAL OBSTRUCTION. 87 both difficult and dangerous; where the case is complicated by peritonitis and adhesions the surgeon may find it impossible to discover the seat of obstruction. Tliese cases then present in their early stages no grave difficulties to the surgeon, eitlier from the mechanical obstacles to be overcome or from the unfavoral>]e con- dition of the patient ; in the latter stages complications and diffi- culties are developed which may well deter the boldcsst froni operating. It is then in the early stages that operation should be advised. All surgeons are agreed upon this point, and many physicians are realizing its importance. The question at once arises, what is meant by the early stages ? A certain amount of time is often necessary to confirm the diagnosis. Vomiting, constipation, pain, and meteorism may be symptomatic of conditions other than those of intestinal obstruction. It is upon the persistence of these symptoms and the development of others that the surgeon must rely, and this may be a matter of hours, or even days. Richardson^ considers stercoraceous vomiting as the index of obstruction requiring operation. Since this symptom is frequently absent even in acute strangulation, cases running a fatal course before fecal vomiting has time to appear, this sign is not for a moment to be relied on, Schramm advises immediate operation upon the diagnosis of obstruction being confirmed. In the discussion of the British Medical Association upon the subject (1887) the general consensus of opinion seemed to be that in doubtful cases no time should be lost but an exploratory section should at once be performed. Obaliuski advises in acute cases that an exploratory incision should be made in the first twenty-four hours. The paralytic impermeability following typhlitis, oophoritis, or other forms of local peritonitis, should, however, be treated expectantly. Of twelve such cases subjected by Obalinski to morphia and bella- donna treatment, nine recovered. Goltdamer^ would limit laparotomy to cases of intussusception ; cases in which symptoms of obstruction are steadily progressive in spite of the free use of opium ; cases in which after opium has produced a remission of all symptoms, these seem suddenly ta develop anew. 1 Med. Press and Circ, Feb. 7, 1889. 2 Brit. Med. Jouru., March 11, 1889. 88 WOUNDS AND OBSTRUCTION OF THE INTESTINES. Kroiilein and Czerny advise early oiJeration ; abdominal section Avlien the strength of the patient is well ])reserved ; Avhen the abdo- men is soft and not distended ; and when by means of jialjiation the seat of obstrnetion ean be partly "determined. In all other oases they advise an ileostomy through a small incision. Both surgeons and ])]iysicians are agreed upon the value of opium in cases of mechanical obstruction. It is best given in the foi'm of morphia subcutaneously, and should be combined with full doses of belladonna or its alkaloid atropia. Of the effects of these drugs we have spoken under peritonitis. We feel convinced that the time to operate cannot be expressed in hours or days, or by specific symptoms. It is first necessary to confirm the diagnosis of obstruction, and this in the majority of cases is quickly and surely done. Immediately, morphia and bel- ladonna having been properly administered and the stomach having been washed out, one thorough trial at reduction should be made. In all cases the patient should be relaxed by the administration of an anaesthetic. If invagination is suspected, slow, persistent gravity injection with abdominal kneading or inversion and shaking. In supposed volvulus and internal strangulation the same treatment with the patient in the knee-elbow position can do little harm. In supposed intestinal paralysis the application of electricity. If this trial is unsuccessful immediate abdonjinal section is indi- cated. At this stage, when the patient's strength is well preserved, when tympany is but mildly developed, when there is reason to believe that no extensive pathological changes have taken place in the gut, we think an enterostomy as a primary procedure should not be considered. The abdomen should be opened by a free median incision, and the ordinary seats of obstruction should be explored by eye and hand. Since the fatal result after abdominal section is commonly due to shock, the operation should be conducted with the greatest possible rapidity. If the seat of obstruction cannot be quickly found ; or if found required a tedious procedure for the restoration of the con- tinuity of the gut, we think an enterostomy would be indicated. Circular enterorraphy has in these cases been nearly uniformly fatal. Ijateral approximation by plates or implantation, or invagi- nation by the rubber ring are quickly performed, and when the GENERAL TREATMENT OF INTESTINAL OBSTRUCTION. 89 operation lias not already been unduly prolonged, may be indieated. A half hour should, in gciueral, be the extreme limit of time during Avhieh the belly should be open. If this period has elapsed, and the seat of trouble is not yet found, or if found the obstruction not overcome, an enterostomy shoidd be performed. Under some circumstances the seat of obstruction, when not acutely congested or influmed, may be switched out of the ali- mentary tract by an anastomosis between the afferent and efferent bowel segments. In general the operator should aim at rapidity of manipulation and the immediate safety of the patient, rather than at an ideal restoration of parts to their normal condition. We think that the danger of secondary occlusion by displace- ment of bowel segments or by intestinal paralysis is lessened by an abundant irrigation of the peritoneal cavity with hot saline solution. Malcolm^ has called attention to the value of this as a means of securing a natural disposition of the intestines after abdominal section. The preservation of the body heat of the patient is most important. The operating table we describe, together with thin ribbed hot water bags placed over the chest and about the portion of the abdomen which is not subject to operation, are efficient means of accomplishing this. Since the amount of heat abstracted from the highly vascular peritoneum is, when the latter is exposed, enormous, it should be the duty of one assistant to keep all exposed bowel segments covered with rubber dam or with thin sponges wrung out in hot saline solution. Nothing should be taken by the mouth for from twenty-four to forty-eight hours after operation. 1 Lancet, Jan. 11, 1890. CHAPTER XI. SPECIAL, TREATMENT OF OBSTRUCTION. In a detailed consideration of the various methods of treatment advocated for intestinal obstruction, including the surgical opera- tions which are indicated, the first subjects which present them- selves are — Diet and medication. — The profession is now practically unani- mous in advising that neither food nor drink should be given by the mouth during the continuance of acute obstructive symptoms. The objection to gastric alimentation is not merely that there can be no digestion and no absorption, but that fresh matter is supplied for decomposition, and that fresh impetus is given to the exhausting vomiting. In one unreported case of acute obstruction we withheld f(jod for six days ; the patient recovered showing no marked emacia- tion as a result of her long fast. There can be no objection to the administration by the rectum of beef peptoids of peptonized milk and eggs, and of stimulants. The thirst is relieved by gently injecting one or two pints of warm water into the lower bowel. If the heart shows signs of flagging, especially if there is a condition of collapse similar to that observed in cholera, three to six ounces of whiskey dissolved in one to two pints of warm saline solution can be thrown by gravity into the cellular tissues. Hypodermics of ether, frequently repeated, are peculiarly applica- ble to this condition. Personally we have not obtained satisfactory results from the use of digitalis. Against heart failure, whiskey is the main stay, and must be pushed to its physiological effect. The rectum may also be used for the absorption of whiskey, but in this case it should be diluted at least six or eight times since acute inflammation of the mucous membrane has been produced by con- centrated solutions. Of opium and belladonna, the two drugs mainly indicated, we have spoken at length under peritonitis. AVe think that both should be given hypodermically. SPECIAL TREATMENT OF OBSTRUCTION. 91 Strychnia is at times of g;rcat service, especially in conditions of profound nervous shock, and in paretic states of the bowel. To be of service it must be pushed till its physiological effect is produced. Purgatives are to be avoided, Stoker' being the only surgeon of prominence advocating their use in recent times. Lavage of the stomach. — This treatment, originally advocated by Klissmaul, has received the highest clinical endorsement. Its effect is direct and readily understood. It mechanically removes a large quantity of putrid septic matter which otherwise would be slowly and laboriously regurgitated by violent muscular efforts, thus still further weakening an already debilitated patient. It assists nature in her eliminative efforts, and almost without exception produces an immediate improvement in the patient's condition. Indeed, there is so great an amelioration of symptoms that this procedure is utterly condemned by some surgeons as producing, like opium, a seeming improvement not warranted by the condition of the bowel at the seat of obstruction, and thus leading to a postponement of operation. In some cases it produces not only relief, but is absolutely cura- tive. Mahnert^ reports several cases of cure. Even where death is inevitable it is productive of such relief that it may be employed if nausea and vomiting are well marked. Curschmann^ ranks M'ashing of the stomach next to opium as a palliative and curative agent. NothnageP and Gerster^ commend this procedure, as do indeed all surgeons who have fairly tried it. Either plain water may be used, or normal saline solution, or mild antiseptic lotions, such as solutions of boric or salicylic acid. Since there is a patulous condition of the pylorus the weak anti- septic solutions are particularly indicated, as by becoming mingled with the intestinal contents, further fermentation is retarded or entirely prevented. We believe that these injections should always be made with hot solutions (106° F.) for reasons given under the section on enemata. Enemata. — In the use of enemata there is more confidence than 1 Dublin Jonrn. Med. Sc, Nov. 1889. 2 Memorabil. Heil., March 16, 1889. 3 Therapeut. Monatsli., May, 1889. * AUgemein. Wien. Med. Zeit., Maj 7, 1889. 5 N. Y. Med. Jonrn., May, 1889. 92 WOUNDS AND OBSTRUCTION OF THE INTESTINES. in all the combined palliative means of treatment. Though peeuliarly applicable to cases of intussusceptiou, paralysis is bene- fited by the stimulus thus given to peristalsis. It is asserted that volvulus may be untwisted provided the injection is accompanied by inversion or massage, and even internal strangulation may be made to yield to the gradual distention of the lower bowel segment, though clinical proof in regard to the justice of these claims is Avanting. In the chronic obstructions dependent upon impacted feces and upon narrowing in some portion of the colon the use of enemata is practically the only palliative measure left to the physician. The method of giving enemata has been described under invagi- nation. Even though the invagination were seated at the small bowel we would not hesitate to employ injection as described. Seun states, on the basis of experiments resulting fatally upon animals, " That the injection of the water beyond the csecal valve, in the treatment of intestinal obstruction, must be looked upon in the light of a danger- ous expedient, and must never be resorted to." We have repeat- edly passed water from the anus to the mouth of dogs without producing the slightest unfavorable symptoms, except in one in- stance, our first experiment, where water was taken directly from the tap (52° F.) ; the dog perished after twelve hours, having suf- fered with tenesmus, and having passed some blood-stained mucous evacuations. The post-mortem examination showed intense coii- gestion of the colon. Battey^ reports a case in which water injected into the anus with an ordinary syringe entered the stomach and was vomited. Though the necessity for injections so copious as this rarely arises, yet there are scattered through medical literature a sufficient num- ber of reports to confirm the results of our experiments upon dogs as to the harmlessness of forcing water past the ileocsecal valve. There are certain points of cardinal importance to be considered in making these injections : — 1. The liquid must enter the bowel by a gradual, steady floAV. 2. The temperature should not differ greatly from that of the body. Atlanta Med. and Surg. Journ., June, 1874. Medical Record, July 1, 1S74. SPECIAL TREATMENT OF OBSTRUCTION. 93 3. The pressure should be uniform and long-continued, starting at two pounds (an elevation of 4 feet), and, if necessary, gradually increasing to not over eight pounds (elevation of 16 feet), this is effected by slowly raising the reservoir. 