ITARY MEDICAL MANUALS

GENERAL EDITOR:

IEON-GEN. SIR. ALFRED KEOG.H G.C.B.. M.D.. F.R.C.H

•QUNDS OF THE

ABDOMEN

,L A.B \ Dl E

EDIT! D BY

SIR W.ARBUTH 4OT

MILITARY MEDICAL MANUALS

GENERAL EDITOR: SIR ALITRBD KEOGH, O.C.B., M.D., V.R.C+.

WOUNDS OF THE ABDOMEN

WOUNDS OF THE ABDOMEN

<N BY

jfABADIE

(OF ORAN)

Chief Surgeon of the Oran Hospital National Correspondent of the Chimrgical Society

WITH A PREFACE BY

J.-L. FAURE

Agreg6 Professor of the Paris Faculty of Medicine

EDITED WITH A PREFACE BY

SIR W. ARBUTHNOT LANE, BART., G.B., M.S,

Colonel (Temp.), Consulting Surgeon to the Forces in England

WITH 69 ILLUSTRATIONS AND 4 PLATES

UNIVERSITY OF LONDON PRESS, LTD.

18 WARWICK SQUARE, LONDON, E.C.4

PARIS : MASSON ET CIE, 120 BOULEVARD SAINT-GERMAIN

1918

GENERAL INTRODUCTION

THE infinite variety of injuries which any war presents to the surgeon gives to military surgery a special interest and importance. The special interest and importance, in a surgical sense, of the great European War lies not so much in the fact that examples of every form of gross lesion of organs and limbs have been seen, for if we read the older writers we find little in the moderns that is new in this respect, but is to be found in the enormous mass of clinical material which has been presented to us and in the production of evidence sufficient to eliminate sources of error in determining important conclusions. For the first time also in any campaign the labours of the surgeon and the physician have had the aid of the bacteriologist, the pathologist, the physiologist, and indeed of every form of scientific assistance, in the solution of their respective problems. . The clinician entered upon the great war armed with all the resources which the advances of fifty years had made available. If the surgical problems of modern war can be said not to differ sensibly from the campaigns of the past, the form in which they have been presented is certainly as different as are the methods of their solution. The achievements in the field of discovery of the chemist, the physicist, and the biologist have given the military surgeon an advantage in diagnosis and treatment which was denied to his predecessors, and we are able to measure the effects of these advantages when we come to appraise the results which have been attained.

But although we may admit the general truth of these statements it would be wrong to assume that modern scientific knowledge was, on the outbreak of the war,

vi GENERAL INTRODUCTION

immediately useful to those to whom the wounded were to be confided. Fixed principles existed in all the sciences auxiliary to the work of the surgeon, but our scientific resources were not immediately available at the outset of the great campaign ; scientific work bearing on wound problems had not been arranged in a manner adapted to the requirements — indeed, the requirements were not fully foreseen ; the workers in the various fields were isolated, or isolated themselves, pursuing new researches rather than concentrating their powerful forces upon the one great quest.

However brilliant the triumphs of surgery may be — and that they have been of surpassing splendour no one will be found to deny — experiences of the war have already produced a mass of facts sufficient to suggest the complete remodelling of our methods of education and research.

The series of manuals, which it is my pleasant duty to introduce to English readers, consists of translations of the principal volumes of the " Horizon " Collection, which has been appropriately named after the uniform of the French soldier.

The authors, who are all well-known specialists in the subjects which they represent, have given a concise but eminently readable account of the recent acquisitions to the medicine and surgery of war which had hitherto been disseminated in periodical literature.

No higher praise can be given to the Editors than to say that the clearness of exposition characteristic of the French original has not been lost in the rendering into English.

MEDICAL SERIES

The medical volumes which have been translated for this series may be divided into two main groups, the first dealing with certain epidemic diseases, including syphilis, which are most liable to attack soldiers, and the second with various aspects of the neurology of war. The last word on Typhoid Fever, hitherto " the greatest scourge of armies in time of war," as it has been truly called, will be found in the monograph by MM. Vincent and Muratet,

GENERAL INTRODUCTION vii

which contains a full account of recent progress in bac- teriology and epidemiology as well as the clinical features of typhoid and paratyphoid fevers. The writers combat a belief in the comparatively harmless nature of para- typhoid and state that in the present war haemorrhage and perforation have been as frequent in paratyphoid, as in typhoid fever. In their chapter on diagnosis they show that the serum test is of no value in the case of those who have undergone anti-typhoid or anti-para- typhoid vaccination, and that precise information can be gained by blood cultures only. The relative advantages of a restricted and liberal diet are discussed in the chapter on treatment, which also contains a description of serum- therapy and vaccine-therapy and the general manage- ment of the patient.

Considerable space is devoted to the important question of the carrier of infection. A special chapter is devoted to the prophylaxis of typhoid fever in the army. The work concludes with a chapter on preventive inoculation in which its value is conclusively proved by the statistics of all countries in which it has been employed.

MM. Vincent and Muratet have also contributed to the series a work on Dysentery, Cholera and Typhus which will be of special interest to those whose duties take them to the Eastern Mediterranean or Mesopotamia. The carrier problem in relation to dysentery and cholera is fully discussed, and special stress is laid on the epidemio- logical importance of mild or abortive cases of these two diseases.

In their monograph on The Abnormal Forms oj Tetanus, MM. Court ois-Suffit and Giroux treat of those varieties of the disease in which the spasm is confined to a limited group of muscles, e.g. those of the head, or one or more limbs, or of the abdomino-thoracic muscles. The constitutional symptoms are less severe than in the generalised form of the disease, and the prognosis is more favourable.

The volume by Dr. G. Thibierge on Syphilis and the Army is intended as a vade mecum for medical officers in the army.

Turning now to the works of neurological interest, we have two volumes dealing with lesions of the peripheral

viii GENERAL INTRODUCTION

nerves by Mme. Athanassio-Benisty, who has been for several years assistant to Professor Pierre Marie at La Salpetriere. The first volume contains an account of the anatomy and physiology of the peripheral nerves, together with the symptomatology of their lesions. The second volume is devoted to the prognosis and treatment of nerve lesions.

The monograph of MM. Babinski and Froment on Hysteria or Pithiatism and Nervous Disorders of a Reflex Character next claims attention. In the first part the old conception of hysteria, especially as it was built up by Charcot, is set forth, and is followed by a description of the modern conception of hysteria due to Babinski, who has suggested the substitution of the term 44 Pithiatism," i.e. a state curable by persuasion, for the old name hysteria. The second part deals with nervous disorders of a reflex character, consisting of contractures or paralysis following traumatism, which are frequently found in the neurology of war, and a variety of minor symptoms, such as muscular atrophy, exaggeration of the tendon reflexes, vasomotor, thermal and secretory changes, etc. An important section discusses the future of such men, especially as regards their disposal by medical boards.

An instructive companion volume to the above is to be found in the monograph of MM. Roussy and Lhermitte, which embodies a description of the psychoneuroses met with in war, starting with elementary motor disorders and concluding with the most complex represented by pure psychoses.

SURGICAL SERIES

When the present war began, surgeons, under the influence of the immortal work of Lister, had for more than a quarter of a century concerned themselves almost exclusively with elaborations of technique designed to shorten the time occupied in or to improve the results obtained by the many complex operations that the genius of Lister had rendered possible. The good behaviour of the wound was taken for granted whenever it was

GENERAL INTRODUCTION ix

made, as it nearly always was, through unbroken skin, and hence the study of the treatment of wounds had be- come largely restricted to the study of the aseptic variety. Septic wounds were rarely seen, and antiseptic surgery had been almost forgotten. Very few of those who were called upon to treat the wounded in the early autumn of 1914 were familiar with the treatment of grossly septic com- pound fractures and wounded joints, and none had any wide experience. To these men the conditions of the wounds came as a sinister and disheartening revelation. They were suddenly confronted with a state of affairs, as far as the physical conditions in the wounds were concerned, for which it was necessary to go back a hundred years or more to find a parallel.

Hence the early period of the war was one of earnest search after the correct principles that should be applied to the removal of the unusual difficulties with which surgeons and physicians were faced. It was necessary to discover where and why the treatment that sufficed for affections among the civil population failed when it was applied to military casualties, and then to originate adequate measures for the relief of the latter. For many reasons this was a slow and laborious process, in spite of the multitude of workers and the wealth of scientific resources at their disposal. The ruthlessness of war must necessarily hamper the work of the medical scientist in almost every direction except in that of providing him with an abundance of material upon which to work. It limits the opportunity for deliberate critical observation and comparison that is so essential to the formation of an accurate estimation of values ; it often compels work to be done under such high pressure and such unfavourable conditions that it becomes of little value for educative purposes. In all the armies, and on all the fronts, the pressure caused by the unprecedented number of casualties has necessitated rapid evacuation from the front along lines of communication, often of enormous length, and this means the transfer of cases through many hands, with its consequent division of responsibility, loss of continuity of treatment, and absence of prolonged observation by any one individual.

In addition to all this, it must be remembered that

x GENERAL INTRODUCTION

in this war the early conditions at the front were so uncertain that it was impossible to establish there the completely equipped scientific institutions for the treatment of the wounded that are now available under more assured circumstances, and that progress was thereby much hampered until definitive treatment could be under- taken at the early stage that is now possible.

But order has been steadily evolved out of chaos, and many things are now being done at the front that would have been deemed impossible not many months ago. As general principles of treatment are established it is found practicable to give effect to them to their full logical extent, and though there are still many obscure points to be elucidated and many methods in use that still call for improvements, it is now safe to say that the position of the art of military medicine and surgery stands upon a sound foundation, and that its future may be regarded with confidence and sanguine expectation.

The views of great authorities who derive their knowledge from extensive first-hand practical experience gained in the field cannot fail to serve as a most valuable asset to the less experienced, and must do much to enable them to derive the utmost value from the experience which will, in time, be theirs. The series covers the whole field of war surgery and medicine, and its predominating note is the exhaustive, practical and up-to-date manner in which it is handled. It is marked throughout not only by a wealth of detail, but by clearness of view and logical sequence of thought. Its study will convince the reader that, great as have been the advances in all departments in the services during this war, the progress made in the medical branch may fairly challenge comparison with that in any other, and that not the least among the services rendered by our great ally, France, to the common cause is this brilliant contribution to our professional knowledge.

A glance at the list of surgical works in the series will show how completely the ground has been covered. Appropriately enough, the series opens with the volume on The Treatment oj Infected Wounds, by A. Carrel and G. Dehelly. This is a direct product of the war which, in the opinion of many, bids fair to become epoch-making

GENERAL INTRODUCTION xi

in the treatment of septic wounds. It is peculiar to the war and derived directly from it, and the work upon which it is based is as fine an example of correlated work on the part of the chemist, the bacteriologist, and the clinician as could well be wished for. This volume will show many for the first time what a precise and scientific method the 44 Carrel treatment " really is.

The two volumes by Professor Leriche on Fractures con- tain the practical application of the views of the great Lyons school of surgeons with regard to the treatment of injuries of bones and joints. Supported as they are by an appeal to an abundant clinical experience, they cannot fail to interest English surgeons, and to prove of the greatest value. It is only necessary to say that Wounds of the Abdomen are dealt with by Dr. Abadie, Wounds of the Vessels by Professor Sencert, Wounds of the Skull and Brain by MM. Chatelin and De Martel, and Localisation and Extraction of Projectiles by Professor Ombredanne and R. Ledoux-Lebard, to prove that the subjects have been allotted to very able and experienced exponents.

ALFRED KEOGH.

PBEFACE

THIS book, which describes the work which Abadie has done in the treatment of abdominal wounds in the present war, is most valuable, since it demonstrates the highest standard of efficiency that has yet been reached and the manner in which the expert surgeon may emulate his success.

The descriptions of the technique are admirable, being clear, lucid, and easily understood. They there- fore afford an excellent source of information and instruction for the surgeon at work at the front. Experience shows how very important it is to specialise. This is especially true in war time, and wounds of the abdomen in particular demand a special training, as well as a distinct aptitude on the part of the operator, the latter being by no means the least important attribute. One realises only too often that, while a surgeon may be able to adapt himself with enthusiasm to one form of surgery, he may be perfectly hopeless in other branches. This fact makes it most important to choose a suitable man for the treatment of each class of injury. One cannot but be impressed with the great care which Abadie has taken in describing and illustrating the subject of wounds of the abdomen in this work, and I personally feel very grateful to him for the benefit that has accrued to me from reading. His teaching and his methods will be the means of saving many lives which would otherwise be sacrificed.

W. AEBUTHNOT LANE.

XI 11

xvi PREFACE

results of operation must be added to this irreducible primary cause of error : the time that has elapsed between the wound and operation, the conditions and duration of transport, the gravity of the wound, the nature of the projectile, the experience of the surgeon and his helpers, the operating installation and instruments, etc. To analyse the facts correctly, to recognise the causes of error, and above all to see this very complex question in all its aspects would require a man who has seen for himself the conditions which the necessities of war impose on this most difficult branch of surgery. In this case perhaps more than in any other, the experience of others is of no avail, or almost none. Personal experience alone can bring conviction.

The author of this work is one of those who possess the qualifications necessary for writing such a book. A surgeon of great distinction and wide experience, who has been able to adapt himself rapidly to the varied conditions of surgery at the front, with a clear and methodical mind, with personal intuition as well as critical power, he has taken account not only of his own work but also of that of his colleagues. He has carefully analysed the writings, the communications, the reports, and the discussions to which this very complex subject has given rise, and his conclusions are the same as those formulated by the Chirurgical Society in a unanimous vote : an operation as speedily as possible, conducted under appropriate conditions.

The immense drama in which we live is still develop- ing its murderous catastrophes, and the formidable hecatomb is not yet near its end. Many further victims are doomed to fall on the blood-thirsty earth. May this little book, so alert and vivid, so easy and attractive to read, bring conviction to the minds of those who are still hesitating, and help to preserve for France the life of some of her precious children !

J.-L. EATJEE,

CONTENTS

PAGE

INTRODUCTION . . xxiii

PART I

WHAT TREATMENT IS TO BE PREFERRED IN PENETRATING WOUNDS OF THE ABDOMEN ?

CHAPTER I

THE FACTS AND TEACHINGS OP PEACE-TIME . 3

CHAPTER II

THE FACTS AND PRACTICAL CONCLUSIONS DERIVED

FROM FORMER WARS . . . .10

CHAPTER III THE EXPERIENCE OF THE PRESENT \VAR . 32

CHAPTER IV ANATOMICAL LESIONS 64

b xvii

xviii CONTENTS

CHAPTER V

FAOK

THE TREATMENT TO ADOPT is LAPAROTOMY—

DISCUSSION . . . . . .118

PART II

UN DEE WHAT CONDITIONS AND SUR- ROUNDINGS IS THIS PARTICULAR TREATMENT APPLICABLE ?

CHAPTER VI

CONDITIONS AND SURROUNDINGS NECESSARY FOR

LAPAROTOMY . . . . . .149

PART III

OF THE METHODS TO BE ADOPTED IN THE PRESENCE OF A DEEP-SEATED ABDOMINAL WOUND

CHAPTER VII

DIAGNOSIS OF THE LESIONS — INDICATIONS FOR

OPERATION . . . . . .179

CHAPTER VIII

LAPAROTOMY FOR PENETRATING WOUNDS OF THE

ABDOMEN . . . . . .216

CHAPTER IX

MEDICAL TREATMENT — EXCEPTIONAL OPERA- TIONS— DEFERRED OPERATIONS . . 270

BIBLIOGRAPHY 283

LIST OF ILLUSTRATIONS

1. SHRAPNEL BULLET ENCYSTED IN THE OMENTUM

(GOUILLIOUD AND ARCELIN) ... 68

2. SHRAPNEL BULLET ENCYSTED IN THE OMENTUM

WITH TORSION OF THE PEDICLE (GOUILLIOUD AND ARCELIN) .... 69

3. CUTHBERT WALLACE'S DIAGRAM: PENETRATING

WOUNDS WITHOUT VISCERAL LESIONS . . 72

4. DIAGRAM OF WOUNDS CURED WITHOUT OPERATION,

AND OF PENETRATING WOUNDS WITHOUT VISCERAL LESIONS ... 73

5. NON-VISCERAL AND NON- VASCULAR ZONES OF THE

POSTERIOR ABDOMINAL WALL ... 74

6. RADIOGRAPHY. LARGE PROJECTILE WHICH HAD

REMAINED SUBPERITONEAL . . . .77

7. THE TRUE PELVIS is THE "COLLECTING-SINK" OF

THE ABDOMINAL CAVITY (FRONTAL SECTION) . 87

8. THE TRUE PELVIS is THE " COLLECTING-SINK " OF

THE ABDOMINAL CAVITY (MEDIAN SECTION) . 88

9. RESECTED INTESTINAL LOOPS : DIFFERENT TYPES

OF LESIONS ...... 93

10. RESECTED INTESTINAL LOOPS AND APPENDIX:

DIFFERENT TYPES OF LESIONS ... 95 1 1. LIVER. — TYPE OF EXPLOSION (COTTE AND LATARJET) 98

12. SPLEEN.— TYPE OF EXPLOSION (COTTE AND

LATARJET) ...... 99

13. STOMACH AND SPLEEN. — PERFORATION AND EX-

PLOSION (COTTE AND LATARJET) . . 100

xx LIST OF ILLUSTRATIONS

FICURK PAGE

14. KIDNEY.— TYPE OF EXPLOSION (CABPANETTI) . 100

15. KIDNEY. — TYPE OP EXPLOSION . . . .101

16. KIDNEY. — LESIONS OP PELVIS AND VESSELS (COTTE

AND LATABJET) .... .101

17. BLADDEB. — LABGE FBAGMENTS OP GBENADE WHICH

HAD BBOKEN INTO THE FtJNDUS OF THE BLADDEB 102

18. PANCBEAS. — LACEBATION OF THE POSTEBIOB SUB-

FACE 104

19. PELVIS. — SHELL FBAGMENT WHICH HAD TBAVEBSED

THE PELVIC OBGANS

20. ABDOMINO-THOBACIC WOUND. — TBANSDIAPHBAG- 110

MATIC HEBNIA OF THE STOMACH . . .113

21. ABDOMINO-THOBACIC WOUND. — BUBST LIVEB, HEB-

NIA OF THE COLON . . . . .114

22. DlAPHBAGMATIC HEBNIA (L.EGBAIN, QUENU,

RICHABD) 115

23. TOPOGBAPHY OF ABDOMINAL WOUNDS ACCOBDING

TO THEIB GBAVITY 116

24. DIAGBAM OF CUBES OBTAINED BY THE MUBPHY

TBEATMENT ....... 122

25. DIAGBAM OF DEATHS FBOM ABSTENTION OBSEBVED

BY A SINGLE WBITEB . . . . .140

26. DIAGBAM OF CUBES BY ABSTENTION OBSEBVED BY

A SINGLE WBITEB . . . . * . . 141

27. DIAGBAM OF CUBES BY ABSTENTION AMONG 121

CASES 142

28. DIAGBAM OF CUBES BY LAPABOTOMY AMONG 125

CASES 143

29. ROOM FOB LAPABOTOMIES (HOPITAL MABGAINE,

STE. MENEHOULD) 152

30. LAPABOTOMY TAKING PLACE . . . .163 31 and 32. SURGICAL POST AT THE FBONT (BOIGEY). —

OPEBATING-BOOM — STEBILISATION APPABATUS 154-5 33. PBOTECTED SHELTEB FOB SURGICAL OPEBATIONS

AT THE FBONT ... 156

LIST OF ILLUSTRATIONS xxi

FIGURE PAGE

34. TRENCH STRETCHER (EYBERT) . . . .162

35. IMMOBILISING STRETCHER (MARTIGNON) . .163

36. 37, and 38. SURGICAL AUTOMOBILE FOR OPERATIONS

NEAR THE FRONT . . . . . .170

39. HORIZONTAL SECTION OF THE ABDOMEN. — THICK-

NESS OF THE ABDOMINAL WALL . . .185

40. DIAGRAM OF NON-PENETRATING WOUNDS OF THE

ABDOMINAL WALL, VERIFIED BY OPERATION . 186

41. WOUNDS OF THE BUTTOCKS. — HORIZONTAL SECTION

OF THE PELVIS . . . . . .187

42. WOUNDS OF THE BUTTOCKS. — VERTICAL SECTION

OF THE PELVIS 188

43. TOPOGRAPHY OF ABDOMINAL WOUNDS ACCORDING

TO THEIR GRAVITY . . . .193

44. ELECTRIC LAMP HEATING APPARATUS . . . 206

45. STRETCHER FOR WARMING PATIENTS (POUCEL) . 207

46. SHELL FRAGMENT IN THE ABDOMEN, BUT EXTRA-

PERITONEAL . . . . . . .211

47 and 47 bis. SURGICAL COMPASS WITH DIRECT CON- TROL UNDER THE X-RAY SCREEN . . 212—13

4vS and 49. INSTRUMENTS NEEDED FOR LAPAROTOMY 217-8

50. AUTOSTATIC RETRACTOR . . . . .219

51. DOUBLE CLAMPS, PERMITTING DIFFERENT POSITIONS 220

52. DIAGRAM OF THE DIFFERENT INCISIONS FOR

LAPAROTOMY 228

53. GRENADE FRAGMENTS . . * . . . 233

54. KEHR'S LAPAROTOMY ...... 237

55. LEFT SUBCOSTAL LAPAROTOMY (GUIBE) . .238

56. AUVRAY'S METHOD FOR REACHING THE LIVER

(GuiBE) 240-1

57. SECTION SHOWING THE ROUTES TO THE LESSER

SAC OF THE PERITONEUM .... 244

58. ACCESS TO THE POSTERIOR SURFACE OF THE

STOMACH BY THE GASTRO-EPIPLOIC ROUTE (FORGUE AND JEANBRAU) ..... 245

xxii LIST OF ILLUSTRATIONS

FIGUBB PAGE

59, 60, 61, and 62. ACCESS TO THE POSTERIOR SURFACE OF THE STOMACH BY THE INTERCOLO-GASTRIC ROUTE (PAUCHET). — DIFFERENT STAGES . 246—9

63. ACCESS TO THE SPLEEN, COLON, AND LEFT ANGLE

OF THE STOMACH ...... 250

64. RADIOGRAPHY OF A PROJECTILE WHICH HAS PENE-

TRATED THE PELVIC ORGANS .... 255

65. FOWLER'S POSITION BY THE HELP OF TWO IN-

CLINED PLANES FIXED TOGETHER . . .271

66. DROP COUNTER FOR CONTROLLING THE " DROP-

BY-DROP " METHOD ..... 272

67. CONTROL OF THE " DROP-BY-DROP " BY A FUNNEL 272

68. CONTROL OF THE " DROP-BY-DROP " METHOD BY A

PIECE OF WOOD 272

69. IMPROVISED METHODS FOR CONTROLLING THE

" DROP-BY-DROP " METHOD . . . .273

PLATE I

EXAGGERATED PTOSIS OF THE TRANSVERSE COLON WITH ABNORMAL POSITION OF THE SMALL INTESTINE ABOVE IT . ..... 200

PLATE II

BURSTING LESIONS FROM A BULLET IN THE LIVER AND KIDNEY. ANOMALIES IN POSITION OF THE COLON AND THE KIDNEY .... 246

PLATE III

PATH OF ACCESS BETWEEN THE STOMACH AND COLON, THROUGH THE OMENTUM, TO REACH THE POS- TERIOR SURFACE OF THE STOMACH. . .248

PLATE IV

PATH OF ACCESS BETWEEN THE STOMACH AND LIVER TO REACH THE POSTERIOR SURFACE OF THE STOMACH .... 250

INTEODUCTION*

THE question of "penetrating wounds of the abdomen in war surgery " has the rare privilege of growing in interest as the months of war succeed each >ther. Among the surgeons at the front it is the first question debated, and the unfailing object of investi- gation. Very rarely are other topics discussed by the learned societies with equal animation.

This is primarily due to the fact that at its root there exists a " conflict " ; a conflict arising, on the one hand, from the precepts of surgery in time of peace, and on the other from the experiences derived from former wars.

In time of peace there is no diversity of opinion. In case of a penetrating, or presumably penetrating* wound of the abdomen, surgical intervention takes place ; and the fact that, where any doubt or hesita- tion exists, intervention is resorted to all the same shows with what exactitude the equation holds good : in peace-time, wound of the abdomen = laparotomy. On the other hand, the trials made and the results btamed in preceding wars have led to practical con-

* This work is published with the authorisation of M le M^derin

Ln?heeCNS"th^ral Br\rd' Ch6f Sup°ri6Ur du Service dfstnt" Alf ^k Armv> *o whom we offer our respectful thanks.

mosl \rTtef ?Thm°td6Sty ^ pr°teSt' * feel bound to render my

Lgr R ^ ^ t0 my colleagues, Aide-Majors Trastour,

Lieutier, Baudoum Pouget, and above all to M. le Medecin-Major

erTtWr ;Ch6f ?f Om> ambula*ce, for their most expert

ive assistance for their clinical reports and their most

whti Critlcfm' The Origi^l drawings contained in this work

larks of h°Tf ^l tal6nt °f M" N°tin' are the least of the f his friendship we treasure in memory.

xxiii

xxiv INTRODUCTION

elusions exactly opposite, and MacCormac's classical aphorism may be rendered by an equally absolute equation : in war, wound of the abdomen = abstention.

Does this war confirm such a confession of surgical failure ? Have we to admit decidedly that, whatever may be the ability of the operators and however per- fect may be the material conditions in which they are placed, they must acknowledge themselves van- quished ? Is it proved again that aseptic surgery, go proud, and with such good reason, of having been able to extend the free exercise of its most daring interventions to the abdominal cavity, must own itself impotent in the special conditions inherent in a state of warfare ? Such is the doctrinal question, and one can understand how it inflames the ardent surgeon, little accustomed to have to admit impotence.

In this conflict facts alone can provide the ele- ments valid for discussion. At this moment those elements exist. An experience of over twenty months of warfare has not only afforded an opportunity of accumulating facts, but also of gathering them under the most varied strategic conditions. Rapid evolu- tions and movements of great extent, great battles between armies in movement, retreats, trench warfare, battles round fixed positions of long duration and between enormous masses — all these different even- tualities have been realised in the varying fortune of war. And these are experimental conditions which actually admit of the formation of precise conclusions, from the doctrinal as well as the practical point of view.

The relative rarity of abdominal wounds met with by the surgeon should not induce us to give them less of our anxious thought. No doubt statistics show a very small proportion of abdominal wounds in comparison with the totality of the wounded. Dupont and Kendirdjy estimate them at 2J per cent., Sencert at less than 2 per cent., Chavannaz at 4 per

INTRODUCTION xxv

cent. In our own ambulance, immobilised for surgery at 12 kilometres from the front, we have only observed 160 abdominal wounds in 15 months among 3,815 wounded, a proportion of between 4 and 5 per cent. We may admit that of this number only two-thirds were really penetrating wounds. But, even then, can we cheerfully accept the idea of doing nothing for them, or, on the other hand, " approve an organisa- tion which would sacrifice on principle, and without an attempt to save " (Quenu) 3*3 per cent., of whom we admit it might be possible to save one-third by using appropriate means ? We have only to consider the total number of wounded to judge of the value of the lives thus neglected, and to convince our- selves that no effort is more legitimate than to seek to diminish their number, even at the cost of a special organisation.

Is it a superfluous task to set forth the present state of this question, addressing ourselves particularly to the surgeons in the army zone ? No, certainly not. Not one amongst us can fix a date for the termination of hostilities ; we only know that, for our part, our national effort will cease only with victory, and that our efforts as medical men will be ardently sustained to the end. If a more distinct idea of what ought to be done for those wounded in the abdomen induces the organisers of the " service de sant6 " to improve and multiply the means of relief, and inspires surgeons to make more prompt decisions, if a focusing of the exact state of the question contributes to the saving of a few more precious lives, it will be our best recompense, and a proof that this attempt is neither premature nor vain.

