It is true that to the Civil Surgeon accustomed to surroundings replete with every modern appliance and convenience, and the possibility of exercising the most stringent precautions against the introduction of sepsis from without, abdominal operations presented difficulties only faintly appreciated in advance; but this alone scarcely accounted for the want of success attending the active treatment of wounds of the intestine when occasion demanded. Failure was rather to be referred to the severity of the local injury to be dealt with, or to the operations being necessarily undertaken at too late a date. Many fatalities, again, were due to the association of other injuries, a large proportion of the wound tracks involving other organs or parts beyond the boundaries of the abdominal cavity.
The frequent association of wounds of the thoracic cavity with those of the abdomen afforded many of the most striking examples of immunity from serious consequences as a result of wound of the pleura. It must be conceded that in a large number of such injuries only the extreme limits of the pleural sac were encroached upon, yet in some the tracks passed through the lungs, although without serious consequences. Under the heading of injury to the large intestine a somewhat special form of pleural septicæmia will be referred to.
It may at once be stated that such favourable results as occurred in abdominal injuries were practically limited to wounds caused by bullets of small calibre, and that, although in the short chapter dealing with shell injuries a few recoveries from visceral wounds will be mentioned, I never met with a penetrating visceral injury from a Martini-Henry or large sporting bullet which did not prove fatal.
Wounds of the abdominal wall.—It is somewhat paradoxical to say that these injuries possessed special interest from their comparative rarity of occurrence, since they were not of intrinsic importance. Their infrequency depended on the difficulty of striking the body in such a plane as to implicate the belly wall alone, and their interest in the diagnostic difficulty which they gave rise to.
In many cases the position of the openings and the strongly oval or gutter character possessed by them were sufficient proof of the superficial passage of the bullet; in others we had to bear in mind that the position of the patient when struck was rarely that of rest in the supine position, in which the surgical examination was made, and considerable difficulty arose. Some superficial tracks crossing the belly wall have already been referred to in the chapter on wounds in general and in that dealing with injuries to the chest, in which the above characters sufficed to indicate that penetration of the abdominal cavity had not occurred. In other instances a definite subcutaneous gutter could be traced, and often in these a well-marked cord in the abdominal wall corresponding to the track could be felt at a later date. Again, limitation to the abdominal wall was sometimes proved by the position of the retained bullet, or sometimes by the presence in the track of foreign bodies carried in with the projectile. See case 160.
Fig. 84 illustrates an example where the limitation to the abdominal wall was evident on inspection. Here the division of the thick muscles of the abdominal wall had led to the formation of a swelling exactly similar to that seen after the subcutaneous rupture of a muscle, and two soft fluctuating tumours bounded by contracted muscle existed in the substance of the oblique and rectus muscles.
Fig. 84.
Wound of Abdominal Wall (Lee-Metford). Division of fibres of external oblique and rectus abdominis muscles. Case 159
The cases which presented the most serious diagnostic difficulty in this relation were those in which the wound was situated in the thicker muscular portions of the lower part of the abdominal and pelvic walls. Such a case is illustrated in the chapter on fractures (see fig. 55, p. 191). I saw one or two such instances, in which only the exploration necessary for treatment of the fracture decided the point. In many of the wounds affecting the lateral portion of the abdominal wall the question of penetration could never be definitely cleared up, as wounds of the colon sometimes gave rise to absolutely no symptoms.