4. Not over three-quarters of an hour should be spent in attempting to force the liquid past the seat of constriction. The danger of rupturing the bowel must not be forgotten. In any case where beginning mortification is feared, as, for instance, in intussusception where shreds of necrotic tissue have been dis- charged, or in cases characterized by acute symptoms which have lasted for three days or upwards, we think that the danger of forced injection is so great, and its probable efficacy so limited, that it should give place to operative procedure. We have knowledge of three unreported cases in which forced injections resulted in rupture of the bowel and speedy death. In each case these injections were made with the Davidson syringe, and the amount of force used was undeterminable. There are many recorded cases where this accident has occurred.' Under any cir- cumstances there is a risk in the employment of eight pounds of pressure, though experiment has shown us that this is far within the bursting strain of normal gut. In view of the hundreds of successful results following this method, or rather very imperfect attempts at it, we think the physician is justified in taking this risk in suitable cases, provided preparation is made for an iinmedi- ate abdominal section, should symptoms characteristic of rupture of the bowel appear (t. e., sudden uniform swelling of the belly, loss of outline of distended colon, and collapse). We would particularly protest against frequently repeated small injections with the Davidson or other pumping syringe. Each hour diminishes the chances of success. That second and third efforts have accomplished their objects has been simply be- cause they were more efficiently made. At the first effort the cir- cumstances are most favorable for reduction, and the physician is justified in using more force and perseverance than at any other time in the course of the disease. This first attempt should, then, be so thorough that he can feel assured the method, and not its mode of application, is at fault. 1 Medico-Cliirurgical Trausactions, 59th volume. 94 WOUNDS AND OBSTRUCTION OF THE INTESTINES. Electricity. — As a means of encouraging peristalsis, electricity has been warmly commended from the time of its general intro- duction into the treatment of disease. How it can effect the me- chanical forms of obstruction is difficult to understand, yet many cases of cure are j)laced to its credit. It is in paralytic distention, however, that this treatment has obtained most brilliant results. As a type of the results sometimes obtained we quote one case, given together with several others by Auffret.^ The patient had a history of previous slight attacks of a similar nature ; after sev- eral days of constipation he entered the hospital with great abdom- inal pain exaggerated by pressure, with meteorism and bilious vomiting. Abdominal facies was marked, the thighs were flexed upon the body, the pain was located about the umbilicus, there was general meteorism, with dilated intestinal loops clearly outlined through the parietes. Pulse scarcely perceptible ; temperature subnormal. The following day all symptoms were exaggerated, and death seemed immediate and inevitable. The two poles of a faradic battery w^ere placed one over the ab- dominal parietes, the other within the rectum. The application w^as continued twenty minutes, and was carried to its maximmn intensity, when suddenly the patient experienced a sudden jar accompanied by a feeling of intestinal displacement. Immediately free evacuation of gas and fecal masses took place through the bowel, and the patient rapidly convalesced. In one of our cases the application of faradism was equally suc- cessful. A patient suffering from chronic Bright's disease remained obstinately constipated for three days, when the abdomen became, rather suddenly, enormously distended ; the patient complained of intense pain about the umbilicus, and frequently repeated bilious vomiting set in. In eight hours the distention had reached such a degree that death from respiratory failure was threatened. The rectal tube, stimulating enemata, large forced enemata had all been tried in vain. Before resorting to puncture of the bowel the poles of a powerful faradic battery were applied, one to the small of the back, the other to the abdominal muscles. In fifteen minutes there was an enor- 1 Mem. sur les Occlus. Intest., Par., 1885. SPECIAL, TREATMENT OF OBSTRUCTION. 95 moiis discharge of gas followed by several passages of tliin yellow feces. Both these cases were probably examples of paralytic obstruc- tion. Where it is imeertain whether this condition or mechanical blocking is causing obstructive symptoms we think the application of the faradic battery should be given a thorough trial, preferably by a metal electrode carried into the rectum the other pole being applied to the belly walls. As a means of applying the current still more directly, Heard* advocates filling the rectum with saline solution and introducing the rectal electrode into this. Perhaps the majority of physicians utterly distrust electricity as a curative agent in intestinal obstruction. This is doubtless owing to its want of success in cases dependent upon mechanical causes. Even that the majority of paralytic obstruction cases Avill yield to its influence cannot be claimed. That some do, is indisputable, and we think that an agent which may do good, which consumes little time in its application, and which, if unsuccessful, can do no harm, should be given a fair trial. Gaseous injection. — The injection of air or gas as a means of locating intestinal obstruction has lately been warmly and nearly universally commended. Belief in its greater permeability is universal, the experiments of Senn, and the statements of Cursch- mann^ and the majority of surgeons being to the effect that the ileocsecal valve is practically closed to the upward passage of water. Malmert,^ Damsch,^ Head,^ Crisp,^ Bryant,^ and many others have employed air injections in the treatment of intussus- ception. Schuetter advocates COg, and Damsch states that a litre of this will fill the colon to the ileocsecal valve without producing peristalsis, but that it will not pass this valve as readily as will air. That air or gas injections have frequently been efficient in removing the cause of obstruction cannot be denied, but as the pressure is less directly under control, and as in certain cases, the mechanical benefit of the weight of water seems to be an important 1 Weekly Med. Eev., Aug. 17, 1889. 2 Log. cit. ^ Lqc. cit. * Berlin. Klin. Woch., April 15, 1889. 5 St. Barthol. IIosp. Kept., 1867, III. 85. ^ London Lancet, 1847, I. 557. ' Brit. Med. Journ., 1884, II. 1801. 96 AVOUNDS AND OBSTRUCTION OF THE INTESTINES. factor iu tlie accomplishment of a cure we do not consider insuffla- tion so valuable a method of treatment as injection of liquids. We performed numerous experiments upon dogs, injecting air from end to end,* and in one instance ligating the cardiac end of the stomach and injecting, with the idea of discovering how readily intestinal paralysis from over-distention, and consequent crippling of the diaphragm could be accomplished. A pressure of foiu- pounds was as much as we could obtain with the means at hand, and this continued for three-quarters of an hour, produced but little more distention than that present when the gas was freely eructated. This proved that the effect upon respiration and circulation was absolutely negative in gaseous injections even when an obstruction in the upper part of the alimentary canal was present. The cause of frequent failure of this method is, as in the em- ployment of enemata, because of an imperfect method of applying it. Any injection into the bowel causes a spasmodic resistance and effort at extrusion — this is increased if the pressure is constantly varying. Spasm ultimately yields to steady continued pressure, even though this be very slight. Time and again we have seen operators fail to pass gas from anus to mouth simply because they did not recognize the importance of the element of time in over- coming muscular resistance. The spasmodically contracted muscles of a fractured thigh, which even the mighty po^ver of windlass and pulley may fail to overcome, yield in a night to the continued traction of a few pounds. So the resistant muscular coat of the bowel may, if the struggle be short and violent, rupture before yielding, but inevitably relaxes under persistent gentle pressure. 1 As a type of this series of experiments the following is given : — Pup, 30 lbs. purged by buck-thorn the night before. Two grains of morphia administered hypodermically. 2. P.M. InsuiBation begun by means of gas bag. Pressure one and a half pounds, circumference of belly 13^ inches. 2.10. Circumference of belly 14 inches. Colon full as denoted by palpation and percussion. 2.15. Loud rumbling and rapid inward passage of gas denoting opening of ileocecal valve ; circumference of belly 16 inches. 2.20. Loud rumbling repeated, denoting entrance of gas into stomach, cir- cumference of belly 17 inches. 2.23. Gas belched up at intervals of a few seconds, loud rumbling accom- panying each eruction. SPECIAL TREATMENT OF OBSTRUCTION. 97 Thus with a pressure of a half pound we have, in forty minutes, passed gas along the entire intestinal tract of a dog. If obstruction is to be overcome, the gas must reach the seat of obstruction, and it is far safer to accomplish this by moderate continued pressure, continued for thirty or forty minutes, than by rapidly increasing the pressure, if in five or ten minutes no results seem to follow. The physician should always have an accurate idea of just how much pressure is being employed, and for this purpose should attach a mercury manometer to the injection pipe. That this is a necessary precaution is shown by repeated cases of rupture during insufflation.^ Our conclusions in regard to insufflation are : — 1. It is a valuable means of overcoming acute obstruction in any part of the alimentary tract, but must rank in order of efficiency after water injections. 2. The injection should be slow and long continued, the pres- sure should be evenly maintained and shoidd be indicated by a manometer. 3. The danger of rupture must be considered in gaseous injec- tions. ' It seems proper in this connection to discuss two subjects intimately connected with rectal injection, namely : — Heat preservation, and The effect of intra-abdominal pressure produced by forced enemata. At the very first glance it will be clearly seen that the mainte- nance of bodily heat at the normal point or at least at a temperature approximating the normal is necessary for the welfare of the patient. This is very well illustrated by the experiments of Brunton, and many others including our own, for it was found that lethal doses of chloral do not produce death if the bodily heat of the drugged animal be carefully watched after. The maintenance of the normal temperature in man is far more important than its maintenance in animals. In the human body every atom of protoplasm is a sensitive tropical plant, only exposed, except in disease, to the variation of a very small fraction of a degree in the heat supplied 1 Medico-Chirurgical Trans., 1876, p. 97. 98 WOUNDS AND OBSTRUCTION OF THE INTESTINES. to it, simply because man's temperature is constant, whereas in tlie dog or other brute the normal temperature is ever varying, now high, now lo^\'. Thus in the dog, the temperature of 12 noon may be 102.1°-; at 12.15, 102.5°; at 12.30 or 12.45, 102°, and by 2 o'clock np to 103°, only to return at 3 to the original number of degrees, and }'et perfect health be present. To express the differ- ence in a homely simile, man is a fine chronometer, never varying, while the dog or rabbit is a Waterbury watch made of cheap and coarse protoplasm which can only approximate. We learn therefore, as one of the first and most important points in the use of injections in obstruction, that the water used must be warm, and that cold water is distinctly harmful. If we remember that the heat functions of the body are chiefly centred in the ab- dominal viscera, and that these viscera are particularly arranged by nature in such a way as to be protected from exposure to cold, we can readily see the importance of this subject. For the pur- pose of avoiding chilling, the skin, soft tissues, and bones, are arranged as one impenetrable, non-conducting covering which neither transmits cold nor heat. Yet some have resorted to cold injections without so much as a thought that the patient, already weakened and exhausted by disease and vomiting, should be care- fully protected from cold, particularly in his vital parts. For the purpose of determining the exact importance of these precautions, we have made a series of experiments Avith results which are well shown in the record given below and which is taken as a typical example of a number of trials. It will be seen that the introduction of water as it comes from the tap lowers the normal bodily heat with great rapidity, and even causes marked coldness of the belly walls. ^ Experiment. — Dog, weight 27 pounds. No morphine or ether used. 11 A. M. Began injecting by hydrostatic syringe four quarts of water at 65° Falir., the pressure being equal to 35 millimeters of mercury. Temperature in the axilla 102°. 