At this point it seems right to emphasise the spirit in which this work is undertaken : it is essentially and exclusively practical.

xxvi INTRODUCTION

Every time a man wounded in the abdomen is brought to the army surgeon, a problem presents itself to the latter. " What shall he do ? " or, to be more exact, " What would he like to do ? " " What can he do ? " There is no therapeutic surgical problem occurring at the front that presents itself with such imperious demand for prompt decision yet whose practical solution is so complex.

This is the concrete problem which we are trying to keep always before our minds in writing the following pages. And we are here endeavouring to follow, step by step and hour by hour, the wounded man and the surgeon from the first instant of their meeting until the end, whether of triumph or resignation, is reached.

With this end in view the plan which we have followed naturally develops. Faced by a patient wounded in the abdomen, the surgeon must —

(1) Above all, have a distinct opinion on the treat- ment to be preferred in cases of penetrating wounds of the abdomen.

(2) He must have at hand the equipment which permits of his applying this treatment ; he must know, on the other hand, what conditions would exonerate him from applying it, or would even compel him to abandon the idea of making the attempt.

(3) He must know exactly what to do in each indi- vidual case, whether to operate radically, to undertake a palliative operation, or to have recourse to medical treatment.

It is, therefore, under a threefold aspect — principles, organisation, and method — that we are about to consider penetrating wounds of the abdomen in the army.

But in saying this we in no way imply that we intend to make a methodical examination of the various heads under which the didactic and classical study of a question of surgical pathology would naturally fall, or to follow the plan which from etiology methodically

INTRODUCTION

XXVll

leads to treatment.* Neither is it possible for us to make a critical review of all the published cases and opinions enunciated. We have read the greater num- ber of them, and a list of the dissertations we have been able to consult will be found in the Bibliography. But, in respect of this necessarily incomplete biblio- graphy, we should like to indicate the conditions under which this work has been carried out, and thus per- haps secure the indulgence of our readers. Eeduced as we have been to consult only the periodicals we have ourselves received without the assistance of any library, and without being able to interrupt for a single day the intense and continuous surgical activity of the ambulance where we operate daily, we have had to depend for inspiration mainly upon the facts we have ourselves seen and experienced.

SAINTB-MENBHOULD, June 1916.

* No special chapter has been devoted to isolated intraperitoneal wounds of the bladder or the kidneys. The reason isobvioS 7>? C£n,dltions ™ust exist- Either diagnosis is absolutely tftain— the kidney only or the bladder only is involved • it is hen a perfectly simple problem of urinary surgery (incision or nephrectomy, early or deferred) showing^ non! of the special iharacteristics of penetrating wounds of the abdomen. Or else tie diagnosis is inexact; abdominal lesions may coexist and if to they immediately absorb all the attention. Diagnosis is'centred entirely on them; they alone render therapeutic decision impera- tive ; their existence, or even their mere possibility, demands opera- tive technique. But in the natural progress of our study the associated wounds of the bladder and kidneys will also come in for consideration.

PART I

.

WHAT TREATMENT IS TO BE PREFERRED IN PENETRATING WOUNDS OF THE ABDOMEN ?

CHAPTER I

THE FACTS AND TEACHINGS OF PEACE-TIME

IT is hardly more than twenty years since exploratory laparotomy became so consistently beneficial that one could consider its risks negligible.

And it is hardly more than twenty years since an understanding was come to amongst all, or nearly all, surgeons as to the treatment of abdominal wounds ; the question, in fact, was not of simply admitting that an undoubted penetrating wound indicated laparotomy, but it was a complete agreement that even the possi- bility of penetration justified direct interference by the opening of the abdominal cavity.

As far back as 1881, under the influence of Marion Sims, American surgeons had been the first to practise and advocate systematic intervention in gunshot wounds of the abdomen ; the results— by no means brilliant— produced by laparotomy, still in its infancy, were not greatly calculated to increase the number of its partisans. It is not enough to enunciate opinions vigorously; they must be confirmed by facts. And f it is true that the " French Party," as Kukula writes 899), remained abstentionist, it could justify itself against the " German and American Party," who were interventionist.

It must be recognised, however, that in 1899 Terrier, whom we are not astonished to find championing a new idea, affirmed the necessity of laparotomy not only in intestinal perforations, but in the case of any

4 WOUNDS OF THE ABDOMEN

viscera whatever. " I should consider it a paradox," he said, " to maintain that it is not better to sew up a wound (of the stomach) than to leave it to itself. Intervention is therefore imperative, and as speedily as possible." Chauvel, Quenu, and Championniere ranged themselves on his side.

But it was only in January 1895, at the meeting of the Chirurgical Society of Paris, that the doctrine of systematic laparotomy was proclaimed in all its ful- ness. It was delivered in a speech by Chaput, con- cerning a case reported by Rochard, and the very animated discussion that followed has become classic.

Called to a woman who had been wounded in the csecal region and in the epigastrium by two triangular sword-cuts, Rochard operated at once, four hours after the accident. A sub-umbilical incision enabled him to locate and close two perforations of the caecum with discharge of contents and gas into the peritoneum ; another supra-umbilical incision proved the absence of any visceral lesion in that region. The patient recovered.

Starting from the discussion of this case, Chaput passed in review the principal problems involved in the treatment of abdominal wounds ; he did not confine himself to wounds made by piercing and cutting instruments, but included also those where the decision is considered far more momentous — gun- shot wounds.

And the arguments by which he defended his thesis have so far held good that one is bound to consider them at this moment as having still the same weight as when he spoke.

The crux of the argument can be thus stated : must one wait to intervene in a case of penetrating wound of the abdomen until complications allow us to diag- nose a visceral lesion ?

" Yes," say Berger and Reclus. Berger had written in 1891 : "In recent cases of penetrating wounds of

FACTS AND TEACHINGS OF PEACE-TIME 5

the abdomen caused by revolver bullets, where there are no complications, in spite of symptoms indicating penetration with more or less certainty, it is advisable to wait, above all when the bullet appears to have involved the stomach or the large intestine." And this opinion he defends by mentioning the signs whose absence justifies abstention : sensitiveness of the abdomen, a certain degree of dulness, a gurgling sound on percussion, frequency of the pulse and respiration, and anxiety of expression. As for Eeclus, experi- mental researches on dogs, experiments which have remained classic, have shown him that a " mucous stopper " can prevent the issue of the intestinal contents through a small perforation, and that the union of an injured loop of intestine to the neighbour- ing loops favours the spontaneous obliteration, or heal- ing, of larger perforations ; finally, statistics concern- ing 88 injuries treated by waiting, with 66 recoveries and 22 deaths (25 per cent.) incline him to reserve laparotomy for cases demonstrably infected.

Quite otherwise is the attitude of Chaput, already supported by Terrier, Qu6nu, and Broca, who were joined later by Nelaton and Schwartz. Chaput describes his mode of procedure in terms that admit of no misunderstanding : " Not only do I make use of laparotomy whenever the wound is penetrating, with or without symptoms, but I also make use of it whenever penetration is doubtful ! " In acting thus he is faithful to the precept : " Act in doubtful cases, whenever action is less risky than waiting."

But, waiting is never without danger !

Too much reliance on the part played by the "mucous stopper," on the adhesions which limit peritoneal reaction, exposes one to frequent disasters. Limited infection of the peritoneum does not kill, it is true ; but Grawitz has shown that wounds of the peritoneum with blood -clot and irregularity of the intestinal surfaces favour the multiplication of germs,

6 WOUNDS OF THE ABDOMEN

and constantly induce general fatal peritonitis — and that is the case in gunshot wounds of the abdomen.

Is the preliminary diagnosis demanded by Berger always possible ? Not at all. There is no " pathog- nomonic sign " for diagnosing a wound of the abdominal viscera in the first few hours. Pain, early vomiting, pallor, and the pulse have no distinct signification ; the temperature is scarcely modified, except in cases of haemorrhage or shock ; haematemesis and melaena do not always occur even when the stomach or colon is attacked ; the signs of peritonitis are only too slow in appearing. " The truth is," says Nelaton, " that in practice, when the hour of appearance of symptoms has struck it is almost always too late to intervene with safety." Before this "bankruptcy of clinical evidence," laparotomy is therefore indicated as the only intervention really " tutelary." " It is a hundred times better," writes Jalaguier in his turn, " to open an abdomen in which there exists no visceral lesion, than abandon in the peritoneum a perforation of the stomach or the intestine."

But what are the results ? What is the respective value of expectant treatment and surgical interference ? To the statistics of Eeclus (a 25 per cent, mortality by waiting) we may oppose those of Stimson ; he gives, not 25 per cent., but 70 percent. ; Chaput also recalls his own experimental researches, which furnish a figure identically the same as Stimson's. Quite other- wise is the coefficient of mortality furnished by laparo- tomy. A recent thesis, well provided with references, by Adler gives 54 per cent, from gunshot wounds and 32 per cent, for " cold steel " wounds. And this number is still further reduced if we reckon only the early operations by laparotomy, performed in the first five hours !

After noting precisely the operative indications and counter-indications, and describing the technique in detail, Chaput reaches the following conclusions :

FACTS AND TEACHINGS OF PEACE-TIME 7

1. In the immense majority of cases, with a narrow and recent wound in the umbilical region, it is im- possible to diagnose penetration from the symptoms presented by the patient.

2. Exploration by probe and laying open the wound would not furnish us with certainty in all cases.

3. In the case of an abdominal wound dating back several hours, laparotomy must be performed whenever there is the slightest doubt as to the soundness of the intes- tine.

4. If the wound dates back several days, laparotomy must be made use of if there is the slightest doubt as to the possible existence of peritoneal septicaemia.

5. There should be no intervention in the case of a wound dating back twenty-four or forty-eight hours, if the general condition is perfect and there is a very marked sensation of well-being ;

6. Expectant treatment is dangerous. It furnishes a mortality of 60 to 75 per cent.

7. Early and well-performed laparotomy is the only rational and beneficial course. According to Adler's observations, early laparotomy (in the first five hours) correctly executed, has given, in 32 cases, 26 cures and 6 deaths (18 per cent.).

8. It is indispensable to examine the whole intestine so as to be quite sure of not leaving in the abdomen one or more undetected perforations.

9. To find the source of a haemorrhage easily, to flush the peritoneum in its innermost recesses, it is neces- sary to turn out the whole intestine.

10. To repair the perforations we must make use, according to the case, of suture in two stages, of intes- tinal grafts, of lozenge-shaped excisions, and even of resection of the intestine.

Of these conclusions there is not one that has not been confirmed by facts during the last twenty years. Expectant treatment, even " armed " expectation, has lost its last adherents ; under the guise of a seduc-

8 WOUNDS OF THE ABDOMEN

tive term it has yielded too many deceptive sur- prises. So that at the present moment we may consider the doctrine of systematic interference as definitely estab- lished ; intervention, as early as possible in every case of abdominal wound, whether from cutting or piercing instruments or gunshot, which is liable to be penetrating, with or without visceral lesion.

But if, in time of peace, such a rule is universally admitted, it is because the wound, the patient, the surgeon and the operating theatre present a certain number of conditions that it will be of interest to consider, before dwelling on those that obtain in time of war.

In time of peace the wound is usually single. One thrust of the sword or dagger generally suffices to calm the fury of a single combat, just as one shot from the revolver assuages the fury of a crime passionnel, revives the taste for life in the amateur suicide, and represents the full extent of an accident. The effective force of the projectiles cannot be compared to that of the arms used in warfare. Therefore the wounds received in time of peace are, generally speak- ing, less numerous, less extensive, and less serious.

The patient also is generally overtaken in the full course of his normal life. He has suffered no excep- tional privations, his power of resistance is not weak- ened by a physical strain of several weeks or several months, he is not predisposed to shock by intense and repeated emotional ordeals. It is simply a question of an accident to a healthy subject.

The surgeon is a surgeon by vocation, usually accustomed to all difficulties by long practice. And that is a point on which Chaput dwelt with emphasis, as also did Championniere. " He must be a surgeon by profession," said he, " to plunge into this class of operations, perhaps the most difficult in surgery ; and I would not advise even a surgeon to operate if he had not sufficient experience in abdominal operations,

FACTS AND TEACHINGS OF PEACE-TIME 9

and above all of operations on the intestines. Good assistants are also indispensable, and it is necessary that they should have assisted at abdominal operations before." In our large towns all these surgical con- ditions are present.

The operating surroundings not only mean the in- stallations in the local hospitals and the perfection of instrumental appliances ; the exigencies of aseptic surgery are provided for wherever one operates, wher- ever one has the "right" to operate. And from the moment of the accident everything, in time of peace, concurs to favour the suflerer from a wound of the abdomen. As soon as the drama is accomplished the alarm is given ; the ambulance arrives, and transport is effected rapidly and comfortably. At the hospital all intended operations are deferred in favour of this " urgent " case, this "interesting " case. Every one makes haste, but only in the interest of the wounded man, and not simply to finish with him without delay in order to give attention to others equally urgent. . . . It is a fact that, in time of peace, the patient with an abdominal wound has the rare, the exceptional fortune to be an urgent case — yes, but, above all, one isolated case, one single case.

Nothing, therefore, is more natural than that all should be willing and anxious to afford him every chance of recovery.

Nothing is more reasonable than to advocate in- variable intervention in doubtful cases, even if it must be purely exploratory.

Nothing is more justifiable than the observation of this rule without the slightest exception.

CHAPTER II

THE FACTS AND PRACTICAL CONCLUSIONS DEEIVED FROM FORMER WARS

WHAT a remarkable contrast exists between the history of the treatment of wounds of the abdomen in time of peace and that of their treatment in time of war ! The first shows progress, sometimes slow but always proceeding towards the conquest of a decisive and definite formula ; here we have facts more emphatic than the words of men ; we have results that draw our operators on to bolder attempts ; we have practical successes preceding the conclusions of theory.

But the evolution of ideas with respect to the wounded in war is quite another story ! It is charac- terised by repeated fluctuations, nay more, by rhythmic variations. In times of peace surgeons, rendered more enterprising by their daily successes, cannot con- ceive that war may be a cause of inaction, and declare themselves more and more converts of intervention. But a war occurs ; they wish to operate, they do operate, and the results bring brutal discouragement to the warmest partisans of intervention ! Then, little by little, in peace-time, these disappointments are forgotten ; it seems possible to do better ; a new wave of courage arises, which a new war will again disperse. . . . These facts incline men to modesty, sur- geons revolt against results, and practical experience holds theory in leash. . . .

It is not without interest to retrace the curve of these fluctuations, if only to bring out more forcibly

10

CONCLUSIONS FROM FOEMEE WAES 11

what is specially noteworthy in the evolution of ideas that has occurred in the course of the present war. For the first time the number of the advocates of immediate surgical action has increased in the midst of war.

It was the War of Secession (1866) that saw the be- ginning of laparotomy in the treatment of war wounds. At that epoch Billings was its warm partisan. But of ten patients operated on, nine died (90 per cent, mortality), while Nancrede registered a 66 per cent, mortality among those not operated on. But at that period the uncertainty of laparotomy was so great, even in time of peace and when surrounded with every precaution, that the same reasons are of weight here as those that guided us in the previous chapter, making us take into consideration only the facts of the last twenty years. We shall therefore draw our conclusions only from the war in the Transvaal, that in Manchuria, the Morocco campaign, and the Balkan Wars.

We must also indicate the state of opinion on the subject before the war in the Transvaal.

The disasters of Billings and his fellow-surgeons in the course of the war of Secession, as we remarked above, did not deter the laparotomists from taking up the cudgels again !

In 1888, at the Paris Congress of Surgery, Chauvel,* in the course of his report on the mode of action in wounds of the visceral cavities caused by gunshot wounds, takes into account the circumstances of the battle-field, and shows the necessity for laparotomy. On the other hand Delorme, emphasising the difficulties of the time and surroundings, resolutely advocates abstention.

From logical premises the majority of authors declare

* Chauvel, " On the Course of Procedure in Wounds of the Visceral Cavities caused by Gunshot Wounds " (Report of the Third French Congress of Surgery, 1888).

12 WOUNDS OF THE ABDOMEN

themselves in favour of intervention. Several collec- tions of cases serve as the basis for their deductions. MacCormac in England, and Nancrede, Parkes, Hamil- ton, and Kinloch in America, had shown that spon- taneous recovery, if possible, was yet extremely rare, and hardly over occurred except in lesions of the large intestine, almost never in those of the stomach and small intestines. Makins, Flockmann, Fingel, and Wieting considered extraperitoneal wounds the most dangerous because of the greater virulence of the stercoral inflammation and of possible septicaemia. MacCormac insisted particularly on the gravity of vascular lesions ; the wound of a small artery or of an inconsiderable vein may become, in the conditions peculiar to the abdominal cavity, the source of fatal haemorrhage .

The results of the Tonkin campaign, though nega- tive, were the first to give rise to a judgment in favour of operation. Mmier compares the results of 72 abdominal wounds observed during the campaign, none of which were operated on, with the results of 81 laparotomies in civil practice ; the former showed a 75 per cent, mortality, the latter only 62 per cent. Nimier concludes that immediate laparotomy is neces- sary even in war wounds.

Such is the general opinion ; the differences of view arise almost invariably as to the most opportune place for surgical interference, whether at the dressing- station (Senn, Kocher), at the ambulance (field hospital) (Nimier, Laval, and Hildebrandt), or at the country hospital (Wagner, Habart).

At this stage of opinion three wars took place :

The Chino-Japanese War of 1893-5 made Haga reject laparotomy as impracticable and useless. Among 52 wounded men medically treated, he observed 75 per cent, mortality; but the only two operations carried out were followed by death.

After the campaign of Cuba the majority of Ameri-

CONCLUSIONS FROM FORMER WARS 13

can surgeons (Girard, Beckman, Delatour, Nancr&de, and Kudberg) condemned intervention, the wounded recovering without it and dying in spite of it. While medical treatment gave 12 recoveries in 41 cases, laparotomy was tried ten times and was followed by 9 deaths (Roberts : 5 cases, 5 deaths). Although the circumstances and the time of interference are not indicated, these results manifestly tell in favour of abstention.*

During the Tirah campaign eight cases of men wounded in the abdomen were observed (Whitehead): 5 laparotomies resulted in 5 deaths ; 3 cases treated medically resulted in 3 recoveries.

In spite of these unfortunate attempts, on the eve of the Anglo-Boer War Colonel Stevenson, professor of Military Surgery at Netley, in a communication to the Congress of the British Medical Association, made an urgent appeal for intervention. Only one of the surgeons present, Surgeon-General O'Dwyer, made reservations regarding the opportunity for the opera- tion. The war in the Transvaal broke out soon afterwards, f

From the beginning laparotomy was frequently employed for abdominal wounds ; sometimes, however, under conditions which condemned it to failure before- hand, a point to which we shall return later. There are no official documents stating the number of inter- ventions ; but, judging from partial statistics, a fatal issue was the rule and recovery the exception. Post- operative mortality was higher than 95 per cent.

* " Wounds of War caused by Gunshot in the Army of the United States in 1898 and 1899 (Report) " (abstracted in Arch. Med. et de Pharm. Milit., 1901, vol. i. p. 332).

f Numerous particulars in the following pages have been bor- rowed from Doche's very interesting study, " Indications and Opera- tive Results on Penetrating Wounds of the Abdomen caused by small War-projectiles" (Revue de Chirurgie, August 1909).

We cannot, however, group or interpret the facts in the same manner, which is directly opposed to speedy intervention.

The other works that we have personally consulted will be found mentioned in the footnotes.

14 WOUNDS OF THE ABDOMEN

Eoberts told the British Medical Association in 1902 that he had only seen laparotomy successful in two cases during the whole course of the Anglo-Boer War.*

Partial statistics by Makins of 15 men wounded in the abdomen give the following details : of 13 medi- cally treated, 10 recovered ; the two who were operated on died.

Watson Cheyne only performed laparotomy once. It was followed by death ; of 11 others wounded, 4 recovered spontaneously.

In opposition to these failures of primary laparotomy, other partial statistics show (with a few exceptions) the happy results of the medical treatment of wounds. Treves estimates their mortality at only 40 per cent. Kiittner had 1 1 deaths in 25 cases, or a mortality of 44 per cent. Flockmann, Bingel, and Wieting give the results as 50 per cent. Herz and Hildebrandt are the only ones who raise the coefficient to 70 or 80 per cent.

Is it astonishing that after the war even those we have mentioned as detractors of medical treatment became advocates of abstention, or showed themselves very lukewarm as regards intervention ?

No conversion of this kind is more characteristic, and none has been more exploited than that of Mac- Cormac ! A determined partisan of laparotomy, he had the courage frankly to avow his discomfiture. " A man wounded in the abdomen" he said before Kiittner, " dies if he is operated on, in this war, and he remains alive if he is left in peace ! " The suppression of the words "in this war" has allowed men to give an absolute value to this relative formula, and under the title of the aphorism of MacCormac to make of it a systematic condemnation of immediate inter- ference in wounds of the abdomen in time of war !

We must, however, remark that if Treves, Dent,

* Roberts, " Treatment of Wounds of the Abdomen in Time of War" (Brit. Med. Journal, October 4, 1903, p. 102; Arch, de Med. et de Pharm. Milit., 1903, vol. i., p 184)

CONCLUSIONS FROM FORMER WARS 15

Flockmann, Kingel, and Wieting are inclined to tem- porise, they still advocate operation in cases of profuse internal haemorrhage, or escape of faecal matter and peritoneal infection.

Makins advises intervention without exception in antero-posterior and transverse gunshot wounds in- volving the zone of the small intestine.

This is a very important first step in the direction of favouring primary laparotomy, even in the un- favourable light of a recent war.

The work of slow crystallisation which, in time of peace, draws together the partisans of intervention will be easier to describe.

In 1901 a warm advocate, Belin Flagg, at the Con- gress of the Association of Medical Men of the United States, tried to reinstate laparotomy as a primary operation in war-time. In the same year Morkovitine in Kussia, and in 1902 Hildebrandt, at the Congress oi German surgeons, showed themselves warm de- fenders of laparotomy.

Von Hippel,* who so late as 1903 published the con- clusions he had formed during the Transvaal War, recognises as indications for primary laparotomy :

(1) Internal haemorrhage, if the general condition

is not too low ;

(2) Wounds of the gall-bladder and of the bile

ducts ;

(3) Laceration of the bladder with osseous lesions ;

(4) Antero-posterior or transverse gunshot wounds

in the zone of the small intestine or of the transverse colon, even in the absence of all sign of intestinal lesion ;

( 5) Wounds in any direction with evident intestinal

perforation. Secondary laparotomy is indi- cated in all cases of generalised peritonitis.

* Von Hippel, "Laparotomy in War-time" (Arch f Klin

3j 1902; Arch- de md- et Pharm- *™*' iw*. T,

16 WOUNDS OF THE ABDOMEN

In 1904 Lejars declared that intervention is, in his view, " the only chance of safety for a great number of cases of abdominal wound."

On the other hand, Nimier has developed leanings towards abstention.

Surgeons were thus divided in opinion when the Eusso-Japanese War broke out (1904). On his arrival at Moukden, the medecin principal Eollenfant,* French military attache, learned from the Russian doctors, and above all from Wreden, that at the beginning of the war some surgeons of the field -hospitals, believing themselves justified by the comfort of their operating- rooms, the completeness of their surgical outfit and the perfection of their material for dressings, ventured on some difficult primary interventions, such as lapa- rotomy ; but the resulting want of success compelled them to adopt total abstention.

" Wreden, at Liao-Yang, found himself in a position to try this operation several times ; but the repeated failures that resulted made him renounce it altogether, and even to advise his subordinates against it."

At Moukden a certain number of hospitals, directed by Kahoumoff, Davidoff, (Ettingen, etc., and super- intended by Wreden, received from the front, hardly more than 30 to 40 kilometres distant, the most severely wounded men. These hospitals were intended for special surgery, they were in the most favourable positions, and were worked by a select staff ; yet all the laparotomies undertaken were followed by death.

" Princess Gedroitz alone, operating in a railway- carriage operating-room, had several successful laparo- tomies; but her patients had the benefit of arrange- ments admirably suited for the operations and the

* Follenfant, " The Russo-Japanese War. Surgical Impres- sions" (Arch, de Mid. et de Pharm. Milit. 1906, ii. p. 57).

CONCLUSIONS FROM FORMER WARS 17

after-attendance necessary. Yet Princess Gedroitz faxes, as the extreme limit for primary operation three hours after the injury, and the certainty of abundant haemorrhage as the determining reason for the operation."

On the Japanese side, Haga,* remembering the Uhmo-Japanese War, and, as we have seen, opposed to operation from that time, had formally forbidden it to the surgeons at the front. He was not able to undertake it himself because of the great instability ot the country hospitals.

At Port Arthur, on the other hand, permanency of the surgical establishments allowed of the systematic practice of laparotomy; but the results were by no means favourable.

Manteuffel f was also inclined to advocate restric- " Wounds of the bladder have been considered, since the Boer War, as insistently demanding opera- tion. Bergmann classes them under urgent opera- tions like tracheotomy, etc. This practice, while benencial for shrapnel-wounds, is worthless for bullet- wounds. The latter recover very well, in spite of all kinds of fistulas."

What, in comparison, is the general evolution of wounds treated medically ?

Some consider it as particularly favourable. Kholini furnishes a list of 27 cases, with only one death ; this s a percentage of the very lowest order. It is higher with Sonnenblick and Logachkine, who, at Turenschen, report 7 deaths in 25 cases, or 35 per cent.

But these figures require an important correction.

, .. *.. H?«?» 'ls.ome Precepts from the Russo-Japanese War " (Mi Ze ^

w -7 , IMO. /, p. 33).

• Von Manteuffel, " Medical Practice on the Field of Battle and First Lines (Russo-Japanese War). German Congress of

* IQOS n * ^' 19°6> P' 7H ; Arch' de md' etpharm-

2

18 WOUNDS OF THE ABDOMEN

As Bornhaupt * observes, " One would have to know not only about the wounded who arrive at the field- hospitals behind the lines, but also about those who succumbed before arriving there." Follenfant esti- mates them at 20 per cent. : " Abundant peritoneal haemorrhages have been only rarely observed, but it is certain that one-fifth of the penetrating wounds of the abdomen have caused speedy death in the mobile hospitals and ambulances at the front."

And here, taken from Bornhaupt, are statistics in which all the figures have their significance. In his Red Cross hospital, which was a base hospital, he received 174 patients wounded in the abdomen, who were admitted from the sixth to the tenth day. He divides them into three categories.

First category. — Of 118 cases treated by abstention, three who had violent peritonitis succumbed ; the others recovered ; which is splendid ! But of the latter number only 13 had pronounced visceral lesions, and 89 presented absolutely no abdominal symptoms. . . . We see the value of the coefficient of 2-3 per cent, mortality arrived at by certain authors !

Second category. — Five cases of penetrating thoraco- abdominal wounds give 4 deaths.

Third category. — 41 cases include 18 wounded already operated on at the front, 2 deaths ; 27 laparotomies undertaken at Bornhaupt's hospital, 14 recoveries, 13 deaths. It must be remarked that these brilliant results only concern deferred laparotomies, partial ones, probably for purulent localised peritonitis. Kablouchkoff noted equally with Follenfant the great number of recoveries observed at the base under these conditions.

Bornhaupt's conclusion is nevertheless as follows : " It is no longer possible to maintain now the principle

* Bornhaupt, " On Gunshot Wounds of the Abdomen during the Russo-Japanese War, 1904-6" (Arch. f. Klin. Chirurg., r6sum6 in Arch, de M6d. et Pharrn. Milit., 1909, ii. p. 234)

CONCLUSIONS FROM FORMER WARS

19

of absolute primary non-intervention, and one must no longer regard as a dogma the aphorism of Mac- Cormac."

