The principles and practice of modern surgery

by Roswell Park

Result of frostbite after two days and nights of exposure. After battle of Mukden. (Major Lynch.)

The subject of injuries to the heart will be dealt with in the chapter devoted to the surgery of that organ. Not every perforation of the heart substance is fatal, and there are enough successful cases on record of radical intervention by resection of the thoracic wall, and of exposure of the pericardium, even of the heart itself, to justify this method of attack in any case which will permit of it. Not the least of the dangers pertaining to heart injuries is the impediment to heart action caused by a collection of blood in the pericardial sac. Should anything further be called for it would be warrantable at any time to explore this sac and withdraw fluid through the aspirating needle, through a trocar, or even by incision and drainage.

In the abdomen all conceivable forms of injury may be met with, from contusions produced possibly by a spent cannon ball, to lacerations from fragments of a bursting shell and multiple perforations produced by one or more bullets. A first requisite in all such injuries is immediate antiseptic occlusion. This will not prevent such prompt and further study of the case as may indicate suitable treatment. When shock is extreme, indicating the possible result of contusions or laceration, or when perforation of the stomach, intestines, or bladder is probable, laparotomy should be performed at once. According to De Nancrède the order of probable frequency of these injuries of the abdomen is small intestine, large intestine, liver, stomach, kidney, spleen, and pancreas. Multiple lesions are also common. The immediate dangers are those from shock and hemorrhage, to be supplemented later by imminent danger of septic peritonitis.

Fig. 59

Scene in operating room in Second Field Hospital of Fifth Division of Japanese Army, at Mukden Railway Station. (Major Lynch.)

The modern small bullet causes few surface indications as to the amount of damage done within, as in the thorax. A careful consideration of the location of the wounds of entrance and exit will indicate the probability of perforation, especially of the hollow viscera. The appearance of blood, either in the mouth or from the rectum or urethra, the recognition of a rapidly accumulating amount of fluid, the presence of gas in the abdomen, are all significant indications of perforating injury. Several years ago Senn advised the insufflation of hydrogen gas into the colon, on the theory that its escape from the intestine into the abdominal cavity and thence out of one of the abdominal wounds, where it could be lighted as it passed through a small tube, would afford a certain and unmistakable test as to perforation of the bowel, and such is undoubtedly the case. Nevertheless, it is not one which is always easy or even possible of application, and no time should be wasted in waiting for a supply of hydrogen for this purpose.

The safest course and the most life-saving one is exploration when there is any doubt as to the nature of the injury. This means an operator possessed of good judgment, a suitable environment, rigid antiseptic precautions, and a small incision to begin with, with the finger as the best of all probes. The escape of bloody fluid, bloody urine, or fecal matter will immediately justify a much more extended incision through which complete orientation may be obtained. The first incision may be best made as an enlargement of the bullet wound, but any extensive operation within the abdominal cavity can be made through a sufficiently long median incision. Only in this way can the source of hemorrhage be ascertained. Thus the intestines may be systematically gone over inch by inch. When perforations are found they may be either dealt with as they appear—each opening being closed transversely—or the entire intestinal canal may be exposed. Contused spots will eventually slough, and should be treated as if they were perforations. Injuries, therefore, of short portions of the intestines might justify the removal of several inches. Instead of making multiple resections, it would be better to remove en masse the involved portion of the bowel, and then make lateral anastomosis or an end-to-end suture. Perforations of the mesentery as well as tears in the omentum should be carefully closed. Everything which is not vitally necessary and which has been injured should be removed. The posterior surface of the stomach, the lesser cavity of the omentum, the region of the gall-bladder and pancreas, the kidneys and ureters, and the bladder should be examined, in order that injury may be detected. After operations of this kind the abdominal cavity may be flushed with sterile salt solution; while the question of drainage should be decided upon the individual merits and indications of each case, as it is safer to drain the contaminated peritoneal cavity than to rely upon mere cleansing and drying.

If the spleen or kidney be injured, it is safer to make a primary removal of them; if they are not removed, posterior drainage should be made.

In uncertain cases of abdominal wounds the back as well as the abdomen should be scrubbed in order that if posterior drainage be necessary it can be made without delay.