1 The method of experimentation consisted in the connection of an ordinary fountain syringe with a Y-shaped tube, one arm of which was attached to a mercurial manometer, the other to the tube entering the rectum of the animal. By raising and lowering the bag holding the water the pressure could be varied at will and the manometer afforded a ready gauge as to the amount of this pressure. Tracings to determine the effect of passing water at 65° F. from anus to mouth upon the pulse and respiration. [To face page 9St. Isy^^^y^-.-.r-'J^'-j^ II. jv/v\A/\^yV A/VnAJV^^ The last tracings before the change induced lyy vomiting movements shows 18 ram, fall in blood pressure. SPECIAL TREATMENT OF OBBTRUCTION. 99 11.10 A. M. Belly walls are exceedingly cold, frequent rigors pass over the body. 11.30 A. M. Vomited contents of stomach and the water which had been passed through. Axillary temperature now found to be 99° Fahr., or in other words a fall of 3° in bodily temperature had taken place in about thirty minutes. Temperature of the internal viscera must have been even less than this owing to the direct contact of the water, for the dog was in a state of collapse and shock, and seemed almost dead from the cold. The time occu- pied in passing the water from anus to mouth was thirty minutes, the pressure being 35 millimetres. [See trac- ings.] Very few persons, even among surgeons, who constantly ope- rate, have any conception of the decidedly depressant effects which anaesthetics exert upon bodily temperature ; and again, very few know that the mere stretching out of the patient upon an opera- ting table also produces a great loss of heat. The following experi- ments performed by us in regard to this point show in a somewhat startling but nevertheless accurate manner the truth of our asser- tions, and w^e have found them to hold good, not only in the lower animals, but also in man. Thus we have experimentally determined that it is possible to lower the normal rectal tempera- ture of the dog as much as from 8° to 10° Fahr. by continuous etherization for an hour, giving two drachms of ether every five minutes after the animal has been put thoroughly under the anaes- thetic influence. These two series of studies on man Mdiich follow are particularly interesting. In the first series the temperature w^as taken in the axilla, and in the second in the rectum. 100 WOUXDS AXD OBSTRUCTION OF THE INTESTINES. Series I. No. Ojieratioii. Temperature before. Temperature after. 1 Anal fistula .... 99° 96.2° 2 Carcinoma .... 98.6 95 3 Arthritis of knee . 99.1 96 4 4 Arthritis of knee . ■ . 98.8 95.8 5 Sarcoma of both testicles 98.6 94.2 6 Vesical stone 99 97.1 7 Arthritis of knee . 99 96.8 8 Vesical stone 98.6 96.4 9 Traumatic epilepsy 98.1 95.4 10 Necrosis of tibia 98.5 97.2 11 Necrosis of phalanx 98.2 96.8 12 Renal calculus 99.4 96.8 13 Nasal sarcoma 98.4 97.2 The average fall of temperature is seen to be over 2|° Fahr., the greatest fall being 4.4° Fahr., the least 1.2°. Series II. No. Sex. Operation. Temperature before. Temperature after. Duration of etheri- zation. 1 Adult, M. Necrosis of femur . 99.5° 98° If hours. 2 Adult, F. Carcinoma of axillary glands .... 100.15 9S.5 1 hour. 3 Adult, M. Excision of the knee Mouth, 99.4 Mouth, 97.2 Short. 4 Adult, F. Abscess of abdominal wall 99.4 98.4 1 hour. 5 Adult, F. Caries of vertebrse . Axillary. 98.4 Axillary, 97 1 " 6 Adult, F. Carcinoma of breast 99.45 96.3 I " 7 Adult, F. Carcinoma of breast 98 95.4 3 U 4 8 Adult, M. Hypospadias . . . 99.2 96.3 9 M., £et. 6 McEwen's, for de- months. formity of tibia 99.2 97.4 i " 10 Adult, M. Necrosis of femur . Mouth, 98.4 Mouth, 98.4 k " 11 Adult, M. Epithelium of nose (plastic operation) Axillary, 100.2 Axillary, 99 4 12 M. Excision of hip . . 102 100.2 1 " 13 M. Empyema, drainage- Avillnrv f)S.4 Axillary, 97.6 k " Average fall of temperature 2.32° F. Greatest fall 3.15° Fahr. Smallest Ml 0.8° F. We find therefore that the present custom of applying heat to the patient is closely allied to locking the door after the horse is stolen, and the results given in these two tables seem at least to SPECIAL TEEATMENT OF OBSTRUCTION. 101 afford siifificient evidence of the propriety of using external heat not after, but during anaesthesia. Since the placing of hot cans about the patient during operation is not practicable, the heating apparatus must be in direct coiuiec- tion with the operating table. This may be accomplished by means of a galvanized iron water bath made in the form of a shallow tray, and of dimensions sufficient to receive the patient. When this water bath is placed upon an operating table and filled with water at a temperature of 110° there is no danger of burning the operator, his assistants, or the patient, but the loss of bodily heat is prevented. Having called attention to the importance of the employment of heat it remains for us to utter a word of warning against the use of water at too high a temperature. This, at first sight, seems absurd, as the merest tyro would not inject very hot water into the rectum or use it over the surface of the body, yet it is necessary to have a moderate degree of heat and no more, for it is as possible to cause heat stroke by the use of too hot water as it is to chill the patient to death by cold injections. The following experiment shows this very clearly : — Experiment. — Dog, weight 50 pounds. Full grown. Temperature of water injected into bowel 115° F. Pressure of water 65 millimeters of mercury. 12.27 Axillary temperature 101.1°. 12.35 Began injection. 12.40 Axillary temperature 102°. 12,55 Axillary temperature 105°. 1 Axillary temperature 106°. Marked signs of heat dyspnoea. Belly walls very hot. Vomited water. Time of passing water through from anus to mouth twenty-five minutes at a pressure of 65 millimeters. Having found that water at the temperature of 115° Fahr. pro- duces symptoms of heat stroke, other experiments were made to determine the safest temperature in every case, and it was found that the water should be at about 105° to 108°, owing to the fact that so much of the heat is lost by the slow progress of the water from the bag to the anus, through the connecting rubber tube. If the tube be very short the temperature need not be above 103°. 102 WOUNDS AND OBSTRUCTION OF THE INTESTINES. The following experiment shows very well the advantages of a moderate temperature : — Dog, weight 40 pounds. Full grown. Axillary temperature Injected hot water at 110° F. from anus to mouth. 12.16 Began injection; pressure 15 to 20 mm. Hg. 12.20 Colon full. 12.24 Belly very distended. Axillary temperature 99 1°. 12.30 Vomited the water. Axillary temperature 101'°. 12.50 Seems quite well. It will be seen on glancing at the three typical experiments which we have given, in which cold, hot, and warm water were used, that several valuable points appear. Where cold water was used tlie animal was severely chilled, shocked, and in collapse, and although he was only 27 pounds in weight it took thirty minutes to pass the liquid through the gut from end to end at a pressure of 35 milli- meters of jnercury. In the instance where the heat was great the dog was nearly twice as large (50 pounds), and it required only twenty-five minutes to pass the water through the gut at a pressure of 65 mm. of mercury. In other words, the increased size of the dog necessarily called for nearly double the pressure, and twice the bulk of water, but the heat enabled the liquid to overcome the muscular resistance which was met with. The heat was, however, too great, and heat stroke came on. In the third experiment, the temperature of the water in the bag was at 110° F., the dog weighed forty pounds, and only had a pressure of from 15 to 20 mm. of mercury on the water. Yet in this case the water passed through, from end to end, in fourteen minutes without any untoward effects, and the animal enjoyed per- fect liealth afterwards. It is evident, therefore, that four things are worthy of note : 1st, that the use of cold injections is harmful ; 2d, that they cause resistance on the part of the bowel; 3d, that very hot water goes through somewhat faster, but causes heat stroke ; 4th, that moderately warm water passes through very rapidly and produces no ill effects. From the results of our studies we would also recommend the addition of about 1 drachm of common salt to each 8 ounces of water used, for it was found, when fresh water was employed, and a post-mortem examination made, tJiat the intestines were SPECIAL TREATMENT OF OBSTRUCTION. 103 whitened or bleaclicd, aud often spasmodieally contracted and stif- fened. The explanation of this is not far to seek. The circulation of a salt solution containing less than the normal quantity of saline (7 per 1000) causes an absor[)tion of salts from the sur- rounding tissues, as is well known to all piiysiologists, whereas a solution of greater strength tlian 7 to 1000 causes an abstraction of water. In the consideration of the use of injections in intestinal obstruc- tions, we at once find ourselves face to face with the question as to whether the pressure exerted upon the intestinal contents by the distention of the bowel can influence the heart and respiration to any appreciable extent, and we have carried out a series of studies to cover these points, with the result of finding that the distention of the primae vise by an injection as it passes through the abdominal cavity, has no more effect upon the system in general than the pas- sage of an inflated tube through the centre of a room or box. This is clearly shown by the following tracing obtained by attaching the carotid artery of a dog to the mercurial manometer and taking a tracing as the injection was made. The slight changes occurring in the tracing are such as constantly take place in all experiments, and are due to arhythmic respiratory movements. In cases of obstruction, therefore, there is no danger in using injections, for distention of the intestinal wall of brief duration cannot produce ill effects, at least wdien due to such a cause. On the other hand it is true that if the abdominal contents be com- pressed by liquids outside of the intestines, that is free in the abdominal cavity, death ^^-ill take place. This will be seen in the following experiments and tracings, the lethal result being due to respiratory failure, produced through pressure exerted on the dia- phragm whereby exhaustion of the supplementary respiratory muscles ensued as a result of diaphragmatic paralysis.^ 1 Since making these studies Heinricus has published a series of expei'iments made by him of identically the same character as our own, which reach results of a similar nature, although performed in the pursuance of a different Hue of study. See Zeitschrift fiir Biologie, 1889. Delbert (Annales de Gynecologie, 1889) has also reached the same results, so that it may be said that three different researches, performed independently of one another, are in accord. 104 WOUNDS AND OBSTRUCTIOX OF THE INTESTINES. Experiment. — Dog, weight 70 pounds. Passed into tlic belly, through a small trocar pushed through the belly wall, a sufficient quantity of warm water to produce complete distention and finally death. The abdominal muscles first ceased to act, then the thoracic muscles failed, and, finally, the cervical muscles, after a few contractions, gave out. Post morton. — The liver and spleen ^vere dirty brown in color and contracted. The intestines were shrivelled, contracted, and empty, except the duodenum and the jejunum. There was mode- rate venous congestion of the omentum and raesenteiy. Thinking that the fatal result might be due to the use of a non- saline fluid, we performed the following test, but found that death was still the result. Dog, weight 70 pounds, Newfoundland pup. Passed into the abdomen warm normal saline fluid in the same manner as in the last expei'iment, but death occurred in the same way. On section the liver and spleen were normal in color, and there w'as no shrinking to be seen. The intestines were somew^hat rigid from contraction of their muscular walls. The trocar had wounded a bloodvessel in the mesentery of the lower part of the ileum, and an extravasation the size of a bean was found at this point between two mesenteric layers (see tracings). Abdominal massage. — Hutchinson^ has given kneading of the abdomen under an ansesthetic, and in combination with injections, high praise as a treatment for intestinal obstruction. He states that the only cases in which the surgeon is the least likely to regret having employed it are those in which peritonitis simulates ob- struction. It must not be forgotten that massage is a treatment which is purely empirical, that its skilful and judicious application is a matter of chance in the obscurity which always surrounds these cases of obstruction, and that not only may it be absolutely hurtful in peritonitis, but may immediately determine a rupture in a greatly distended and congested loop of gut. It is easy to see how it vwy be beneficial in every form of acute obstruction ; but to so apply it that it necessarily will produce the result desired is an impossibility. 1 Loc. cit. Tracings showing the primary slight effect of great intra-abdominal X-'i'^sure, with ultimate death from respiratory failure. Water injected into abdom- inal cavity. 1. [To face page 104. •iW WVVWiAA/lMA hi ■A'f''':Tt'l III. IV. VI. ^IWiffHW'i'M VII. Tracings shovnng effects oj passing into the oMoniina.l mvity two gallons .7 per cent, saline solution at a temperature of 10^ F. I, [To face pagf 104. MPMtH\J'H\MAN'^W^' 3 ht^i^^^^fy^^- V. SPECIAL TREATMENT OF OBSTRUCTION. 