To judge of the comparative gravity of lesions accord- ing to their locality, we have the statistics of Khar- bine (1904) :

Lesions.	No.	Deaths.	Recovery at once.	Dis- charged.	Mortality.
S t omach- intestine Liver Spleen _ . Kidneys	254 31 7 1	42 1	69 1 0	125 24 6 I	16% 20% 7%
Bladder .	14	4	1	9	28%

(The number of subsequent laparotomies performed in the base hospitals is unknown.)

The coefficients are of small value, for two reasons i

they only register a provisional mortality, since one

pes not know the fate of the discharged, and the

inherent parts of the intestine are grouped, though

there is a primordial interest in separating the small

intestine and the colon.

More importance ought therefore to be accorded to this statement of Follenfant : "As always happens perforations of the stomach, the upper portions of the small intestine, and those of the bladder have caused far higher mortality than wounds of the large intestine the lower portions of the small intestine."

The Morocco campaign did not produce many new

Only one primary laparotomy has been

formed to our knowledge," writes Doche "in

onsequence of an attempted suicide, and the lesions

•e such that, in spite of intervention, the wounded

man succumbed in a few hours." Toubert noted

the principal base hospital at Casablanca, three

t penetrating abdominal wounds in a total of

20 WOUNDS OF THE ABDOMEN

about 200 wounded, or T5 per cent, (which does not mean that there were few men wounded in the abdomen in the battles, but that nearly all died on the spot or in transit). The three cases of penetrating wounds recovered, two of them after having been complicated by suppurating retroperitoneal hsematoma, and with a pre- and peri-vesical abscess with hypogastric fistula (none of these cases, it would seem, was accompanied by lesion of the intestinal canal).

Gauthier, for his part, has communicated a state ment concerning 22 abdominal wounds, without pri- mary interference, among a total of 194 men wounded in war whom he looked after in the hospital at Casa- blanca, or at the field-hospital at the Boucheron camp ; but from these 22 cases 14 simple parietal wounds should be deducted. There then remain :

Case. Death. Recovery.

Perforation of the intestine ';•'. 1 1

„ „ liver . *' f 3 2

I, „ bladder . 1 1

Section of the internal iliac vessels 2

Without important visceral lesions 1

Thus 11 penetrating wounds show 5 deaths, or 46 per cent. But we must bear in mind the special conditions of transport for long distances, by the primitive means of cacolets or " arabas." This state of things would only permit of those coming in alive who were, truly speaking, very tenacious of life !

If from these results we are bound to conclude that they support the theory of medical treatment as op- posed to laparotomy, we must remember that they occurred in wars and under strategic conditions which rendered any immediate surgical interference out of the question.

The Balkan Wars gave rise to almost identical state- ments, all having very slight encouragement to hold out as regards laparotomy.

CONCLUSIONS FROM FORMER WARS 21

Consergue * writes : "The statements made during the Anglo-Boer and the Russo-Japanese Wars have again been verified in the course of the Balkan War : penetrating wounds of the abdomen from projectiles of small calibre, when left to themselves, heal in sur- prising numbers, even when complicated by lesions I the kidneys and liver. The following statistics are in themselves convincing :

" Belgrade Military Hospital : 28 penetrating abdo- minal wounds, 8 immediate deaths, 8 deaths after interventions for localised peritonitis, 18 recoveries, 6 of them after intervention.

" Russian Red Cross Hospital at Belgrade : 10 cases, 10 recoveries, 4 of them after operations for circum- scribed peritonitis.

"French Hospital at Salonica : 7 cases, 6 recoveries without intervention, 1 death."

V<$ras f was struck with the rarity of abdominal wounds and with their simple evolution. The 4 or 5 cases he observed all recovered without operation, but they all arrived, on an average, three days after the date of their wound.

^ According to Le Fort, j abdominal wounds were very rare in the hospitals of the interior, and they progress most frequently in the same manner as simple wounds, even after hsematuria, melaena, or some other symptom has shown the penetrating nature of the wounds. Laparotomies are absolutely exceptional, unless this term is applied to incision of abscesses formed around projectiles. . . . If the circumstances," he adds, " allowed of active surgery at the front,

* Consergue " The Balkan War. Organisation and Work of the Service de Sante in the Allied Armies" (Arch, de Med. et de Pharm. Miht., August and September, 1913) ^ I0!?11 V4r,aS andLe F°rt' " Four Months in Montenegro during

522 ( ' d& Mid' et de Pharm' Milit-> May 1913,

,» ^-5 ForJ' ™The Service de Sante in the Balkan War " (Arch de Med. et de Pharm. Milit., April 1913, p. 432).

22 WOUNDS OF THE ABDOMEN

it seems to me that the attention of the medical men should be directed to cranial surgery, and not to abdominal surgery (even in automobiles de luxe)."

The remarks of Delorme,* to which his great authority gives singular impressiveness, are, on the other hand, alarming : " Curious and striking instances of uncomplicated recovery should not make us mini- mise the immediate or rapid urgency of abdominal wounds, notwithstanding the less frequent and less pronounced rupture of vascular viscera, and hollow organs at relatively short distances. Even at medium, and still more at long distances, the perforations are narrower, and spontaneous occlusion is possible in the stomach, intestine, or bladder. The surgeons at the front will inform us of their relative frequency, their real gravity, and will give us all the needful particulars ; but it would be a singular error to suppose that a bullet could traverse an abdomen with impunity, as these happy recoveries have caused too many to maintain. As a matter of fact, abdominal lesions have been very rare in the various base hospitals. ..."

Reverchon has also been good enough to furnish us with the following remarks : " All those with abdominal wounds were retained in the dressing- stations at the front. In the various convoys passing into the station of Scoplje I did not observe a single one. But when I arrived at the front, hardly eight hours after the last serious combat, there were no wounded of this kind left in the ambulances; their fate was settled. . . . How ?

" The results of laparotomy were not brilliant. As in all other wars, the surgeons made systematic trial of it, especially at the beginning. Cohen, after Krivolack, operated on men after thirty-six hours, and six hours of transport — he had one survival in

* Delorme, " Precepts of the Balkan War (Campaign of Thrace, 1912). ( Evacuati on, Wounds from Instruments of War) " (Acad. of Medicine, April 1st and 22nd, 1913).

CONCLUSIONS FROM FORMER WARS 23

twelve operations. He only operated in undoubted penetrating lesions. Interventions in confirmed peri- tonitis did not result in a single recovery, notwith- standing the use of rectal saline and the sitting position. Similar results were obtained elsewhere. The first part of MacCormac's aphorism is therefore confirmed : ' Those wounded in the abdomen by small projectiles died when they were operated on.' But the second part of the proposition, ' Those who were not operated on survived,' has not been realised.

"The abdominal wounds received in the course of the second Balkan War were extremely serious. I certainly have seen survivors, notably two cases in which penetration was proved by a slight peritoneal re- action. But was there an intestinal lesion ? We may doubt it, or at least we may admit that there were not multiple perforations of intestinal coils, as the direction of the wound was what I should call ' super- ficial perforating,' anterior in one case, posterior in the second.* On the other hand, all the Serbian and Bulgarian doctors I have questioned in the course of my journey have made the same answer : ' I have not seen one single case of antero-posterior or slightly oblique shot-wounds in the umbilical or para-umbilical region, indicating multiple lesions of the intestinal coils, recover without operation.'

" In a word," concludes Reverchon, " the question remains open. Systematic abstention has only the value of a provisional dogma ! "

Whatever partiality one might entertain in favour of laparotomy, one could not, in truth, draw encour- agement from the preceding wars. Would it not be

* First case. — Entry on the median line, midway between the umbilicus and the xiphoid : exit in the nipple line in the vicinity of the costal border. Second case. — Entry in the right lumbar region, 15 centimetres from the median line, in the llth intercostal space, a little outside the margin of the kidney ; exit on the leffc flank, less than four inches outside and above the umbilicus.

24 WOUNDS OF THE ABDOMEN

possible to find reasons for the almost invariable failure of primary intervention ? And what is the precise value of the success attributed to medical treatment ?

Recoveries by abstention are undeniable. That is the first point.

A lesion of the intestinal canal that had shown itself by haematemesis, followed by melaena, and even by the passing of the bullet by the anus, has never- theless been followed by recovery. Makins, W. Dick, Marche, and MacCormac have seen indisputable lesions of the stomach thus healed, Mathiolius has seen it in the kidney, and MacCormac in the ascending colon. One of Haga's wounded passed the projectile by the rectum at the end of five days, and another at the end of three years. More frequently still the per- foration has been closed in the course of an operation for localised peritoneal infections, following a lesion of the intestine.

The mode of healing in such cases has been experi- mentally studied in time of peace (Reclus and Nogues, etc.), and the operative investigations in time of war are of peculiar interest as verifying the process. It results from the narrowness of the wounds produced by bullets of small calibre * from the empty state of the canal, and from the usual absence of extravasa- tion of the intestinal contents (direct observations of MacCormac, Treves, Mathiolius, Follenfant, and Whitehead) ; the perforation remains impervious owing to the contraction of the muscular wall, to a hernia of the mucous membrane which is soon covered by

* " An exception must be noted when the firing is at close range. The destructive effect of the projectile on the intestine is then enormous. It is split and mangled, the continuity of the intestinal tube is interrupted at several points, and fragments of the bowel are scattered in the abdominal wall (Wreden). The greater number of these wounded, remain, moreover, on the field of battle (Hilde- brandt) " (Doche).

CONCLUSIONS FROM FORMER WARS 25

a fibrinous material (Follenfant, Ringel), and to the adhesion of the wounded loop to the neighbouring coils (Follenfant, Lardy, Haga).

But is this spontaneous repair of visceral lesions as frequent as it is asserted to be ?

The cases in which the projectile can traverse the body without wounding any part of the digestive tract are numerous. After Lebel's personal experi- ments of bayonet-wounds on recent corpses, taking into account Reclus's experiments with revolver-shots at dogs, Sieur estimates that in 15 per cent, of cases, at least, a bullet can traverse the abdomen without injuring one of the viscera that it contains. Observa- tions made in time of war corroborate this. After the war in the Transvaal, Bowlby, Makins, and Hildebrandt reported instances of it.

Equally numerous are the wounds of the abdomen wrongly classified as penetrating, which nevertheless serve to establish a high percentage of cures by absten- tion. Have we not seen, for example, that in 118 cases observed by Bornhaupt, 89 presented absolutely no symptom of perforation ?

Infinitely more numerous, again, are the cases of men wounded in the abdomen who died before they could be registered in the published statistics. These statistics, in fact, nearly all come from the base hospitals ; it is sufficient for us to recall the long delay before the wounded arrive at the surgeon's station. Bornhaupt reckons it at the sixth to the tenth day, Veras at the third day, Cohen and Rever- chon at thirty-six hours, of which six are occupied in transport ! Follenfant estimates the number of those who die between the dressing-station and the base hospitals as 20 per cent. And this without taking account of those there has not been time to remove from the field of battle ! The only statistics of real value would be those coming under the observation of the doctors in the posts nearest to the front, and

26 WOUNDS OF THE ABDOMEN

those seen by the surgeons stationed in intermediate positions between the front and the base. In no war has such a record been made, and, if it were ever attempted, it would still be necessary to take into account the errors of diagnosis inseparable from absten- tion !

Real as are the successes of medical treatment, we must not ascribe to them a fictitious importance ; where the intestine has been involved, recovery has been rare.

And for us, who are seeking in the experiences of earlier wars for instruction that may be of use to us in the present war, there is one important detail that cannot be too strongly insisted on. In former wars — Delorme himself has pointed it out — it was the rifle- bullet that put the greatest number of soldiers out of action ! Shrapnel wounds were rare, and there was no question of the bursting of percussion shells. The same fact increases in our eyes the rarity of spontaneous heal- ing that can be considered due to abstention, since only bullet-wounds can be thus healed, while the number of wounds due to shells increase every day.

Now let us ask, What are the causes of the failure of laparotomy in war ?

There is one that dominates all the others — the delay in intervention. During the Chinese campaign of 1900 Haga kept account of the time of arrival of the wounded at the hospital ; the average interval was nine hours, while some only arrived after twenty- four hours. On arrival nineteen out of twenty-two presented symptoms of peritonitis. Laparotomy was thus doomed to failure.

In the Transvaal, Neale excised successfully thirty centimetres of intestine which was divided and per- forated ; but this took place only six hours after the man was wounded. Von Hippel has compared the results of six laparotomies performed in the first

CONCLUSIONS FROM FORMER V7ARS 27

twelve hours and those of ten others carried out at the end of the thirteenth hour, or on the second, third, and fourth day, after prolonged transport. The first gave 3 recoveries and 3 deaths ; the latter, 1 recovery and 9 deaths !

We have already mentioned a success by the Princess Gedroitz in Manchuria ; but the colonel whom she thus saved was operated on between four and five hours after he had been wounded ; he presented two perforations of the intestine and section of a mesenteric artery ; after the operation he was so anaemic that it was necessary to give frequent injections of saline, and for ten days he was in a dying condition ; in the end he recovered (Follenf ant) . But what would have been the result had the operation been delayed by one1 hour ?

In the Balkans Cohen, who was a surgeon in the

Danube division at Kumanovo, saw a man who was

wounded in the abdomen at the commencement of

the battle ; it was a case of para-umbilical gunshot-

t wound. The operating-theatre was empty, the wound

'was only an hour and a half old. He sewed up seven

or eight perforations in the intestine. The patient was

carefully deposited in a bed in the train that waited

by the side of the ambulance, and at once transported

to Belgrade, where he recovered (Keverchon).

The material conditions under which laparotomy is performed in the vicinity of the field of battle are often most precarious. In the Transvaal they had to instal themselves in farms, often in the open air. The country swarmed with insects. Treves reports that during laparotomies the intestines were black with flies, while the wind brought clouds of dust to the wounds in squalls ; they operated on biscuit -boxes ; they were short of water.

Still, not all operations were carried out under such disastrous conditions. MacCormac, Makins, Watson, and Roberts had at their disposal a surgical equip-

28 WOUNDS OF THE ABDOMEN

ment and sterilising material that were perfection. It was the same in the case of the foreign surgeons who were present at the war as members of the Red Cross Societies, like Kiittner, Habert, Mathiolius, and Herz.

In Manchuria, Follenf ant * very judiciously observes that " for the first time the circumstances were very favourable for efficient collection and transport. These circumstances will most probably be repeated in future battles. They included the slowness of military offensive operations and the prolongation of the resistance, the use of the railway on the field of battle, the inviolability of the fronts and the temporary security it ensured." Why, then, were not better results obtained in the case of abdominal wounds ?

" It is well to remark," says Follenf ant again, " that in the practice of the civil surgeon, operations are only performed very rarely outside the hospital on abdominal wounds. If it is true that with any advan- tage that circumstances can afford a surgeon may occasionally obtain a splendid result in dealing with a single accident or operation, how different is the situation of the ambulance surgeon — he has to treat a large number of cases in circumstances of the greatest difficulty, at a time when security is uncer- tain and when conditions are inferior to the very worst of those encountered in time of peace. How is it possible, then, to guard against such infections as we may still meet with in the best-equipped hospitals, and what surgeon could, in these circumstances, hope for a series of successful results ? " The successes obtained by the Princess Gedroitz in her railway- carriage operating-room, reserved for a small number of serious cases, confirm these observations.

We now find ourselves naturally led to recall the

* Follenfant, Etudes sur le service de sante en campagne" (Chapelot, 1910).

CONCLUSIONS FROM FORMER WARS 29

requirements of the surgeons of former wars with respect to the surgical treatment of abdominal wounds.

First comes the specialisation of sanitary units for the benefit of such serious cases. (Ettingen thinks that abdominal surgery will play a great role in future wars, but on condition that it remains in the hands of capable surgeons and is restricted to a very limited number of cases. Bornhaupt declares that the most experienced surgeons ought to be at the field-hospital (ambulance) and that the appliances ought to be of the first quality. Von Hippel proposes the creation of hospitals three or four kilometres from the field of battle, with a specially trained staff ; when the opera- tion is over, an ordinary hospital building should be at hand, as discharge could not be expected in less than ten or twelve days. Tomasi had formulated the same idea.

The second requirement is the use of ambulance trains, which gave such brilliant results when em- ployed in Manchuria. Not all of them were as luxurious as that of Princess Gedroitz ; the operat- ing rooms were established in ordinary carriages or in goods-wagons. When peace was made a train of this kind was prepared at every important station (Follenfant). In this way an operating-station com- pletely installed and ready for immediate use was provided, and it could be moved as required into the immediate neighbourhood of the fighting region. This is a most inspiring idea, and one that deserves to be put into practice again.

There is, lastly, the necessity for a hospital on the spot, quite as much for the wounded who are operated on as for those treated by abstention. Having to turn them out would undeniably aggravate their condition.

At Jacobsdal, in the Transvaal, where the German Red Cross ambulance was installed on the field of battle, nearly all the wounds healed without suppu- ration ; at Spion Kop, on the contrary, where trans-

30 WOUNDS OF THE ABDOMEN

port was particularly difficult, where the wounded had to be taken down steep descents and over rocks, all the English wounded in the abdomen and moved under such conditions succumbed (Kiittner).

During the Chinese campaign, following an evacua- tion lasting about nine hours, Haga saw 22 patients, of whom 19 presented symptoms of peritonitis on arrival.

In Manchuria, after the fight at Turentchen, 22 wounded, included in the convoy of evacuation organ- ised thirty-six hours after the engagement, had to travel 60 kilometres, either in carriages, on stretchers, or on horseback. Of these 22 wounded, 4 presented symptoms of peritonitis and soon died (Sonnenblick and Logashkine).

Kholini has also remarked on the frequent appear- ance of symptoms of acute peritonitis following hasty transport in badly hung vehicles.

Similar results occurred in laparotomies. Brentano saw those operated on in Manchuria arrive at the hospitals of the second line only to die.

If the patient operated on by Cohen suffered no harm from removal, it was because that took place im- mediately after the operation, and in one of the best suspended cots.

1 The man wounded in the abdomen dies," writes Reverchon, " particularly if he is operated on too late and undergoes too many removals and transhipments."

' The delay between the traumatism and the opera- tion should be shortened as much as possible, and the evacuation before and after must be perfected."

If we now glance at the history of the treatment of abdominal wounds in the course of the wars of the last twenty years, two essentially practical ideas seem to stand out from the mass of facts, and confirm the impression that we recorded at the beginning of the chapter.

CONCLUSIONS FROM FORMER WARS 31

First, immediate laparotomy has nearly always dis- appointed the hopes of even the most favourably inclined surgeons, and the boldest. It still retains adherents, however, who count on the development of better organisation and conditions for the attainment of more frequent successes.

Again, abstention is followed by genuine recoveries, but a close examination of the results shows that successes are much rarer than has been thought, and perhaps there is a call to revise the technique of laparo- tomy.

The question, therefore, remains open. The experi- ence of the war now in progress is bound to furnish new elements for discussion and decision.

CHAPTER III THE EXPERIENCE OF THE PRESENT WAR

THE facts observed and the works published between the outbreak of the war and the present moment seem naturally to divide themselves into three periods.

In the first period it is admitted without question that laparotomy is disastrous. That is the undis- puted verdict. On the other hand, what is the out- come of purely medical treatment ? In this respect, opinions differ. Some claim an important proportion of recoveries ; others, on the contrary, register a de- pressing quantity of failures. As to surgical inter- ventions, they are limited to drainage of the area or to preventive supra-pubic aperture with drainage of the pelvis, called " Murphy's operation." This is also the period of anastomosis, of multiplied openings for drainage, etc.

The second period is marked by a very distinct reaction in favour of laparotomy. A close analysis of the statistics concerning abstention shows the greater part of the successes registered concern wounds either non-penetrating or without visceral lesions. Laparo- tomy now begins to register successes, and these successes prove that a good surgeon can, by operating, " at a period soon after the wound has been received and in favourable conditions, deal successfully with abdominal wounds which, without his intervention, would prove fatal " (Quenu). Corroborating facts begin to multiply. Two ideas stand out — it is untrue that laparotomy entails nothing but disasters, and it is untrue that abstention produces frequent successes.

32

EXPERIENCE OF THE PRESENT WAR 33

A third period follows, in which there is again a reaction in favour of medical treatment. Impressive statistics again appear, and by the nature of the cases and the professional rank of those who publish them, endeavour to demonstrate that surgical treatment by laparotomy is only practicable in exceptional circum- stances, that its employment is not to be generally recommended, that recourse must therefore be had to abstention, and that practically medical treatment affords numerous successful results. But here again criticism steps in and shows once more that the re- coveries observed are very doubtful from the point of view of penetration and of visceral lesions ; it main- tains, besides, that to submit tamely to materially defective conditions is no solution, and that an efficient organisation ought to be substituted for an inefficient one.

That is where we stand at present.

It is important to remark that these three periods coincide approximately with three different phases of strategical conditions ; a sort of parallelism, which is easily comprehensible, exists between them.

During the first months the war was one of rapid displacements and of great masses ; fighting occurred daily ; retreat was going on, and even when the retreat was interrupted, the uncertainty of the im- mediate future necessitated instant evacuation to a point as far as possible from the front ; the multitudes of wounded overcrowded the sanitary installations, still badly organised ; the means of transport were primi- tive ; the equipment was insufficient and badly dis- tributed ; the staff was inexperienced and without cohesion, while a strange fantasy and forge tfulness of specialisations seemed to have presided in the utilisa- tion of the various departments. Is it astonishing that laparotomy under such conditions was followed by disasters ?

But the war of the trenches follows the war of

34 WOUNDS OF THE ABDOMEN

movement ; the adversaries are stationary ; they no longer move from place to place ; their change of position is measured in yards and not in miles. The ambulances, immobilised, complete their equip- ment, and the hospital conditions of the wounded improve ; automobiles carry out the transport of the wounded to the surgical centre where they can be operated on more easily and more rapidly ; operating staffs are organised. Laparotomy finds the con- ditions necessary for effective action. It ought now to repeat its successes and to regain its credit ; it does so. More than that, the installations of the laparo- tomists are at last established in the immediate vicinity of the front ; the interval between the wound and intervention is reduced to a minimum ; all these influences make themselves felt, and statistics improve.

Meanwhile the almost regular war of the trenches gives place to surprises, to unexpected attacks, to combats murderous in their effects, even though their front is not of great extent. The material conditions that necessitate a series of laparotomies are over- thrown ; abstention has perforce to be observed. Then, in September 1915, an attack of great extent reopened the question of the possibility of operations on the abdomen at the moment of great battles, or where the evolutions are by advance en masse. The difficulties that the practice of laparotomy have now to overcome have again to be faced by its numerous partisans.

We shall find these different modes of considering the problem set forth as we examine one after the other the works published during the three periods that we have just sketched.

• • • • .

First Period. — The experience of former wars, as we have said, had led surgeons to consider MacCormac's aphorism as a dogma, or at least the first part of it. The doctrine of abstention reigned paramount at the

EXPERIENCE OF THE PRESENT WAR 35

outbreak of the present war ; it was insisted on at the Val-de-Grace ; it was accepted by all or nearly all military surgeons.

All attempts running counter to this dogma were considered to be so definitely doomed to failure and exposing those wounded in the abdomen to such risks, that an administrative circular, dated October 15,' .914, impressively reminded military surgeons that medical treatment alone was to be employed, and that all intervention was to be confined to Murphy's operation. The following is the text of Delorme's communication, which inspired the circular :

'The treatment of abdominal wounds with lesion of the intestine merits all the attention of the surgeons, above all that of the surgeons at the front. It has been enriched by numerous resources, still insufficiently known, whose employment should do much to diminish the very fatal prognosis of these wounds. If there is 11 discussion as to the opportunity for much lapa- rotomy in the abdomino-intestinal wounds of ordinary practice, it is otherwise as regards war surgery.

"In principle immediate laparotomy is to be rejected The most recent wars, those of the Transvaal, Man- churia, and the Balkans, have shown its ill effects.

' In the Transvaal, although it was carried out by eminent laparotomists, under the most favourable conditions for ensuring success, it produced far fewer recoveries than operative abstention.

;< The German bullet, reaching the abdomen with

high velocity, especially at long or medium range, pro-

nces a narrow orifice of entrance in the abdominal

rea, and does not introduce any infecting particles of

>thmg. In the intestinal coils it only makes very

small orifices, and minute perforations which have a

tendency to close spontaneously. In certain cases it

even insinuates itself between the coils without per-

; orating them. Instinctive evacuation, before going

36 WOUNDS OF THE ABDOMEN

into action, of the intestine and bladder, the fact that the wounded man remains on the spot for hours, and does not have to undergo the jolting of transport — all these conditions help to prevent intraperitoneal suffusion, or limit it and favour recovery.

" For traumatisms of this character the old methods of treatment seem to suffice : absolute rest, the absence of transport to a distance, complete privation of food, and, above all, of liquid for several days — a regimen that can be supported with the aid of inces- sant rinsing of the mouth, rectal or subcutaneous injections of artificial serum, and opium, added to the half -sitting position advised by Fowler.

" When, on the other hand, the speed of the projec- tiles has been greater, when the bullet has ' see-sawed,' or when the wound has been made by the large shrapnel bullet, the orifice of entry through the skin, circular or oval, is larger ; the wound or wounds of the intestines are also larger ; they are less susceptible to close spontaneously, and contamination by pieces of clothing is frequent.

" In these cases peritoneal infection is certain, but the surgeon is not without resources. To the treatment already indicated he adds, if possible, continuous instillations, drop by drop, as advised by Murphy; above all, Murphy's early incision and drainage, and the cleansing of the peritoneum with ether (Souligoux).

" Murphy's incision is a short button-hole made in the abdominal wall above the pubic arch. By this incision, performed quickly, under simple local anaes- thesia and after a very rapid disinfection of the skin with iodine, the pelvic cavity is drained where, in Fowler's half-sitting position, the septic fluids have a tendency to accumulate. This position represents a safety-valve ; it anticipates a dangerous tension which would favour the reabsorption of the septic products.

" In 17 cases of shot-wounds with perforation of the

EXPERIENCE OF THE PRESENT WAR 37

intestine Harris has had, owing to Murphy's incision, 17 recoveries.

"Murphy's conception and technique accord well with the actual practice of the ' Service de Sant6 ' in the ambulances and the country hospitals. It opens to our surgeons a path along which they should resolutely proceed. It is not a complicated operation like classical laparotomy, which a body of qualified surgeons could not repeat more than three or four times in one day without neglecting all the other wounded— a fatiguing operation, increasing the shock, liable to destroy salutary adhesions, demand- ing a special installation, and minute aseptic precau- tion, to produce, I repeat, fewer recoveries than operative abstention. It is a very simple act, very rapid in^ execution, within the compass of every prac- titioner."— Communication to the Academy of Sciences August 10, 1914.

Some surgeons,and not the least distinguished among them, still opined that there was something better to be done, and that laparotomy at least deserved to be tried again. Their experiments were, however not encouraging.

Tuffier had himself to declare later on that only one remained alive of those he had operated on, or caused to be operated on, in the field hospitals at the front, in the Vosges ; but he does not give the number of operations.

Picque[54] recently related how at B the first

svening of the battle of the Aisne, during the second

hour of his improvised instaUation, he performed on

i wooden table covered with oil-cloth, with rudimen-

baiy material and aseptic conditions, a laparotomy

the extraction of part of a shell from the iliac

fossa, which operation was completely successful.

?hen he operated, without success, in a series of

very critical cases, with extensive multi-visceral lesions

38 WOUNDS OF THE ABDOMEN

and evisceration, evidently beyond the resources of surgery. He was not disheartened by his want of success, and would have declared himself justified if he could have saved one case in five, until one day when an exceptional case of revolver-shot, brought to him a quarter of an hour after it occurred, proved to him, by its loss, that laparotomy was not possible at the ambulance station without absolute asepsis and perfect instruments. He therefore voluntarily ceased all laparotomy, until these conditions could be realised. And in the meantime he observed, among the wounded under treatment by abstention, a spontaneous progress that was always fatal. So marked was this that Picque remained, theoretically at least, a partisan of intervention.

