place of the expectant or do-nothing plan so generally resorted to in cases of this character? The general plan of treatment in incised, punctured, and gunshot wounds of the peritoneum, has been to enjoin absolute rest, give opium to arrest peristaltic action of the bowels and encourage the formation of adhesions, in the almost idle hope of preventing extravasation into the peritoneal cavity. The followers of this course of treatment say that the instrument which makes the wound may paralyze the muscular coat of the bowel; or in small wounds the mucous coat is everted and closes the aperture; or the part injured, as a portion of the colon, may not be covered with peritoneum and the extravasation be external to the cavity of that structure; or that the serous membrane covering the intestine at and near the wound may become adherent to the omentum, or to an adjoining loop of bowel, or the inside wall of the abdomen, and the orifice in the bowel become permanently closed in this way; or that the rarest of all terminations may ensue, as when the extravasated mass becomes encysted, ends in abscess and discharges itself through neighboring skin or mucous surface. In perforation of the bowel from disease, or rupture of intestine without external wound, such results are not looked for. Effusions then are expected. When we remember that the alimentary canal is never completely empty, common sense teaches us when an opening of any size is made in any portion of it contained in the peritoneal cavity that the contents will escape; that there will probably be less resistance to the passage of fecal matter through the unnatural aperture than along the sides of the canal itself. Gas may at first be expelled, separating peritoneal surfaces, and then the fluid or solid contents of the bowel follow. There may be exceptional cases to this rule of extravasation after penetration or perforation of the bowel, but they are very rare, as is shown by the fact that only one or two instances are reported in the late war (Surgical History of the War, Part II., vol. ii., p. 194). Besides alimentary effusion, blood, air, bile, or urine may also be extravasated into the peritoneal cavity. Penetrating wounds of the belly with fecal effusion are rapidly followed by general acute peritonitis, and the average limit to life, according to Dr. Otis, is from 36 to 48 hours, and according to Baudens and Legouest it is fatal generally within 24 hours Such is the record of (p. 199, Surgical History of the War). gunshot wounds of the peritoneum. within 48 hours. Does peritonitis from any other cause, as a rule, kill as quickly? Nearly every surgeon engaged in the late war, and others of much experience, will probably recall a case of penetrating wound of the belly in which the patient recovered under the expectant plan of treatment. Some of these cases of recovery may have been wounds of a portion of the large intestine not covered by peritoneum, in which recovery with fecal fistulæ is not uncommon; others may have been penetrating wounds without visceral injury; and others again may have been parietal wounds without peritoneal penetration. Recovery, after shot wounds penetrating the belly and wounding the solid or membranous viscera, is of extreme rarity, but it is these very occasional instances of recovery which have induced surgeons to continue the expectant plan of treatment in place of what appears at first sight to be a desperate surgical interference. The fatality is not, however, confined to shot wounds of the peritoneum with visceral injury. Although Malgaigne and others have asserted that the organs contained in the belly fill the cavity to such repletion, that shot wounds of that space without visceral injury are impossible, post-mortem examinations and experiments upon dead bodies show that wounds of the peritoneum can be made without injury to the contained viscera. It has fallen to my lot to witness four cases of shot wounds of the peritoneum without visceral injury. Two of these cases occurred in civil life, and being the subjects of legal investigation the autopsies were made in the most careful manner. In one case a round ball entered the body two inches below and to the right of the umbilicus, passed horizontally between the muscular planes of the abdomen to the linea alba. At this point it was deflected, entered the peritoneal cavity, and going downwards, backwards, and to the left, lodged near the left iliac bone. Examination after death, which occurred during the third day, showed that the ball had glided between the bowels without wounding or contusing them, or any other viscera. A piece of cloth, flakes of lymph, and two or three pints of reddish serum were found in the cavity. In another case a conoidal pistol ball struck two inches above and to the right of the umbilicus, went obliquely through the abdominal wall for an inch and a half, then entered the cavity, and passed for two inches closely along the posterior surface of the anterior abdominal wall, tearing in its course the parietal portion of the peritoneum, and making its exit five inches below and to the left of the umbilicus. Death followed on the third day; and an autopsy showed no visceral injury whatever, but general peritoneal inflammation with flakes of lymph, and about three pints of red serum in the cavity. The two other cases were soldiers, who received during the late war gunshot wounds of the abdomen. Both died from peritonitis, and post-mortem examinations revealed the absence of injury of the viscera and the presence of lymph and abundant red serum. One of these men was wounded by a ball from a Shrapnel shell, which passed through the cavity of the belly and lodged in the muscles of the back; and the second one was wounded by a minié bullet, which passed obliquely through the wall, entered the cavity for several inches, and then escaped through the anterior wall of the belly. Two of these cases occurred in private practice, and two happened to have been noticed in the hurry and confusion following a battle, but the four