105 The use of metalHo mercury. — The use of nuitallic rncrra(;ticc, wlicre tlio (liuni(;tor of tlie ball is frequently but -^-^-^ inch, and its weight GO grains. Much larger balls are used, ^-^-^ calibre j)erhaps being the common size. We have in our tables instances of No. 38 and No. 44 re- volvers having been used at close range. These would, of course, inflict as much injury as the rifle ball. The first thing to consider in dealing with gunshot wounds oi the abdomen is as to whether or not the bullet has pierced the parietal peritoneum. This, which would seem an easy problem at first glance, is in reality one which is difficult to solve. We have seen two penetrating gunshot wounds, inflicted by a f\^^-g- ball, and from which the patient shortly perished, thwart every effi^rt of the operator to follow with the finger or probe .the course of the vul- neratiug body. In experimental work upon dogs we have in the majority of instances not succeeded in passing a probe along the track of the ball into the peritoneal cavity. In deciding as to peneti'ation, certain facts will materially aid the surgeon. First must be considered the size and length of the cartridge. A Flobert cap or a 22 short, may not have sufficient force to penetrate the clothing and the abdominal wall ; the bullet of a larger cartridge will almost certainly penetrate if its course is straight. The distance from which the ball was fired, the direction from which it came, the position of the wounded man when struck, are all important matters. The possibility of the ball being deflected by a button or by any foreign body in the pocket, or, after it has penetrated into the body, by bony prominences, must also be con- sidered. McGraw claims that balls are not deflected by soft parts, but against this is the record of well authenticated cases. In our own experiments (20 in number), the ball was deflected in but one instance. It was fired from a distance of ten feet, in a direction downward, and at right angles to the long axis of the dog. It passed in (calibre 22) upon the left side, half an inch below the rib margin, and one and a half inches to the left of the nipple line. It perforated the colon, made four wounds in the ileum, two in the cfecum, and lodged in the pelvis of the right side, a deflection of fully four inches. It struck against no bony part, nor were there hardened feces which misht have turned it from its course. This 124 WOUNDS AND OBSTRUCTION OF THE INTESTINES. positive evidence is, of course, fur more conclusive than many nega- tive experiments. As a rule, and as general in application as the one which states that all penetrating wounds of this class are attended with visceral injury, it may be stated that the course of the bullet is a straight one. The application of this rule would be of very great practical value to surgeons, but for one circumstance. To determine the track of the ball the surgeon nuist knoM' the direction from which it was fired, and the exact position of the wounded person when struck. This information, in the majority of cases, cannot be ob- tained. We can determine that the injury was inflicted from in front, or from the side, but rarely can eye-witnesses or the patient himself tell us whether or not he was rising from his chair, was vStooping forward, was twisted sideways, was running, or was mak- ing any violent muscular effort. The shape of the wound some- times suggests the direction from which the ball has come, the surface impact making either a clear cut hole or a grooved or con- tused track, depending upon whether the ball is received from the front or strikes obliquely. It may generally be accepted foi* granted that a ball from any revolver, with greater penetrating power than that given from the 22 short cartridge, which has struck the abdomen squarely from the front, has penetrated into the peritoneal cavity. As positive knowledge upon this point is of cardinal importance, the value of the information thus gained constitutes a sufficient excuse for both probing and digital exploration under rigid antiseptic precau- tions. If, after this method of examination, the surgeon is still in the dark, we can see no objection to carefully following up the ball track by incisions. In case of non-penetration the original wound has not been seriously complicated. If the abdominal cavity is entered, the surgeon's finger arrives at the point where the signs of serious visceral wounds are most likely to be manifested. The diagnosis of penetration having been made the question as to whether or not serious visceral lesions have resulted becomes one of prime importance. In every one of our experiments a penetrating gunshot wound was followed by wound of the ab- dominal contents. In our appended tables but four cases were, upon section, found to have no internal injury. When we speak of the abdominal cavity it must be borne in mind WOUNDS OF THE INTESTINES. 125 that this space is absoUitcly and entirely filled with important organs. There are no interstices or spaces in whieli nothing is placed. Each viscus is accurately packed, and is kept in close apposition under alterations in size, by the ever changing tension of the belly walls. Hence even the slightest penetration of the peritoneal cavity, by a missile travelling with the velocity of a bullet, will almost certainly result in injury to the contained organs. It can be assumed, then, as a working rule, that every penetrating wound of the aljdomen has produced more or less serious visceral lesion. On the basis that certain eases which recover without serious symptoms after penetrating or perforating gunshot wounds of the belly recover, because there are no visceral lesions, the percentage of wounds entering the abdominal cavity without wounding the viscera is fre- quently stated to be ten in the hundred. We shall presently show that statistics founded upon this estimation are not reliable, since patients do frequently recover from these injuries even though there may have been multiple and extensive visceral lesions. Our own figures show that the percentage of penetration without visceral wound is about S^ per cent. As a second proposition it may be stated that the lesion inflicted by a penetrating gunshot wound of the abdomen, especially if the ball has passed through and through, is multiple. Since it is especially with intestinal wounds that we have to deal in this paper, it is next in order to study the pathological changes which occur in a portion of the gut lacerated by a pistol ball. The first effect is to produce a local spasm, so marked that Bau- dens^ used it in his digital intra-abdominal search, as a diagnostic point. Immediately, consequent upon muscular contraction, there is an eversion of the loose mucous coat of the bowel, sufficient to entirely occlude even comparatively large wounds. Following the spasmodic contraction the involved portion of the gut becomes paretic, absolutely losing all peristaltic motion. Beck^ observes that in his vivisection experiments, so long as the healing can be delayed by peristalsis the animal instinctively refuses all food. This paralysis is not so absolute but that purgatives, or even the irritation of the ordinary ingesta may overcome it. It is sufficient, 1 Cliniqne des Plaies d'Armes a Feu. 2 Schusswuiuieii, Heidelberg, 1S49. 126 WOUNDS AND OBSTRUCTION OF THE INTESTINES. however, to splint small wounds until they can be tightly closed in the further process of healing. The next step in the process is the effusion and organization of plastic lymph. This may simply envelop the seat of trauma, or, and tliis is much more common, may serve as an organizable glue for the purpose of tightly apposing healthy omentum or peritoneal surface to the bowel wound temporarily closed by prolapsed mucous membrane. At times the omentum enters as a cork through the wound into the bowel lumen, and is secured in this position by rapid adhesive inflammation. The opening is frequently closed by neighboring intestinal loops which act as temporary occluders. Subsequent cicatrization of the effused plastic lymph accomplishes the permanent healing of bowel wounds. By the constant peri- stalsis adhesions may subsequently be drawn out into bands; more frequently they entirely disappear. Jobert claimed that, although the muscular contraction and mucous membrane prolapse prevented the escape of feces, gas nearly always passed out through a bowel wound, and by the immediate resultant tympany gave rise to a pathogenic symptom of this form of injury. It is recognized now that the closing which nature spontaneously effects is sufficient to retain both gas and feces. Even though the latter escape in small quantity there is still a method of cure. By plastic inflammation the extravasation can be shut off from the general peritoneal cavity, and the resultant abscess may gradually work its way to the surface, generally through the track of the wounding body. Although it is true that even very small wounds may be followed by fecal extravasation, it should be well recognized that this com- plication is an exception rather than a rule. Even though the intestinal walls be torn, since there is in reality no cavity into which the bowel contents can be poured there is no natural ten- dency for extravasation to take place. If the bowels are inflated with gas, this, diffusing itself in all directions, may create space by passing into the general peritoneal cavity and pushing out the abdominal walls. Consequently when there is escape of intestinal gas, this is, as a rule, followed by fecal extravasation. This acci- dent is of course far more likely to occur if the bowels are full, Vastin^ mentions a case where the bowel was completely torn across in two places, yet there was no fecal extravasation. Archer^ 1 Craig. Franc de Cherin, 1888. 2 N. Y. Med. Jour., vol. 15, p. 215. WOUNDS OF THE INTESTINES. 127 reports an instance where, tlirongh a two-inch wound of tlie stomaf!li the patient's dinner was discharged, a jjortion passing into the general peritoneal cavity. Nine days later there was suppuration in the groin. On evacuation of the abscess, pus and cabbage were discharged. The patient recovered. The natural tendency of extravasation is to escape through the external wound, since in this direction only is the space not already filled. Guthrie notes this, and states that when the visceral con- tents are poured out through a small external wound, the latter should be enlarged, the gut wound being sutured. As a result of extensive extravasation, excepting when the external wound gives free exit, a fatal peritonitis is nearly always developed. This is the most dreaded of all complications and ter- minates with the life of the patient in from twenty to forty-eight hours. It is not, however, the general, or even the usual result of abdominal gunshot Avounds. In a record of 127 cases we found fecal extravasation mentioned in but 16 instances, giving a ratio of 12 per cent. A very frequent complication, and one which is responsible for the great majority of deaths occurring very shortly after the wound, is internal bleeding. We found, in our experiraeuts, that sixty per cent, of the dogs shot through the belly died within the hour of hemorrhage, or would have died had not the bleeding points been secured. In our statistics we find thirty-three per cent, of cases in which internal bleeding was a- grave complication. We know of no source frjm which may be determined the number of fatal cases due to this cause. Even in surgical war records, complete in other respects, the whole number lost in battle is simply classed as killed. As seen, abdominal hemorrhage results fatally in a few hours. It is impos- sible to say how great a proportion perish from the wounding of important bloodvessels. It is claimed by many surgeons that the shock, which is such a frequent complication of intestinal wounds, is never present, except as a symptom of internal bleeding. This view cannot stand under careful examination, since there are many cases re- ported in which subsequent examination showed there was no bleeding, and yet in which shock was so profound as to threaten death. The symptoms of hemorrhage into the abdominal cavity 128 WOUXDS AND OBSTRUCTION OF THE , INTESTINES. do not differ from those dependent on bleeding in any other part of the body. The same disorders of respiration, of sensation, and of heart action, are to be noted. lu addition there are certain local signs which are of great value to tlie surgeon. Increasing dulness of the flanks, with deepening shock, particularly if associated with the desire to urinate frequently, would be almost pathognomonic of this complication. To this bladder condition Baudens has called attention, stating that when there is much blood gravitating into the pelvis, there is a constant insupportable desire to urinate, due to the mechanical pressure. Of course if the hemorrhage be slight in amount it may be entirely circumscribed, ultimately being either absorbed, or breaking down, and discharging as an abscess. Where the bleeding is free it inevitably gravitates into the pelvis and dependent parts. Shock is a condition which very commonly accompanies intes- tinal wounds ; some surgeons cons.der it of diagnostic value, the amount of shock denoting the intensity of intra-abdominal injury. That patients, suffering from gunshot Avound of the abdomen, are profoundly shocked, or even collapsed, from the very beginning, cannot be doubted, but it is found that this condition depends more upon individual peculiarities than the actual amount of injury, and that it is impossible to differentiate these symptoms from those characterizing bleeding. Our tables show many instances of most extensive wounds, where the shock was slight or wanting, and we have repeatedly seen burly men suffering from a light flesh wound, exhibit temporarily, all the symptoms of profound shock. It is most important to determine whether the patient suffers from shock or internal bleeding, since the treatment for bleeding- is immediate operation, while the treatment for shock is, of course, quite the reverse. It is certainly true that many of the cases, in which shock has been most profound, have been found to be suffer- ing from internal hemorrhage ; where the shock is prolonged and steadily deepening, even in the absence of other symptoms it is perhaps safest to act as though a diagnosis of hemorrhage had been made. We think we have discovered a means by which this differentia- tion possibly may be determined, not under all circumstances, it is true, but Avith sufficient frequency to be of value to the surgeon. WOUNDS OF THE INTESTINES. 