Sencert[a], on the contrary, declares himself very categorically a defender of abstention. He falls back on three essential arguments : obstruction, shock, and the possibility, even the frequency, of spontaneous healing. He goes so far as to draw up a code for the surgeon in an ambulance at the front when confronted with a penetrating wound of the abdomen : (1) he should intervene in the very rare case of a wounded man "having a large wound in the abdomen with external haemorrhage, evisceration, and obvious section of the intestine ; (2) he should abstain, and adopt ' armed expectation ' in the case of a narrow wound in the abdjomen ; (3) he should make a triple drainage of the abdomen if peritonitis appeared during the following days ; (4) if the diffuse peritonitis stops short and encysted peritonitis appears, it must be sought for, located, and opened." Eeducing to such a point the very exceptional indications of laparotomy in desperate cases is equivalent to condemning it.

Abstentionist conclusions have also just been de- fended by Weiss and Gross [*]. Thanks to the situa- tion of the town of Nancy, distant 10 to 15 kilo- metres from the strategic position of Grand-Couronne,

EXPERIENCE OF THE PRESENT WAR 39

where important actions have taken place, they were able to observe the wounded at the end of two and three hours, as the latter were brought straight from the firing-line in motors ; thus Weiss and Gross were in the position of a regular field-hospital. But by exceptional good fortune they could operate in hospital surroundings specially constructed for surgery — that is to say, in the very best material conditions, whether as regards assistance, equipment, or post-operative care. In spite of all these favourable circumstances, four laparotomies resulted in four deaths. It is right and interesting to consider the results furnished by Murphy's operation (5 cases, 5 deaths) and by medical treatment (57 cases, 49 deaths — the recoveries including five lesions of the small intestine, one lesion of the ascending colon, one lesion of the liver and one vesical lesion). Thus all the laparotomies ended fatally, and Weiss and Gross decide definitely in favour of absten- tion. In no case, they consider, should laparotomy be undertaken deliberately simply for the discovery of lesions. They limit operative indications as follows : haemorrhage ; intra-abdominal wound of the bladder, in which incision and Murphy's treatment could be made use of simultaneously ; drainage or lateral colotomy if a lesion of the large intestine is suspected ; incision by thenro -cautery if there is an escape of the intestine through the wound. As to Murphy's opera- tion, it is no more effectual than laparotomy in checking lesions of the peritoneum developing in the first few hours.

Cadenat [10] reports 26 casesof penetrating abdominal wounds in which he intervened 17 times (5 recoveries), and 9 abstentions (6 recoveries), giving a mortality of 70 per cent, with operation and 33 per cent, with abstention. Murphy's treatment afforded him one recovery (in a bullet-wound) in four cases. Hence he deduces the uselessness and danger of suture by lapa- rotomy ; he is sceptical about the results of Murphy's

40 WOUNDS OF THE ABDOMEN

operation (so-called) ; in short, he considers abstention pure and simple the wisest course. Hartmann, who re- ports this, contents himself with summing up Cadenat's account without formulating a personal opinion.

Now comes an enthusiastic plea in favour of what Duval calls " the very administrative formula of the supra-pubic button-hole " Beveze's work [7] is an apology for the operation named after Murphy. Thirty-one cases afforded him 11 recoveries. Of these 11 cases Tuffier shows that five times only blood flowed from incision of the peritoneum ; twice it was a question of a wound of the large intestine, so that only in 4 cases recovery followed a wound of the small intestine. It is to be noted that in 11 cases 10 of the wounds had been caused by a bullet.

After a lapse of several months we find in a few lines of an article by Miramond de la Roquette [>4] another late plea in favour of Murphy's incision. Miramond proposes to supplement it by anastomosis through the skin of an injured intestinal loop by " the opening of an iliac anus which assures the drainage of the intestine and prevents the dreaded phenomena of intestinal paresis so frequently met with."

We shall see further on (page 123) what to think of this.

All these are only isolated voices, far off and hardly audible. For it is now quite a long time since the chorus of the interventionists began to collect and to increase in volume.

Second Period. — The hymn to laparotcmy covers all the second period. We can distinguish in it three themes : definite condemnation of Murphy's opera- tion ; keener criticism of the recoveries attributed to abstention ; growing eulogy of laparotomy as the general method of treatment in penetrating abdominal wounds even in time of war. And very rare are the discordant notes that make themselves heard !

EXPERIENCE OF THE PRESENT WAR 41

First came a cry of alarm uttered by Duport and Kendirdjy f1] at the meeting of the Chirurgical Society in November 1914. "The benefits of abstention are advocated in text books and even administratively. How is it, then, that in 40 cases we register 40 deaths, although 38 of the wounds were from bullets ? " And from this time the surgeons began to develop the idea of a special ambulance so that the wounded could be taken rapidly to the dressing-station by automobile and operated en by laparotomy.

They did not confine themselves to theorising — en February 9th, 1915, they made a new communication [*]. This time they reported 4 cases operated on. Among these 4 cases they had 1 recovery. A soldier hit by a rifle-bullet in the lumbar region was laparotomised six hours after the wound was received ; five perfora- tions of the small intestine were stitched up. In the other 3 cases the operation ended in death. The first case was a wound at close range from a Lebel bullet and the operation took place an hour after- wards. There were two perforations of the small intestine, besides perforation of the bladder and a wound in the prostate. The second case was an accidental wound from a revolver-bullet. The opera- tion was performed two hours afterwards. There were six perforations, of which two were not discovered. The third case was a bullet-wound ; it was first treated by abstention, and operated on nineteen hours after, when the symptoms were fully developed.

At the same meeting Routier read a report on a work by Hallopeau [8] entitled, The Working of a Mobile Surgical Hospital at the Front. In this field- hospital Hallopeau had to treat, among other cases, 9 wounds of the abdomen, of which 7 were penetrating. One of the first operated on, brought in with an im- perceptible pulse, died three hours afterwards. Of the 6 others, only 4 underwent real laparotcmy with investigation of the lesion. The results were as

42 WOUNDS OF THE ABDOMEN

follows : " 2 underwent transverse laparotcmy in the region of the liver, 1 of whom died. The other was discharged in a favourable condition 31 days later ; 2 underwent a large median incision with evisceration ; 1 of them had a wound in the liver and 6 intestinal perforations — he succumbed ; the other also had a wound in the liver and a lesion of the duodenum — he made a surgical recovery but succumbed to scarlatina." It would therefore appear that there is no definite recovery from intestinal wound to record.

M. Chavannaz [6], at the meeting held on February 24th, made an important contribution concerning 51 cases in which he intervened 13 times ; of the 13 patients operated on, 9 died, which gives a 69 per cent, mortality ; of the 38 not operated on, only 22 died, showing a mortality of about 58 per cent. Accord- ing to these statistics, surgical intervention would appear to give disadvantageous results ; but he hastens to add that the mistake of considering as penetrating the wounds that have not affected the peritoneum is easy to commit, especially when it is a question of lumbar wounds. Retaining, then, only the indisputable cases (34), 12 operations give 9 deaths, and 22 not operated on give 20 deaths, which reverses the proportions and shows 75 per cent, with operation and 90 per cent, with abstention. Summing up, Chavannaz is inclined to increase the operative indications, but he would confine abdominal surgery to immobile field hospitals, or even to stationary hospitals placed near the front.

At the meeting of March 24th, returning from a surgical mission "for a new trial in the army of the Marcille sanitary formation " (the formation in which Hallopeau had already obtained the results quoted above) Cosset [8] definitely takes his place in favour of complete surgical intervention. Influenced by the prevailing doctrines, he began by treating medically the first 5 wounded brought to his ambulance ; all the 5 died, although 2 appeared only to have slight

EXPERIENCE OF THE PRESENT WAR 43

injuries. In a second series of 7 wounded, Gosset intervened by laparotomy ; of the 7, 4 recovered as follows : A perforation of the sigmoid flexure (bullet- wound operated on eight hours afterwards) ; a per- foration of the liver, the stomach, and the jejunum (bullet- wound, operated on 6 hours after) ; a wound of the liver and of the right colic angle (hepatic flexure) without opening of the intestine (bullet-wound operated on 29 hours afterwards) ; a shrapnel wound with multiple perforations of the small intestine, operated on 11 hours afterwards ; in other words, 3 cases of perforation of the intestines, of which 2 were of the small intestine. Gosset concludes in favour of operation, if it can be performed early and carried out under good conditions and followed by sufficient care. In operating on the wounded " we shall heal a certain number, if we are mindful not to operate on those whose lesions appear a priori (for instance, those wounded by shells) beyond our resources."

The laparotomies of Vertraeghe [•], analysed by M. Tuffier on April 28th, afford the special interest of having been carried out from half an hour to six hours after the wound was received, and close to the firing- line. Eight failures first resulted, due chiefly to the extreme gravity of the lesions. Of the three successes that followed, one concerned a perforation of the small intestine. On this occasion Tuffier declared: " I do not believe there actually exist, among all the wounded of the French Army, twenty recoveries from wounds of the small intestine treated by laparotomy and sutures. In spite of these failures, we must persevere in operative treatment whenever the surgeon, the installation, and the case afford reason to hope for a favourable result " ; and Tuffier gives us to understand that he considers these conditions are rarely realised or realisable.

To sum up, taking into account the communica- tions that we have noticed in the course of the first

44 WOUNDS OF THE ABDOMEN

period, the following are the opinions expressed so far at the Chirurgical Society regarding the use of laparo- tomy in the treatment of abdominal wounds caused by war projectiles :

Those with a definitely antagonistic attitude are MM. Sencert, Weiss and Gross, Cadenat (reported by Hartmann), and Devize (reported by Tuffier) ; the three first are abstenticnists, the last is an advocate of the supra-pubic button-hole. Those in favour of operation are MM. Duport and Kendirdjy, with very few documents (reported by Baudet), Hallc- peau with very few documents (reported by Routier), and finally Gosset. Chavannaz, a little wavering, leans to the side of intervention. Tuffier remains undecided.

Here Quenu enters the arena, and his influence promises to be continuous and decisive. In four fun- damental reports, he sets forth a number of increas- ingly numerous case-reports, and brings to their analysis a rigour and impartiality that inspire con- viction ; during his exhaustive study of penetrating wounds of the abdomen he produces at every stage new arguments in favour of laparotomy. Encouraged by the moral weight of his renowned sagacity and of his long experience, the young surgeons in the first line undertake with more confidence and ardour an operation hitherto officially discredited, and events soon begin to justify the master. It is no exaggeration to say that if laparotomy has saved many and many a man who would otherwise have been irremediably condemned, if the surgeons have adopted it and if the military authorities have been led to perfect the equipment which allows of its general practice, it is to the utterances and the tenacity of Quenu that this revolution is due.

The first of his reports is dated June 16, 1915 ; it is supported by 19 cases observed by Schwartz, 9 of which were laparotomies, and 33 observed by

EXPERIENCE OF THE PRESENT WAR 45

Bouvier and Caudrelier, all with systematic laparo- tomy. The 9 cases operated on by Schwartz included 8 with perforations of the small intestine ; 1 with perforations of the spleen and wounds of the mesc-colon and the great omentum ; there were two complete recoveries, 2 operative recoveries, and 5 failures. In comparison with these results, 10 cases treated by abstention resulted in 7 deaths ; the 3 recovering were in no way concerned with lesion of the small intestine, 2 of them being wounds in the lower part of the abdomen, and 1 being an uncertain wound in the left iliac colon, Schwartz concludes in favour of laparotomy.

But the essential basis of Quenu's report consists of the observations of Bouvier and Caudrelier [l2] ; their number is the most considerable hitherto met with. Laparotomy was systematically practised on all the wrounds, whatever the gravity of their condition ; most often it was a question of wounds caused by the explo- sion of shells or bombs ; the surgeons operated quite close to the front, in an advanced post, specially fitted up for abdominal operations of extreme urgency ; and the number of recoveries was not less than 15 in 33 cases (45 per cent.). Starting from these observa- tions, Quenu studies successively — the nature of the projectile, the interval elapsing between the wound and the operation, the condition of the wounded at the time of the operation, the nature of the lesions observed, the surgical method adopted, and lastly the results. He then makes a recapitulation and retrospective criticism of all the previous communica- tions, sifts the recoveries attributed to expectant treatment, and shows that their number must be considerably restricted if only penetrating wounds or those with certain visceral lesions are considered, and concludes finally that " laparotomy is the best form of treatment, and the one giving the best results, provided that the operation is performed under certain condi-

46 WOUNDS OF THE ABDOMEN

tions of promptitude (which are not always realisable), of installation and of operative technique, of post- operative attention and subsequent discharge from hospital."

A complementary case — report by Goinard, Poiret and Roland [w], quoted by Quenu at the same meeting, concerns a wound with intestinal perforations and multiple vascular sections. Laparotomy was followed by recovery.

On September 22nd Quenu made a second report, including two observations by Petit [l7], 47 by Bichat, 15 by Pascalis, 24 by Pellot, lastly and chiefly 66 new laparotomies by Bouvier and Caudrelier, forming a collection of 153 cases, among which are 110 operative interventions, of which 6 are Murphy's operations, 1 secondary laparotomy, and 103 primary laparotomies. In the first part of his paper Quenu gives a critical analysis of each particular case. We will content our- selves with recording that Bichat [1$], originally a partisan of abstention, comes at length to practise laparotomy systematically, as does also Pascalis [19]. On the other hand, Pellot [20] attributes genuine and numerous successes to operative abstention ; he limits the indications of laparotomy to very serious haemor- rhages, and to omental or intestinal hernias. Apart from these cases, it is a question of "armed expectation," classified in the following manner : (a) Small projectile : intervene only if the state of the patient becomes aggravated, and then make, preferably under cocaine, an intestinal suture or an arterial ligature ; if the wounded man is too weak for this, use the median button-hole, lavage by ether or drainage, adding, if the liquid is not clear, lateral incisions for drainage. (b) Large projectile ; abstain if the colon is involved ; but if it is the umbilical or periumbilical region that is concerned, operate; "for as a rule these patients are doomed to die." It is obvious that these conclusions are not shared by the reporter. The

EXPERIENCE OF THE PRESENT WAR 47

cases reported by Bouvier and Caudrelier ["], still more numerous than in their first communication, retain the same reasons for special interest, with a still better proportion of successes — 54 per cent. From all the case-reports thus collected together the reporter eliminates the non-penetrating wounds ; he thus obtains a total of 96 penetrating abdominal wounds treated by laparotomy, with 53 deaths (55 per cent.), and, of these 96 wounds, in 60 cases the intestine was involved. Now the preceding report gave a mortality of 67 per cent, for abstention, and this figure is abnormally favourable, for the cases are numerous in which one believes oneself justified in clinically affirming penetration, when in fact neither the peritoneum nor the intestine has been attacked. Quenu then handles the following secondary questions : the indications for operation ; the conditions in which one should operate to have the best chance of success ; operative technique ; post-operative attention, includ- ing the discharge of the wounded.

Quenu's third report to the Chirurgical Society was made on November 24th, 1915. Forty-six are cases credited to Schwartz and Mocquot, and 26 to Mathieu, making a total of 72. The exceptional gravity of the lesions encountered by Mathieu [26] explains the high rate of mortality, 77 per cent. As to the results obtained by Schwartz and Mocquot (**], they prove that they have saved by laparotomy a certain number of wounded who, without their intervention, would have died (total mortality of 60 per cent.). "Could they, in other conditions, have saved a greater number ? It is probable, if they had had the wounded a little earlier ... it ought to be possible to make progress in this respect." The reflections of the reporter are therefore centred on the conditions of collection, trans- port, and overcrowding : " The improvement in the results does not depend only on the enorts of the surgeons, but on the co-operation of those in command

48 WOUNDS OF THE ABDOMEN

and those in charge of the organisation of the service de Sante."

Although it is later in date than several important works that we shall find later on (notably Rochard's report and the sensational communication of Chevassu) we shall here quote Quenu's fourth report, as it com- pletes and is intimately connected with the three preceding ones ; and this conjunction renders still more emphatic the importance that should be attri- buted to the energetic campaign carried on by Quenu. At the meeting of January 5th, 1916, he successively passes in review : a note by Rouhier [28] on the urgency of the localisation of abdominal projectiles and its utility in the choice of operative indications ; 26 cases of penetrating wounds coming from Barbet and Bouvet [2>] ; from which one may conclude that the results will be better " if one does not take such extreme care not to open the abdomen for a non-pene- trating wound." Twenty case-reports by Didier[3°] must, after discussion, be classified in this way : 10 laparotomies, 4 recoveries ; 7 Murphy operations, 2 recoveries ; 3 abstentions, 3 recoveries (wounds of the upper abdomen and the flanks). Didier declares himself convinced of the superiority of laparotomy, if it can be performed very soon, and if the operative installation is adequate. Ga teller's 23 cases have the experimental value of opposing two comparable series : thus, 12 wounded treated by abstention all died ; and, of 11 laparotomies, 5 recovered (mortality 54 per cent.). These observations lead to the writer's reflec- tions on anaesthetics (he inclines to chloroform) and on thoraco-abdominal wounds, certain of which ought be treated by abstention.

This concludes a first series of studies by Quenu with which is connected a communication to the Academy of Medicine of October 26th, 1915 [§1]. They form the most convincing argument, and a most elo- quent one by virtue of the facts, completely in favour

EXPERIENCE OF THE PRESENT WAR 49

of laparotomy. (Still later Quenu intervenes again in its defence, but that occurs in the course of what we have called, in our classification, the third period.)

There are other communications to the Chirurgical Society that deserve to be quoted.

Chaput [15]is of opinion that, to be just with regard to laparotomy, the following should be eliminated from the statistics : wounds with numerous intestinal lesions and large mesenteric wounds, which are almost fatally doomed (one recalls here that it is to these cases Sencert would confine the imperative indication of a laparotomy certain not to be harmful) the cases in which the wounded died some hours after the operation ; late operations performed after twenty hours of violent peritonitis. Statistics do not possess their full value unless they include wounds of moderate gravity.

Tartois [22], returning from the first Balkan War an adherent of the principle of surgical abstention, re- pudiates it to become the champion of a rational surgical intervention — that is to say, as complete as possible by including laparotomy. Duval's report brings out all the interest offered in the 34 observa- tions of Tartois by arranging them in three series : 8 abstentions are followed by 8 deaths ; 15 Murphy operations produce three recoveries (a mortality of 80 per cent.) ; and 1 1 laparotomies procure 5 recoveries (mortality 55 per cent.). A comparison which speaks eloquently for itself.

In an " Essay on Operative Indications in the Zone of the Armies," analysed by Quenu on July 21st, Heitz-Boyer [16] had incidentally touched on wounds of the abdomen. Influenced by the opinions of Sen- cert, he insists that "the indications for operation are found to be dominated by the equipment ques- tion "; primary laparotomy appears to him more and more susceptible of being put in practice, but only if new operative formations realise the necessary 4

50 WOUNDS OF THE ABDOMEN

conditions. Again, he remarks that the "relative rarity of these wounds should deter us from according them a disproportionate importance ; in any case, they could not demand a special organisation for their treatment." Qu6nu is less readily resigned than Heitz-Boyer; laparotomy is the preferable treatment ; it should be rendered practicable ; an organisation is to be con- demned " which would sacrifice deliberately 3, 4, or 5 wounded out of 300." Thus, at every opportunity, Que"nu defends his favourite thesis.

Analysing a monograph of Stern's [27] concerning 143 abdominal wounds of which 34 were treated by laparotomy, with 14 recoveries, Rochard showed a not less decided conviction. From the outset he does not conceal his determined opinion. " Logic," he declares, " has triumphed over paradox : pene- trating wounds of the abdomen caused by the projec- tiles used in war at last enter the domain of active surgery. And what a solace to our understanding ! Our minds found a difficulty in admitting that what had been verified before the war, and what will no doubt be verified when the war is over, could suddenly become an error in the course of it. . . ." Rochard, in his turn, undertakes to prove that " laparotomy ought to be applied to war- wounds as well as to civil wounds." In this study, in which the method and the pains he takes to be thorough yield in no way to Quenu's, he proposes a new classification of the lesions, rather different from that of the preceding authors. (He eliminates from abdominal wounds those which are purely parietal ; to which Quenu objects that very often under clinical conditions and in the choice of a decision as to operation, it is very difficult to distinguish accurately penetrating from non-pene- trating wounds. He also separates exclusively ab- dominal wounds from associated abdominal wounds.) Clinical diagnosis, operative indications, operative counter-indications (state of the wounded, external

EXPERIENCE OF THE PRESENT WAR 51

I circumstances, age of the wound), the choice of opera- tion, operative technique, post-operative care,anatomo- I pathological findings and results, receive separate I consideration. Rochard ends with some general I statistics of all the cases published up to that date by I the Chirurgical Society, which show that in 266 laparo- I tomies there were 161 deaths, a mortality of 60 per \ cent. ; in 322 cases not operated on, 258 deaths, or a I mortality of 80 per cent. Thus the best treatment I still appears to be that of early operation.

We would also notice a communication from Aba- die [33J dated March 1st, 1916. He studies succes- I sively the treatment to be preferred, the practical con- ii ditions of its application, and the means for rendering I these conditions most often realisable. It would be ; superfluous for us to dwell longer on this contribution, as it is inspired by the same ideas as those we are I elucidating, and reflects the same mode of discussion. I We will content ourselves with recording that 15 j laparotomies resulted in 6 recoveries.

Lastly, we have the comprehensive study by Rouvil-

lois[3'] of March 22nd, 1916. Having observed 247

I abdominal wounds, Rouvillois reports 132 cases, and

arrives at the following conclusions : abstention in

j undoubted peritoneal wounds gave him 89' 5 per cent.

J mortality, and, if he added to this, the deaths which

[would have been sure to take place among cases

operated on who recovered, it would make the total

•very nearly 100 per cent. Murphy's operation gave

ihini a mortality of 82' 1 per cent. Close analysis of

these facts would bring a total of as much as 100 per

cent. ; in any case, he considers Murphy only a last

! resource ; laparotomy (74 cases with 20 cures) repre-

sents a mortality of 73 per cent., and is incontestably

the preferable treatment ; thoraco-abdominal wounds

should be treated by abstention ; laparotomy results

in 100 per cent, of mortality. These conclusions are

preceded by a very detailed exposition of the lesions

52 WOUNDS OF THE ABDOMEN

and symptoms observed, with a discussion on diagnosis and indication of technical details.

This work concludes the series of memoirs sent to the Chirurgical Society, which, however late the date of their appearance, are all inspired by the same tendency. They ought also to be grouped in the second period, with the four fundamental reports by Quenu.

It is the same with other studies that appeared out- side the Chirurgical Society. Everywhere laparotomy is gaining ground.

Leriche [42] showed " the necessity for systematic operation in wounds of the abdomen." Laparotomy alone would diminish to an appreciable degree their frightful mortality. The author notes that in 117 cases observed by him, in which an operation did not take place, the mortality was 89 per cent. ; he only knew of two interventions, made in very precarious conditions, yet both were crowned with success.

Delore [*3] is still more severe with regard to absten- tion ; in over 100 cases not operated on, not one recovered. He proves, by examples, the remote dangers of abstention (sub phrenic, " Douglas " ab- scess (in recto-vesical pouch) and chronic peritonitis). On the other hand, he supports by some typical facts his warm advocacy of laparotomy " whenever sur- rounding conditions are not against it."

Cotte and Latarjet [**] arrive at the same conclusions. Their article includes anatomical observations very carefully drawn up, with photographs of characteristic lesions. We note that seven laparotomies afforded them four successes.

Murard ["] is of quite a different opinion ; he distin- guishes "closed abdomens" from "open abdomens." For the first, laparotomy is dangerous and inefficacious ; Murphy's button-hole, on the contrary, has the great advantage of being simple, safe, and of being " some- times " useful. For the second, surgical intervention

EXPERIENCE OF THE PRESENT WAR 53

is only successful if it is used in simple omental hernia ! That is not saying much.

According to Tisserand [*7] nearly all, if not all, "true abdominals " succumb if they are not operated on ; Murphy's operation is insufficient in serious cases, and useless in slight ones ; laparotomy alone is the rational treatment, and special surgical posts ought to be multi- plied in the immediate neighbourhood of the front.

Vignard [46] counsels moderation. Although he takes his stand by the side of the interventionists, he shows by 20 observations that the cacoethes secandi should not dominate the spirit of observation and criticism without discussion.

Chalier ["] is eclectic. Fifteen abdominal penetra- tions, certain of them treated medically, resulted in 4 deaths ; but the 1 1 cases healed included 5 uretero- renal wounds, 1 vesical wound, 3 wounds of the liver, 2 wounds of the large intestine, none in the small intes- tine. Fifteen probably penetrating wounds recovered. Nineteen cases treated operatively included : 2 in- cisions in encysted purulent collections, 2 recoveries ; 12 Murphy operations, 10 deaths ; 3 lateral button- holes, 1 recovery ; 2 laparotomies, 2 deaths. Chalier concludes by condemning Murphy's operation. In spite of his personal want of success, he inclines to favour early systematic laparotomy "if the material conditions permit of it."

In a month of abdominal surgery at the front in an advanced post similar to that in which Bouvier and Caudrelier operated, Delay and Lucas-Championniere [49] practised 22 laparotomies with 11 recoveries (mor- tality 50 per cent.). It is to be noted that in 10 cases in which there were multiple wounds of the small intestine, there were nevertheless 4 recoveries. These two authors evidently range themselves in the camp of the interventionists, and advise laparotcmy when- ever there can be united " a wounded man in the third or fourth hour after he receives his wound, an instal-

54 WOUNDS OF THE ABDOMEN

lation affording every guarantee of asepsis, and a staff of surgeons and assistants, reduced it may be, but keen and specialised."

In the medico-chirurgical meetings of the different armies, it was inevitable that the healing of abdominal wounds should many times form the subject of discussion. Gaudier [83] — 6th Army — in 75 cases not operated on had only 3 recoveries ; he considers that Murphy's operation may transform acute into chronic peritonitis, but hardly ever prevents death, quite the contrary — and these figures are truly interesting — a first series of 9 laparotomies gives 4 failures ; but a second series of 5 gives only 1 failure. Gaudier insists that laparotomy must take place very quickly.

In the 4th Army, Pellot [M] obtained 32 per cent, of recoveries by operating. Mocquot denounces absten- tion, and relates the results that we have seen com- municated by him, in conjunction with Schwartz, to the Chirurgical Society. Vouzelle is convinced that, in time of war, more even than in time of peace, inter- vention should be had recourse to, and that for two reasons : the first is the great seriousness of the wounds, due in most cases to the explosion of shells ; the second, on which he insists, is the frequency of fatal haemorrhages. Brechot reports two cases of fatal peritoneal complications developing late in wounded men who had not undergone laparotomy. Potherat considers that there ought not to be interventionist and non-interventionist surgeons ; with abdominal, as with all other wounds, it is not admissible to decide d priori. In his opinion, there are cases in which it is impossible to abstain from intervention — in hernias of the intestine or of the omentum, in haemorrhages of the liver, the spleen, and the intestinal arteries, which are so frequent and so critical. There are, on the other hand, wounds where abstention is to be recommended : in those confined to the colon, or involving the stomach. Regarding wounds in the region of the small

EXPERIENCE OF THE PRESENT WAR 55

intestine, intervention is doubtful. It is fully justified if one can intervene in the first twelve hours, and when the state of shock is not too marked ; otherwise it is better to abstain. Se*journet presents ten un- published observations, with three recoveries ; in four of the cases followed by death the lesions were ex- tremely serious.

Clermont [56] — 10th Army — operated on 1 simple penetrating wound (1 recovery) ; 11 univisceral wounds (6 recoveries) ; 6 multivisceral wounds (6 deaths). The whole mortality is, therefore, 61 per cent. A communication by Gorse [ 5] has the excep- tional merit of defending Murphy's operation, which we have so far seen more and more discredited. Gorse has obtained 4 recoveries in 15 cases ; in each case it was a question of a bullet- wound.

