The principles and practice of modern surgery

by Roswell Park

Treatment.

—The principles of surgical treatment for gunshot wound of the intestines include a free abdominal incision, an inspection of the entire length of the intestinal canal, which can only be made by passing it through the examining fingers while exposed to sight upon the abdominal surface, the accurate securement of all bleeding vessels, and the closure of all punctures. Any portion whose blood supply has been so completely cut off as to threaten or produce gangrene should be removed by resection, with end-to-end or a lateral anastomosis. The patient having been thus eviscerated and the intestinal viscera examined, the abdominal cavity should be further explored, not so much to find the missing bullet as to discover what further harm may have been done; while if such be found the indication should be met. Then after an exceedingly careful toilet of the peritoneum the intestines may be restored, it being of course assumed that every puncture has been fully recognized and properly sutured and secured. Nearly all of these cases will call for some abdominal drainage, which may or may not be posterior, as shall seem best.

The location of the bullet is a matter of minor importance. Should it lie where it can be easily identified and removed this should be done. Otherwise one should not waste valuable time in hunting for it, remembering that he is performing not an autopsy but an operation.

ULCERS OF THE SMALL INTESTINES.

There is no point of the intestinal tube between the pylorus and the anus which may not be involved in an ulcerative process, either acute, chronic, or malignant. Acute ulcers of the upper bowel are usually of typhoidal origin, while those of the lower bowel may be due to either typhoid, tuberculosis, or syphilis. At certain points ulcers assume somewhat distinctive character. Thus the acute catarrhal ulcer, so called, seems to have a more definite entity than a declared pathology, it being somewhat difficult to account for its existence. The peculiar duodenal ulcers which have been met with after operations or burns have been elsewhere discussed, and are to be regarded as of an acutely toxic origin. A special type of ulcer of the duodenum has also been noted opposite the anastomotic opening which is made in the ordinary gastro-enterostomy, for whatever purpose performed. This appears to be due to the outpour of the gastric juice upon a surface not normally prepared for it, upon which it acts as an irritant, in time producing more or less acute ulceration. This is the so-called peptic ulcer of the duodenum, an occasional complication of gastro-enterostomy.

Duodenal Ulcer.

—Duodenal ulcer of a type corresponding to gastric ulcer has been recently determined to be a more frequent lesion than has been supposed. A series of over fifty operations for this condition, reported by Moynihan, in 1905, thus occurring in the practice of one surgeon, will dispose of the question as to its great rarity. Its symptoms are often so characteristic as to admit of reasonably easy diagnosis, and it has, therefore, become more and more a matter of greatest interest to the surgeon, since duodenal like gastric ulcer is essentially a surgical condition.

These ulcers are usually located in the first portion of the duodenum, i. e., in at least 90 per cent. of cases. They may be solitary or multiple, and may be associated with gastric ulcers. In the ordinary postoperative peptic ulcer the sequence of events is usually gastric ulcer, hyperchlorhydria, and duodenal lesion. It may occur at any age, and is the frequent cause of melena of the newborn or of the young.

Symptoms.

—Symptoms of duodenal ulcer include pain, hematemesis, and melena. Pain may be a vague uneasiness or may be severe. It is usually described as of a burning character, felt mainly in the middle line or along the right costal margin. It becomes gradually more severe and may finally disable. It is sometimes described as cramp-like. When severe it is referred to the right of the middle line. In cases where there are adhesions to the liver or gall-bladder, pain radiates upward to the right breast, or even around the chest to the back. The pain is associated, by more or less marked time limit, with the ingestion of food, coming on from two to four hours after a meal, whereas that of gastric ulcer comes soon after eating. Sometimes it is even regarded as a “hunger pain,” and patients find that the taking of a little food will give relief. So soon, however, as this is digested pain returns, when they again call for more food. Hematemesis and melena may be present together or either may appear without the other. Small quantities of blood in the vomitus is more likely to attract attention than considerable quantities in the stools. It has been estimated that in from 25 to 30 per cent. of acute cases hemorrhage is frequent, and occurs in 40 per cent. of chronic cases. In the stools blood is found in perhaps one-half of the instances. The amount of blood may be considerable, even sufficient to produce faintness. In fact, the intestine has been found full of blood when the abdomen was opened, and Moynihan has seen even the colon distended with blood.