129 The effect of rapid or prolonged hemorrhage upon tlie eonijiosition of the blood is well known ; such patients will be found to exhibit deficient haenioglobin, and the corpuscular count will be low. We have made several observations on the human to determine whether or not this condition is sufficiently constant to be of clinical value. We find that, with certain limitations, the percentage of hiemoglobin is a fairly accurate guide as to the amount of blood lost. Tliis test may be made in two minutes. Of course it is impossible to know what the normal for each individual may be. Blight variations will be of no consequence, but serious bleeding so profoundly affects the blood that the haemoglobin will necessarily show a dimi- nution far below the line of individual peculiarity. Thus, in case of tumor in the neck, upon which an operation was performed, and in which there was much bleeding, the symptoms of hemorrhage were slightly marked, hsemoglobin count giving seventy-five per cent. In a case struck by a locomotive, and very profoundly- shocked, temperature 96, pulse 138, the hsemoglobin was over 100.. In a case lacerated by car wheels, the right leg and arm haiving been torn off, and in which it was alleged there had been no blieed-- ing, there was thirty-eight per cent, of hsemoglobin, showiiig: that the statements of those around this patient were not true. The only instance where this test failed was in a case of severe shock from spinal injury. The temperature was 96|, the pulse 80, the respiration 30. The man was very pale. Capillaries seemed empty, there was much difficulty in obtaining blood. Haemoglobin seventy-eight per cent. In this ease other symptoms sufficiently excluded severe hemorrhage. In instances where patients suffering from abdominal wounds exhibit the characteristic symptoms of either hemorrhage or shock, we think the hsemoglobinometer may aid in determining which of the two conditions is really present. Diagnosis. — We have alluded to the difficulty of determining whether or not a ball has penetrated the abdominal cavity. The question of deciding as to the presence of one or more severe lesions of the abdominal contents is still more complicated. As a general rule it is safe to assume that such lesions have occurred, but it is of extreme importance to the patient to be able to recognize the exceptions. To those who hold that visceral injmy 130 AVOUNDS AND OBSTRUCTION OF THE INTESTINES. is necessarily accompanied by shock, the distinction would be easy, but to the modern surgeon experienced in these cases or well read in the literature of to-day, a diagnosis is impossible. Certain symptoms are classical, as characterizing bowel lesions. Either fecal extravasation or the escape of gas through the external wound would positively denote that the alimentary tract had been opened, but in the absence of these two signs, and they are both as a rule absent, there is absolutely nothing which can be always relied upon in making a diagnosis of this injury. It is true that bloody vomit suggests a wound in the stomach, yet Me know the symptoms may occur, although the stomach has not been opened. Thus a ball may produce simply a contusion, with the resultant rupture of bloodvessels of the mucous membrane and hsematemesis ; the same is true in regard to the evacuation of blood from the bowels. Blood in the passages is extremely suggestive of a wound of the large intestine, if this blood be partially digested it has been proba- bly eifused from the small intestine, yet this symptom may be present without penetration of the bowel, and may be absent though there be multiple lesions of the digestive tube. Prompt meteorism was considered by older surgeons to be of peculiar value in making a diagnosis. Jobert ascribed this phe- nomenon to the escape of intestinal gas from the bowel wound. This is' not reliable, since many cases may run to a fatal termina- tion and never exhibit this symptom ; and simple contusion of the belly walls often produces extreme distention. Though as a general rule it is true that the belly does become tympanitic after pene- trating wounds, it is due more commonly to intestinal 2)aralysis, than to escape of gas into the general peritoneal cavity. The direction of the ball, the shape of the orifice, the wound of exit, if it is present, the presence of blood in vomit or feces, the position of the patient when injured, the constitutional condition, pain, all must be carefully examined into, as all these points con- tribute to a diagnosis. Even after a most extensive examination of symptoms, however, it must be confessed that there is but one way to determine the presence or absence of bowel wounds, and that is by opening the abdominal walls and searching with eye and finger. Stimson says that exploration is justifiable in every case of doubtful penetration. Baudens advises seai'ching for the WOUNDS OF THE INTESTINES. 131 wound. Chauvel states that every penetrating wound of the al)- donien by wea})on of small calibre, with probable vascular or visceral lesions, requires exploratory examination of the wound. Baudeus states that the intestinal wounds are almost always seated behind the abdominal opening ; hence, if there is any injury to tlic gut, enlargement of the peritoneal wound -will probably successfully demonstrate it; if not, the finger should be carried into the peritoneal cavity in search of blood or feces, or even a sponge may be thrust down through the intestinal loops to the dependent portions of the abdominal cavity. After such an examination, if no hardening of the gut, no feces, no blood, and no bubbles of gas are discovered, there is either no wound or one with which nature can cope. Prognosis. — This is unfortunately bad, and under any form of treatment the chances of recovery for a patient who suiFers from a penetrating gunshot wound of the abdomen are not good. In military surgery there can be no question but that the vast majority of these cases perish on the field. Beck remarks, " I have never seen any hospital patients suffering from wounds of either the small or large intestine." In all, death came quickly. Otis gives the mortality of penetrating abdominal wounds, as shown in our Civil War, as 87 per cent. He states that a great number of recoveries were those in which the large intestine w^as wounded in one of its portions not covered by peritoneum, the cure being frequently complicated by the formation of an artificial anus. Cases of re- covery where the solid or membranous viscera are wounded, with extravasation of their contents within the peritoneal cavity, Otis considers so rare that well authenticated examples can be counted on the fingers, while penetration of the peritoneal cavity without wound of its contents is nearly as rare. Gurlt states that in the Franco-German War of 227 cases of penetrating wound of the abdomen 59 recovered, 148 died and 22 were unaccounted for. In this last class it is possible that at least the majority recovered. Leaving them entirely out of the question, however, this would give a mortality of about 72 per cent. In the Crimean War 10 per cent, of cases were said to have recovered. In the Franco- Italian-Austrian War 34 per cent. The Franco-German War has shown a still larger percentage of recoveries (Chenu). Nimier "gives out of 5003 cases, a mortality of 80 per 100." 132 WOUNDS AND OBSTRUCTION OF THE INTESTINES. In all these statistics, differing so widely in their results, the mor- tality is probably understated. The only efforts at tabulating the result of gunshot wounds as inflicted in time of peace by weapons of small calibre, and not treated by operatiye interference are first that made by Stimson, who places the mortality at 65 per cent. ; next the records of Reclus and Nogues, who in a total of 88 cases note a mortality of 25 per cent. Against this last compilation must be urged, the objection which is applicable to all tabulations from reported cases. Hundreds of gunshot wounds terminating fatally are not reported by physicians simply because this termination is what is to be expected, and without interest to the medical reader. If, howeyer, there is clear eyidence that a ball has penetrated the peritoneal cayity, and in spite of this the patient subsequently recoyers, the case becomes one of great interest and rarely escapes becoming a part of current medical literature. Hence the rate of mortality giyen by such a table is far too fayorable. Against Stimson's table it must be urged that the diagnosis of penetration was not positiyely made, he eliminated, howeyer, many cases terminating fayorably, in which there was no symptom beyond penetration to proye intestinal wound. It has been shown that such cases may recoyer in spite of multiple intestinal injury, hence we belieye Stimson's figures represent more fairly the general result to be looked for from expectant treatment in wounds such as are ordinarily inflicted in centres of population, than any other com- pilation "that has yet appeared. The same is undoubtedly true of his table upon abdominal section, to which we shall later make reference. Reclus and Nogues haye included in their tables mainly such cases as give positive evidence of penetration with visceral wound. These cases they divide into three classes. The first comprising six, three of whom recovered, represent cases where an autopsy con- firmed the diagnosis of intestinal wounds, with, in the recovered cases, complete cicatrization. The second includes 56 cases, in all of which blood from the mouth or anus, or fecal extravasation evidenced visceral wound ; 44 of these survived. The third class, numbering 26, comprises cases w^here visceral lesion is made proba- ble only by the fact of penetration; 19 of these recovered. This gives a general mortality of twenty-five per cent. We WOUNDS OF THE INTESTINES. 133 have already given reasons for believing that it is by no means representative of the true mortality in these cases. Otis and many surgeons grant that wounds of the large intestine may heal, but are inclined to reject the possibility of this termina- tion in wounds of the small intestines. Our table shows that of 130 cases of abdominal wound, in 48 the small intestines only were wounded. In 4 the stomach only was wounded, in 8 the colon only. Unless the bullet enters antero-posteriorly in the lumbar region, no surgeon can say that the large intestine only has been injured, since siiot wounds are nearly always multiple and the small intestine is commonly involved ; still there is an almost universal belief in the greater mortalitv of wounds of the lesser bowel. This is perhaps owing to its more fluid contents, and greater mobility. Our statistics show that of 48 wounds of the small intestines only, 36 (75 per cent.) died ; while of 8 wounds of the large intestine only, 5 died, giving a mortality of 62.5 per cent. Of course it must be remembered that the small intestine wounds were usually multiple, while those of the colon were single, or at most through and through. Treatment. — As in the treatment of obstruction, the opinion of medical men is divided between expectant treatment and opera- tive intervention. Just now a great wave of surgical ardor has swept over our country, and the almost unanimous opinion seems to be that since these wounds usually penetrate, usually injure the viscera, and that when this occurs death is the rule, the first resort of the surgeon should be a formal section, with the idea, primarily, of determining whether or not the ball has entered the peritoneal cavity, next to find the seats of lesion, and apply to them the proper surgical treatment. The advocates of this treatment have pointed with much pride to the statistical record of cases operated upon, and of those treated expectantly. As types of the former they have taken patients wounded by weapons of small calibre, and in cases where medical aid was promptly rendered, comparing these results with those obtained when the wound was by a large musket ball, and was inflicted many hours before the patient could have the benefit of professional assistance. Because the results of operation