The second period marks the triumph of laparotomy.

Third Period. — Things were at this stage when on November 17th, 1915, Chevassu [35] read to the Chir- urgical Society a "Study of 210 Cases of Abdominal Wounds observed in a Fifteen Days' Offensive in a Surgical Automobile'Ambulance, and especially of the Good Results of Abstentionist Methods." All the terms of this title deserve attention : the large number of cases observed by the same author ; the sustained offensive, replacing the momentary combats of the trenches ; the automobile surgical ambulance — that is to say, a surgical installation realising the most perfect conditions of operative surroundings then possible ; lastly, the title, which does not hide, but rather takes pains to inform us, that the results are favourable to abstention. If we take into account, besides, the rank and also the scientific position of the author, we can imagine the sensation his communica- tion must have caused, and the trouble it must have produced in the minds of those who seek only facts that shall strengthen their convictions.

56 WOUNDS OF THE ABDOMEN

Tuffier's report [3B] on Chevassu's Study only appeared on March 15th ; this explains the number of works appearing in the interval that merited classification in the second period.

The following are the figures of Chevassu's memoir : in 210 abdominal wounds observed, he includes 136 peritoneal wounds with 53 deaths and 79 discharges from hospital. These 136 cases are further divided thus : 41 operations, 27 deaths ; 91 abstentions, 27 deaths ; 4 deferred operations, 3 deaths. Thus, in striking terms, we have a mortality of 65 per cent, with abstention. Is it astonishing that Chevassu, hitherto an interventionist, rendered an abstentionist only by necessity, should now become an abstentionist by conviction ? For if these figures are rigorously established and indisputable, if the abdominal wounds (even the intestinal ones) heal by themselves better than after operation, it is evident that intervention is useless. Nothing remains but to resist " the old surgical instinct that springs up, and to allow the abdominal wounds to evolve in their own way."

Only — and here is the delicate point — these figures must be carefully scrutinised. Tuffier is the first to criticise them. To begin with, he only admits as valid 100, in which penetration was positive ; they gave 53 deaths ; but, as 15 of the wounded died almost immediately, before treatment, only 85 cases should be retained, with 38 deaths, or a 44' 7 per cent, mor- tality ; in the 36 remaining cases, where the lesion of viscera is only a probability, 4 deaths give a mortality of ITU per cent. If we only retain the coefficient of 44V7 per cent., it still remains very small and impres- sive. When this is done, Tuffier classifies the cases successively according to the organ attacked, and com- pares, in each series, the coefficient of mortality obtained in all the cases operated on which had been published up to that time with the coefficients obtained by Chevassu, whether by operation or by abstention ; such a com-

EXPERIENCE OF THE PRESENT WAR 57

pans on must evidently be very instructive. We represent it in tabular form.

	Chevassu : Ab-	Previous cases :	Chevassu :
	stention.	Operations.	Operation.
	Cases.	Mortality.	Cases.	Mortality.	Cases.	Mortality.
Eviscerations: intest. ^	3	100°	26	76-92	7	75 °
omental J	2	50	32	62-5	3	66-60
Stomach .	9	0	25	64	1	100
Liver	11	1818	70	54-28	5	80
Kidney	12	25	20	65	2	50
Spleen	1	100	21	857	—	—
Large intestine .	2	0	—	?	5	40
Small intestine .	32	1875	185	72'45	8	62-5

We see that for all the lesions, except for intestinal hernias and serious wounds, the coefficient of mortality obtained by Chevassu with abstention is very notably lower than that given by operation. * The only lesions that demand attention are wounds of the small intestine. Chevassu presents 40 of these cases, of which 8 were operated on, with 5 deaths ; 32 were not operated on, and 6 deaths resulted. Now Tuffier, after criticism of the case-reports, retains only 28 in which peritoneal penetration is certain, and only 10 in which the small intestine was certainly injured ; and these 10 cases give 5 deaths. Thus the mortality of 18' 75 obtained by Chevassu now amounts to 50 per cent. ! But it still remains stupefying, altogether out of proportion to anything that had been established since the com- mencement of the war !

Besides that,itcannot but be somewhat disappointing for the laparotomists to find that one single absten- tionist has, without any trouble, obtained 26 recoveries from intestinal wounds, while, according to Tuffier, up to that time only 31 recoveries had been with difficulty

* It is to be noted that three Murphy operations gave three deaths.

58 WOUNDS OF THE ABDOMEN

brought about by the successive efforts of numerous operators !

The conclusions of the reporter may be summed up as follows : " The figures of M. Chevassu are striking, but they are insufficient for judging of the matter ; they demand new documents to establish them, and our conduct since the commencement of hostilities is justified." And in conclusion he adds : " Laparotomy aggravates the prognosis very slightly whenever the state of the wounded, the material organisation, and the experience of the surgeon permit of its execution."

Conclusions so reserved and so exceedingly prudent only aggravated the sensation produced by Chevassu's memoir ; they certainly justified retaliation on the part of Quenu, and his new defence of laparotomy. "The communication of M. Chevassu," he declares, " is pregnant with dangerous consequences and con- trary to surgical truth, hence I conclude that it is my duty to complete in a clear and categorical manner the work of the case-reporter." Ought one to operate on the wounded, or leave them to the healing of nature ? This is, again, the burning question. Take, in the first place, the wounds of the small intestine. From 40, Tuffier has reduced the number to 10, with 5 recoveries. But we have also to eliminate a wound of the stomach and not of the small intestine, and a wound with an uncertain intestinal lesion. Of these 8 wounded, only 2 recovered, giving 75 per cent, mortality, and — another very interesting fact — these two single re- coveries from undoubted wounds of the small intestine were cases of bullet- wounds, in which the wound of the intestine was situated opposite the parietal wound : the intestine therefore could evacuate its contents outside, instead of pouring it into the abdomen. Figures so greatly reduced retain no interest as to the coefficients of recovery or death. On the other hand, the reduc- tion to 31 of the total number of recoveries obtained

EXPERIENCE OF THE PRESENT WAR 59

by the laparotomists cannot be admitted. Que"nu redresses the balance : he gives 64 ; here we have 64 wounded men all, or nearly all, snatched from death by operation !

Similar criticism is made as to the wounds of the large intestine, the stomach, the kidneys, and the liver ; the indeterminate peritoneal wounds, particu- larly, present 16 deaths for 16 cases !

And Quenu again confirms what he has always maintained : " The non-punctiform perforations of the small intestine can only heal by being stopped up ; and with regard to the punctiform ones, they repre- sent the really favourable cases, and those which most surely benefit by intervention."

The therapeutic indications, therefore, remain as before.

Chevassu's communication had incited Marquis [2§] to enter the debate with the figures furnished him by abstention, which he had adopted primarily by con- viction, but also by necessity during the battle of the Marne. Of 68 abdominal wounds (among which an indefinite number were non-penetrating) 32 recovered (21 being bullet-wounds).

The desire to react against the mischievous influence of Chevassu's communication can be perceived in the view of " Evolution " given by R. Picque [34], writing of the treatment of abdominal wounds in his ambu- lance at the front. It is nothing less than a very complete study of the question, starting with operative indications, as they concern the surroundings, and the wounded, and going on to the technique, with useful reflections by the way on the " para-peritoneal syndrome " and the radioscope. But we may definitely gather from it that " having been at first an interven- tionist, and going through an attack of voluntary absten- tion, he again finds himself a resolute interventionist."

Can we wonder ? Sixteen cases of abstention yielded him 2 recoveries ; 14 palliative operations, 14 deaths ;

60 WOUNDS OF THE ABDOMEN

15 laparotomies, 6 recoveries. From these statistics we again observe the rarity of spontaneous healing, the failure of palliative operations, the absolute harmless- ness of laparotomy and its encouraging results, which the future will only accentuate. But, to improve these results, certain ambulances must be specialised for surgery, and even for the treatment of those grievously wounded. And progress in this direction, writes Picque, " should put an end for ever to the hindrance of overcrowding, as well as of surroundings." A valuable declaration, considering its origin.

The same opinion is expressed by Gregoire [B7] : " Can we under present conditions operate on abdo- minal wounds at the moment of a great offensive ? Decidedly, no ! " he replies. But there are means of avoiding the overcrowding. Certain ambulances must be specialised and confined to these wounds ; special automobile carriages must be designed for the trans- port of those wounded in the abdomen ; the surgical installations must be placed as near as possible to the fighting-line and on the most accessible route ; the surgeons must be able to watch, to look after, and to follow their wounded until they are out of danger.

Agreed, but . . . that is just where the difficulty lies.

Twenty new laparotomies by Simonin [38] are the object of a supplementary report by Quenu, April 12th ; they afford a total mortality of 60 per cent. Here, again, stands out the difference of gravity between univisceral wounds (mortality 60 per cent.) and the multivisceral (mortality 100 per cent.). Reflections follow on the often invincible difficulty in the diagnosis of penetration or non-penetration, and on the neces- sity of specialised units, since the others will be over- whelmed by the influx of wounded, etc.

Forty-six observations by Rouhier [40] serve as a point of departure for Pozzi to make, in an attractive paper, another study of the question which interests us, in which, incidentally, his personal experience con-

EXPERIENCE OF THE PRESENT WAR 61

firms practical advice ; we note specially the views on "trophic shock." In 15 laparotcrnies for really penetrating wounds Rouhier obtained ti recoveries (mortality 40 per cent.) ; of this number 12 operations were for intestinal wounds, and gave 3 recoveries (25 per cent.).

In the meanwhile Pauchet [73], investigating the >est method fcr reaching the organs in relation with the lesser sac of the peritoneum, and notably the posterior surface of the stomach, advises the incision of the gastro-colic omentum ; he heightens the clearness of his description by eight demonstrative figures.

Here, as characteristic of the actual state of the question, we must report the conclusions that ter- minated the discussion, sometimes a very lively one, which took place at the Chirurgical Society. Quenu had already written, when criticising Tuffier's report on Chevassu's communication : "Absence of organisa- tion or bad organisation should not be allowed any weight in falsifying therapeutic indications, There is no lack of resources either in material or in men — we have only to utilise them. Do we always do so?"

In a lively meeting en May 10th, Pierre Delbet, Souligoux, Rochard, Monprofit and Broca intervened in turn to oppose the " restrictions " with which Tuffier was reproached, and his lukewarmness with respect to intervention ; but, above all, to demand anew a better material organisation and a more judicious use of the means at disposal. And the following resolution was unanimously adopted :

" The Chirurgical Society pronounces in favour of early intervention in cases of wounds of the abdomen. It also gives utterance to the desire that, to ensure attention to these cases, and to all others severely wounded, where the rapidity of the operation has great influence on its success, motor ambulances should be concentrated as required, and for the necessary period,

62 WOUNDS OF THE ABDOMEN

at the spot where the wounded arrive in greatest numbers."

At this point our historical record stops.

We can now summarise, in a few lines, the three periods in which we have seen the evolution of the treatment of abdominal wounds develop during the present war.

During the first period, under the influence of previous wars, as we find it expressed in administrative circulars, abstention is the rule ; the only operation allowed is the supra-pubic button-hole. The results obtained by either of these methods are gradually found to be disappointing.

In the course of the second period, dominated entirely by the influence of Quenu, at once combative and encouraging, laparotomy multiplies its successes and increases the number of its partisans.

A third period sees the development of a reaction in favour of abstention, not as the method to be pre- ferred, but as the method of necessity affording numerous successful results. But these successes are contested, and often appear illusory as regards genuine penetrating wounds with visceral lesions.

We have also seen that these three periods correspond with three different modes of strategy, which necessi- tate special conditions of operative surroundings.

First came a period when the armies were inces- santly in motion, when there were battles of great importance, and the surgical organisation was defec- tive.

Then followed a time of stationary armies, of trench warfare, of improvement in transport and surgical equipment and hospital provision. Two types of specialised organisations came into being : surgical automobile ambulances and advanced surgical posts close to the front.

A return to the war of offensive conflicts in great

EXPERIENCE OF THE PRESENT WAR 63

masses shows that these organisations are insufficient. Is this inevitable ? May we not hope for better things from an organisation more supple and more judicious in the use of the means at its disposal ?

Another parallel may be drawn as regards the nature of the projectiles most frequently encountered.

During the first period the projectiles were bullets, and the greater part of the wounds healed by absten- tion were produced by them.

In the second period trench mortars and shells came into play. Abstention was shown to be in- efficacious, and laparotomy proved itself the only therapeutic resource of any value.

In September 1915 numerous bullet- wounds were again observed, and abstention again asserts itself as a means of heah'ng.

All these facts are data which will prove their utility when the time comes to discuss what is the treatment to be preferred in penetrating wounds of the abdomen.

CHAPTER IV ANATOMICAL LESIONS

CAUSES, FREQUENCY, GRAVITY, AND THERAPEUTIC CONSEQUENCES

IT is not a question here of describing, organ by organ and degree by degree, the different lesions that the wounds of war may cause in the abdomen.

The important matter is to indicate details which may help :

(1) To realise the anatomical possibilities of the spontaneous healing of the lesions, and consequently the limits in which one may reasonably count on a salutary effect from simple abstention.

(2) To support the necessity for direct surgical in- tervention, and to show that it is necessary in the majority of cases ; we shall see, also, that certain lesions too often remain beyond the resources of even the most expert operative action.

(3) To specify the details of technique.

It is under these different aspects that the lesions have an immediate interest for us in practice.*

* As we proceed, we shall support our statements by statistical figures. They have been obtained from the totals of the case- reports hitherto published, so far as we are acquainted with them. We have thus sought to obtain coefficients more exact, as repre- senting a larger number of facts. (See the recapitulative table on p. 130). In the case of anatomical lesions it is obvious that only autopsies or exploratory operations are taken into consideration. In general we rely on the latter.

64

ANATOMICAL LESIONS 66

But one great primary idea must be borne in mind, that of :

THE INFLUENCE OF THE NATURE OF THE PROJECTILE ON THE FORM AND GRAVITY OF THE LESIONS

In former wars only wounds from side-arms, bullets, and sometimes from shrapnel were met with, and had to be reckoned with from the surgical point of view. There was no question of the wounds caused by the bursting of shells. It is a sad privilege of the present war that we have beheld the appearance and the increase in importance, even to the point of eclipsing all the others, of wounds caused by the bursting of percussion shells, and by trench machines (grenades, bombs, mortars, etc.). And we shall see that these are precisely the most serious.

Wounds from side-arms are absolutely exceptional. I do not think that a single case of sabre-wound has been published. That is easily explained. The cavalry- has hardly intervened, and then only at the beginning of the war, except for reconnaissances : single combats are the exception, it being the carbine or the rifle that plays the part of offensive or defensive weapon at long range : the group of combatants is already de- stroyed, or surrounded and forced to lay down its arms, before the sabre can be brought into play. Cavalry charges almost seem to belong to another age, and the sabre has made and will make hardly any victims.

The bayonet is still frequently mentioned ; it is possible that " Kosalie " may frequently be a cause of wounds on the opposite side of the lines : but wounds from German bayonets are rare with us (personally I have only seen three cases in 3,500 wounded) : wounds of the abdomen caused by them are rarer still. A few instances are mentioned by Picque, and by Petit.

Picque [s4] has observed and operated on three bayonet-wounds, with two recoveries. One was a case of double perforation of the transverse colon and 5

66 WOUNDS OF THE ABDOMEN

free stercoral effusion into the left paramesenteric fossa. This resulted in recovery. The second had puncture of the left kidney and submesenteric hsema- toma — this also resulted in recovery. The third, with double perforation of the sigmoid flexure, died.

Petit's case was due to an accident (wound of the liver with very great haemorrhage).

Besides, the bayonet is habitually wielded with such violence and so unmercifully that wounds made by it are usually fatal.

It is the same with the trench knife, and to any one who is acquainted with its form and the manner of use of this instrument, so typical of a war without mercy, it is evident that when it is handled by a " cleaner-up of trenches " it will leave little room for the appearance in an ambulance or on an operating- table of a man with a knife- wound in the abdomen.

The modern bullet might seem to have humanitarian qualities owing to its small calibre, but its speed of propulsion and rotation, the living force with which it encounters all obstacles modify, and generally amplify, the presumably small size of its track. Although the part played by detached splinters as independent projectiles cannot be gone into here, we know that the abdominal viscera are very diversely injured according as the bullet arrives from a point close at hand, in full course, medium course, or at the end of its course.

When the shot is a close one, the bullet makes great havoc in the abdomen by its " explosive effect." This is easily explicable in the region of the solid viscera, like the liver, the spleen, or the kidneys, and we shall consider these effects later on ; but it also acts in the region of the stomach and the small intestine, especially if these viscera are not empty, as during the process of digestion. Although occurring on a smaller scale, being more limited, and acting simply on richly vascularised intestinal regions, where the pro-

ANATOMICAL LESIONS 67

portion of fluid traversing the tissues is large, the " burst " still produces an effect ; it makes orifices out of all proportion to the calibre of the bullet ; it rends and detaches ; it occasions mesenteric separa- tion by mediate action, not by direct tearing. And ;hese serious lesions are principally met with in the mullet-wounds of trench warfare and fights at close quarters.

Here is one of the most typical examples from many others :

" D was hit on March 1st, 1915, by a bullet com-

ng from a short distance. The wound of entrance on ihe left flank was punctiform : the wound of exit on ;he right flank was as large as the palm of the hand ; :>lood was flowing from it in abundance. The shock was intense. The pulse was imperceptible. Immediate aparotomy (in the third hour) showed the abdomen full of blood and faeces. I closed five perforations of the small intestine, and then found three coils entirely divided at several points, extensive mesenteric separa- tion, fragments of the small intestine floating about n the mixture of blood and intestinal contents. Nothing could be attempted. We had to close up the wound. The patient died two hours later." (Abadie["]. Obs. 5.)

When the abdomen is hit by a bullet in full course, at a moderate distance, say 200 metres, the most favour- able conditions exist : the ball goes right through, making very narrow parietal openings, and intes- tinal punching perforations or intra-parenchymatous tunnels.

When the bullet is at the end of its course it may remain in the abdominal cavity, for instance in a solid viscus (this happens most frequently in the liver) ; 3ases have even been observed where the bullet has remained loose in the peritoneal cavity, having traversed the abdominal wall without causing any visceral lesions (Quenu [7l]).

68 WOUNDS OF THE ABDOMEN

When a projectile strikes by ricochet, the gravity of the lesions is at once increased, and this fact is specially noticeable as regards bullets, as the contrast is greater in them than in any other projectile between their ballistic properties before and after. Instead of a penetrating movement around its axis with regular rotation, the bullet is projected according to an un- accountable trajectory, oblique or curved, and above all it seems to be animated by a movement of rotation around some chance point of its substance ; becoming " mad," it attacks the body at some un- certain incidence, presenting itself by the point, the side, or the bottom, and continuing in the tissues its erratic gyration. This gives rise to considerable damage.

Shrapnel bullets, of hardened lead, in the form of a billiard-ball, or part of a billiard-ball, have generally a feeble penetrating force. They hardly ever entirely traverse the body. Some have even been extracted that had stopped in the peritoneal cavity and remained encysted in the omentum (see Figs. 1 and 2 and Walther [69]). The injuries they produce are local, with- out bursting or irradia- tions, but they have the great drawback of bring- ing into the wound sep- tic fragments of cloth- ing. Though almost the only cause of wounds due to artillery during the wars of Manchuria and the Balkans, and still frequent at the

FIG. 1. — Shrapnel-ball encysted commencement of the Gouiuioud and present war, they are becoming rarer as the use of percussion shells becomes more general, and since these latter are not confined to the destruc-

ANATOMICAL LESIONS

69

are

tion of buildings, but are liberally employed against the troops themselves.

Revolver-bullets are rarely met with. They chiefly found in ac- cidental wounds caused by impru- dence. Nothing re- markable is discov- ered as to their gravity which was not known in time of peace. We may observe, however, that they are bullets of large calibre ( 8 mm . or 7'5 mm.), and of great initial swiftness .

Fragments of shells are now found to be the usual cause of the wounds we meet with. Their size is very variable, ranging from that of a grain of corn to a large thumb, but their surface is always rough, with sharp angles, finely jagged or fringed (Figs. 19 and 46), and they are possessed of a force of pene- tration that varies according to the distance at which the shell has burst. Their lesions are rendered much more harmful in that they nearly always drag in with them pieces of clothing, and the septic nature of these pieces aggravates the infections caused by the contents of the abdominal viscera. One has even observed cases in which the entry of fragments of this sort through the abdominal muscles has accounted for the separation of the edges of a laparotomy or the suppuration of the edges of the traumatic wound, or even the appearance of gas gangrene in the abdominal wall. We have ourselves observed two instances of this. (See pp. 233 and 255.)

FIG. 2. — Shrapnel bullet encysted in the omentum. Torsion of the pedicle. GouilHoud and Arcelin [76].

70 WOUNDS OF THE ABDOMEN

The splinters of grenades, bombs, shells from mortars and minenwerfers, in short, the effects of the engines of the trenches, are equally to be dreaded. Their form is infinitely varied : fragments of iron wire drawn to a point, chips of tin fringed or bent back into little grooves, etc. (Figs. 17 and 53.) There is a surprising disproportion between their size, their very small weight, and the extent of the muscular, parietal, or visceral lesions that they occasion. Just as we often see a minute particle form a veritable cavern in an osseous epiphysis or in a bone of the tarsus, so we see the projectile form round itself, in a solid viscus, a vast cavity of irreparably damaged tissue. The force of penetration due to the almost invariable nearness of the explosion is aggravated by a mad rotation of the projectile. The segments of spherical cast-iron grenades, comparable to "soft caramels " as to form, are generally less dangerous. All these different fragments bring in textile particles : it would seem also that certain of them have a necrotic effect, due to the chemical substances with which their parts had been in contact. And what still more increases the gravity of the wounds caused by the trench mortars is the multiplicity of wounds, which in some cases become innumerable and disseminated over the whole body. The danger is greater when an abdominal wound is found to be accompanied by penetrating thoracic lesions, or when the number of the wounds in the limbs considerably aggravates the shock.

The little arrows of the air-men have gone out of fashion, but some observers mention them as being the cause of penetrating abdominal wounds.

To draw up in figures an estimate of the comparative frequency of the wounds caused by one or other of these different projectiles would have only a very relative value. We have seen how it changes, accord- ing to strategic conditions, with the different periods

AS ATOM 1C AL LESIONS 71

of the war, and even with the sectors in which the cases are investigated. Here, however, is a com- parative table, from 479 observations of laparotomies :

Bayonet-wounds .... 3

Bullet- wounds . . . . . 147

Shell-wounds 271

Grenade-wounds .... 58

It is more interesting to notice the comparative gravity of the wounds as shown by the number of recoveries or deaths observed after laparotomies :

Cases. Recoveries. Mortality.

Bullets . . 147 81 45%

Bombs— petards 58 31 47%

Shell fragments 271 94 66%

We will now study the

ANATOMICAL LESIONS

in order to obtain practical information from them.

There are five essential ideas that seem to stand out from the anatomical lesions observed, and by the help of which these lesions may best be described.

(1) A certain number of penetrating wounds do not injure the viscera, even when the abdomen is traversed from one side to the other.

(2) A certain number of visceral lesions may recover spontaneously.

(3) There are some lesions which cannot possibly heal spontaneously.

(4) Multivisceral wounds are much more serious than univisceral ones.

(5) Associated abdomino-thoracic lesions are either benign, or extremely serious.

72

WOUNDS OF THE ABDOMEN

(1) A CERTAIN NUMBER OF PENETRATING WOUNDS

DO NOT INJURE THE VlSCERA, EVEN WHEN THE

ABDOMEN is TRAVERSED FROM ONE SIDE TO THE OTHER.

< In the first place, if the projectile stops, at the end of its course, in the abdominal cavity, it may conceiv- ably insinuate itself, between the coils, and stay in the folds of the mesentery and the meso- colon, without in any way injuring the intestine or solid viscera, or confine itself to slight contusions. Bouvier andCau- drelier ([»], Obs. 9), in dividing the intestine, caused the ball to fall out : it had only bruised a loop of the small intes- tine ; in another case (Obs. 11) the ball was loose FIQ. 3.*— Penetrating abdominal wounds jn the abdomen, verified without injury to a single viscera. , . ,

Cuthbert Wallace [•*]. having only oc-

casioned a cha- fing of the jejunum. Arcelin [76] twice extracted a shrapnel bullet wrapped up in the omentum (Figs. 1

* In this and all the following diagrams, orifices situated in front are represented by • ; at the back by O ; direction of the course by ••>.

ANATOMICAL LESIONS

73

and 2), and the observation of Delore [67] is still more strange, as he met with a pile of louis d'or which had fallen into the recto-vesical pouch !

The occurrence of a projectile stopping against the coils or gliding between them is rarer in proportion as the projectile is rugged. Thus it is seldom observed in the case of shell-wounds or those caused by trench mortars ; at the point where the latter stops short there is nearly always a con- tused wound or perforation of the gut, however small the perfor- ation may be.

P , wound- ed by shell-frag- ments, Novem- ber 4th, 1915, showed in the right iliac fossa a parietal wound of irregular shape, from which start- ed a diverticulum penetrating into the abdomen. Median sub-um- bilical laparot- omy demonstra- ted a tangential rent in a loop of the small intes- tine without p erf oration, and a perforation of the omentum. The projectile itself had remained in the parietes, only its point had perforated the peritoneum

FIG. 4.— Wounds that have healed without operation and penetrating wounds, operated on, in which the absence of visceral lesions has been verified. (Rouvillois [38].) We see that neither the one nor the other belongs to the umbilical region.

74

WOUNDS OF THE ABDOMEN

and reached the viscera. The man recovered. (Ab- adie ["], Obs. 2.)

Another case : the projectile may entirely traverse the abdominal cavity, implant itself in the opposite wall or pass out, thus making a complete seton of

the abdomen, and that without visceral lesions.

This has been observed inmany instances.

In 275 opera- tions examined by Tuffier[39] as to this point, 31 proved to be simple peritoneal penetrating wounds, or 1T27 per cent. This estimate is really too low, for it only applied to cases operated on, and there are many where the complete tra- versing of the FIG. 6. — Non- visceral and non- vascular abdomen is evi- zones of the poster! or abdominal region. 1,2, 3: projectiles that, after having glided be- tween the intestinal coils, may pass out at the back without grave lesions. 4: Projectile that, passing from back to front, may re- main in a " meso," though approaching very near to the anterior wall. (The circles tra- versed by the arrows 1, 2, 3 represent the orifices of passage through the anterior wall.)

the surgeon, even the intervention- ist, abstains from operating in the absence of all re-

actionary pheno- mena. Of these cases, which are fairly frequent, we should naturally find no traces in operations described.

ANATOMICAL LESIONS 75

Quite lately we extracted from under the skin, against the external edge of the right rectus at 2 cm! below the umbilicus, a piece of shell that had pene- trated the right flank ; being surrounded by omen- turn, it was obvious that the projectile had traversed the peritoneal cavity. The absolute localisation of peritoneal reaction, the absence of any affection of the general condition, and the long delay that had taken place, made us reject the idea of laparotomy. The patient recovered perfectly without the least fistula

The preceding diagram by C. Wallace, consult- ing-surgeon to the English Army, represents paths the projectiles verified by laparotomy where no viscus was injured, in spite of penetration or peritoneal passage (Figs. 3 and 5). We now reproduce a similar diagram by Rouvillois, in which, besides the peritoneal wounds that healed without intervention, and in which the projectile has been localised by radiography, we have added the simple peritoneal wounds verified by laparotomies (Fig. 4).

