SUBCUTANEOUS INJURIES OF THE ABDOMEN their anatomical position. Engorgement during ...

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SUBCUTANEOUS INJURIES OF THE ABDOMEN
BY DEAN LEWIS, M.D., AND I. RIDGEWAY TRIMBLE, M.D.
OF BALTIMORE, MD.
PAPERS have appeared from time to time during the past several years
which have dealt with subcutaneous injuries of the abdominal viscera and
penetrating wounds of the abdomen. During the period from i885 to I890
the mortality of subcutaneous injuries of the abdomen was-from 6o to 70 per
cent. By I900, the mortality in this type of case had been reduced 30 per
cent. Demel published a paper from Eiselsberg's clinic in I925, which cov-
ered a period of twenty-three and one-half years, during which time I26
cases had been observed. The mortality in this series was 2I.9 per cent.
The character of the force causing subcutaneous injury or injuries is
extremely variable and it may be applied in a number of different ways.
Some have emphasized especially the importance of the way in which the
force is applied in affecting different viscera. Force applied to a circum-
scribed area is more apt to injure the intestine or kidney, while force which
is applied more diffusely over a wide area is more apt to injure the liver,
spleen, pancreas or blood-vessels. Some viscera are protected because of
their anatomical position. Engorgement during physiological activity may
predispose to injury, also pathological changes in the organ to which the force
is applied indirectly. The viscera of the young and those which have plas-
ticity are not as frequently injured as are those of the old, or those which,
because of fixity, cannot change form or location when the force is applied.
The mortality has been reduced in the subcutaneous injuries because
the possibility of involvement of the solid viscera or intestines and bladder
has been so emphasized that caution is always exercised, and with increasing
experience the surgeon has improved in diagnostic ability. Exploratory
laparotomy is much more frequently resorted to than before, and, as a result,
many injuries are recognized and repaired which formerly would have ter-
minated fatally because of haemorrhage or peritonitis.
In the series about to be reported there are I40 cases of subcutaneous
injuries of the abdomen. Forty-five of these cases have not been analyzed,
as they were treated expectantly and the injury of the abdominal viscus
was not demonstrated. All of these patients had symptoms of intra-
abdominal injury which were marked and serious enough to warrant
hospitalization.
Injuries of the Liver.-In this series are twenty cases of rupture of the
liver. An operation was performed on fourteen of the twenty and six of
these died, giving a mortality of 4o per cent. Four patients were not
operated on because of many complicating injuries. The mortality, then, in
the twenty verified cases of rupture of the liver was 5o per cent.
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DEAN LEWIS AND TRIMBLE
How extensive the injuries may be is indicated by the history of one of
the cases admitted to the hospital in the eal-ly 'nineties. The patient was a
forty-nine-year-old Negro who was unconscious when brought to the hospital
after having been run over by a cart. The pulse was iio and feeble, the tem-
perature was 95.60 F. Judging from physical findings, some of the ribs on
the right side were fractured. The patient soon regained consciousness, but
complained of thirst, became extremely restless and the extremities were cold.
The patient died seven hours after admission, not having recovered suffi-
ciently from shock to justify any operative procedure. The autopsy revealed
a rupture of the right lobe of the liver and right kidney, intra-peritoneal
haemorrhage and fat embolism of the lungs.
The histories of two cases of rupture of the liver with associated injuries
follow:
CASE I.-D. T., a white male, aged thirty-four, fell into the hold of a vessel, a
distance of twenty-five feet, about two hours before admission. Both femurs were
fractured at the middle third, but no other injuries were discovered. The lower ex-
tremities were dressed in extension and the patient seemed fairly comfortable. The next
day the temperature rose to IOI.80, pulse I20. The patient complained of severe pain in
the left side. He became delirious, the temperature and pulse rose rapidly, reaching
io8.8° and 170 at the time of death six days after admission. The autopsy revealed frac-
tures of both femurs, rupture of the liver and haemorrhage into the pleural and peri-
toneal cavities.
CASE II.-A. G., a white girl, aged nine years, was struck by an automobile, and
when brought to the hospital was in acute distress. She complained of pain in the
abdomen and left arm. The pulse was as high as I30 and almost imperceptible. Gen-
eralized abdominal tenderness, most marked in the right upper quadrant, was noted.
The left humerus was fractured.