have been slightly better than those following non-operative treatment under 134 WOUNDS AND OBSTRUCTION OF THE INTESTINES. tlic circuiiistanccs described, it 1ms beeu held that these figures con- stitute au absolute justification for the use of the knife. It is certain that not only is such a comparison unfair from the very nature of the two series of cases, but also because the tables compiled from reported cases are absolutely misleading. Stimson has given most positive proof of this fact in his analysis of the operative treatment of these cases in the city of New York. Whereas, for the purposes of the statistician, there were on record 1 2 cases of section, with 4 recoveries, giving a moi'tality of 66| per cent., in reality there have been 31 operations performed, of which 25 resulted in death, thus raising the mortality to 80.6 per cent. Applying these figures to the general tables, our own for instance, it will be seen that for purposes of com])arison, the latter are of little value. A comparison of cases treated by operation with those treated expectantly, in two hospitals in New York, each set of cases being under the charge of men prominent for their skill, gave about the same mortality for each method of treatment. From a statistical point of view Stimson's paper is undoubtedly the most powerful argument yet advanced against formal section as a routine treatment for intestinal gunshot wounds. The vari- ous objections to this procedure have been most ably collated by Reclus and Nogues who, as the result of a careful examination into statistics and after a certain amount of experience in these cases, formulate their ideas in the following words : — " In the present state of science, we believe that systematic abstention is less murderous than laparotomy." " By probing of the wound, introduction of the aseptic finger preceded by enlarge- ment if necessary, we can determine whether or not the peritoneum is opened. From this we decide as to whether the wound is in the stomach or intestine. We close the external wound by a pledget of iodoform and collodion, uniformly compress the abdomen by bandage, use morphia hypodermically, insist upon abstention from food, and by the mouth give only a few coffee spoonfuls of iced milk. Under this method we have had three successes from penetrating wounds by revolver balls." It is certainly true that the vast bulk of the profession favor immediate abdominal section and there can be no question but that this procedure has many times saved lives which would otherwise have been- lost ; but it must be carefully considered whether inter- SUEGICAL TEEATMEKT OF INTESTINAL OBSTRUCTION. 135 vention saves more lives than can be preserved by non-snrgical treatment. A very brief pernsal of our tables will show that the many deaths occur so sliortly after laparotomy tliat the inference as to this being the direct causative agent is most direct. It is clearly recognized that the success of operation diminishes in proportion to the time intervening between the infliction of the wound and surgical interference. Trelat states that after twenty-four hours the operation is practically fatal, and that septic peritonitis is the most frequent cause of death. An examination of the reported cases shows that hemorrhage, shock, and collapse must take the place of prime importance in case of death within twenty-four hours of operation. We believe that the advice given by Baudens fifty years ago is still in advance of the latest surgery of the day. His counsel is neither for formal abdominal section nor for abstention. Believ- ing, as he did, that practically all penetrating gunshot wounds of the abdominal cavity wounded viscera, but that these wounds were capable of spontaneous closing unless fecal extravasations had occurred, he counselled enlarging the wound and primarily dis- covering whether or not the peritoneum had been punctured. If this were the case he made a careful exploration of the abdominal cavity with the finger. If profuse bleeding or fecal extravasation was discovered he did not hesitate to make as large an opening as was necessary to find and remedy the cause of trouble. If, how- ever, neither of these complications were present he advised closing the parietal wound, even though intestinal injuries were almost certainly present, holding that nature was able to cope with these. Still earlier (1801), Dufort performed exploratory section, but as suture of the intestine was not then formulated, he fixed the wound in the external opening. It may be claimed that incision along the track of the ball ren- ders accessible only a very small portion of the peritoneal cavity, that where a ball has traversed from side to side or obliquely from above downward, such an incision may be absolutely inadequate for a thorough dealing with all lesions. This procedure consti- tutes, however, no contraindication to formal abdominal. It is used, primarily, simply as a diagnostic means. It decides whether or not the formal operation should be performed. In itself it but 136 WOUNDS AND OBSTRUCTION OF THE INTESTINES. slightly complicates the original wound. We believe with Baudens, with Stimson, witli many surgeons, that a wound of the intestine is not in itself an indication that the latter should be sutured. That this is the preferable course cannot for a moment be doubted, but where there is profound sliock, where every moment of continuance of operative procedure imperils a life ah-eady hanging in the bal- ance, we think there is less risk in leaving these wounds for nature to take care of than in unduly prolonging the operation. It will be seen from our tables that some of the operations lasted between three and four hours, hundreds of sutures being applied, the bowels being turned out from the peritoneal cavity, and sub- jected to an incredible amount of handling. Where the vitality is already weakened by severe traumatism, it is difficult to understand how life can be preserved under such treatment even for a few hours, and more than one case has perished on the table. The statistics of Keclus and Nogues are absolutely conclusive not only as to the possibility of cases of wound of the viscera by weapons of small calibre recovering spontaneously, but also as to the relative frequency with which this occurs. Where fecal extravasation has taken place, as ascertained by the exploratory incision, death is practically certain unless the gut wound be closed. Here the surgeon is justified in searching for and closing the source of leakage, no matter how grave the patient's condition may be. Where there is extensive hemorrhage into the peritoneal cavity, we believe that the formal operation should be performed and the source of bleeding sought, though, in one in- stance where this was done, the surgeon, after failing to discover and check the bleeding, finally produced haemostatis by closing and tightly compressing the belly wall. Manier advises in cases of hemorrhage where there is no indica- tion as to the vessel injured, medical treatment, compression of the belly, ligature of the extremities, and morphia hypodermically. There is fortunately in the treatment of gunshot wounds of the belly, not the same contest between the advocates of salines and morphia as there is in the treatment of other pathological conditions of the abdominal contents. All are agreed that morphia should be given and given freely in the first stages of these injuries, not so much for its direct effect upon the intestinal walls as for its con- stitutional effect. SUEGICAL TREATMENT OF INTESTINAL OBSTRUCTION. 137 It must be borne in mind that every severe injury to a segment of the gut produces a temporary paralysis of that segment, hence morphia given with the idea of checking peristalsis is not indicated. If the physician adheres to the older method of feeding by the mouth active peristalsis may be excited, but where the stomach is given entire rest there is nothing to inaugurate peristalsis until the wound is sufficiently advanced for it to do no harm. These cases should be fed by the rectum, should be stimulated hypodermically, and should be kept comfortable and quiet by the use of morphia administered beneath the skin. It must be recollected that fecal extravasation is most likely to occur in the neighborhood of the external wound, consequently this should be kept carefully under observation, and on the first symptom of inflammation should be promptly opened, since by this treatment fecal abscesses have been evacuated, which, if left to themselves, might have ruptured into the general peritoneal cavity. Senn's hydrogen test in the diagnosis of intestinal perforation is a means which if properly applied may be of service to the operator though it is not without decided disadvantage. The possibility that it might fail to detect wounds, even though these were present, was suggested to us when Senn's paper first appeared, and we performed a number of experiments which proved as conclusively as work upon the lower animals can, that this was the case. We stabbed one dog, making two wounds in the ileum, each a quarter of an inch in length, we then passed gas from end to end through the dog without getting the slightest escape through the parietal wound, although this was held open. We shot a dog, making two wounds in the stomach, one of the caecum and two of the lower portion of the ileum. The calibre of the ball was tVt5 again we passed gas through and through without having any escape from the wound. We then opened the peritoneal cavity and passed the gas, when it bubbled up from the region of the caecum, this wound was secured ; the bubbling still continuing, we secured the wounds of the ileum. Gas was now passed until it was belched up. Careful examination showed two stomach wounds through which only by the insertion of a probe we could make the gas escape. The ball had passed through the stomach obliquely, making a valvular opening. Even though the gut be widely opened it is conceivable that this 138 WOUNDS AND OBSTRUCTION OF THE INTESTINES, breach may be closed by fragments of food or of hardened feces. There are nearly a dozen reported cases where this test has failed on man. It is readily conceivable that it may determine a fecal extravasation ^\liich would not otherwise be present or act as the starting point of paretic distention, which might have been avoided. It is quite true that a wound that would not allow the gas to escape would probably not permit fecal extravasation, and if the surgeon accepts the teaching that only such wounds as are accompanied by extravasation imperatively demand formal laparotomy the test may be of value. If, however, he believes that all wounds must be sought and sutured whether primarily occluded by nature or not, he can place little confidence on this test. It is not for a moment claimed that wounds which primarily per- mit no escape of intestinal contents may not subsequently, from imperfect adhesions, from sloughing, or from too early establishment of peristalsis, gape widely and permit extravasation of intestinal contents with resulting diffused peritonitis. The standpoint taken is that the mortality will be better if the surgeon is content to treat cases in which there is neither primarily extravasation nor hemor- rhage expectantly, reserving the formal operation for cases in which these complications are present. As in obstruction, we would strongly protest against evisceration, unless this procedure be absolutely necessary, and would urge the importance of hastening all operative details. It is generally ac- knowledged that very small wounds need not be closed, that the first effort should be made at repairing the larger breaches, that if resection is necessitated by extensive laceration, or wound of the mesenteric attachment of the bowel, the quicker operations of lateral, or end to end approximation, are to be perferred to circular enterorraphy. In some instances it may be justifiable to form an artificial anus. Finally the peritoneal cavity should be thoroughly flushed with hot saline solution, and in all these cases drainage should be established for twenty-four hours. Symptoms other than those due to local peritonitis would indicate reopening of the belly with treatment appropriate to the condition found. (See Paretic Distention, Peritonitis, etc.) A high rate of success can never be expected, but it is certain that the mortality now prevail- ing can be lowered by proceeding with all the dispatch possible, SUHQICAL TREATMENT OF INTESTINAL OESTEUCTION. 