Two Cases of Penetrating Wound of the Abdomen
Boston Medical and Surgical Journal
For this exploration it, would seem that air would be. equally good with hydrogen gas. The suggestion of this procedure adds one more to the capital points in abdominal surgery for which we are indebted to Dr. Senn. To return now to tin.nsidcrat ion of the cases reported. In both of them laparotomy was performed at once when they were lirsl seen. This practice of immediate laparotomy) without waiting for convincing symptoms of serious infraabdominal lesion, seemed wise, for the following
... he following reasons : -First: It was felt that the enlargement of the penetrating wound through the abdominal wall added little or nothing to the severity of the injury, and would give the opportunity to discover and repair any lesion of the intestines or other abdominal contents before the occurrence of peritoneal inflammation. The absence of danger in a simple incision into the abdomen is generally recognized. Secondly: W'c know that symptoms are often very poor guides to an appreciation of the severity of infra-peritoneal injuries, and if we wait, until the patient's condition demands an operation, we shall often lind that a serious infla mm,fury condition has arisen, which we are powerless to stop, even though we may succeed in closing the intestinal wound that gave rise to it. The cases are as yet, loo i'rw to delerniine the ratio of the increased danger in delayed operations, but experiences are not, wanting to show that it is very large. Thirdly: In the event, of any considerable vessel being injured it, is, of course, important to stop the bleeding early before the patient is seriously exhausted. Here again, if we wait until the symptoms of internal luciiinrrhage arc unmistakable, we shall run a serious risk of letting the patient, slip into a condition from which he cannot be recovered. In view of these considerations it seemed to the writer, and he still thinks if a good rule in practice, that-1*11 a case of penetrating wound of the abdomen, made by a sharp weapon or by gun-shot the wound should be followed carefully down until the operator is convinced that it enters the abdominal cavity. When this is established the peritoneum should be opened with enough freedom to allow of a sufficient inspection of the abdominal contents, ami for the repair of any injury found. It seems probable that by this immediate operation cases will be saved which would be lost if time were given for flic peritoneum to inflame or for sciions loss of blood to occur; whereas with proper care in making a clean, aseptic opérai ion the surgeon will rarely, if ever, feel that he has added to his A. D., thirteen years old, came to the Massachusetts (¡encrai Hospital, September IOth, 1887. He was slabbed in the abdomen with a knife, about midway between the umbilicus and pubes, and two inches to Ihe lell of Ihe median line. The wound was about one inch in length. Through this wound protruded a, mass of onientuni, completely plugging it. The wound was enlarged to about, double its size. This allowed an easy reduction of Ihe onientuni. and gave an opportunity to inspect the intestines lying directly beneath the incision. The omentum, when returned to tin; abdominal cavity, began to bleed. The constriction made by the edge of the incision had controlled the bleed ing until this constriction was removed. The bleeding points were tied. No injury to the intestines was found, and nothing pointing to such Injury was seen. The patient was about the ward on the eighteenth day, the wound having entirely healed. Case II. Pistol wound of the abdomen: laparotomy ; death. W. C, a teamster, twenty-four years old, was brought to the Massachusetts (¡encrai Hospital. August Gt.h, 18K8, at about (¡..'JO p.m., pulse 80, temperature 100.8", respiration ;>0. lie had been shot one-half an hour before. Examination showed a strong, vigorous man. A bullet wound in left chest between first and second ribs, three ling u's-brcadth from the clavicle's sternal end. There was a bullet wound one inch below the umbilicus and two or three lingers-breadth from umbilicus in left side. There was also a bullet wound on the inner side of the femoral vessels in Scarpa's triangle. No bleeding of any account from cither wound. Wounds not probed. The urine was drawn by catheter and found to be bloody, but there were no clots. Spit, some blood from the throat. No cough. No pain in chest. Abdomen lender, l'ain in small of back. The Hanks are Hat, on percussion, otherwise the alv domen was tympanitic. Morphia and brandy were given. At 8.30 the urine was more bloody. The pulse had become rapid. The patient seemed to be sinking from loss of blood. It seemed best, to attempt a laparotomy. Two quarts of blood mixed with intestinal contents were evacuated. Blood and intestinal contents were flowing into the abdominal cavity freely. Three holes in the small intestine and two lacerated wounds of the intestine were sewed up with silk. The abdomen was washed out with warm water. The posterior course of the bullet was not determined. It was thought that if might have cut the ureter or have entered the kidney. The patient rallied slightly, but died at 12.20 in the morning! On autopsy it was found that the left kidney had been pierced by the bullet which had injured the intestines. There was considerable haemorrhage into theperinephritio tissues. The abdominal cavity, upon removing the intfertines, was found to be perfectly clean, notwithstanding the large amount of blood and ficccs which it had contained before washing. No other intestinal wounds were found. The bullet wound of the chest, passed flirt ugh the apex of the lung. No wound of the intestines had been overlooked. Insufflation was not used.