cases coming under the observation of one individual, and having their exact character shown by postmortem examinations, prove that penetrating wounds of the belly without visceral injury are not impossible, and probably not as rare as we have been led to suppose. The same pathological appearances in all-peritonitis and the presence of large quantities of acrid, bloody serum in the abdominal cavity. I have little doubt that death was the result of blood poisoning, produced by absorption of this bloody serum which peritonitis had poured out. There is one point of interest in connection with these cases which I think is worthy of notice. In none of them was shock of injury or diminution of temperature appreciable. One of them, a soldier, assured me that he did not know that he had been wounded until some time after he had been shot. Another, wounded in a duel, insisted that he was able to stand up and give his antagonist another fire; and I had some difficulty in convincing a third that his wound was serious enough to require quiet and absolute rest. In all of the cases of peritoneal wounds with visceral injury which have fallen under my observation; shock of injury was a prominent symptom; and if my experience of the absence of this symptom in wounds of the belly without injury to the contents of the cavity is confirmed by other observers, the presence or absence of prolonged shock will help us to determine the presence or absence of visceral lesion. Jobert claims that sudden meteorism is pathognomonic of intestinal rupture in wounds of the belly. Whether it is always present or not, or present only in rupture of the bowel, has been doubted; but that it more constantly exists than other signs of this lesion is unquestionable. The presence or absence of shock and meteorism would thus strongly indicate the presence or absence of intestinal wounds; and if to these be added the character, extent, and direction of the wound, bloody discharges from the bowels or stomach, an almost certain diagnosis by rational symptoms will be reached. But why are all penetrating wounds of the belly, with or without visceral injury, so fatal? Why, when the patient has escaped death from shock, exhaustion, and hemorrhage, should peritonitis kill him within forty-eight hours? I believe the mortality is often due to some kind of blood poisoning connected with peritonitis, just as we often see septicemia associated with peritonitis under other circumstances, notably after parturition and ovariotomy; that this blood poisoning after gunshot wounds of the peritoneum is consequent upon the pent-up, red, serofibrinous exudation which traumatic peritonitis invariably produces in abundance, and that if this effusion could be drained. off as soon as it is formed, septicemia might be prevented. Lacerated wounds of the abdominal walls exposing the cavity, so far as my experience enables me to judge, are nothing like so fatal. I recall in civil practice three cases of lacerated wounds of the anterior abdominal wall-in two with visceral protrusion and in one with visceral exposure. One was inflicted by machinery in rapid motion, another by the horn of an infuriated cow, and the third was a child who fell from the second story of a house upon a sharp piece of iron railing attached to the window below. The edges of the wounds in all of these cases were brought together as nearly as their ragged condition would permit, and all of them recovered. I think I am safe in asserting that there are few surgeons of much experience who have not seen cases analogous to these. I remember four instances. of laceration of the abdominal wall by shell wounds with visceral exposure or protrusion, where recovery took place. One of the cases is so remarkable that it is worthy of record. Col. A. was wounded at Cedar Run, August, 1862. A shell from a Federal gun exploded very close to his body, and a fragment struck him one and a half inches below and a little to the right of the ensiform cartilage, and passed downwards towards the right anterior superior spinous process of the ilium. The missile fractured three of the ribs on the right side, tore off the anterior superior spine and a part of the crest of the ilium, and laid open the cavity of the belly from the point where it struck an inch and a half below the ensiform cartilage to a point an inch below the anterior superior spinous process of the ilium. After leaving the abdomen it made a deep flesh wound in the upper and outer part of the right thigh. He fell from his horse into the road, and when found was lying on his back with a large mass of his bowels protruding from the abdomen, and hanging over his side on the ground. The dust and dirt with which the protruded bowel was covered were washed off with warm water, some pieces of cloth removed from the cavity of the abdomen, the bowel, which was uninjured, returned to the cavity, and the wound closed as nearly as possible with sutures. He recovered and returned to duty in the field eight months after. He is still living, and at present is in this city. In all of these cases the character of the wound prevented union by the first intention, and drainage of abdominal effusions readily took place. Dr. Otis says in regard to shot wounds of the small intestines treated during the war, that "it may still be considered doubtful if an incontrovertible instance of recovery was observed;" and of shot wounds of the stomach there was but one case of undoubted recovery, and in this instance a fistulous opening in the abdominal wall communicated with the stomach. In the fifty-nine cases of recovery after penetrating wounds of the large intestine, fifty-five were perforating wounds, the large aperture of exit being usually on the posterior surface of the body, dependent and facilitating drainage. In one of the four instances of recovery in simple penetrating shot wound of the large bowel, the edges of the opening in the bowel were fastened to the wound in the abdominal wall, and in this, as well as the other three cases, fecal fistula were formed. |