139 and with the sole view of preserving life rather than of making an absolutely perfect operation. Conclusions. — Penetrating gunshot wounds of the abdomen wound the contained viscera in over 95 per cent, of cases ; in Go per cent, of all cases the small intestines are involved. The lesions are generally multiple. (2) These visceral wounds are capable of spontaneous closure and healing by prolapse of the mucous membrane, exudation of plastic lymph, and adhesions to neighboring peritoneal surfaces. (3) The common causes of death in abdominal gunshot wounds are hemorrhage and septic peritonitis. Though shock is generally a symptom of hemorrhage, especially if prolonged and deepening, it may, in itself, cause a fatal termination. (4) The mortality of gunshot wounds as treated by abdominal section is not better than that of those treated expectantly. (5) Beyond extravasation of feces there are no pathognomonic symptoms of wound of the viscera, though bloody vomit, blood in the passages, and long continued shock, suggest that such wounds are present. (6) Internal bleeding may be diagnosed from shock by means of the hemoglobinometer. (7) Wounds of the small intestines are more fatal than those of the large. (8) The treatment of abdominal wounds with probable wound of the intestine is, enlargement of the external wound for the purpose of proving penetration and injury to the viscera. If no blood or fecal extravasation is found in the peritoneal cavity, the external wound may be closed. If the visceral wounds are suffi- ciently patulous to allow of extravasation these must be sutured, formal abdominal section being performed if necessary. (9) Suture methods or other surgical procedures requiring much time are contraindicated, the mortality depending directly upon the length of operation. Evisceration should only be performed when absolutely necessary for the speedy completion of the operation. (10) Nothing by the mouth for from two to four days ; morphia to control pain, stimulants hypodermically and by the rectum, and food by the rectum constitute the after treatment. 140 WOUNDS AND OBSTRUCTION OF THE INTESTINES. CHAPTER XIY. RUPTURE OF THE INTESTINES. The term as here used is meant to imply a laceration or tearing of the bowel without rupture of the abdominal parietes. It may be consequent upon severe trauma applied to this part of the body, or may result from blows, jars, or falls, involving the body as a whole. Curtis, who has written most elaborately upon this subject, states that the rupture is really of the nature of a lacerated and contused wound, the gut being crushed between the contusing body and the bony walls. The jejunum and ileum are most frequently injured. The injury may tear completely across the lumen of the bowel, may produce a small rent, or may involve simply the outer coat. Extravasation is very frequent, though spontaneous healing may take place. Curtis describes two cases in both of which, although the bowel was torn across, the open ends were practically entirely closed owing to the mucous membrane prolapse, muscular contrac- tion, and adhesions of surrounding parts. The mesentery is very frequently involved, and when this is the case w^e have a most serious form of the injury, since bleeding commonly occurs, and in a form so violent as to be rapidly fatal. The form of violence which is most commonly followed by bowel rupture is that which is severe and concentrated, as by the kick of a horse, or of a man, or by the passage of a heavy wheel over the abdomen. The theory of laceration against bony j)arts would seem to be sustained by the fact that in general jarring, such as comes from falls, or from large bodies travelling with great momentum, the intestines commonly escape, the liver more frequently exhibiting the effects of the violence. Guthrie* instances a case where the ileum of a child was ruptured 1 Wounds and Injuries of tlie Abdomen. KUPTURE OF THE INTESTINES. 141 by contusion against tlie thumb of a person tossing it up and catcli- ing it. At times the intestinal coats may be only partially torn through, no extravasation taking place for some days when, as a result of secondary sloughing, the wound may involve all the intes- tinal coat, and give rise to a general peritonitis. Jobert says that a person frequently recovers from the shock of an abdominal contusion, but suffers from pain in but one spot, the rest of the abdomen remaining in a normal condition ; there is here produced a slough which may be subsequently thrown oif without harm to the patient, may lead to perforative peritonitis with localized abscess, or to general peritonitis with all its sequclse. As an ex- ample of this Poncet records the case of a soldier struck in the left hyj)ochondrium by a spent fragment of shell. There was no rupture of the skin, but symptoms of peritonitis developed imme- diately. Opium was given in full doses and the peritonitis was localized to the contused area, the rest of the belly being free from pain or inflammatory symptoms. An emphysematous tumor with central softening was shortly formed, which, on incision, yielded fecal matter. The patient died on the eighth day. Spaeth^ records a somewhat similar case, the patient recovering with an artificial anus. As an instance of how the intestines may escape in spite of extensive wounds, Vaslin^ describes a case in which the right flank was torn out by a shell, completely exposing, but not injuring the intestines. It has been shown that nature is equal to the temporary and permanent closure of a rent in the bowel even though this be exten- sive. Guthrie, in one instance, saw a patient aged 22, who had been run over by a carriage. The belly immediately became dis- tended and tympanitic ; there was practically no shock. Recovery was nearly complete when death took place from lung hemorrhage. A healed rupture of the small intestines, occluded by a button of omentum, was found. Guthrie states that apparently some effusion of air took place before the wound was plugged. When fixed viscera are wounded, or the mesentery is involved, rapid death from hemorrhage commonly occurs. When the intes- tines are ruptured, however, septic peritonitis is the factor in the fatal determination. 1 Berlin. Klin. Wocli. 21, Nov. 1887. ^ Cong. Franc, de Cbirur., ISSS. 142 WOUNDS AND OBSTRUCTION OF THE INTESTINES. Prognosis. — The prognosis of severe contusion, followed by symptoms of hemorrhage, or of intestinal wound is exceedingly gloomy. The outlook for contusion Avithout visceral injury, though threatening is comparatively favorable. Chenu,^ out of 130 abdominal contusions, states that 106 >vere cured. In the Civil War out of 125 cases, but tive died. Under the heading, " Wounds of viscera without involvement of the abdominal wall," 41 cases are recorded of Avhich number 21 died. Opposed to these figures are the statements of Albert,^ who, in 60 recorded cases, found but one recovery. The practical experience of every surgeon will at once lead him to contradict the truth of this appalling mortality. In the general wards of a large hospital it is not rare to have patients brought in suffering with the symptoms character- istic of abdominal contusion with visceral lesions. We have lately seen four of these cases, two of w'hom recovered after exhibiting the symptoms of a sharp peritonitis. One of the most striking instances of recovery after abdominal contusions is that narrated by Fryer.^ A lad, after a blow in the hepatic region, suffered from severe abdominal symptoms. He Avas jaundiced on the fourth day. Twenty-one days after the accident there was great abdomi- nal distention. Thirteen pints of apparently pure bile were with- drawn by means of a trocar. In the next three weeks twenty-eight more pints were removed. The patient recovered. Since, in cases of recovery, it is impossible to say whether or not the gut has been ruptured, in a given case of injury of this kind the chances for life cannot be calculated from statistics. Judging from the symptomatology of observed and of reported cases we believe that the mortality is not nearly so absolute as is generally believed, yet we freely grant that the chances of recovery, when the symptoms of bowel rupture are well marked, are few. Symptoms. — The first symptoms following intestinal rupture are usually those of shock, though this may be entirely absent as was noted in one of our fatal cases. Followino- this, extensive abdominal meteorism is the most char- 1 Cong. Franc, de Cliirur., 1888. s Lehrb. der Cliirur., 1885, Bd. 3, S. 39, 3 Medico-Chirur. Traus., vol. iv. RUPTURE OF THE INTESTINES. 143 acteristic and ominous sign. The pulse is very (piickly affeded, becoming rapid and weak, and either tlie chara(;teristic symj)toms of diffuse peritonitis, Math vomiting, constipation, tenderness, thoracic breathing and fever, or those of abdominal septicajmia with sub-normal temperature developed. Beck^ holds that the seat of rupture may be determined by local pain and dulness on percussion, and by hicreased resistance on palpation. This was particularly marked in Spaeth's case, developing within twelve hours of the original wound. Diagnosis. — Since rupture of the intestine is an exceedingly fatal accident, it is most important to determine whether or not this has really taken place. We believe the intensity of primary shock is misleading, since we have seen this condition far more marked in cases of contusion than in those where the gut was ruptured. Meteorism, too, may be well developed after simple contusion, and may be complicated by bilious vomiting and constipation. Where the vomiting continues and increases in frequency, where local pain, dulness on percussion, and sense of resistance are marked early in the case, and where other symptoms of peritonitis rapidly develop, then the diagnosis of rupture can be made almost posi- tively. The fact of recovery after the development of these symp- toms does 'not prove that rupture was not present. Treatment. — When the features of bowel rupture as detailed above, are present, we believe that an immediate abdominal section is indicated. It is well recognized that these lesions may be multi- ple, that the mortality of section in such cases is over 90 per cent., that the chance is desperate. We think, however, that it should be taken pi^ovided the characteristic symptoms are present. In the absence of these symptoms expectant treatment is indicated. In any case morphia and alcohol, particularly the latter, and in full doses, are indicated. Absolutely nothing should be given by the mouth. In cases characterized by deepening shock we should endeavor to exclude hemorrhage by means of the haemoglobinometer, and by careful palpation and percussion of the abdomen. If still in 1 Deutsch. Zeithschr. f. Cliirur. Bd. 15, S. 14. 144 WOUNDS OF THE INTESTIXES. doubt, tlicre should be no hesitation in making a small median exploratory incision, since this would add but little to the gravity of the case, and would at once decide whether or not Weeding were present. In cases of internal hemorrhage, no matter how desperate the patient's condition an effort should be made to secure the torn vessel. SECTION FOR GUNSHOT WOUNDS. 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H So PH CO H iJ a-s W X 0) in t< 01 ;^ .0 CO 0. ■ - . 0) w .^0 bb 2^S m M w . w . fp m 150 SECTION FOR GUNSHOT WOUNDS. v: O a OS l.z >.bot; i>>.i: ; cj a> ti ^ S o 'C S o « 5 h-^ o ^ .£ a IS oja &.a ~ca 3 a u a-a ©..a a a"TS a S a w a' 3 S o o a a IS 5 Srt ^ "q 00 O • A <^.;g.5 a S i^ " p S-2 o5 '-< • - . -^ .; S si's a o.t: S o ci s - S, bo a.S ^ o a § _bo.~ 'E.S aa B"^ bo -2S S g _0 IM ^ O I bo "3 a 2 a " a'lL r-'o'd ^ob o ^ >< -§■§3^ ai^ •B'^ta « 2 11: I 2-1 =s 2 a3 a a •—* otS-a o cd ..--a a «M .2 a § bi) .=3'^ ."fl c ^■a.S 2 s^-g &5 ^ a oja rt\ ■^ ,-, Q) ' ' (V^ £t 'CJCl ■?^ rt a o 3 3 ^ ' u &: o W 5 « ^ ? >5 ft ^ SSa« W Q !<; C3 ^ a:V^'"- hS .-<»j •^ fe •-; n m a. IB a«r a5 . ,2 "a ^ CO a " • cj _• «> oj .- _. ^ '^ _• i-h" S .0)00 -TO) -Cgcp ~2 s-^ 5 CC fc. rt g r^ (M 3 i-l 1^ rH c8 <; K- o u o ft ^s" =^bb^ .:2^ .te aS i-i - a' a 31" _S a ^ ft to . o5 a 00 bo<;" "S^ - 5 3 a ar'" J ^00 SECTION FOR GUNSHOT WOUNDS. 151 5 « K q .S o'S a! « ^ Es ^ -C^ ,^ ^ 9 s's I fl ? a <".:: ,!- tn d S 3 1) i i "g ol p 5 a.; « .rt be ■- r £ * • 2&S Ph "^ Si O □ --a 't3 S'" I o P o 3°-3|§-9 i .t- n :3 ni ^ .2 ^ i; a ° rt o> '§ s a pns Vs &o o T t^ C-° CD O --S •"S m"* ..'« ° ! 3.2 S p © bcg-jj i _ S o C r:, !h o a " M o S C C O o s --^3 •S o c« a O) o a ^ MI'S S ft g « a o rSr ■-2 " S !« so" c CO p.a a p- ,a -S ^sas. ~a? "a-^" CHESTS <.S a a ^ a c« h2?^ = a .=, ° '" ST 2 a' « > -. +^ _, O c^ p _o S ® ft < S S 5 a ^'dj aJ ri"^ '3 o -*J M >H W 5r K > p O M H £ Hs Q f1 \^= S-2S «-° a 2 ° a a S S_ 55.^ 3 « o.a t3 o 2 ." .^ '"» .S S al^ a o "g 5 ^^' a^s^-jll O gj 0) 13 ^ a Vi ^'3 en ° m'5 a ■wJ-^ a 2 a5 ="-2 S -• ^ ^^ g «^ a.2° °»a "^ a a a § o er' ,p -. "tH'^'N f^ CD 1^ T » =3 o -B ?: 5 a a o ^ S o o -g -^ ^,a S — >.a -Sfto ga 29 fi^ a; fcH r-t C3 CC _ !- .t; a ' a a o' .5'io -Sao 3 1 S ■ o a £■.£> a ?; aS is o a 2 o S 3 ^ o p s o r? -2 a-S SS IH o5 Ci +J 'C .a-s 5 g -iSTjiS a . .0 S ao ts a g « » -g . CJ--; 3 g rt a o « 2 3.2 m=S.:3 o2 S 3 •-=« S •- -t^'' a C3 0)— !h " ^ gj QJ 5 S.O m o „ P-~<„ ""5 s o s S o -• re's*; a.a o ° a^S •£^a JT3 a S aJ : 3 o r^ a ' o'&o'-S r» t. '" ai ^ a aS a S=3 S_o a a „ .3 o Ore ._a v^ -§ fe a o a ..o V '^.S O (p " o a -*-^ ^ a Qj g o2r;-« £ a ^r^ 2 O 3f !„ rt i.S.S a.^ F fe^— 2 a ; o is $ 5 J3 (>. ' M f^ W) — s fcs 3 d. a ■- a K .> BJ3 l?g &la1 0) Ot„ alls 3 g'33a;5=t's -i3 S;-S.S o.a-2 « ^ g o S Z W 2 ^ K Q < ^ B a ^ -tl ^ o*J m " S S- Si) (L, M 1 ^ 1 M a CD ■30 ci t^ a CO (M e-i f^ S f^ '"' 2 s < ss w u OJ < s & a a -< T-l t* • S 2 — • 5 g • C3.S .--, r^ 3 ^ O 9-= -a s O t» w o T3 '13 S -3 ;=•-; o c3 S ^ o i'S) CD r^ ■«^« 1§ ■ "O o "' o 2 ci9 ^ g'bB ^ § a GO'S 2-s tio.ti OS -a a o ^ cS O f^S .2 S a -w 13 S 5 ^ « a Sao 3 5 O 3 c3 o 2sg^ '^a "^ I ° S 2 § S'o »rt 3 ^^ " a^-o .5 2=2^ S g 1 3,rt o , ag.; g"ss a a a S S a 2 ? a^^ " -o ^ j3 a •- -.a.S'^ a « ^ ^ +^ o a c4 a Q,c3 m 'rf.2="'3 fi^ ° a S-Sa- '^ 1-2 a H a'B-j ^|a O O) * aid !«r-.'S las «^a ^ m a t. « a 3_g >.2 9"S ? w >i w ;? C5 > p O i-H ;^ 1 1^ M O i-^ T 03 W 1^ « Q 1^ <5 4) g o 3'i3 £ « g 0) O.P 3^ S £-.2 1 --o^s 2 g ^ O § g .2.52 2 --rg &-2 S g a ^ ^.