The principles and practice of modern surgery

by Roswell Park

Of acquired malformations of the small intestine we have mainly to deal with those which are produced by injury or disease. Among the former would be the results of violent contusions or of any of the lacerated, incised, or gunshot wounds to which the bowel is so often exposed. Should recovery ensue cicatricial contraction is likely to result. On the other hand, such previous disease conditions as ulcerations—tuberculous or typhoidal—or the so-called chronic catarrhal or malignant, may in one way or another occlude and thus finally obstruct the lumen of the bowel. Distention diverticula may also result, which correspond to the traction diverticula of the esophagus already described.

WOUNDS OF THE SMALL INTESTINE.

The small bowel, like the larger or the stomach, may be ruptured in consequence of abdominal contusions, the condition depending on the nature of the injury, the degree of fulness of the bowel itself, and other obvious causes. This character of injury has been already sufficiently considered in dealing with rupture of the stomach. Their symptoms are not essentially different, neither are the principles of ordinary surgical treatment. Of all gunshot wounds those of the abdomen constitute about 6 per cent., being more frequent than stab wounds.

Gunshot Wounds.

—Gunshot wounds of the intestine would by themselves fill an interesting chapter in a work on surgery. In such an epitome as this they can be given but short consideration. The condition was for centuries hopeless, until the American surgeons Parkes, Bull, and Senn took up the subject and taught the profession how to more quickly recognize the injury as well as to treat it. The special dangers of all punctured wounds of the bowel, like those of the stomach, are hemorrhage and escape of fecal contents. The great length of the intestinal tube, and its coiled arrangement within the abdominal cavity, subject it to the possibility of multiple punctures, from a dozen to twenty having been inflicted by the passage of one bullet. The multiplicity of these injuries, therefore, gives a still more formidable character to their presence. Much will depend upon the size and velocity of the bullet and the distance from which it is fired. The perforated gunshot wounds of the abdomen which occur in civil life are usually inflicted by a smaller bullet than those occurring in actual warfare, while, at the same time, the distance is usually short.

Gunshot wounds are followed by an apparently disproportionate amount of collapse. There is no accurate method of recognizing from the exterior the amount of harm done by the passage of a bullet into or through the abdominal cavity. This constitutes one of the greatest arguments in favor of immediate exploration, an argument which is strengthened by the fact that almost every penetrating wound of the abdomen is complicated by injury of some abdominal organ. The greatest danger attaches to perforation of the transverse colon or of the small intestine, because these are the most movable parts of the intestinal canal. The dangerous wounds are those which lie in the frontal plane. Bullets which pass through the abdomen obliquely are perhaps less likely to produce fatal result. Astonishing differences prevail between the severity of those accidents received upon the field of battle and in civil life. In battle men are shot through the abdomen and not conspicuously disabled, recovering sometimes with no other treatment than antiseptic occlusion. It is impossible to assume that the bowels have not been injured, and yet they recover. The fact thus stated best indicates the reason for abstention from intervention on or near the firing-line in battle, and its most prompt and early performance when the patient is in a well-managed civil hospital.

Symptoms.

—The symptoms of intestinal perforation in these cases are not so prompt as when the stomach is wounded. Blood may occur in the vomitus or in the stools, but only ordinarily after the expiration of a few hours. Should fecal matter be found within the external wound evidence would be complete, but this is rarely the case. The probe may show whether the abdominal wall has been completely perforated or not; beyond this it will give little information. By far the best probe is the sterile finger, introduced through the opening enlarged for the purpose. With this more distinct information may be gained. Some years ago Senn proposed the method of inflating the colon and small intestine with hydrogen gas, on the expectation that it will escape through any intestinal perforation into the abdominal cavity, which it would distend, and that then by inserting a small glass tube in the abdominal wound it could be lighted and made to thus identify itself at the distal orifice of this tube; but this method requires special conveniences which are rarely at hand in emergency cases, and has been practically abandoned.

A study of the direction of the abdominal wound which may be sometimes made from an accurate account of the accident, and at other times by noting the location of the wounds of entrance and exit, will do much to determine whether intestines were probably in or out of harm’s way. If it can be established that the bullet has probably avoided them then some would wait for the inception of the first serious sign of mischief before exploring. On the other hand, if it should seem inevitable that such injury must have occurred, or, without such reasoning, if the patient present a serious condition, he should be promptly operated unless practically moribund.

The general principles of recognition and treatment of gunshot wounds have been considered in an earlier chapter and the subject will not be further considered here except as regards treatment.