A laparotomy was performed two hours after the injury. A large laceration was
found in the dome of the liver. This laceration was packed with gauze and some sutures
inserted. The child recovered rapidly and completely, although some consolidation of the
lung was noted and there was a pleural effusion.
The mortality of rupture of the liver is greatly increased, as may be seen
by associated injuries. Edler collected I89 subcutaneous injuries of the
liver and found that the mortality was 85.8 per cent. when there were associ-
ated injuries. In -rupture, unassociated with other injuries, the mortality
was 78.2 per cent.
The diagnosis of rupture of the liver cannot be made with certainty.
A provisional diagnosis can be made when there are symptoms of internal
hzemorrhage, when there are localized tenderness and rigidity in the right
upper quadrant, and when the force applied has been such that rupture might
be suspected. Falls from a height, the patient striking upon the feet, not
infrequently cause rupture of the liver. We have not noticed bradycardia,
which Finsterer regarded as a rather characteristic symptom; neither have
we noted pain radiating to the right shoulder.
In all the cases the capsule of the liver was torn. The "sub-capsular
rupture" with destruction of liver parenchyma described by Brandberg has
not been encountered.
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SUBCUTANEOUS INJURIES OF THE ABDOMEN
The treatment has conlsisted of packing with gauze combined with suture
when sutures alone would not suffice. Gutta-percha has also been used as a
drain to facilitate the escape of bile from the surface of the laceration.
The prognosis in the uncomplicated cases depends upon the early diag-
nosis and early control of the haemorrhage. It is somewhat surprising that
the uncomplicated cases in some statistics have a higher mortality than the
complicated, for the patients are brought to the hospital later, when the
injury to the abdominal wall, unassociated with other injuries, seems slight.
Rupture of the Spleen.-In 1928, Connors read a paper before this society
in which he summarized the studies of thirty-nine cases of splenic injury.
It included all injuries of the spleen encountered in the Harlem Hospital
during a twenty-three-year period (I905 to 1927, inclusive). The injury was
demonstrated at autopsy or by operation. In this paper it is pointed out
that in the period (i906 to I9I6) there were twelve admissions to the hos-
pital for ruptured spleen, and of these twelve only three were due to auto-
mobile accidents; while in the subsequent eleven-year period (I917 to I927)
there were twenty admissions for splenic rupture and fourteen of these
twenty cases were the result of such an injury.
The following cases will be cited to indicate the mechanism of rupture and
the symptoms:
CASE III.-This boy, aged twelve, was standing at a corner when an automobile
passed. The driver leaned out of the window and slapped the boy over the left upper
abdomen. The boy doubled up with pain. That night he became pale, perspired freely,
suffered from abdominal pain and vomited. He was brought to the hospital thirty
hours after the injury. The temperature was ioO°, pulse I30, blood-pressure IIO/70 and
hlemoglobin 6o per cent. He complained of pain in the left upper quadrant of the abdo-
men, which was somewhat distended. The abdomen was generally tender, but the rigidity
was most marked over the left half and dullness could be made out in the iliac fossa.
Repeated blood counts revealed a falling cell and haemoglobin count. Because of the
symptoms and the character of the injury, a diagnosis of ruptured spleen was made.
The abdomen was opened through a high, left, pararectal incision. A fragmented
spleen was removed and the patient recovered rapidly.
CASE IV.-E. J., a colored man, aged twenty-three, was struck in the lower left
back by a brick about one-half hour before admission to the hospital. He experienced
severe upper left quadrant pain. The temperature was IOO.40 F., pulse 92, haemoglobin
8o per cent., white blood-cells I9,250 and blood-pressure I5O/88. Extreme tenderness
was noted over the entire abdomen, most marked in the left upper quadrant. An opera-
tion was performed and a ruptured spleen removed.
Another mechanism of rupture is illustrated by the following case:
CASE V.-T. W., a colored male, twenty-nine years of age, fell three stories, striking
on a concrete pavement. When brought to the hospital the temperature was ioI° F.,
pulse 82, respirations as high as 48, blood-pressure II5/7O. There were no signs sug-
gesting injury of the brain or cord. Pain in the abdomen increased while the patient
was being observed, as did the rigidity. The symptoms as they developed pointed to a
rupture of the spleen. When the laparotomy was performed a rupture of the spleen
was found. A splenectomy was performed. Pneumonia developed and the patient died
on the fourth day. An autopsy was performed. There were no peritoneal changes.