Anatomically, these facts can easily be understood. But on seeing the abdomen cut open, even in frozen subjects, the thing would seem impossible. We have to remember, however, that these openings are most often made on horizontal subjects, while the wounded are almost invariably hit standing. In this position the stomach, the transverse colon, and the mass of the small intestine have a tendency to stretch vertically ; the free^ spaces between the viscera widen and the mesos" (mesentery) stretch, while a considerable portion of the coils of the small intestines fills the pelvis. But, above all, the course of the projectiles that do not reach the viscera (of which we have a demonstra- lon in the diagrams of Wallace and of Rouvillois) is neither truly antero-posterior nor transverse, neither horizontal, but all, or nearly all, are distinctly obhque, and from front to back, from below upwards, from right to left, or vice versa. Hence a projectile may

76 WOUNDS OF THE ABDOMEN

easily pass the mass of the small intestines, at a tangent, glide along the mesentery between two loops, and reach the posterior region in one of the parts — few, it is true— where no important organ or important vessel is met with (see Fig. 5) It may also be tangential to the intestinal mass behind (Obs. 10, Kouvillois), and pass either within or without the loops of the colon.

One of our wounded, C , May 19th, 1916, was

hit in the epigastrium slightly to the right under the costal border by a piece of shell A wound as large as a five-franc piece gave access to the liver, the anterior edge of which was torn. There were no abdominal symptoms. No operation was attempted. During the following days a biliary fistula developed. It was very abundant at first, but gradually diminished. The man recovered. The radioscope showed the projectile a little above the right iliac crest, and against it, at 14 cm. from the spinal column.

The projectile had therefore damaged the edge of the liver, moved in front of the transverse colon, glided between the ascending colon and the mass of the small intestines to plant itself in the posterior

wall.

One of Vertraeghe's patients ["] was traversed obliquely from the right lumbar region to the left flank by a cylindrical copper fuse 2 cm. long by 1 cm, in diameter. The projectile injured the lumbar roots, traversed a vertebral body, entered the abdomen to the left of the lumbar column, passed through it, and stopped under the skin of the left flank, after having perforated the anterior abdominal wall. It had carried in fragments of clothing. Laparotomy showed no intestinal lesion. The wounded man recovered.

There is another point in which the diagrams of Wallace and Rouvillois are in agreement : no pro- jectiles are to be seen in the umbilical and perium- bilical regions without visceral lesions . The pro j ectiles least likely to injure any viscus are found in the

ANATOMICAL LESIONS

77

flanks, the iliac cavities, and more rarely the hypo- chondria.

Somewhat similar in results are the cases where the projectile has entered from behind, glided into the substance of the mesenteries, and ended by occupying an entirely intra-abdominal position but not an intraperitoneal one. We have seen two typical cases of this.

In the case of B we extracted from a lumbar

wound a fragment of shell 5 cm. by 3 cm., situated 8 cm. be- hind the a n terio r wall, above and to the right of the umbilicus. This pro- jectile had apparently penetrated the mesen- tery or the transverse mesocolon without in- juring any hollow vis- cera. We shall see the interest of this case

again in ^IG. 6. — Small projectile which had perforated relation the bladder, the rectum, the small intestine, and to the in- tlie Pu^is- ^ large projectile that had remained subperitoneal.

terpreta-

tion of radioscopic findings (p. 211).

The patient, H (see p. 255), whose case was

78 WOUNDS OF THE ABDOMEN

exceptional from many points of view, presented this special feature, that a larger fragment of shell (40 grammes of cast iron) having entered by the left ischic- rectal fossa, fixed itself, remaining subperitoneal, in a peritoneal fold situated between the caecum and the external lateral and posterior wall. It was a radioscopic surprise to discover its presence, as there were no reactionary phenomena in that region. The foreign body was not removed until several months after the initial wound. The first operation had been concerned only with perforations of the rectum, of the bladder, and of the small intestine caused by a small fragment of shell that had entered by the buttock and lodged under the pubis !

Are we to conclude, from this, that intraperitoneal wounds, not visceral, will always be benign ? No, certainly not, especially if it is not a question of bullets but of shell or grenade fragments, etc. The latter pro- jectiles are septic, they bring in fragments of clothing, they make more irregular parietal breaches, with muscular damage often out of all proportion to the small size of the cutaneous orifices, and they may be complicated by gas gangrene (C. Wallace).

In addition to this, they have great liability to produce visceral contusions, from which may result late necrosis of the walls and the appearance of a septic peritonitis which has only been deferred.

There is another complication which modifies the apparent benignity of non-visceral wounds : that is hernia. Under the influence of abdominal pressure, either immediately or gradually, a piece of gut or omen- turn works into the orifice, remaining pro-peritoneal or intraparietal, or comes out at the exterior. If only the omentum is herniated, it isolates the abdominal cavity, and even if strangulated and later sphacelated, it will nevertheless have acted the part of a salutary stopper. An intestinal loop is much more dangerous : it has infinitely more opportunity, owing to contamina-

ANATOMICAL LESIONS 79

tion, of causing generalised peritonitis by propagation. Its size may also increase indefinitely, rendering the hope of spontaneous healing more and more illusory ; or else, being strangulated, it may become gangrenous' and will be the seat of an artificial anus : the latter

the only favourable issue, provided this fistulisation is far enough away from the origin of the small intestine and near to the caecum.

In short, penetrating peritoneal wounds without visceral lesion may be benign in the cases of a bullet arriving at slow speed ; spontaneous cures are very frequent in such cases • they enter largely into the number of successes registered by the abstentionists. But we must bear in mind that, in the case of shell- wounds, the gravity is enormously increased, and, if there is a hernia, e.g. a large omental hernia, and still more if there is an intestinal hernia, the prognosis is very serious and intervention is necessary.

• • •

(2) A CERTAIN NUMBER OF VISCERAL LESIONS MAY HEAL SPONTANEOUSLY

It is as regards the small intestine that this fact is the most contested. Text-books nevertheless admit that a minute perforation of the small intestine may heal of itself. It does so by the triple effect of its oblique passage, the mucous stopper, and the ad- hesions. The oblique passage through the wall prevents the super-position of the different planes perforated ; the obliteration is effected by gliding. The mucous topper prevents the issue of the septic intestinal contents ; its role is still essentially mechanical. The adhesions, facilitated besides by the septic qualities the mucous stopper, which give rise to a defensive eaction all round it, rapidly unite the injured coil the viscera, to the gut and to the neighbouring >tal peritoneum. Thanks to these adhesions, the perforation is isolated from the rest of the peritoneal

80 WOUNDS OF THE ABDOMEN

cavity ; the reparation of the orifice is gradually accomplished ; the adhesions disappear later. The recovery is complete.

But in order that this process may play its salutary part, it is absolutely essential that the orifice should be small, with regular edges, so that the mucous mem- brane may be condensed and form a stopper there, and not become on the contrary a funnel leading towards the exterior. It is also essential that the adhesions should be able to form — that is to say, that the coils should remain stationary ; they have a natural tendency to do so : paresis, dilation, and congestion are manifest in every diseased intestinal coil. It is necessary also that no external influence should induce an untimely movement.

The internal pressure must also not be excessive, otherwise the intestinal contents may be forced out. This would be the case in an empty or contracted intestine, in the " dog's intestine " of a fasting subject.

It is essential also that the intestinal contents, and hence the mucous stopper, should not be so septic as to infect the whole of the peritoneal cavity — a perfora- tion very close to the stomach will be more septic than towards the middle portion of the small intestine.

It is also essential that the haemorrhage from the intestinal wound should not be at all excessive.

Are so many favourable conditions ever realised in the wounds received in war ? Certainly.

Some observations of Schwartz and Mocquot [a4] are instructive in this connection : we find, for instance (Obs. 18, second series), that ten perforations caused by bullets, some as large as a lentil, others as large as a pin-head, were spontaneously obliterated.

Chevassu [3I] has also witnessed the recovery of two wounded men in whom the perforation of the intestine was situated opposite the parietal wound — thanks to that, the intestine could evacuate its contents outwards and not into the abdominal cavity (these two,

ANATOMICAL LESIONS 81

amongst the recoveries that he mentions, are also the only ones that had undeniable wounds in the small intestine).

But such fortunate coincidences are very seldom realised. To begin with, it is rare to meet with small perforations, and it is still rarer to find them isolated. And that can easily be understood. A single perfora- tion can only be produced by a projectile exactly tangential to the convexity of a loop, or again by a projectile at the end of its course, falling into the cavity of the intestine. Two orifices imply a path similar to the one we have described, permitting the passage of the projectile between the coils — that is to say, very oblique. But let the bullet or shell come in a decidedly antero-posterior or horizontal direction, and not one only, but several coils will be involved ; the perforations will be 6, 8, or 10 in number. This happens frequently (see Figs. 9 and 10).

Now, however small their size, the multiplicity of these perforations renders the possibility of spon- taneous healing very unlikely : accumulated on the same loop, they compromise its vitality, and this is more liable to happen since the mesentery may itself be affected. If, on the other hand, they are scattered over numerous coils, they necessitate more extensive plastic work, and also render more probable dis- seminated infection of the serous membrane.

Haemorrhage is far from being slight. Very often it is disproportionate to the size of the perforation. Such abundant, peritoneal haemorrhage, favourable to the development of peritonitis, may accompany a very small perforation.

As to immobility, one cannot count on that because of the many displacements of the wounded man be- tween his fall and his bed in the hospital ; the intestines are subjected to a violent shaking by the lifting up, the transport through the trenches, and above all by the journey in the automobile. 6

82 WOUNDS OF THE ABDOMEN

And, admitting that it does take place, how insecure this spontaneous repair of the intestine is likely to be ! An observation of Chevassu's is a typical proof of this. A wounded man went to the water-closet on the sixth day, when his condition was excellent and his abdomen quite supple. The post-mortem showed eight quite small perforations, about 3 mm. in diameter, closed, with the exception of one, by the adhesions of the coils amongst themselves. Yet this plastic process had not resisted some rather sudden movements on the sixth day.

We perceive, by this example, how exceptional and uncertain it is for wounds of the small intestine to heal by abstention.

It is quite a different matter with the large intestine, or, more precisely with the vertical portions of the large intestine — the ascending and descending colon enjoy, in fact, exceptional privileges.

It is only slightly mobile ; hence no collection of the infection ; greater facility for the work of adhesions ; and the relative frequency of tangential wounds. (Here there occurs a shadow in the picture : very often these tangential wounds are confined to a contusion, and the delayed loosening of the slough will be full of dangers !)

Again, it has no circumvolutions — we only meet with one or two perforations.

Being near the parietes, it can easily attach itself to them, either to limit by adhesions a stercoral cellulitis whose tardy opening to the parietes by the traumatic orifice would be one method of healing ; or to send outward its own perforation as a hernia ; or to establish at the first onset free communication with the exterior, the true artificial anus which in its results allows of the easy escape of faeces and gas, and the peritoneal cavity remains free. This is a considerable factor of safety.

Another peculiarity is that it possesses an extra-

ANATOMICAL LESIONS 83

peritoneal portion. Its width is evidently very vari- able ; all forms of it are to be observed, from the clearly sessile colon, partly spread out against the lateral abdominal wall, to the colon with a mesenteric pedicle. In the first case,' which is the most frequent, a pro- jectile may reach the colon in three ways, each more favourable than the preceding : (a) The colon may be perforated where it is covered by the peritoneum, and in its extraperitoneal part : as this second perforation may give rise to a fistula immediately or in a short time, thus favouring a faecal cellulitis, the peritoneal orifice will have so much less chance to open and infect the abdominal cavity. (6) The colon is perforated tan- gentially or at two neighbouring points in its extra- peritoneal part, but by a projectile that has previously traversed the abdomen, very near the parietes, it is true, (c) The projectile has injured the colon, but its passage has been entirely extraperitoneal.

In all these cases the adhering surface of the colon cicatrises directly, or else a cellulitis ends in a faecal fistula.

M was wounded by a bullet, June 20th, 1915.

There was only a punctiform orifice below and outside the right antero-superior iliac spine. An oblique sub- peritoneal laparotomy, by following the track, came to the external surface of the ascending colon just above the caecum ; here the finger reached a focus con- taminated by intestinal contents, but appearing very limited ; we confined ourselves to inserting a drain. The patient recovered.

The radioscope showed the bullet to the right of the lumbar column, half-way up, 9 cm. in depth from the abdominal wall (Abadie).

Lastly, the contents of the large intestine are less liquid than those of the small intestine, and thus will have less tendency to escape by the per- forations.

It is to be noted that all these reasons, favourable

84 WOUNDS OF THE ABDOMEN

to spontaneous healing of the wounds of the colon, are, on the contrary, aggravating factors as regards direct surgical intervention. Having little mobility, the colon is rendered difficult to explore, or to open for the facilitating of excisions or sutures ; and, if one has recourse to Quenu's or Duval's liberation, it is at the expense of a rather long manoeuvre, which fatally exposes large cellular spaces to septic con- tamination. The part not covered by the peritoneum is difficult of access and for surgical action ; sutures there are painful, slow, and hold together badly. If burying of the serous membrane is not possible, faecal fistula is almost invariable, however careful one may be to multiply the planes of suture. Finally, if the contents are less liquid, they are, on the other hand, extraordinarily septic, and an infection of the peri- toneum in the course of operation is almost always fatal.

These facts relate, as we have said, to the vertical portions, and not at all to the transverse colon ; the wounds of the latter, and particularly of the left angle, are as serious, if not more serious, than those of the small intestine. None of the causes of comparative benignity exist ; on the contrary, the contents are more septic than those of the small intestine.

In the same way the sigmoid flexure often has a wide mesocolon, and is sufficiently mobile ; but it has a tendency to occupy the true pelvis, where we are aware that infective foci are isolated and collect most easily.

We have here a case in which the very great mobility of the sigmoid flexure facilitated healing by the mechanism of visceral hernia with gangrene and an artificial anus.

Quenu [l6] observed a colonial in whom a bullet, entering a little behind the left antero-superior iliac spine, made its exit by a large wound in the fold of the left groin. A loop of the ilic-pelvic colon, already

ANATOMICAL LESIONS 85

perforated; was protruding there. The loop sphace- lated ; and a spontaneous inguinal anus formed. The man recovered, and four months later Quenu effected the surgical closing of this anus.

We have to remember, then, that wounds of the colon frequently meet with anatomical conditions which allow of healing by abstention ; on the other hand, laparotomy is particularly difficult and serious.

In the stomach perforations of the anterior surface, and even of the posterior surface readily cicatrise. In the latter case, however, a discharge may be formed in the lesser sac of the peritoneum, which one must know how to open and treat at the right moment. But there is one essential condition for the healing of stomach perforations — it is that the subject must be fasting, so that there is no tension of the chyme.

The wounds of the liver capable of spontaneous healing belong to the following types :

(1) Tangential grooves.

(2) Blind tunnels, complete setons made by pro- jectiles not provided with sufficiently violent force to produce bursting lesions.

(3) Lacerations, or limited marginal contusions, with- out deeply irradiating fissures.

These different wounds, the last particularly, produce abundant haemorrhages, which, however, stop spon- taneously in a short time. An operation having for its object direct haemostasia will often expose the patient to a recurrence of haemorrhage, and if the latter can be arrested (sutures in " U form," plugging with a tampon), it will be because there existed great probability of spontaneous cessation.

Bullet-wounds close up on the outside, and the lesions evolve thus. The cases are numerous in which the radioscope shows a bullet enclosed in the substance of the parenchyma.

86 WOUNDS OF THE ABDOMEN

When there is a complete seton, it is very unusual not to find at the same time an associated abdominal lesion, or above all a thoracic lesion, which takes precedence over the former as regards prognostic importance.

The escape of bile is fairly frequent, especially in the case of irregular projectiles (shell-fragments or grenades), and when small splinters of ribs accompany- ing them add%o and aggravate the lacerations. Here also the discharge gradually dries up, provided always that the wound is of small extent, the liquid not too abundant, and that there is no discharge into the main abdominal cavity — in the latter case the peritoneum would very seldom remain aseptic.

On the whole, except where there is great destruction, wounds of the liver have great chances of spontaneous healing.

The spleen, on the contrary, is so friable, and so gorged with blood, that trauma tism rarely affects it without causing serious haemorrhage, and in many cases total destruction. A simple tunnel perforation is very rare. One example can, however, be quoted (Duval ["]).

We will only study the kidney which has been hit by a projectile that has traversed, or is about to traverse, the abdominal cavity. Hence the lesion is secondary in interest compared with that of the viscera simul- taneously injured. If the latter heal it implies the existence of the special conditions of benignity that we have already studied, and a fortiori the kidney will also heal. It suffices to recall the frequency with which wounds of the kidney improve after penetrating lumbar wounds. The very great facility with which the kidney bleeds as soon as it is injured or bruised explains the haematuria, often abundant and disquieting at first, but which gradually dries up. Afterwards, according to the case, healing proceeds regularly, or one intervenes secondarily to remove a

ANATOMICAL LESIONS

87

septic collection round the projectile, near or inside the kidney.

It is the same in the case of the wounds associated with penetrating wounds of the abdomen.

The rectum, too, is hardly ever involved except in connection with other organs, which are of predominant interest. The only eventuality that would seem to admit of the spontaneous cicatrisation of a wound of the rectum in its peritoneal region, is that of a bullet or small splinter with an exclusively pelvic course, reaching only the rectum and bladder, or the rectum and the sigmoid flexure, and causing perforations sufficiently narrow to bring about a purely local reaction, a peritonitis limited to the pelvis. When the rectum is in- volved in its extra-peri- toneal part, the likeli- hood of spontaneous &£f£J&£££

healing IS greater Still, even discharged into the abdominal

if the lesions are not cavi*y (blood, intestinal con- produced by small pro- jectiles. If the passage of communication with the exterior in the sacro-coccygeal region is widely opened we can observe the progressive cicatrisation of the rectal wound.

The same remarks may be applied to the bladder : in wounds of the same degree the gravity is manifestly greater in lesions which afect the peritoneal region. We nevertheless observe spontaneous healing of per- forations of the bladder by bullet, shrapnel, or small projectile entering the suprapubic or transpubic part.

88

WOUNDS OF THE ABDOMEN

Sometimes the bladder is obliterated at once, and the cicatrisation proceeds plane by plane ; sometimes fistula of the passage, purely urinary, or pyo-urinary, is set up as an intermediate condition. Cases of this kind are not extremely rare.

One observation is applicable to all the pelvic organs, and to the iliac cavities and the hypogastrium. All intra-abdominal effusions have a general tendency to descend towards the pelvis, which thus plays the part

FIG. 8. — The pelvis is the " collecting- sink " of the peritoneal cavity, particularly in Fowler's position.

of a true " collecting-sink." The organs situated low down that we are now considering are evidently placed in privileged conditions, as blood or faecal matter coming from their perforations will proceed to the collecting-sink without traversing or infecting the general peritoneal cavity (see Figs. 7 and 8).

We have now analysed the anatomical conditions in which the different viscera, considered separately, are likely, when involved by a penetrating abdominal wound, to heal spontaneously— -that is to say, to benefit by abstention.

ANATOMICAL LESIONS 89

The chances of healing vary with the different organs. Very poor in the case of the intestine, they are consider- able, in comparison, for the liver, the stomach, and the ascending and descending colon.

To sum up : Spontaneous healing of the small intestine is exceptional — it is a risk that would not justify any confidence in treatment by abstention. Spontaneous healing of the stomach, the colon, and above all of the liver are sufficiently frequent, on the contrary, to justify abstention in certain cases. As Tuffier says, " There is matter for reflection here for irreconcilable operators."

(3) THERE ARE LESIONS THAT CANNOT POSSIBLY BE REPAIRED SPONTANEOUSLY

And there are also some that will remain, whatever one may do, beyond all therapeutic resources, even surgical ones.

But what is interesting is just to draw attention to these "limited cases" — that is to say, on the one hand the lesions which cease to become spontaneously curable and hence necessitate direct surgical action, and, on the other hand, those whose gravity forbids the hope of success in any intervention whatever. But we must never forget that we always have in view the number of cases in which laparotomy is, first, ne- cessary ; and, secondly, may still be found efficacious.

In this connection everything is dominated by the nature, the form, the weight, and the dimension of the projectiles.

There are small projectiles, and there are large ones.

Large fragments, large splinters of bombs or shells, arriving with very great force and erratic gyration, cause considerable damage, which too often nothing can set right (see Fig. 17).

The abdominal wall, cut and sometimes torn, allows a voluminous visceral hernia to present. Sometimes

90 WOUNDS OF THE ABDOMEN

it is the injured viscera that thus protrude ; sometimes it is intact coils, and one cannot judge from their aspect of the extent of the deeper lesions : multiple intestinal sections, pieces of coils of intestine at the end of their torn mesentery, extensive portions of bowel floating free, remaining attached to the mesentery higher up, the end of the mesentery having been projected far from the corresponding segment, large vessels torn, solid viscera burst or crushed. All these may be immersed in blood and intestinal contents. If material reparation of the lesions were operatively possible, death would follow notwithstanding, as the haemorrhage and shock deprive such patients of all resistance, and their tissues of all possibility of re- action. Death is at hand, whatever one may do ; the rapidity of the intervention and the skill of the operator will, in any case, be in vain.

Thus it happened that in one of Vertraeghe's pa- tients ['] a projectile having passed through the abdo- men transversely, they found in a portion of the small intestine, of about a yard in extent, four complete sections of the intestine, two small segments of the small intestine free in the abdomen, and nine large perforations of the intestine, into several of which the thumb could easily have been inserted. Besides all these wounds there were three other perforations scattered over the small intestine and one perforation of the caecum.

We have seen an analogous case on p. 67.

Here is an example of still more serious lesions :

G was struck on September 24th, 1915, by a shell

that caused on the right side, a little below the um- bilicus, a wound as large as the palm of the hand ; a bundle of coils of the small intestine had escaped thence ; three perforations and a complete section could be observed ; the pulse was uncountable. Immediate intervention (second hour). After having treated the visible lesions (suture of the perforations,

ANATOMICAL LESIONS 91

resection, and anastomosis in the case of the complete section), a vertical exploratory laparotomy was made : in the neighbourhood of the csecum the small intestine was irregularly jagged and torn, as was also the caecum, close to which was extracted a heavy fragment of shell 9 cm. long by 2 cm. in width and 1 cm. in thickness.. A resection of the csecum and a latero-lateral ileo-sigmoid anastomosis were made. The wounded man died the following night. (Abadie [3S], Obs. 11.)

The very gravity of the lesions has justified, from the point of operative decisions, two diametrically opposite attitudes. " These wounded have nothing to hope from medical treatment," says Sencert ; " one should therefore operate without hesitation, as intervention may here and there produce some astonishing success ! " Gosset, on the contrary, con- siders that the great traumatisms of the abdomen caused by shells with lesions of the parietes and escape of the viscera demand, as a rule, abstention. When the lesions are obvious, this is evidently the wiser course. But very often the deep lesions cannot be perceived, and can only be recognised in the course of an operation ; except in extreme cases, it is better to give the patient the benefit of the chance.

Among the small projectiles, bullets arriving from a short distance cause wide perforations, detachments, and even explosive lesions. Splinters of shell, even small ones, have nevertheless their sharp, jagged edges, and, even more than their volume or their extent, the irregularity of their form and movement explains the havoc wrought by the small explosive projectiles of the trenches. Whatever organ may be involved, con- tused and irregular wounds, with ragged edges, are doubly formidable : they bleed, and they have a de- plorable tendency to marginal necrosis. Besides, these projectiles, are always contaminated and carry in with them fragments of clothing which are particularly septic,

92 WOUNDS OF THE ABDOMEN

Let us now consider the damages they cause.

In the small intestine we meet with lesions of every degree, from perforation to detachment and bursting. When they attain the dimensions of a sixpence, perforations may be considered incapable of spon- taneous obliteration. A fortiori, when the edges are irregular, contused, ravelled out ; in many cases the peritoneum is roughened, frayed, torn all round, or in patches.

The multiplicity and the surroundings of the per- forations compromise the vitality of the whole seg- ment of the coil ; the same happens with the perfora- tions of the mesentery level with the coil, whether the latter is involved or not.

Incomplete section, transverse or oblique, is one degree higher in intensity ; the edges separate. It is in vain that the lining forms a little marginal pad — the wound remains gaping. Complete sec- tion reaches as far as the mesentery, itself most often involved to a variable depth. Another type of lesion is the detachment of the mesentery, either above without wound of the intestine at this level, which nevertheless remains non-vascular and doomed to necrosis ; or associated with an intestinal section. When affecting a single or neighbouring coils, perfora- tions and even complete sections may heal after one or several resections of variable extent.

The specimens represented by the Figs. 9 and 10 are very instructive ; we see collected there every type of perforation.

Here follows their history, at once encouraging and deceptive. Encouraging, for it shows that multiple and grave lesions are susceptible of healing, thanks to intervention ; deceptive, for pulmonary com- plications irresistible in their development may render the most powerful efforts vain.

The specimens represented in Fig. 9 came from E , wounded June 7th, 1916, by fragments of

ANATOMICAL LESIONS

93

shell, one passing under the left crural arch and remaining intraparietal ; the other penetrated the abdomen at the level of the middle of the left rec- tus. Considerable pallor, imperceptible pulse, shock. General rigidity of abdomen, no motion, no flatus, urine clear on catheterisation.

Fio. 9. — Loops of the small intestine resected in the case of

E , p. 92. At the top (A), large perforation, causing a section

of two-thirds, and two wide perforations involving the intestine and the mesentery. Lower figure (B), three large perforations of the intestine, and two large perforations of the mesentery.

After 1,000 grammes of saline and adrenalin, cam- phorated oil, and the application of heat, the wounded man was operated on (at the ninth hour).

94 WOUNDS OF THE ABDOMEN

Median subumbilical laparotomy ; very abundant bleeding ; repair of the lesions apparent in the dilated subumbilical loops of the small intestine. There were found, at some distance from each other, separ- ated into four groups : a perforation large enough to admit the thumb (transversely closed in two layers) ; one wider perforation (lozenge-shaped resection, trans- verse suture in two layers) ; in a length of about 30 cm. three wide perforations of the small intestine, with edges turned outwards, of which two encroached freely on the mesentery; two large perforations of the mesentery independent of and tangential to the intestine (resection of 35 cm. and end-to-end anasto- mosis) (Fig. 9, B) ; again, in a length of 25 cm., a wide perforation of the small intestine, causing a transverse section of two-thirds of it, the edges much everted, and two tangential perforations of the small intestine detaching the mesentery (resection of 30 cm. of the intestine, end-to-end anastomosis (Fig. 9, .4)). Drying of the abdomen by warm compresses of saline ; 100 grammes of ether after rapid exploration of the pelvis, where nothing abnormal was observed. Large drain in recto-vesical pouch. Suture in one plane with bronze thread. Duration, 55 minutes. Drop by drop. Fowler ; strychnine, fluid diet.

On the fifth day the situation was as follows : tem- perature normal, pulse 120, but the drain showed escape of urine. It was therefore evident that the projectile has reached the bladder by a peritoneal orifice passed unnoticed, which would happen the more easily since the clear urine gave no indication of the least vesical lesion. And, in fact, the radioscope showed the pro- jectile behind the root of the right thigh ; it had passed by the sciatic notch.

On June 18th: temperature 38'5 ; pulse 120. Cystotomy was performed and a Freyer's drain was inserted, and a continuous drop-by-drop irrigation made into the bladder and the recto-vesical pouch.

ANATOMICAL LESIONS

95

The condition improved, and on the 21st recovery was looked upon as a certainty.

FIG. 10.— Specimens from a laparotomy with appendicectomv d.*f pie resection Performed on the wounded man D 96). Recovery. A, wide perforations, united, leaving

perforations * the

But at this moment signs and symptoms of diffuse broncho-pneumonia of the right lung appeared. From

96 WOUNDS OF THE ABDOMEN

that date first one segment and then another gave signs of breaking down ; the left base was similarly affected. Purulent expectoration grew more and more abundant. The patient sank, and died on July 4th, when the intestinal lesions had been cicatrised for some time and the bladder was going on well.