£ 0.3 'B. OS rH 3 O CO •2 3 5 " 6iOa r-'S'S O S '-' o '^ "3 <" o^ ="3 9 ^ o o s o •SScSP W S.9 > o .9 R 8 9^ ^■. ^ m 3 O <^ tH ' o t, a> o "^ .„ c P P-S^^^ ■S ^ o " » '^.S a g a3 § a 60£ SRn3 ■S = p3 . •"^ o c„=« . o to ^^ c3 a Bgoa^5 ^2.1 00 ^ £a 03.2:=: Sa'gS'S O o SSH as h fcjto is „" oco f»rH ^ . (DO aj'di--'' soaco m a' pS<) 5 Hi *i 5^ !C Lutz, F. J. Annals of gery, VII., 91. .2_: =^ a: 5 5 156 SECTION FOR GUNSHOT WOUNDS. 55 to 3 § so c o c c ;c;soco^'c55' 3===r, r5of"S2t2' & ci " c i^ ^ "W £• bt 1; .;; 0) c c t; i^ < o 3 :■ SB OJ ® § ^-S S I o y^* is 2 ^ « •« O ■? ?^ O o ._^ S ja -a .q •-' /- ■5(M as<: "S •-'o !D a V t- O ^ rt 1 ci « t-i 3 .); bccs -ti' a5^ S S fe QJ 'I' o 01 oS'' ^-° S ^ « « o g o5 irt^- ft o 1 >i -a S_; ^ "■§,:; 9 's^a'S as a " q a « 3 ^a) - "^ X 36) mi "• . -g OJ cj A '< S— , CO Jill' „ llo-ati'a^ Ore?; l>^S'd P, g S S <«.1: 3 ..S.2 ■ '^ >■ o o " i« 3 o ■2 O ^•? -= = 0*3 t-.a-s 3 OS § 1 'OS '3®ga •-0) o^ — CJ3 O o -»-' r* ^ I- a. ■^ o fc: 3 3 „ a 3 g T3 3 M O 3 c« ■^ 22-- « S . §^ <=^fta s "|^a|-^1 g 3 g^-a Sar ^ o ? 3 rt 'i^ a3 ca^ P c3 3 3 -.J 3 3 P X S sa .2=S| »S| 173 o 2 ^ 3 QJ-S 3 = ad "^-32 3«-iS :5^ is W.5 a>i2 .2 -as ^a .3 K_- ^"^ o all! A S 2 o m O S Oj „ P t3 k Ji ^2 .2S. ^.2 --.2 a a " M a~S'3 t^ .S ^'■'^ o * 9 (2 O -fJ rt o =« -■~=w a. 9oo r-i\o a £ a ^ "^ -2 ""■^ oi2 "i2 a ^^ c<) ^ a o a ^75 a o) a tH I* .s t! n S ° 2 a ^ ■'"la'agti 2a-^^ = a^ ';< o3 0) S^ a n3 O 0.2 ^ o ^SS-^Mg, O O) -ti"^ ^ .2 k--2 ^ ■ a a. § g,-^ ^' a -^ oj 3 aSf C-i'ag o o"" 2 S?<" a «■£ od""S .2Sa3£-a, .2-^ a-r-e a O S TS O O rA VI a ^ O M o a o B,Q t-. " S^ CO 3 ^ S ■n o '-l r « ^go^ <=> 0) 2 a ^ TI •■ IC tH a .r^ r4 '■— a d o p,a bOo ■-2«^ to O r-l ^* ^ O ^ S'a.2 a p S w a-g^-^ M-3 ffl -2 p,^ '3 (-1 — t-^ ^ o a •7_^ o -g -t;;2'><"" a oo -^^^^ =^^=2 . a a"';3 OHN--.S =« > T-< en o ais o 3 a. tH rt o o .-to oj a > r; .a ^ c3 ■-: t; o « a g o^ a a" = ^=*S H H fc; K fe p O M a ? :: „ H ^ 1 H fi5 N f=i li t< S o P f« 02 m Hi S9« gCO I" ■a^ ai-H =5 - W fflS aw o !5 - ?;i^ i=i CO r-' — ■:; =0 158 SECTION FOR GUNSHOT WOUNDS. p Died. Died. Died. Died. Died. Recov'd. Died. s| ii mil -m^mf mi^i o i-* S-s -S-c^^'S g,ao •-•>>-" Ph PhPh (ilpHPHPHP-i SECTION FOR GUNSHOT WOUNDS. 159 3§ 2 p< ■H'2'2 * o c3 . .2 =^ O S fi fl ci .gS C4.2 S Ors"- -? « V. o _,. Ill ^ S s M'siil 'g ^ re be- O 2 9-^ 5^ B 0) ^^ - ,_ o c c o t- o o a ^ 07:; o -g^ 2 — ' 2 « fl ,2 o -i e jg,^ c3 iH ce o'Bio oj g-g iria. O ^ ; ^ "o CS o t< o ^ a o 3 ? 3 ? = ^5 •SPo-j: rf— ■ 00 o -r;!*. «-Q a.-s s > D c3 (-"5 —o C3 O « o o ■- •- ' ^r^ o^^ 2:a-r-i'^ o a^'d_r m'd t^ iH tuna 3 rH o>iic o S g a.3-s-°a^ as 2 s -° 2^ 2 --= «■ C3 O - o Cfi boo «iJ P S --^ ■sago =i h X o P O

■ & o'n o.S^ a a c o 2 =^ p ^ 3 a S ^'d S r-a -« o 3 E='3 - 0) o ^ t>.0"« o « c3 O o :a5§ ' . a 3 » 2 e^ ag- es -5 - S a C g ^ a = ai a a a a Cm mjO '^-■ 5; Jj^ o o p o ? a; s o (*^-r'5 a § - - . _ a S 3 o" E - 5-SS^|o 5 B : c ^ o o S =3 1= 2"-^ a'" 5S a?! -co Ck Pk 's a as -to .t^ ID c ur ^ bo i< ■ K-a oM si5 f« ^ CO c a r a o'lSL-i .2i^S'^ d|1 160 SECTION FOR GUNSHOT WOUNDS. H •6 D t: 13 rs ■0 Pi « o Q « < go. O c o a. 3 .a S 3 ■a i o- ^5 g i .a 3 a 0) a a a a a C 3 • S = 5 .= - S S g^2.i:;iag| Se =.£ =;2 f H . t^ £ =«• aJ a ai A ^ •s a a §1 !^ N C-l Si- .2 a a ^ a «,eg OM "^ T! % ■s 3fl< a> o S ° OQ O O (A G O -^3 n a S a -^ a a •-— ■-'tf « . S f 2 - >> - E-i OS w a' O C3 a o o a O d =1 SiJ gli'SIa c S b a ■5 a •B rt i- J; u k>.a tiK ^ O "3 '5 a ■*^ o C3 a ;3c.2 1-2 a ■='a--=i;-3o j4 a a o a 5 OJ 0) •a 3 m a O a r; a^ a « £;'"Sai-\.o I5|l5a ■< _ <^_ 1-^ < M — Oj oi §• ,S.a 60 >-.o3.2 m -^•^ £-2.2 a ^■:3 53 U5xl^'a a tutstj c a fc. o a o aa IS 2'a ,a.; a.s p o ^ 05^;^ .9 -^'-i '?. I o.:i o a ^ a -- "13 -o 2.a 5^^ o a O !ao'^ a ; 5: c g ' cu^a 3 i.S.a o OS ■p'a o^-a 5' 2 rt x: ^ ^ 3 « ^ o P S t< „> =* a. Sal^N Ft vh g > a a & <_ fe-2 ui- a- ^ a 'Zr — — -* ■S°a3 i's^ bdS a^io.s o ? 3 SS5S ft -!! 14 >j t/J n H Q ^A V^i <) -?aD -S ° sa ' fl'bc O '-^ O =* O C3 '^ fl« o a g fSrd s a ><: ^ Vl SE &D g SaS.a i^G ^^-Vl C3, 1-2 <4h c5 ^XJ p; &o" (M or^^oji— I .i- rj O HH f^ M K ? ■< CO " M 1-1 a =3 o-H , a.s's K n M (D'-l C 13 O 00 a SS .^^^- . a S « g-as at-jgcB aS '^^ >a3fW^ £t7L°a> 162 SECTION FOR GUNSHOT WOUNDS. s 3 0 jJ S n1 bo? 3; c« « 3 -^^ 0) 2 Ot3 3 S3 9 < s o • t- — 3 • ;_^g 0.2 ps- ^ bo a> bo ■;3^-: a 3 >.iS S 3 a c - o C cs ••- 3.2 g| 9c'H 35 2§ *^'? 3,0) 2? m-^ ■ £j3^ a >» ° '- S * ^ a •-c|xi S.2 .2 '? >-^ !*.§<« a « >-t„ S 's ■°^-2o-§.9 :|.^23o2 fi^ 9 i '*'!3 a S ",£:-!3 3 _« b ?.9"Sb a. 2 P= ^ ■< Cd in H 5r* a jais o=" o o ■ ^.9fl t^^-" 3 2 f= 3.9 ;s "f-i a g a § o g fi o g " 3 a o " '5? =? ^ ' o.S s-g 5= a cS°a.^ .2S,°| "1 2"* V a r a3 CO ja _ '^ booo <^ 300 SSPh SECTION FOR GUNSHOT WOUNDS. 163 Died. Died. Died. Died. Died. Recov'd. Died. o Sec Si fi0^p«!g ft -ft m- s^'^S. i5 O 1 ft ?^- aS III, ^r 1 .2° 1. 1 II i"i!l 1i 1 II II 1 r^ Ills |.s 1 1^ 1^. Condition op Patient. , §§-5-^ oHS-a 2„ S"=sg.2 1 ' III! 1 |iai|i! |li.li >^ P I-! !a M fH O « o P5 B . ^^ -Isll l^s III .i: liasl •a gs r^-=^ =:^|'s gli i^sl ^^|g^i g gg 5=*|« «-o^, S .> ^5° ^|;-.^?2 ■S =^-2 I^^'S.S? . fl -« 0053 «.S?o a'^ag"^ Interval BETWEEN injury AND OPE- RATION. S S Sh" CO g 3 3 3 b 3 12 2 ^ 1 ' .a .a .a "* ' .a 4 Ill II II 1 1 || II II Age AND Sex. s s as s ^ |S ^ i K ^.j'SlgS^^^.'S -^Sg a-S" |ii "^-^.^S 3d CB H f> ^ ^ ^ 164 SUMMARY OF SECTION FOR GUNSHOT WOUNDS. SUMMARY OF THE TABLES OF GUNSHOT WOUNDS OF THE ABDOMINAL CONTENTS.! Gunshot womids of abdomen Result not determined Mortality of 129 cases Wounds of small intestines only . Recovered 12. Died 36. . Wounds of small and large intestines Recovered 10. Died 4. Wounds of large intestines only Recovered 3. Died 5. Wounds of stomach only Recovered 1. Died 3. Wounds of hollow viscera (stomach, intes- tines, and bladder) . Recovered 2. Died 13. Wounds of solid viscera Recovered 5. Died 7. Wounds of solid and hollow viscera Recovered 3. Died 9. . No visceral wound Recovered 6. Died 2. 130. 1. 48. 14. 4. 15. 12. 12. 8. 66. G per cent. (86 cases). Mortality 75 per cent. Mortality 28.6 per cent. Mortality 62.5 per cent. Mortality 75 per cent. Mortality 86| per cent. Mortality 58^ per cent. Mortality 75 per cent. Mortality 25 per cent. TIME INTERVENING BETWEEN THE INFLICTION OP THE INJURY AND SURGICAL INTERVENTION. Two hours Four hours . . Eight hours . . Twelve hours Twenty-four hours 24. 20. 21. 7. 22. Recovered 11. 10. 3. 3. 3. D After twenty-four hours 11. ied 13. " 10, " 18. " 4. " 19. " 9. Mortality 54^ per cent. 50 " 81.8 " 57.1 " 86.3 " 81.8 TIME INTERVENING BETWEEN OPERATION AND DEATH Two hours Four hours Eight hours 8 cases (shock or hemorrhage). 2 <( a u 8 " (shock or hemorrhage, except 1 from peritonitis), (shock, hemorrhage, and peritonitis). Twelve hours ... 6 Twenty- four hours . . 13 " " " " " After twenty-four hours . 32 " (peritonitis, intestino-peritoneal septi- caemia, hemorrhage). Death within twenty-four hours is usually due to bleeding or shock. Death after twenty-four hours is usually due to peritonitis. 1 In preparing the preceding table we freely consulted the statistics of Coe and Morton. SUMMARY OF SECmON FOR GUNSHOT WOUNDS. 1C5 TIME CONSUMED IN OPERATING. One half hour . . 2 cases. Recovered 1. Diec 1 1. Mortality 50 XJer cent. One hour . . . . 4 3. 1. 25 " One and a half hours (3 4. 2. 33^ " Two hours . . . 8 2. 6. 75 Two and a half hours 3 1. 2. GO?, " Three hours or more 5 0. 5. " 100 " CALIBRE OP BULLET. Shot by No. 22 bore. 10 cases. Recovered 5. Died 5. Mortality 50 per cent.- 32 " 2(i '* 10. " 16. 01. 5 " «' " 38 " 17 " "9 i( 8. 47 it (< 44 a 5 u << I (1 4. 80 " Intestines resected 10 cases. Died 10. Mortality 100 per cent. The tabulation also shows that multiple wounds and profuse internal bleeding may be accompanied by very slight shock ; that comparatively slight wounds may pi'oduce profound shock. The mortality in cases of severe shock is about 90 per cent. In cases of moderate or slightly marked shock about the same as for intestiiaal wounds in general. INDEX. ABDOMEN, ice to, for obstruction, 105 puncture of, in obstruction, 107 Abdominal massage in obstruction, 104 section for obstruction. 111 Acute peritonitis, symptoms of, 68 Atresia of oesophagus, 19 BELLADONNA in obstruction, 90 Blood, general evacuations of, in intussusception, 33 Body heat in obstruction, 97 Bullets in treatment of obstruction, 106 CHRONIC intestinal obstruction, 18, 63 Classification of intestinal obstruction, 17 Colotomy for obstruction, 110 Complication of abdominal section, 121 Conclusions as to gunshot wounds of intestine, 139 Concussion of intestines, 141 Congenital malformations, 19 Constipation in volvulus, 49 DIAGNOSIS of gunshot wounds of in- testine, 129 of intestinal obstruction, 81 of intussusception, 35 of obstruction due to foreign body, 55 of obstruction of intestine, 21 of peritonitis, 72 of rupture of intestine, 143 of volvulus, 50 Distention of abdomen as a symptom of intussusception, 34 Diet in obstruction, 90 Diffuse septic peritonitis, 67 ELECTRICITY in treatment of ob- struction, 94 End to end approximation, 116 Enemata, treatment of obstruction by, 91 Enteroliths, obstruction from, 54 Enterostomy for obstruction, 108 Ether in treatment of obstruction, 106 Etiology of intestinal paralysis, 57 FOREIGN bodies, obstruction from, 52 G^ ALL-STONES, obstruction from, 54 IT Gaseous injections in treatment of obstruction, 95 General peritonitis, 66 Gunshot wounds of the intestines, 122 diagnosis of, 129 prognosis of, 131 treatment of, 133 H EAT, bodily, in obstruction, 97 ICE to abdomen for obstruction, 105 Ileo colostomy, 118 Injections, gaseous, in treatment of obstruction, 95 of ether for obstruction, 106 in treatment of obstruction, 91 preparation of, in obstruction, 102 Implantation, 118 Internal strangulation of intestine, 40 Intestinal obstruction, 17 diagnosis of, 81 prognosis of, 85 paralysis, 57 prognosis of, 159 rupture, treatment of, 143 symptoms of, 60 Intestine, rupture of, 142 Intestines, gunshot wounds of, 122 prognosis of, 131 168 INDEX. Intestino-peritoiieal septicaemia, 68, 70 Intussusception, 28 LATERAL apposition, 116 Lavage, treatment of obstruction by, 91 MALFORMATIONS, congenital, 18 Massage, abdominal, in obstruc- tion, 104 Medical treatment of peritonitis, 76 Medication in obstruction, i^0 Meteorism in volvulus, 49 Mercury, metallic, for obstruction, 105 OBSTRUCTION, abdominal section for, 111 belladonna and opium in, 90 bodily heat in, 97 chronic, 63 treatment of, 64 colotomy for, 110 diagnosis of, 21 diet for, 90 enteroliths as a cause of, 54 enterostomy for, 108 from foreign bodies, 52 from gall-stones, 54 gaseous injections in treatment of, 95 ice to abdomen for, 105 injections of ether for, 106 t mercury, metallic, for, 105 posture in treatment of, 106 prognosis of, 22, 64 puncture of abdomen for, 107 salt solutions for relief of, 102 spasmodic, 63 surgical treatment of, 107 symptoms of, 20 treated by abdominal massage, 104 treatment of, 23 by bullets, 106 by electricity, 94 by injections, 91 Old age as a cause of volvulus, 50 Operative treatment of intestinal ob- struction, 86 of peritonitis, 73 Opium in obstruction, 90 PAIN in volvulus, 49 Paralysis, intestinal, 57 Pathology of obstruction due to foreign bodies, 54 of strangulation, 42 of volvulus, 48 Peritonitis, 66 acute, symptoms of, 68 diagnosis of, 72 operative treatment of, 73 -treatment of, 73 Position in treating obstruction, 106 Preparation of lic^uids for injection in obstruction, 102 Progressive suppurative peritonitis, 66, 74 Prognosis of chronic obstruction, 64 of intestinal concussion, 141 obstruction, 22, 85 paralysis, 59 of intussusception, 35 of gunshot wounds of intestine, 131 of obstruction due to foreign body, 55 of volvulus, 48 Puncture of the abdomen in obstruc- tion, 107 RUPTURE of intestine, diagnosis, 142, 143 treatment of, 143 SALT solutions for injection in obstruc- tion, 102 Section, abdominal, for obstruction. 111 Senn's modification of Jobert's invagi- nation, 116 Septictemia, intestino-peritoneal, 68, 70 Strangulation of intestine, internal, 40 pathology of, 42 treatment of, 44 symptoms of, 42 Spasmodic obstruction, 63 Surgical treatment of intestinal obstruc- tion, 107 Summary of subject of intestinal ob- struction, 27 Symptoms of acute peritonitis, 68 of internal strangulation, 42 of intestinal paralysis, 60 of obstruction, 20 due to foreign body, 55 of rupture of intestine, 142 of volvulus, 49 TEMPERATURE of body in obstruc- tion, 97 Tenesmus in intussusception, 33 Treatment of chronic obstruction, 64 of gunshot wounds of intestine, 133 of intestinal paralysis, 61 rupture, 143 of intestino-peritoneal septicaemia, 75 INDJOX. J GO Treatment of intussusception, SG of obstruction, 23 by bullets, 10(j by enemata, 91 by ether, 100 by massage, 104 by lavage of obstruction, 1)1 due to foreign bodies, 55 peritonitis medical, 71 posture in, 106 of progressive suppurative perito- nitis, 74 of peritonitis, 73 operative, 73 of strangulation, 44 surgical, of obstruction, 107 of volvulus, 50 Tumor as a symptom of intussuscep- tion, 34 yOLVULUS, 47 V constipation in, 49 diagnosis of, 50 meteorism in, 49 old age as a cause, 50 pain in, 49 pathology of, 48 prognosis of, 48 symptoms of, 49 treatment of, 50 vomiting in, 49 Vomiting as a symptom of intussuscep- tion, 33 in volvulus, 49 WOUNDS of the intestines, gunshot, 122 treatment of, 133 12 DEC IE V^.li' COLUMBIA UNIVERSITY LIBRARIES (hsLstx) RD 540 IVI36 C.1 The surgical treatment of wounds and obs 2002246562