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DEAN LEWIS AND TRIMBLE
Extensive bronchopneumonia was found. A number of ribs on the left side had been
fractured.
During the past few years several papers dealing with rupture of the spleen
have appeared. The prognosis depends upon the severity of associated in-
juries and the time at which the operation is performed. Early diagnosis,
as in most surgical emergencies, is of prime importance.
The principal symptoms are those of shock and haemorrhage. It is often
difficult to determine whether the patient is suffering from shock or haemor-
rhage. Operations undertaken while the patient is in severe shock will in-
crease the mortality, and, on the other hand, operation should not be delayed
until so much bleeding has occurred that the chances of recovery are
greatly reduced.
All patients complain of abdominal pain. This, in by far the greater
number of cases, is in the left hypochondrium. It may, however, be general-
ized. Abdominal distention occurs in most of the cases. In our experience
the most important points are the history of the accident, pain in the left
hypochondrium, abdominal rigidity, dullness in left iliac fossa, increase in the
pulse rate and a falling cell and haemoglobin count. In suspected cases a
blood count should be made on admission and repeated at frequent intervals.
Other symptoms have been described, such as pain in the left shoulder, and
vomiting, and considerable importance has been attached to them. These are
not infrequently incidental, and undue significance should not be attached to
them. In some instances the case may be regarded as that of an acute abdo-
men, and the rupture of the spleen is found when the abdomen is opened.
Surgical judgment must be exercised as to when an operation is to be
performed. In the badly shocked case a fatal outcome may follow a poorly
timed operation. Pool has pointed out that in some cases there is a distinct
latent period between the subsidence of the symptoms of shock and the
beginning of the symptoms of internal haemorrhage. The operative risk will
be reduced if this is kept in mind and the operation is performed in the
interim (the latent period).
We much prefer removal of the spleen to suture of the rent, which is
impossible in many cases, and to tamponade, which may be followed by
secondary haemorrhage. In most cases, splenectomy is as simple as either of
the other procedures. The physiology is not altered and the patient, if he
survives the operation, makes a complete recovery.
Spinal anaesthesia is advocated by some. We have used a combination of
gas and ether anaesthesia.
There are seventeen instances of ruptured spleen in this series, fourteen
of which were operated upon. Four of the fourteen patients died, giving a
mortality of 28 per cent. The four deaths occurred in patients with multiple
injuries. One had a ruptured lung; one a rupture of the kidney, laceration
of the colon and fractured ribs; one a fractured skull, fractured femur and
fat embolism; and another died on the fourth day of bronchopneumonia.
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SUBCUTANEOUS INJURIES OF THE ABDOMEN
This patient also had several fractured ribs. The associated injuries were the
cause of death in these cases.
The diagnosis must be made early, but considerable surgical judgment
must be used in determining when the operation should be undertaken.
Injuries of the Intestines.-The intestines are not infrequently involved in
subcutaneous injuries of the abdomen. The small intestine is more frequently
injured than the large and the stomach less frequently than the large intes-
tine. Wyss, in his paper, deals with thirty-nine injuries of the gastro-
intestinal tract. The duodenum was involved in five cases, other segments
of the small intestine in thirty-two and the large intestine in two cases. The
force is usually circumscribed, and the patient gives a history of being kicked,
struck by a stone or run over by an automobile. A bursting rupture is also
occasionally seen. The intestinal loop may be ruptured from within by its
contents of liquid and air. A bursting rupture of this kind is usually long,
extending over a considerable segment.
As a rule, an initial shock follows the application of the force. Not infre-
quently, however, the patient walks into the hospital and clinically shows no
evidence of impending danger. The possibility of rupture of the intestine
must be kept in mind when circumscribed blunt force is applied to the abdo-
men, and the patient should be hospitalized. Within a short while, we have
seen a patient die who refused hospitalization. This patient, an elderly man,
was kicked in the abdomen one morning by his son-in-law. He was a Pole
and understood English with difficulty. Many attempts were made to hos-
pitalize this man, but he refused to enter. The next morning he was brought
to the hospital, ,a spreading peritonitis having developed. He died shortly
after an operation was performed. All suspected cases should be hospitalized.
There are eleven cases of rupture of the small intestine. Eight of these were
operated upon and five died, giving a mortality of 62 per cent. One case
that recovered was operated upon within three hours and another within
twelve. A perforation of the ileum was found in the third, but a local
abscess had formed which was drained.