D , on July 31st, received a small fragment of

shell in the left iliac fossa. Median laparotomy (fifth hour) evacuated a great deal of blood, mixed with carrots, lentils, undigested peas, etc. Evisceration showed that the upper part of the small intestine was intact. But in the lower part there were found and successively operated on :

(a) Lateral perforation of the rectum (suture in two layers).

(b) Lateral perforation of the appendix (appendicec- tomy) (Fig. 10, B).

(c) Perforation of the mesentery (closed).

(d) Three perforations, two of them in the small intestine, closer together (resection of 8 cm., end-to- end anastomosis). See Fig. 10, C.

(e) Wide perforation of the small intestine soaked in green intestinal contents (resection of 6cm., end-to- end anastomosis) (Fig. 10, A).

(/) Three small perforations of the small intestine, with three perforations of the mesentery impairing the vitality of the gut (resection 12 cm., end-to-end anastomosis) (Fig. 10, D).

The projectile was found in the recto-vesical pouch, Ether, hot compresses. Drainage. Syphon in recto- vesical pouch. Closed in one plane. Duration, 1 hour 10 min. Normal course. Recovery.

We must also note the intestinal lesions caused by "bursting." Stern, for instance, observed them twice, once in the small intestine : by the side of an almost complete section there were two small wounds side by side, on the free margin of the intestine (Case

ANATOMICAL LESIONS 97

30) ; the section and the perforations were close together on the same loop. Another time he observed it in the large intestine — one single shell-fragment, penetrating from back to front, had produced in the caecum and in the ascending colon two large rents and three punctiform orifices, all situated on the anterior wall of the intestine (Obs. 18). "The phe- nomena can only be produced when the projectile surprises the intestine at a moment when the latter is distended with fluid. This is just what causes the special gravity of this sort of intestinal wounds, for at the operation faecal liquid is found diffused in the peritoneal cavity, except in the case of an eviscerated loop" (Rochard).

In the stomach, though a quite anterior penetrating wound of small dimensions has a great chance of healing spontaneously, it is not so if a marginal wound reaches the vascular belt that surrounds the stomach - when a posterior perforation has produced an abundant flow of blood or of gastric fluids into the posterior cavity of the omentum ; when the wounded man has just eaten, in which case there will almost certainly follow the escape of its contents ; when, lastly, it is a question of extensive wounds or bursting. In the latter case it too often is to be feared that all inter- vention will be ineffectual.

In the case of a wounded man operated on by Gosset, the bullet, by bursting, made a breach in the greater curvature large enough for the fist to enter ; the great omentum was detached for 15 cm.

In such cases the lesion is in itself difficult to treat, and it is rendered still more so if it is accompanied by a great outpouring of septic fluid into the peritoneum.

The transverse colon is open to the same comments

the small intestine. And, in estimating the proba- uhty of spontaneous healing, one could not count on the fortunate accident of a free spontaneous com- munication with the exterior.

98 WOUNDS OF THE ABDOMEN

In the ascending and descending colon, the benignity of wounds is not so probable in the case of shell- fragments as with rifle-bullets or shrapnel. In most cases the damage is extensive, the lacerations wide, and the haemorrhage abundant. The wound extends to the intraperitoneal region by an irregular aperture, so that some of the intestinal contents may fall into the ab- dominal cavity ; they are then infinitely more septic than when coming from the small intestine, and thus

G.B.

FIG. 11. — Typical explosion of the liver by bullet. It was a thoraco-abdominal wound, with multiple lesions of the lung, liver, and right kidney. Abstention; death. Cotte and Latarjet [**], Obs. 11.

the comparative benignity of the wounds of the colon and those of the small intestine is reversed. Extensive wounds of the colon, except in the case of a simple wound making an artificial anus permitting complete evacuation outside, are of the greatest gravity.

In the region of the liver, fissures or grooves that enter the parenchyma somewhat deeply give rise to

ANATOMICAL LESIONS 99

haemorrhages and discharge of bile which are not prone to spontaneous healing (Fig. 11 and Plate I p 200)

Similarly, very small projectiles (splinters of grenades) i excavate, by their gyratory movement, veritable

caverns m the hepatic tissue. Le Fort has reported a typical case of this : hit

m the paravesicular region, a patient developed a

limited hepatic necrosis, and eliminated a necrotic

mass from the right lobe weighing 200 grammes.

Death resulted from sep- ( tic aemia and haemorrhage. I, The autopsy showed a

smooth single cavity

large enough for the fist

to enter, open to the .outside, without pleural lor peritoneal communi- cation, and without in- (fection of the serous i membranes.

Unfortunately, in such cases there is very little jto be expected from an ! operation ; suture and (V-stitches in the injured Fro. 12.— Wound of the upper

tissues will not often P?le °f the spleen. Type of burst

, _ wi-fVi AaaiwAM 4.^. _ _J»^.j ^

Urrest haemorrhage, any more than plugging, and

t would be inadmissible .*> suggest here free opening up, to prevent

nfective complications. The spleen, when it

Is involved, does not heal of itself, and serious haemorrhage from it is a ways dangerous. The only i-dmissible surgical action is ablation (see Figs 12

nd 13).

The kidney has a tendency to spontaneous arrest of

was herniated with the great cul- de-sac of the stomach into the left pleural cavity through a hole in the diaphragm of 6 cm. There was simultaneous burst of the left kidney. Death ensued. Cotte and Latarjet [««], Obs. 6

100

WOUNDS OF THE ABDOMEN

the haemorrhages of its parenchyma; but, in order that this may take place, the capsule must have

FIG. 13. — Punctiform perforation of the anterior surface of the stomach. Small, limited, marginal wound of the spleen, which was, however, sufficient to induce fatal haemorrhage. Simultaneous perforation of the left lobe of the liver, by shrapnel. Cotte and Latarjet [«*],. Obs. 14.

remained sufficiently intact to be inextensible, and the renal tissue must not have been too deeply lacerated. When the fis- sures are deep, when there is bursting (Figs. 14 and 15 and Plate 1), and still more when there is rupture of important vessels (Fig. 16), the haemorrhage rapidly becomes grave and fatal. When the wounds of the blad- der and rectum are somewhat ex- tensive, they are rarely isolated, but it is certain that in the case of either of these two organs an intraperitoneal perforation that is not absolutely punctiform, or

FIG. 14. — Bursting of the upper pole of the left kidney. Internal haemorrhage; nephrec- tomy; death. The pro- jectile had perforated the small intestine, tra- versed the diaphragm, and finally lodged in the posterior mediasti- num. Carpanetti ['*].

ANATOMICAL LESIONS

101

FIG. 15. — Kidney from a nephrecto-

my. (See Obs. J , p. 253.) Effect

of bursting by a bullet which had traversed the upper pole. Also sec- tion of the colon. Serious haemorrhage. Laparotomy; recovery.

is contused will have no chance of healing spon- taneously. This is the case with wounds caused by shell-fragments and trench mortars.

G , wounded April

26th, 1916, by a large fragment of a grenade, showed a large wound of the left buttock near the point of the coc- cyx, from which blood was flowing very freely ; the abdomen was pain- ful, the pulse uncount- able ; catheterism col- lected drop by drop a mixture of blood and urine. At the laparo- tomy (seventh hour) the

FIG. 16. — Effect caused by the bursting of a bullet on the kidney (left kidney, posterior surface) with traumatic section of the pelvis and the renal vessels. The same patient presented the other lesions shown in Fig. 18. Cotte and Latarjet [**], Obs. 8.

102 WOUNDS OF THE ABDOMEN

blood came from a small perforation of the vesical peritoneum ; after dressing the intact intestines with ether and forming barriers with saline compresses, an incision was made in the vesical peritoneum, when a perforation of the bladder was found ; this was en- larged ; the finger then felt in the bladder, which was

full of blood, a long pro- jectile (Fig. 17) ; this was taken out, covered with portions of the bladder ; it was 7 cm. long by 2 cm. wide ; the fundus of the bladder was reduced to FIG. 17.— Fragment of grenade pulp. The large cavity 7 cm. by 2 cm which had divided was isolated by suture of

the rectum and broken into the ,, .,

fundus of the bladder: (Obs. G., tn^ peritoneum, and a p. 101.) drain was placed in the

recto-vesical pouch ; then

the bladder was inosculated to the hypogastrium and a syphon-drain was placed at the top, while a catheter for continuous Dakin solution was tied into the urethra.

Then the buttock was laid open, and a transverse section of the rectum was found. A large rectal tube was inserted, the edges of the wound in the rectum were freshened and sutured, and two Dakin tubes were placed between the rectum and the bladder. Nevertheless, death took place the next day. (Abadie.)

Complications. — All the lesions we have just been considering are rendered much more serious if there exists one of the following common complications : haemorrhage, escape of the intestinal contents, trau- matic hernia, or septic infiltration of the retroperitoneal tissue.

Intra-peritoneal haemorrhage is constant, but variable in quantity. When abundant, it may come from the mesenteric or omental vessels, from an extensive

ANATOMICAL LESIONS 103

wound of a solid viscus such as the liver and spleen, or from a large vessel (renal or iliac artery). But as a rule — and this is the most serious — it comes direct from the wounds of the intestines ; out of proportion to the dimension of the lacerations and the calibre of the vessels attacked, this haemorrhage is slow, pro- gressive, and continuous ; and it does not encounter in the peritoneal cavity the causes of limitation which arrest a haemothorax.

How many times, on opening the abdomen, one sees black or even red blood flow out in abundance, without any tendency to coagulation ! It comes from every- where, from the pelvis, the flanks, from between the coils ; one stops it, but it still continues, and at first one has the impression that the source of the haemor- rhage is a large vessel or a solid organ ruptured. Now, very often it is none of these ; it is blood flowing from dependent parts. When it is over one recognises that its only cause has been laceration of the small intestine, without any important hepatic, splenic or vascular lesion.

Such haemorrhage is the cause of anaemia, of ab- dominal reaction, and of the diffusion of infection. Hence its gravity.

Vignard writes, not without irony : "To speak paradoxically, I should be almost tempted to suspend all intervention on a man wounded in the abdomen or the small intestine, on condition that I could be assured that he was not bleeding ! " Now, as a rule, he does bleed ! And very difficult it is to say what is the gravity of the haemorrhage, for even with vascular sections of the mesentery, the wounded die of intra- peritoneal haemorrhage, with the abdomen still flat and with intense pain.

The lesser cavity of the peritoneum may be the seat of a haemorrhage whose origin is in the neighbouring organs. It gets gradually distended, and the resulting tumour forces out the anterior abdominal wall.

104

WOUNDS OF THE ABDOMEN

The same thing is observed with the retroperitoneal hsematomata arising from organs such as the pancreas and the duodenum, or from vessels such as the branches of the coeliac axis and the vessels of the root of the mesentery. It is often a question of posterior transverse tracks (Fig. 18). The hae- morrhage may be great enough " to displace the small intestine, to raise the colon, and bring the lateral portion of the posterior wall into contact with the

Portal V,

Sp/enio V.

FIG. 18. — Laceration by bullet of the posterior surface of the pancreas with section of the splenic vein. The same bullet entered the lumbar region and burst the kidney (see Fig. 14), struck the pancreas and the lower surface of the left lobe of the liver, per- forated the small omentum, and then lodged in the epigastric abdominal wall. Haemorrhage occurred both in the lesser sac of the peritoneum and under the posterior parietal peritoneum. Cotte and Latarjet [*«], Obs. 8.

anterior wall. Such a haemorrhage appears like a large red tumour ; the peritoneum that hides it may be intact or may present orifices from which the blood flows slowly." " Such cases are often fatal, either from the haemorrhage itself or from injury to the pancreas. The shock is considerable, whether produced by the actual extent of the wound

ANATOMICAL LESIONS 105

or by interference with the sympathetic." (C. Wal- lace [52].)

Escape of the intestinal contents is less frequent than haemorrhage, but it is at least as serious.

For in the abdomen we do not meet only with intestinal fluid, gas and bile, mixed with blood ; we also encounter alimentary debris, bones, French beans, lentils, sweetmeats (Bouvier and Caudrelier) ; or, better still, worms, whole or divided by the injury 1 (see Obs.,p. 110).

One can readily imagine that such contamination of the serous membrane, especially if it has gone on for some time, will considerably diminish the probability of healing, even after operation. Besides, Quenu has clearly shown, in studying the second series of cases by Bouvier and Caudrelier, that deaths occurring rapidly after operation took place most often in cases where, on opening, they had found the abdomen full of blood, especially when the blood was mingled with faecal matter.

Visceral hernia includes either the omentum or the intestine, and the latter may or may not be itself injured.

For the most part, if one disregards the herniated omentum which might cause by obliteration a decep- tive haemostasis, profound lesions of the intestine reveal themselves by an issue of blood or fo3tid gas mingled with intestinal contents. If the herniated intestine is itself involved one cannot conceive of recovery as possible, unless it were an isolated lesion, widely gaping (an artificial anus), and situated low down in the small intestine. As a rule, such lesions are fatal if left to themselves, and hold disappointment in store for the operator.

This is still more the case if we consider complex eviscerations, such as the liver and omentum, the liver and colon or intestine, and the multiple coils of the intestine.

106 WOUNDS OF THE ABDOMEN

Infection of the retroperitoneal tissue proceeds from two sources, from the intestine and from the bacillus capsulatus of gaseous infection. It is usually met with in the retroperitoneal wounds of the colon, and its appearance is so delayed as some- times to await the apparent external closing of the wound. But it may also accompany the dorsal wounds caused by shells, with hsemorrhagic infiltration of the parietes. The appearance and the evolution of gaseous infection are then rapid, the result is speedily fatal, and gases have been found, says Wallace [IJ], in the distended vena cava.

(4) MULTIVISCEEAL WOUNDS ARE MUCH MORE SERIOUS THAN UfrlVISCERAL

The term " multivisceral " is only applied to the wounds of several abdominal viscera.

The most frequent association is that of the small with the large intestine ; next in order come the simultaneous wounds of the large intestine and one of the neighbouring viscera (stomach, liver, kidney) ; lastly come the simultaneous wounds of the small intestine and other viscera (spleen, stomach, liver, bladder, etc.).

And this manner of grouping — small and large intestine, colon and viscera other than the small intes- tine, small intestine and viscera other than the colon — corresponds also to differences in gravity.

From the statistical table of all the laparotomies published (see p. 130), we gather the following figures :

Multivisceral wounds treated by laparotomy :

Cases. Deaths.

Small and large intestine 65 55 (84 per cent.)

Colon and other viscera . 32 27(82 „ )

Small intestine and other

viscera . . .25 22 (88 „ )

Other viscera . . .19 16 (88 )

ANATOMICAL LESIONS 107

This gives a total mortality of about 85 per cent, for the multivisceral, while it is only 62 per cent, for the univisceral cases.

This difference is striking.

Does it arise from the larger number of the intestinal wounds ? Not entirely, for when we were considering univisceral wounds we found instances of multiple wounds of 4, 9, and even 12 perforations and sections that recovered.

Quenu, after discussing a series given by Bouvier and Caudrelier, accused the large intestine of being the essential factor of aggravation ; but, from the figures just quoted, which bear on a very much larger number of cases, it would not seem to be so. On the contrary, the large intestine would seem to afford the same coefficient of benignity in these cases as charac- terises its isolated wounds. When attacked alone it produces a mortality of 54 per cent, as against 65 per cent, for the small intestine. When taking part in multi- visceral lesions without lesion of the small intestine, it gives a mortality of 82 per cent., while multivisceral wounds with lesions of the small intestine without lesions of the colon stand at 88 per cent., and the multiviscerals in which the small and large intestine are simultaneously involved yield a mortality of 84 per cent. The factor of aggravation would therefore seem to be the small intestine.

In the following case the lesions of the small intestine manifestly surpassed those of the large intestine :

M— - was struck on September 19th, 1915, by a shell that caused a small wound 6 cm. below the right antero-superior iliac spine. The parietal rigidity was very marked ; there was no flatus ; the face was drawn and pale, and the nose cold.

At the twelfth hour lateral laparotomy, right side, along the external edge of the rectus, showed abundant intraperitoneal haemorrhage ; progressive evisceration revealed two big lacerations of the small intestine,

108 WOUNDS OF THE ABDOMEN

longitudinal and irregular, at 80 cm. from each other ; on each of these resections an end-to-end anastomosis was performed. In the ccecum there was a per- foration of 1 cm. ; this was sutured ; at another point there was subperitoneal ecchymosis and a non- penetrating wound ; this had purse-string sutures. Ether; pelvic drainage. Recovery. (Abadie[8S], Obs. 9.)

That associated wounds of the large intestine should be more serious in themselves than when the colon alone is involved is, however, quite natural. An appreciable number of isolated lesions of the colon are only slightly or not at all intraperitoneal. On the other hand, the fact that other viscera have been affected implies that the passage of the projectile has not remained localised in the lumbar region or flanks, but has traversed the peritoneal cavity ; under these circumstances, the lesions of the large intestine could hardly be benign — on the contrary, owing to gaping perforations, to the issue of solid contents, and to the extremely septic qualities of the contents, they are of exceptional gravity.

What above all contributes, as it seems to us, to give multivisceral wounds so dark an outlook is not only the greater importance of the lesions themselves but also the dissemination of these lesions ; hence arises an initial diffusion of the foci of infection, and especially a shock to the sympathetic system that is much more marked and injurious. This is immediately shown by more extensive and more violent pain, and its action is verified by the subsequent atony of the tissues, and the delayed and sluggish cicatrisation of the visible wounds — the "trophic" shock has paralysed the powers of reaction and defence. Why should it not be the same here as with the limbs, especially the lower limbs ? The abnormally augmented gravity of disseminated lesions which affect, not one limb only but both symmetrically, is a matter of common

ANATOMICAL LESIONS 109

observation, is it not ? Do we not see the phenomena of shock most markedly present in these cases ? It is the same with the abdomen.

This is also the explanation of the gravity of abdominal wounds that are complicated by extra- peritoneal visceral lesions. It is in the pelvic region that this association is the most formidable. The bladder and the rectum are two reservoirs whose rupture, or simple traumatic leakage, are equally serious, the first because its fluid contents filter everywhere and become infected, the second because these contents are from the beginning extremely septic. The fat and connective tissue that surround them form a region all ready for infection. Finally, these pelvic wounds are most often wide, complex, and have extensive detachments or tracks.

The wounded man G , whose story was told on

p. 101 as an instance of serious wound of the bladder, had also a transverse section of the rectum.

Here are other examples of eminently complex lesions.

M was struck on September 18th, 1915, on the

left buttock by a small fragment of shell which passed out by the left iliac fossa, causing a wound as large as a two-franc piece with escape of a voluminous omental fringe, and a continuous flow of foetid blood. There was no micturition ; the abdomen was painful everywhere ; there were shock and an uncountable pulse. Median subumbilical laparotomy at the sixth hour followed the resection of the herniated omentum ; exploration by progressive evisceration showed : complete section of the small intestine at two different points (for this double resection was employed, with end-to-end anastomosis, one with Murphy's button), lateral, and almost posterior subperitoneal laceration in the rectum — probably also in the ureter — an extensive rent in the bladder. Suture of the bladder was made, and catheter inserted; drainage of the pelvis

110

WOUNDS OF THE ABDOMEN

by the buttock and the hypogastrium ; drain at the traumatic orifice. Cleansing of the abdominal cavity, where blood, f aecal matter and a worm were found. Ether, 150 grammes ; closed up in one plane.

Death, however, took place in the night, as could easily be foreseen. (Abadie["], Obs. 14.)

Another case was that of A , wounded May 23rd,

1916, by a shell whilst squatting on his heels. A wide transverse sacral wound was found, about 3 cm.,

and on the right side, ecchy- mosis of Scarpa's triangle with bubbling sounds on pressure. The abdomen was tense and painful ; no micturition ; the catheter gave blood and urine without pressure. The operation took place at the sixteenth hour. (A) In Depage's position (ventral in j\, legs hanging), vertical incision to enlarge the transverse wound which exactly sepa- rated the coccyx and the FIQ. 19. — Fragments of sacrum ; resection of the

shell which had penetrated POPPVTT • rp^ofinn r>f + ko +iV

by the sacrum and lodged in COCCV1X > ^section Ot the tip

the middle of the thigh, after ot tne Sacrum to obtain

traversing the pelvis at the light. Exploration led to

men (Obs. A— ^p!?ioj?*" ^e rignt s^e of the rectum,

whose mucous membrane re- mained intact, and into a cavity whose edges were traced and recognised as the bladder freely perforated ; large siphon drain; then suture of the layers of the rectum, and plugging of the cavity with gauze. (B) In the position for laparotomy slightly inverted : (a) Exploration of Scarpa's triangle, incision over the ecchymosis at a point where the sounds could be heard; haematoma. The passage of the projectile

ANATOMICAL LESIONS 111

along the femoral vessels was followed : ablation at the middle of the thigh of a fragment of shell 6 cm. by 4 cm. (Fig. 19) covered with pieces of clothing ; drainage of the passage, (b) Exploration towards the pelvis, as small projecting splinters had been found ; this led into the obturator foramen, (c) Supra-pubic incision : exploratory laparotomy which showed the peritoneum intact ; careful closing of the wound. (d) Suprapubic cystotomy ; the finger felt a right lateral perforation low in the bladder : a large drain was put in the bladder, and another in contact with the bladder and coming out at the root of the thigh.

Death did not ensue until three days later.

It is easy to reconstruct the passage of the pro- jectile ; the man being in a squatting position, the fragment entered by the sacrum, traversed the pelvis, and crossed the bladder laterally, passing through the obturator foramen and lightly grazing its edges, then following the sheath of the vessels to stop finally in the middle third of the thigh.

In the case of H , of which we shall see a more

detailed observation on p. 255, a piece of shell had also entered by the groove between the buttocks, and had perforated the rectum, the bladder, and the intes- tine. After a most eventful operation and com- plicated sequelae, H recovered completely.

Fractures of the pelvic girdle are particularly harmful : the detached splinters aggravate the visceral lesions ; the bones, bathed with septic liquids, rapidly become the prey of destructive infiltration for which nothing can be done.

(5) ASSOCIATED ABDOMINO-THORACIC LESIONS ARE EITHER BENIGN OR EXTREMELY SERIOUS

The whole evolution of the case is dominated here by the thoracic lesion.

112 WOUNDS OF THE ABDOMEN

Penetrating wounds of the hypochondria and of the epigastric region are usually so benign that they evolve spontaneously towards recovery. This is also the case when the wounds involve the ninth and even the eighth intercostal space and hence become thoraco- abdominal.

We can, systematically, distinguish four types :

(a) A blind, penetrating wound, or a rapidly closed tunnel-wound, that has traversed the hypochondrium or the epigastric region, simultaneously involves the ninth, or even the eighth, intercostal space.

It thus becomes abdomino-thoracic, but the thoracic lesions are limited to the pleural cul-de-sac or to the lowest part of the lung. This wound generally maintains the benign qualities of similar wounds in the upper part of the abdomen.

(6) With a projectile of the same kind and an abdominal passage equally benign, the more oblique penetrating wound reaches the thorax higher, and causes serious pulmonary lesions. The latter alone dominate the situation.

(c) A wound of the upper region of the abdomen, sufficiently serious (hepatic, splenic, or stomachic haemorrhage, perforation of a colic angle, piercing of the stomach, etc.), sufficiently serious, I say, to neces- sitate surgical intervention, has also reached the thorax.

It is evident that haemothorax or hsemopneumo- thorax of variable gravity will here considerably darken the prognosis ; immediately, for anaesthesia is much more dangerous (shock, dyspnoea) ; and later, for it is in these cases that one observes early or delayed complications of pneumonia with areas of pulmonary breaking-down. (Stern, Caudrelier, Gatelier.)

(d) Lastly, we have a wound that establishes a wide communication through the diaphragm and facilitates the hernia of an abdominal viscus, injured or other-

ANATOMICAL LESIONS

113

wise, towards the pleura and the lung which may be, involved in various ways (Figs. 20 and 22).

— , wounded March 7th, 1916, by a bursting shell, had been hit in the left median thoracic region (ninth rib, axillary line).

At the third hour operation on the ninth rib ; the omentum was then seen, forming a hernia ; resection ; in withdrawing it a little to cleanse its neck at the

FIG. 20. — Abdomino-thoracic wound with transdiaphragmatic

hernia of the perforated stomach and the omentum (Obs G

p. 113).

level of the diaphragm, the stomach was seen to be also herniated ; it showed a large perforation of its anterior surface (Fig. 20), near the greater curvature. Suture in two layers was applied to this perforation. The diaphragm was sewn and brought into contact with the parietes and fixed in that position : pleural siphon by an independent drain.

A complementary laparotomy was impossible, on account of the weakness of the patient. He died nine hours afterwards. 8

114

WOUNDS OF THE ABDOMEN

Sometimes the single aperture is freely open exteriorly over the splintered ribs, and one can see the lacerated liver grooved or partially broken up, the diaphragm split with widely separated edges, the pleura gaping

where the bleeding lung appears and disappears with noisy traumatop- nea (Fig. 21).

L , wounded April

22nd, 1916, showed a large right lateral tho- raco -abdominal groove, with wide opening of the pleura above, caused by section of the tenth and eleventh ribs; lower down there were hernia of the colon and of the omentum, and a wound of the crushed hepa- tic border. Very free haemorrhage. Patient gasping, pale, and dis- tressed.

A wide opening was made by section of the cutaneous bridge, the edges of the diaphragm, after free resection of the ninth, tenth, and eleventh ribs (Pig. 21), were at- tached to the muscular borders so that the thoracic cavity above might be isolated ; the pleural orifice was reduced to admit only a drain, through which aspira- tion was conducted, to diminish the total amount of pneumothorax ; thus the abdominal cavity was isolated. The herniated parts were cleansed with ether ; gauze-wick placed in contact with the bruised liver ; drain going towards the abdominal cavity. Closed up on one plane.

FIG. 21. — Abdomino-thoracic wound with hernia of the omentum, the colon, and the crushed liver ; fractures of the ribs ; wide rent in

the diaphragm. (Case L , p.

114.)

ANATOMICAL LESIONS

115

The dyspnoea became aggravated. The patient died on the 24th, at ten o'clock.

In this case again it was the thoracic lesion which, even after reparation of the abdominal lesion, remained preponderant, and rendered the prognosis almost neces- sarily fatal.

There is, therefore, no middle term. Thoraco- abdominal association is either benign, justifying simple abstention, or so serious as to render illusory the benefit of intervention in almost all cases. This double con- sequence has to be borne in mind.

RESUME.

The synthetic idea that is evolved from the study of anatomical lesions is

as follows :

" The essential lesion is not the peritoneal penetration, it is the v is ce ral penetration ; and among the visceral lesions it is necessary to distinguish those which create danger from haemorrhage (the liver, the spleen, and Duo*> the mesentery), and those which create danger from the effu- sion of their contents (the intestinal canal)." (Quenu.)

Greater

Splee •Desc. colon

Omentum

FIG. 22.— Diaphragmatic hernia. View of the organs taken away in

"-•f-j*^**^ VC«IXWA.J. CbYYcVy ill

Looking now at the the mass with tne fibrous diaphrag- matic ring. (Legrain, Quenu, Rich

ard["].)

topographical distribu- tion of the lesions, we see that the abdomen may be divided into five regions : (1) The umbilical and peri-umbilical region extend-

116

WOUNDS OF THE ABDOMEN

ing to the colon externally, and upwards to the stomach. Its lesions affect the small intestine and the transverse colon. These lesions do not heal spontaneously, except in very exceptional cases.

( 2) The hypogastric, and pelvic region. The lesions in- volve the small intestine, the sigmoid flexure, the rectum,

or the bladder. '*" • Their chances of spontaneous healing are negligible.