Petry reports I99 cases with a mortality of 87.5 per cent.; Hertle I38
cases with a mortality of 76.8 per cent.; Wyss thirty-nine cases with a
mortality of 33.3 per cent. Just reports eleven cases of rupture of the small
intestine from Ranzi's clinic (Innsbruck) with but one death, a mortality of
9.99 per cent. These figures are the best yet given. Seven cases were
operated upon within six hours with one death; two cases in from seven to
twelve hours with no deaths; two within from thirteen to twenty-four hours
with no deaths. All were ruptures of the small intestine without associated
injuries.
A provisional diagnosis may be made by the history and usual clinical
signs and symptoms. The X-ray assumes a role of unusual importance in
these cases, for when free air is demonstrated in the peritoneal cavity there
is no doubt as to the procedure to be followed. Exploratory laparotomies are
44 689
DEAN L.EWIS AND TRIMBLE
not inifrequenitly performed. If recovery occurs, there are few, if anly,
sequelae-these may be post-operative hernia and steniosis of the bowel.
Rutpture of the Kidney. In the records of the hospital there are foundl
thirty subcutaneous injuries of the kidneys. In twenty-one cases a diagnosis
of an injury of the kidney was made because of the local signs and bloodl
in the urine.
The following cases may be cited:
CASE VI.-J. H., white male, age not giveni, was struck by a traini six hours before
adlmissioni to the hospital. When he entered the hospital the temperature was 980 F.,
pulse 65 and a tenider mass could be palpated in the left flank. He was carefully watchedl.
There was no aggravation of symptoms noted on admission. The haematuria decrease(d
rapidly in amount. The patienit was discharged three days after admissioni against advice.
CASE VII.-L. S., white male, aged fifty-one years, slipped and fell heavily agailnst
a planik, striking his left flanik. Within twenty minutes he passed a large quanitity of
smoky urine. His pulse on admission to the hospital was 56, temperature 97.80. There
were no signs or symptoms of increasing hoemorrhage, although marked dullniess was
found in the left flank. Red blood-cells were found in the urine for several days, but
the patient rapidly recovered.
The following is the record of a patient who sustained a subcutaneous
rupture of the kidney. In this instanice an operation was (leemed advisable.
CASE VIII.-P. R., colored girl, thirteen years of age, fell downi some cellar stairs,
striking the right side of the abdomen. She had difficulty in getting to her feet and
ascending the stairs. Severe pain developed in the right flanik. When brought to the
hospital twelve hours after the accident the temperature was I02.40 F., pulse I20,
respirations 28, blood-pressure 95/50. Tenderness was elicited by deep palpation over
the right side of the abdomen. The tenderness was, however, most marked over the
region of the right kidney posteriorly. The urine consisted almost of pure blood.
At operation the right kidney was exposed. A transverse tear through the middle
was found. The tear was closed by suture and a drain placed dlown to the kidney bed.
The patient recovered rapidly after suture of the tear.
Two deaths occurre(d in the twenty-one cases of cointusionl of the kidney.
In these two cases there were associatedl injuries. .An injury of the kidney
was predicated upon the local findings and haenmaturia.
Nine patients were operate(l uponl. Three (leaths occtirre(l among the
ninle-a mortality of 33 per celnt. Different operative procedures were em-
ployed, such as suture of the tear, nephrectomy, packing and placing of a
clamp on the pedicle of the kidney. The last procedture was emiployed olnce
in the early days of the hospital. The patient had sustained a severe injury
with a dislocation of onie hip. The patient's condition did not improve. A
conitinuing hoemorrhage from the kidney was suspected and( the simplest
procedure was employe(d to conltrol it.
Injuries of the kidney slhouild he treate(d conservatively uinless there are
Aucreasing signs of hleiorrhage. Twenty-olne ouit of thirty occturrinlg in this
series were so treate(l, with a niortality of 9 per cen1t. It has alreacly been
inentiolne(l that the concolnUtant extelisive injiluies inl tw() cases were prob-
al)ly the cautse of death.
Ruptiirte of the Bladder.-Only eleven cases of l)erforation anld rulpture
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SUBCUTANEOUS INJURIES OF THE ABDOMEN
of the bladder have been observed. Among the eleven cases are but two in
which the rupture was hydrostatic.
CASE IX.-C. B., colored male, twelnty-two years of age, was knocked dowln while
fighting twenty-four hours before admission to the hospital. He had been drinking
freely. On admission to the hospital he complained of abdominal pain and passed bloody
urine. The temperature was 96° F., the pulse 96, white blood-cells 22,000. The abdomen
was greatly distended and marked tenderness, especially to the right of the umbilicus,
was noted. Muscular rigidity was also marked. Shifting dullness could also be made
out in the lower part of the abdomen. Eighteen hundred cubic centimetres of bloody
urine were withdrawn by catheter. An immediate operation was performed. Bloody
urine was found in the peritoneal cavity, which was walled off on the right side. A rent
six centimetres in length was found in the bladder on the peritoneal side. This extended
somewhat into the anterior wall of the bladder. The rent in the bladder wall was
sutured and a catheter placed in the space of Retzius for drainage. Patient recovered.
In one case no operation was performed.
CASE X.-A colored male, aged fifty, was brought to the hospital August 25, 1903.
He was brought by the police and was said to have been overcome by heat. He had
stopped work in the fields four days before. The patient was unable to void and suffered
severe abdominal pain. On admission the abdomen was of board-like rigidity. The
patient died forty-eight hours after admission. At autopsy an intraperitoneal rupture
of the bladder was found.
The cases of extraperitoneal rupture were frequently associated with
fractures of the pelvis, and the treatment consisted either of suture of the
tear and drainage, or simply drainage of the space of Retzius.
The immediate symptoms of intraperitoneal rupture may vary. Lewis
has seen' a patient walk into the receiving ward twenty-four hours after
having been kicked in the abdomen while in a drinking bout. This patient
had no shock and not enough abdominal symptoms to arouse any great sus-
picion. In another instance the patient was in a railroad wreck. The wreck
occurred in the morning at about five o'clock when the patient's bladder was
full. He said that when the collision occurred he experienced a slight jolt
and was rolled out of his berth. Strangury developed soon and he experi-
enced severe pain in the abdomen. When he was brought to the hospital six
hours later, he appeared shocked. Marked rigidity was noted over the lower
abdomen and there was marked tenderness. The patient was catheterized
and blood-stained urine withdrawn. An immediate operation was performed
and a longitudinal rent, extending from the apex to the base of the bladder,
was found on the peritoneal surface. Considerable urine was found in the
free peritoneal cavity. The rent was sutured, and the patient made an
uneventful recovery.
The history is of great importance in making a diagnosis of injury of the
bladder. With the modern methods of cystoscopy the diagnosis should be
made in a high percentage of cases, but unfortunately these methods do not
always give us all the information we desire. Strangury, blood in the urine,
lower abdominal pain and rigidity are symptoms of greatest significance. In
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DEAN LEWIS AND TRIMBLE
some instances an exploratory incision is indicated and should be advised.
With refinements in diagnosis, the mortality of subcutaneous and perforating
wounds of the abdomen have been gradually, but consistently, reduced.
Early recognition of the probable nature of the lesion and early use of the
surgical therapeutic procedure to correct the lesion will be followed by reduc-
tion in the mortality. There is an irreducible minimum, however, and this is
due to the associated or complicating injuries.
DIscuSSION.-DR. I. RIDGEWAY TRIMBLE remarked that there is one interesting
operative procedure, one that is erroneously thought to be life-saving in many cases, that
should possibly be mentioned. In subcutaneous injuries in which great haemorrhage is
incurred through rupture of the liver or spleen, not infrequently blood is collected,
filtered, and reinfused into the vein of the patient. Thus, Allen reported a patient with
a ruptured liver who was reinfused with 8oo cubic centimetres of his own blood recovered
from the abdominal cavity, andwho died fifty-six hours later with complete anuria.
The answer to this unfortunate result may lie in the dam,age done by the toxins
elaborated by a ruptured liver in which autolysis takes place so rapidly. Helwig reported
a patient withtraumatic pulpefaction of the liver who died eleven days later with jaundice,
extensive nephrosis, diffuse hemorrhages in the serous cavities, with a greatly increased
blood nitrogen content, especially the creatinine. The reinfusion of a patient's own blood
is often fraught with great danger.
DR. JAMES M. MASON (Birmingham, Alabama) said that he lived in a section of
the country where, on account of the large colored population and for other reasons
perhaps, they are forced to deal with a large number of these cases. He had been
surprised to find there was a mortality in the Johns Hopkins Hospital of around 30 or
35 per cent. in them.
He said the average mortality for that class in the country, as Doctor Lewis said, is
between 50 and 6o per cent. In 1923, he attended 127 cases with a mortality of 58.8 per
cent. and in 1930 Moyer reported 202 cases in Cincinnati, with 50.8 per cent. In 1931,
Billings and Walkling, from Philadelphia, had 156 cases with 55.14 per cent. In 193I, he
assembled twenty cases with 55.5 per cent. mortality. In the past year there had been
operated on for supposedly penetrating wounds of the abdomen in Hillman Hospital in
Birmingham sixty cases with a mortality of 50 per cent.; thirty recovered and thirty died.
Operations were done on eleven with non-penetrating wounds (and they had forty-
nine cases for that year) with twenty-eight deaths and a mortality of 57.14 per cent.
These collected cases were not done by any individual surgeon but were from the
hospital and visiting and resident staff in the hospitals. As compared with this 50 to 6o
per cent. mortality in 193I, B. C. Willard reported sixty-three individual cases with a
mortality of 35 per cent. He said that compared very favorably with the mortality which
Doctor Lewis had just reported for Johns Hopkins Hospital.
He called attention especially to the influence of haemorrhage in this 50 per cent.
mortality. In the 127 cases that he reported in 1923, he subdivided them into penetrating
wounds with extensive visceral injury with minimum hemorrhage. He found in the
parallel cases they had forty-seven cases with large haemorrhage and forty-one deaths,
a mortality of 87.2 per cent. Of the penetrating injuries with small haemorrhage, forty-
seven cases, there were seventeen deaths, a mortality of 36.I per cent.
As to irreducible mortality he said there is room for improvement to take place in
the item of mortality due to haemorrhage. He considered from what he had read and
what he had gathered, particularly from some questionnaires he sent out to ioo of the
best offices in the country, that the question of blood replacement is not receiving the
important consideration that it should receive for this type of case.
A sociological question comes in here. Most of these penetrating wounds of the
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SUBCUTANEOUS INJURIES OF THE ABDOMEN
abdomen occur in people in the lowest strata of society and are either the results of
brawls and fights among people of that class, or encounters with officers of the law.
They are, as a rule, treated not in our more especially organized and better operated
hospitals, but in the large charity hospitals of our cities and counties. Blood replace-
ment in these cases to be most successful must be applied not the day after the patient
is operated on, nor two or three days later, but immediately, at the time, to receive just
the same consideration at the hands of the surgeons as the laparotomy.
He said we all learned about the curability of gunshot wounds in the days of Doctor
Fogelbaum. We know that we can prevent peritonitis if we operate promptly and
control haemorrhage. One can reclaim a certain number of cases that would die from
hwmorrhage. In that day we did not know about blood replacement and we did not
consider it in its proper light.
Blood for transfusion to be of benefit to this class of patients must be obtainable at
the same time they come in for the operation, before the laparotomy. The only way that
city and charity hospitals can be organized for furnishing this blood is to consider blood
as a therapeutic agent of highly specialized type for which there is a definite demand
and for which the hospital ought to be prepared to pay, just like it is for elaborate
hospital equipment and elaborate X-ray, expensive and elaborate sera and anti-toxin
and things like that. Whenever we can establish our charity hospitals and our big public
institutions and things of that sort where they recognize that a certain amount of blood
ought to be used at a definite time on this particular class of patients, then we can
reduce in a large measure this difference between 87'2 per cent. mortality where hemor-
rhage carries them out, to about 35 per cent. in those cases where they die from com-
plications and things of that sort. He looked forward confidently to the time when
all hospital boards will recognize this and supply this blood. In reply to a questionnaire
of ioi hospitals in this country, less than 40 per cent. said that they included in their
regular expense the question of supplying blood for transfusions for indigent patients.
DR. LE GRAND GuERRY (Columbia, S. C.) remarked, in discussing the paper of
Doctor Lewis, that some years ago he published in the ANNALS OF SURGERY, a paper of
"Twenty-seven Cases of Penetrating Gunshot Wounds of the Abdomen with Three
Deaths." He was more convinced now than ever before that a number of these cases
were saved by taking the necessary time to improve the patient's condition before
operating.
Specifically as regards the problem of haemorrhage, one must remember that in
the presence of traumatic shock it takes comparatively little loss of blood to produce
a profound circulatory disturbance. He said oftenthey have had this experience; incases
of perforating wounds of the abdomen with hamorrhage, they have operated on and re-
paired ten or twelve perforations, practically emptied the abdomen of blood, and com-
pleted the operation without finding the source of the hamorrhage. An irregular tear
in a small vessel coupled with a profound drop in blood-pressure permits thrombosis of
the vessels, thereby controlling the hamorrhage before the operation is undertaken. This
is one of the main reasons why we never operate with precipitate haste.
We believe it to be a great mistake to take these patients with penetrating, per-
forating bullet wounds of the abdomen that come in in a condition of profound shock,
with or without haemorrhage, rush them to the operating room and operate immediately.
If one does so one is inviting disaster and an excessively high mortality.
He had collaborated on this thought in the text of his paper by pointing out that
one has immediate soiling in perforated wounds of the abdomen-but not a true peritonitis.
It takes time to develop a spreading peritonitis-several hours of time-and this time
can be well spent in making the patient a safer surgical risk.
There are those, however, who disregard the above-mentioned principles which he
believed to be fundamental not only in relation to bullet wounds of the abdomen, but
as applied to the broader field of acute abdominal emergencies. However, when these
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DEAN LEWIS AND TRIMBLE
p)rinciples are so disregarded the proponents will continue to come to the forum of
surgical practice in America and talk about 40 per cent. and 50 per cenit. mortality.
DR. WILLIAM L. ESTES (Bethlehem, Pa.) said there is one feature of Doctor Lewis'
paper that he would like very much to emphasize, anid that is the effect of noni-pene-
trating wounds of the abdomen. He said that most wounds that we have seen have had
lacerations and have shown their injury. He had, however, had the experience of seeing
quite a number of others, in which nothing visible was evident externally to indicate that
there had been any serious injury within the abdomen. Yet because of long shock and
weakness and other evidences it was apparent there had been a very serious intra-
abdominal injury.
Among the other injuries of the intra-abdominal viscera which he had had occasion
to see were lacerations of the greater omentum.
He had distinctly in mind a man who was thrown forward, struck on the edge of
a projecting bolt, which made a wound penetrating only the skin and the superficial
fascia. That man apparently had such a trifling injury that he was kept at home for
a while. Not improving, he was sent to the hospital, evidently in a serious condition
of exhaustion and with evidences of some sort of intra-abdominal effusion. He was
operated on and it was found that his greater omentum had been torn and that he had
been bleeding seriously from the omentum for over twenty-four hours. Doctor Estes
said "seriously"-at first it was serious, and then it clotted and finally the clots were
being absorbed by the escaping sera.
Another intra-abdominal laceration is a rare condition which he had seen, and that
was a laceration of the upper edge of the mesentery. In one case this was torn so that
the vessels were opened and the individual was bleeding profusely. It resulted from a
precipitation forward by moving machinery, the man striking in spread-eagle fashion
on the floor. He was brought in with the tear in the upper part of the mesentery from
which he was bleeding profusely.
The fourth rare inury which he had seen was laceration of the jejunum just distal
to the duodenojejunal fold, just beyond the membrane, where a part is held firmly and
the rest has considerable excursion in the abdomen. These fixed points where an
intestine, especially the small intestine, is held and the rest of it is mobile, are vulnerable
points. The effect of being thrown forward or being violently propelled forward on the
abdomen, with the concussion and sliding pressure, may cause a laceration of the
jejunum.
In the case he had in mind he found a transverse laceration, involving almost half
of the periphery of the gut.
He was glad to hear that Doctor Lewis' statistics do not indicate that lacerations of
the kidney should have operation invariably. He had for many years given up operating
on lacerations of the kidney unless there was a very large haematoma. Unquestionably
the results were far better by expectant treatment.
DR. M. L. HARRIS (Chicago, Ill.) said he wished to mention that the injury to the
abdomen may not be a severe one in order to cause serious injury to the viscera.
Recently a young man was brought into the hospital. He was strong and healthy,
eighteen years of age. He had been riding a motorcycle. He had a collision with a
truck. He did not injure the abdomen at all. He came into the hospital and all he
complained of were slight bruises on his leg.
Doctor Harris happened to be in the hospital shortly afterward and examined the
patient very thoroughly. He seemed perfectly well. There was no tenderness or pain
in the abdomen, and the patient complained of none. There was no soreness of any
kind. His condition was practically perfect.
The patient was simply put to bed. Within a few hours his condition was abso-
lutely alarming and he died shortly afterward. At the autopsy they found that the
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