( 3 ) The flanks. This is the territory of the ascend- ing and de- scending colon. The wounds have a chance of healing spon- taneously if their entire course is on the same side, antero- posteri- orly, and if they are caused by bullet or a very small frag-

FIG. 23. — Chart of the regions. Topogra- ment of shell,

phical distribution of wounds of the abdomen * obliaue

according to their gravity and their variable •

tendencies towards spontaneous healing. (The centripetal

lightest region corresponds to a greater benig- course, proba-

nity, the darkest region to the highest degree j, multivis- of gravity.) J

ceral, or a large

fragment of shell, does not leave much real hope for a favourable termination.

(4) The upper region. Here the wounds affect the

ANATOMICAL LESIONS 117

liver, the stomach, or the spleen. Their tendency to spontaneous healing diminishes from right to left ; satisfactory and almost invariable as regards the liver, it suffers exceptions in the case of the stomach (when wounded just after eating or when the arterial circle is involved), and is diminished in the case of the spleen by the frequency of haemorrhages caused by bursting. Lastly, the neighbourhood of the left colic angle, and the anomaly of coils of the small intestine above the transverse colon render wounds near the left hypo- chondrium still more serious in character.

(5) Higher still, thoraco - abdominal association is frequent ; being either benign or very serious, these wounds are either liable to heal of themselves or they are beyond surgical help.

And on the adjoining diagram (Fig. 23) the regions are made darker in proportion as the spontaneous evolution of penetrating wounds in that quarter affords less chance of healing.*

* If we comparethis with Wallace's diagram (Fig. 3), wesee that non-visceral penetrating wounds are found appearing precisely in the zones that the above sketch shows to be the most favourable. But a wound of the umbilical region implies an oblique passage through the whole abdominal cavity ; it proves the possibility (on which we have already insisted) of a projectile gliding between the coils without injuring them.

CHAPTER V

THE TREATMENT TO ADOPT IS LAPAROTOMY— DISCUSSION

penetrating wounds of the abdomen, but that the clinical examination of each case ought to guide us, that it is unwise to wish to establish a clear line of demarcation between the interventionists and the abstentionists ; that one should not be the slave of an " a priori formula."

A slave, no ; but one must in practice have a formula of treatment, an almost systematic conception of what is nearly always needed for a penetrating wound of the abdomen. One must be impelled to apply a certain treatment in preference to any other : it is an essential condition of rapid decision, prompt execution, and tranquillity of mind. And where the clinical sense intervenes (for that must never lose its authority) is in recognising the exceptional cases, those in which one would not apply the chosen treatment, and in recognising the counter-indications to this usual treatment.

The choice to be made is between medical treat- ment, Murphy's treatment, so-called, and laparotomy.

Murphy's operation, or suprapubic button-hole with pelvic drainage, was proposed by Murphy for the treatment of peritonitis caused by perforation of the small intestine in the neighbourhood of the caecum, perforation of the caecum itself, of the duodenum, and

118

TREATMENT TO ADOPT IS LAPAROTOM Y 119

of the stomach. Its object is to drain the abdomen into the dependent part, into the pelvic cavity where we have seen the different intra-abdominal effusions collect by their own weight. It is the " siphonage of a collecting-sink," or simply the escape granted to the " overflow."

Such an operation is rapid, and by no means serious. Local anaesthesia with cocaine is sufficient. In short, it is the type of simple intervention that can be realised everywhere and always.

Is it efficacious ?

In favourable cases the pain is eased, the abdominal reaction is alleviated, and the general condition gradu- ally improves. Sometimes it brings about veritable transformations. One of Murard's cases [45], who was extremely weak, in a " dying " condition (but whose pulse was nevertheless 88), made a surprising improve- ment in a few hours.

At the same time the effusion is lessened, though composed wholly of black blood, it diminishes in abundance, and clears ; when f aecaloid it may change into an actual pyo-stercoral fistula, or a f aecal fistula whose spontaneous healing will be indicated by the normal exit of faeces at the anus.

Didier [so] obtained two great successes in two unfavourable cases, and they were really penetrating visceral wounds, as in one of them there was an escape of faecal matter and in the other of bile.

Even when finally terminating in failure, the supra- pubic button-hole has sometimes brought temporary relief from pain and has calmed the anguish of a wounded man (Murard).

But it is far from being always — or even often so !

' There is unfortunately a shadow in the Murphy picture," writes Tuffier[7]: "they are all cases of effusion of black blood without escape of faecal matter and followed by death. If in these cases laparotomy

120 WOUNDS OF THE ABDOMEN

had been performed, and if the real causes of the haemorrhage had been discovered, a ligature might have put an end to it and consequently saved the wounded man's life ! "

One may even ask if in these cases the suprapubic opening confines itself to being inefficacious and does not rather become injurious. Cadenat[10] remarks, not without reason, that when there is simply haemor- rhage this opening diminishes or puts a stop to the abdominal hyperpressure which has come into play to attenuate or arrest haemorrhages in the closed abdominal cavity ; besides that, it brings the chance of exogenous infection to a haemorrhagic focus hitherto safe from all outside contamination. In short, it may be the cause of death in cases where spontaneous healing might have taken place.

But, above all, we can hardly consider exceptionally efficacious an intervention that ignores the causal lesion ; now though the laceration of an empty viscus is of ever such small importance, we have seen that it is anatomically impossible that it should heal locally.

Lastly, even the working of the drainage is uncertain. Murard recommends the following plan : " By intro- ducing a large upright drain into the recto- vesical pouch and placing the wounded man in a sitting position, one can see the blood flow as from a fountain ; several days after the intervention we have seen the blood flow as if it came from a tap when we inclined the free end of the drain downwards." Is it constant ? Two cases of Chalier's [48] prove that drainage is too often only transitory, and that it is powerless to drain the whole peritoneal cavity, since it did not prevent the rapid development of an enormous subphrenic abscess which carried off both the wounded men in spite of the secondary evacuation. "It is probable," adds Chalier, " that early laparotomy might have disclosed the lesions produced, hindered the formation of the abscess, and brought about recovery." And yet

TREATMENT TO ADOPT IS LAPAROTOM Y 121

in one of these cases there was a very marked improve- ment in the state of the patient, giving rise to the most hopeful expectations for two days — hopes doomed to disappointment !

Besides, look at the summary of the results obtained :

STATISTICS OF THE CASES TREATED BY MURPHY'S OPERATION

Observers.	Total of Oases.	Deaths	Re- coveries	Observations.
Dupont and Kendirdjy Weiss and Gross	2 5	2 5	—
Deveze	31	20	11	10 from bullets, 5 cases in
				which only black blood
				was seen, 2 cases of lesion
				of the large intestine ; 4
				cases of definite lesion of
				the small intestine.
Cadenat .	4	3	1	From bullets. Right nipple
				to left lumbar region ; haemorrhagic fluid, slight-
				ly faecal.
Bichat	4	3	1	From shrapnel bullet.
Pascalis .	2	2
Tartois	15	12	~3	One by bullet.
Didier	7	5	2	2 from shrapnel bullet ;
				entry dorsal, exit right
				flank, bile.
				2nd case : right flank, faecal
				matter.
Rouvillois .	28	23	5	4 thoraco-abdominalwounds; blood only ; one wound
				of descending colon.
Tisserand . Gorse	2 15	1 11	1 4	Right hypochondrium.
Chalier	12	10	2	1 from bullet ; 2 thora- co-abdominal ; blackish
				blood.
Murard	18	14	4	Shells ; 3 right lumbar re-
				gion or right flank ; 1
				only para - umbilical :
'				black blood in all cases.
	145	111	34
	Mortality: 76%

We notice here the high rate of mortality. And is even that rigorously exact and sufficiently high ? No ; the observers themselves object that a number of these wounds were not undoubtedly visceral penetration: in most cases they found nothing more than an

122

WOUNDS OF THE ABDOMEN

effusion of black blood, without gas or faecal odour,

intestinal debris or fseces.

"Besides," writes Rouvillois [36], on the subject of his

personal cases (and this remark must be true of several

others), "the perusal of the observations shows that they

would probably - j? have healed by

abstention pure and simple, and that in appro- priate surround- ings explora- tory laparoto- my would have been justified. Whatever meth - od had been adopted, they would really have healed in the same way, and their recov- ery would have been placed to the account of the method." Rouvillois therefore con- siders that the already high percentage of mortality ought to be increased, and would amount to near- ly 100 per cent.

C = Cadenat. Ch = Chalier. D = Devfcze.

Di = Didier. Ta = Tartois. Ti = Tisserand.

R = Rouvillois. B = Bichat. M = Murard.

FIG. 24. — Recoveries obtained by the Murphy treatment. * The two para-umbilical wounds only showed an effusion of pure blood. It is interesting to compare this diagram with Fig. 23 (anatomical regions), 3 (no visceral lesions), and 4.

* To these must be added 4 cases from Deveze with ascertained lesions of the small intestine ; but we have no note as to their locality.

TREATMENT TO ADOPT IS LAPAROTOMY 123

As to the situation of the wounds healed by the Murphy treatment, it nearly always belongs to the upper region, thoraco-abdominal, or to the hypo- chondria, the flanks, or the lumbar regions The adjoining diagram (Fig. 24) which represents them is nterestmg m comparison with the one in which we have divided the abdomen into regions of different gravity, and also with those of Wallace and Rouvillois which represent the tracks of the projectiles without visceral lesions (see Figs. 3, 4 and 23).

Only two of the wounds were para-umbilical, and both only gave rise to effusions of pure blood through the orifice of drainage.

In short, insufficient in serious cases, useless in slight cases, and sometimes harmful— such we find the Murphy treatment, of which it has been well observed that the wounded have recovered in spite of it and not thanks to it ! " (Weiss and Gross.)

Fallen into deserved discredit, abandoned even by those who had shown themselves its partisans the suprapubic button-hole merits only to be retained for penetrating abdominal wounds seen too late to be treated by laparotomy, or for cases treated by abstention and in which a hypogastric, iliac, or pelvic localisation of the subsequent peritonitis is mani- tested.

From the point of view of immediate treatment we have only mentioned it in order to eliminate it

Ihe same might be said of a method defended by Miramond de la Roquette [••]. This consists of a completion of the Murphy treatment by the opening . an iliac anus which " ensures the drainage of the intestine, and prevents the phenomena of intestinal paresis, so frequent and so formidable." This descrip- tion is indefinite. Is it a question of deliberately opening in the iliac fossa the first loop that presents itself whether healthy or not ? Or is it a question

making a wide opening in the skin, but at the level

124 WOUNDS OF THE ABDOMEN

of the parietal wound, of the perforated coil of the small intestine supposed to lie nearest to it, in which case the coil will not always be iliac ? ... In either case the end proposed will not be reached. The intestinal paresis is caused by the peritonitis ; the effect of the latter is the arrest of all contraction, and hence the stoppage of the evacuations and the dis- tension of the gut. Operations on cases of peritonitis with distended intestines suffice to assure us that all intestinal drainage is nugatory ; the loop operated on empties itself — the others, even those nearest, remain as inert as before. And if, as Miramond has observed, recovery has supervened in several cases after spon- taneous fistulisation, this did not happen because the intestine was not under tension, but because its contents did not make an irruption into the peritoneum ; it was not because the intestinal liquid ran " outside," but because " it did not run inside."

Sencert has proposed a triple drainage in the hypo- gastric region and in each of the iliac cavities ; he reserves it for the hopeless cases, and therefore this intervention, he says, requires no " counter- indication." That is true, but neither does it afford " indication." If the case is hopeless, it is useless to disturb him ; if any chances of success remain, laparo- tomy will bring them all into action. In the absence of demonstrative cases one cannot retain this method of treatment except in exceptional cases. This, moreover, would accord with the views of Sencert himself, as he does not profess to make it an habitual method of immediate treatment.

Hence the choice to be made rests between MEDICAL TREATMENT and TREATMENT BY LAPAROTOMY. " Should one operate on those wounded in the abdo- men, or leave them to the healing powers of nature ? There is the crux." (Quenu.)

The arguments in favour of each method occur to

TREATMENT TO ADOPT IS LAPAROTOMY 125

the mind so naturally that there is hardly any need to enumerate them.

Medical treatment represents the maximum of simplicity ; it is applicable everywhere, with one reservation — the wounded must be kept motionless, and there must be no premature discharge from hos- pital in their case. Applying equally to all cases, from wounds simply suspected of penetration to the most extensive shattering (unless, like Sencert, one has recourse to surgery because there is no risk of doing more harm than good), the abstentionist method dispenses with all subtlety of diagnosis and prognosis. No special competence is necessary; no complicated installation is required; the superintendence of the nursing is as easy as it is imperative in its precepts ; the control of the surgeon himself need be neither immediate nor assiduous. In short, it is the ideal of the " pass-key " treatment.

Laparotomy, on the other hand, offers in all these aspects as many drawbacks as abstention afforded advantages. To compensate for all these strong arguments against it, we have only one to bring forward in its favour — laparotomy addresses itself to the cause ! It is not ' ' palliative ' ' of peritonitis or of haemor- rhage ; it is prophylactic of peritonitis and a corrective of haemorrhage. It is not blind: it searches out the vis- ceral lacerations themselves and repairs them straight- way ; it ties up the bleeding vessel. Lastly, and chiefly, it is capable of repairing serious lesions against which the healing power of nature is obviously powerless.

And these advantages are of such force that, after triumphing over all resistance and allowing of the establishment of a therapeutic dogma in time of peace, we have seen them, in spite of the experiences of former wars, reaffirmed in the present war.

And what is more forcible than arguments, it will be observed, is the total of results obtained by both methods, which must be compared !

126

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II.-COMPLETE STATISTgSROFoTI;IE CASES TREATED

	Total of the Laparotomies.	parotomies with sion of the Small Intestine.
No. of )ases .	No. of Cures.	No. of Cases.	No. of Cures.
Chirurgical Society :
Sencert .	4	—	2
Weiss and Gross .	4	—	—
Cadenat . ...	14	2	14
Dupont and Kendirdjy	4	1	3
Chavannaz .	13
Gosset	7	4	3	2
Vertraeghe ....	11	3	•
Schwartz . ... Bouvjer and Caudrelier (I) .	32	15	18	• 6
,Duter and Hallez	1 1	1 1	1	1
Charrior	1	1	—	—
Petit	2	2	—	—
Biehat	20	7	8	1
Pelot . ...	11	10	—
Pascalis . ... Bouvier and Caudrelier (II) .	3 65	3 35	21	10
Tartois .....	11	5	4	4
Schwartz and Mocquot	46	16	15	5
Mathieu .....	26	6	13
Stern	34	14	16	3
Rouhier .....	2	1	2
Barbet and Bouvet	15	7	5	3
Didier .	10	4	3	1
Gatelier	11	K	5	1
Proust .....	101	15	I
Abadie	15	6	12
Picqu6 Rouvillois . .	15 74	20	4 40	8
Simonin ....	20	8	6
Abadie (not yet published) .	17	5	8	2
Outside the Chirurgical Society :
Leriche ....	4	2	2	—
Cotte and Latarjet	7	4	2	2
Tisserand ....	7	3	4
Chalier	2	—	1	—
Delay and Lucas-Championniere	22	11	10 •	4
Gaudier	14	i
Sejournet .... Clermont ....	10 18	7	15	6
Carpanetti .	2	1	2
Murard ....	3
Total	688	249	251	76
	Recoveries : 36	Recoveries : 30 %
	Mortality : 64 °	Mortality : 70 %

TREATMENT TO ADOPT IS LAPAROTOMY 129

This is just the delicate point. Nothing appears simpler than to oppose statistics to statistics, but the figures themselves have to be strictly scrutinised to have any value as regards comparison.

Here are the figures. They are presented in three tables, which include the greatest possible number of published cases in order that the percentages may be the more accurate, and that the observations recorded by the different observers may balance each other.

The first table gives the results obtained by operative abstention and medical treatment; we have added to the figures some observations, in the cases of recovery only, relating to the nature of the projectile, to the seat of the lesions, to some symptomatic pecu- liarities, etc., and these remarks will have their value a little later on.

The second table gives the whole of the results furnished by laparotomy, while a parallel set of statistics concerns only the cases in which the small intestine was involved alone or with other organs.

The third table enters into more detail on the subject of the laparotomies ; it classifies the cases according to the situation and the gravity of the anatomical lesions, and therefore allows of the forma- tion of a prognostic percentage according to the lesions observed ; a column is also reserved for the nature of the projectile.

From the comparison of these tables a marked contrast appears :

Abstention has a mortality of from 75 to 80 per cent. •

Laparotomy has a mortality of 64 per cent.

The advantage is, therefore, seen to be on the side of laparotomy.

But one could not accord absolute certainty to these figures. They are open to criticism, the result of which is still more favourable to laparotomy. 9

WOUNDS OF THE ABDOMEN

TREATMENT TO ADOPT IS LAPAROTOMY 131

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132 WOUNDS OF THE ABDOMEN

Is it not surprising to see attributed to the same therapeutic method, abstention, such different rates of mortality as these ? Reduced to 1 8 per cent. by Chevassu, the amount is 33 per cent, for Cadenat, 58 per cent, for Chavannaz, 86 per cent, for Gross and Weiss, and 100 per cent, for Dupont and Kendirdjy, Delore, etc.

The reason is that into the cases treated by ab- stention many incongruous, uncertain facts enter ; with " true abdominals," the result of wounds at least penetrating, if not visceral, are mingled the " false abdominals," where only the abdominal wall has been involved, and where the organs have been injured without the peritoneum having been traversed or affected at all.

How, in fact, in the greater number of cases, has the penetration been established ? From the sup- posed or verifiable passage of the projectile, from the situation of this projectile as shown by the X-rays, or from the symptoms of peritoneal reaction. Now we shall see in the chapter on diagnosis how frequent are the causes of error leading to the conclusion that a visceral penetration exists, when in fact it does not exist ; and thus many cases resulting favourably come to swell the statistics of abstention.

This is so true that certain authors, like Marquis, are careful to point out themselves that many of the recoveries they register very probably concern wounds that were evidently abdominal, but not in the least penetrating. Chavannaz himself reduces his initial figures of 38 cases with 16 recoveries, to 22 cases with 2 recoveries, if they are limited to those in which penetration was absolutely certain.

Equally striking is the difference so frequently remarked between the figures presented by the ob- servers and those retained, after close scrutiny of the observations, by the reporters. Nothing is more typical than these two facts— 97 of Chevassu's cases are brought down to 78 by Tuffier, and 57 by Quenu !

TREATMENT TO ADOPT IS LAPAROTOMY 133

and, more especially, 32 cases of wounds of the small intestine cited by Chevassu with 26 recoveries are reduced, after discussion, to 8 cases with 2 recoveries with faecal fistula !

But here is another proof still more convincing. Quenu [51] thought that the treatment of abdominal wounds could be judged by its results shown in the evacuated cases in the zone of the interior. " I have been able," he says, " to observe carefully 62 men wounded in the abdomen of whom only 9 had been operated on in the ambulances at the front. It seemed at first to be a triumph for abstention, but the triumph was only apparent." In reality, of the 53 evacuated without operation, 28 had been suffering from non- penetrating wounds, and yet their labels bore the diagnosis of perforating wounds in half the cases.

" In five other cases penetration was doubtful ; thus the number of undoubted abdominal wounds was reduced to 20. But amongst these 20 patients have to be counted those who were lost a few days after arrival or even on the way ; I notice four cases of this kind. Of the 16 remaining, three wounded had to be operated on immediately or in a few days ; this reduces the number of penetrating wounds to 13. These 13 cases are classed as follows : 7 simple pene- trating wounds, that is to say without visceral lesions, and 6 visceral penetrating wounds. Of the 7 simple penetrating wounds 4 were complicated with omental evisceration ; these had to be operated on, and it would certainly have been better, if possible, to operate at once."

' The visceral wounds not operated on include three wounds of the liver, one supposed wound of the stomach, and two wounds of the large intestine.

" Of the three wounds of the liver, one gave rise ultimately to an abscess in the lumbar region. Of the two others occasioned by bullets, one was not at all deep, for the projectile felt at the end of the probe

134 WOUNDS OF THE ABDOMEN

was extracted simply by the enlargement of the track and neither had given given rise to haemorrhage of any importance, and seemed to have taken their course at some distance from the hilum."

" Lastly, of the two wounds of the large intestine, one had its track in the right flank with the two orifices not far from each other, and the other affected the ileo-pelvic loop ; when the patient was carried to the ambulance this loop was eviscerated and perforated. One might regard this as a favourable circumstance, and consider that the traumatism had itself performed the operation, so to speak, by placing the perforation in communication with the exterior. Abstention was not complete, either, as soon after, at the ambulance, the result had to be completed by the resection of the gangrenous and herniated loop.

" In short, as regards visceral wounds, the good results given by abstention are limited to one supposed wound of the stomach, to three wounds of the liver of small importance, and to two wounds of the large intestine on the particulars of which I have enlarged." (Quenu.)

And if one considers that the massed official statistics of the medical service can be used as a basis of appreciation, we see how much these remarks of Quenu's deserve to be dwelt on ! It might even occur to one to contrast two sets of figures— those of the wounded who recovered, and those of the recoveries of the men not operated on, who arrived at the base. Now the number of units where operations are per- formed is much smaller than that of the ambulances where abstention is practised; therefore the total number of those operated on is very inferior to that of the non-operated. But again, among the non-operated are unfairly included, as suffering from penetrating wounds, many who were not so wounded ; and many were counted as not operated on who would have to undergo^an operation later on.

TREATMENT TO ADOPT IS LAPAROTOMY 135

And abstention alone benefits by all these errors of diagnosis ; on the other hand, they are placed to the debit account of intervention, which is reproached for its exploratory laparotomies !

The partisans of medical treatment also maintain that a very large number of seriously wounded whom no treatment would be able to save from an inevitable and speedy death are forcibly counted in the lists of abstention, and unduly darken its statistics. No doubt, but the same thing happens to the results of those who, like Caudrelier and Bouvier, Schwartz and Mocquot, Mathieu, etc., have tried to maintain an exact balance, and have systematically operated on all the wounded brought to them.*

It would seem logical, therefore, to eliminate such cases from both statistics ; but how would it be possible to eliminate the desperate cases without being arbitrary ?

And there is another cause that detracts from the absolute value of the figures. A formation close to the front will receive a great number of desperate cases, whereas a more distant ambulance will not — • they will have died on the spot or during removal.

There is also another fact to be considered. In a period of intense fighting, the wounded are gathered in more slowly ; numbers of the most serious cases do not reach the sanitary formation. On the other hand, in calmer intervals nearly all those wounded in the abdomen have time to be taken to the ambu- lance, and the surgeons, not being over-driven, are able to make the most of their chances, even the slightest. Operative losses mount up in consequence. So many more deaths will occur, that a more rigorous

* In Bouvier' s second series, for instance, no less than 15 very serious cases are counted in which, the abdomen being full of blood or fsecal matter, death supervened in the few hours following the operation, or — it must in justice be added — their arrival at the ambulance.

136 WOUNDS OF THE ABDOMEN

selection would have driven back into the failures of abstention !

What can we conclude, after enunciating so many necessary corrections, but that a mere contrast of statistics is vain and without any real signification ?

We have also thought out another mode of com- parison, and here are the terms in which we have described it to the Chirurgical Society on March 1st, 1916:

" However paradoxical it may appear, it is only the cases operated on that allow us to estimate the value not only of surgical, but also of medical treatment"

We could not, in fact, compare the statistics given as assets of either method. The figures furnished for cases operated on have alone an exact value : only the cases operated on furnish, first, the proof of penetration, and, secondly, the control of the lesions.

What we can deduce from the statistics of abstention, or rather from certain well-observed facts, is the possibility of recovery by abstention.

On the other hand, we have sufficiently exact anatomical data to know what lesions are capable of spontaneous recovery, without direct surgical inter- ference.*

The analysis of the cases operated on will therefore allow, according to the lesions observed, of separating

* Qu6nu, at the meeting on April 5th, confirmed our point of view by saying : "I believe we ought to proceed otherwise : we ought to reason with what general pathology and our clinical experience have taught us. We are allowed to believe that when an important vessel bleeds, even if there exists some chance of spontaneous hsemostasis, the surest plan is to tie the vessel ; we have reason to suppose that fragments of clothing, of earth, of projectiles, above all of faecal matter, are injurious when in contact with the peritoneum.

" We persist in believing that the non-punctiform perforations of the small intestine can only heal by being sutured, and that, as to the punctiform perforations, they precisely answer to the favour- able cases, or those which most certainly benefit by intervention.

TREATMENT TO ADOPT IS LAPAROTOMY 137

and contrasting, with supporting figures, those cases which offered no chance of recovery without operation, and those which might . . . perhaps . . . recover by abstention. And one can see how much such a classification would be advantageous to abstention: all the benefit of the doubt, when doubt exists, goes to abstention.

To press the question more closely, we can even separate the cases operated on into three categories :

Category A. — Wounded who, without laparotomy, would certainly have recovered (from their abdominal lesions, obviously). That is to say : laparotomy use- less, perhaps injurious.

Category B. — Wounded who, without laparotomy, would perhaps have recovered. That is to say : la- parotomy perhaps useless.

Category C. — Wounded who, without laparotomy, would certainly have died. That is to say : laparotomy necessary or powerless.

In accordance with this classification, I have taken all the observations published at the Chirurgical Society in which the description of lesions is sufficiently exact to allow of an opinion on the possibilities of spontaneous healing, with the endeavour, in doubtful cases, always to give medical treatment the advantage, that is, to favour Category B. I thus arrive at the following figures.*

I would therefore establish the balance in another way : I would put on one side the cases in which laparotomy has furnished few or no in- dications, where it has been only or almost entirely exploratory, and I would note the losses imputable to the operation or to the anse sthesia. I would place on the other side the cases in which the ligature of an artery, a necessary plugging, the removal of great pollution, and the obliteration of perforations have more than justified inter- vention, and I would note the number of lives saved.

" The balance, between the victims of the first series and the ' escapes ' of the latter, appears to me to give the equitable solution."

How well these lines of Qu^nu's corroborate the point of view that we advocated ourselves in one of the preceding meetings !

* Here is the classification of the control cases :

138 WOUNDS OF THE ABDOMEN

Sencert : (C) Obs. 26, 37, 56.

Dupont and Kendirdjy : (C) Obs. 2, 3, 4.

Chavannaz : (B) Obs. 9, 10, 11; (C) Obs. 1, 2, 3, 5, 6, 8, 12,

13.

Gosset : (B) Obs. 2, 6, 7 ; (C) Obs. 1, 3, 4, 5. Vertraeghe : (B) Obs. 1 ; (C) Obs. 1, 2, 8, observations in which

" grave lesions," not specified, existed. Schwartz : (B) Obs. 8 ; (C) Obs. 1, 2, 3, 4, 5, 6, 7, 9. Bouvier and Caudrelier : (A) Obs. 11, 31 ; (B) Obs. 1, 14, 18, 19,

29, 32, 33 ; (C) Obs. 2, 3, 4, 5, 6, 7, 8('), 9, 10, 12, 13, 15, 16,

20, 21, 22, 23, 24, 25, 26, 27, 28, 30. Goinard : (C) Obs. 1. Duter and Ballez : (B) Obs. 1. Petit : (B) Obs. 1 ; (C) Obs. 2. Bichat : (B) Obs. 5", 6", 5'", 10'", 12"', 13'" ; (C) Obs. 1, 2, 3, 1",

2", 1"', 2"', 3'", 4'", 6'", 7'", 8'", 9'", 11"'. Pascales : (B) Obs. 2, 3 ; (B) Obs. 1. Bouvier and Caudrelier: (A) Obs. 1-7, 13, 40 ; (B) Obs. 8-12, 16,

23, 28, 29, 30, 31, 35, 36; (C) Obs. 14, 15, 17, 18, 19, 20, 21,

22, 24, 25, 26, 27, 32, 33, 34, 37, 38, 39, 41-65. Tartois : (C) The eleven observations of the series. Schwartz and Mocquot : (A) Obs. 7, 16, 17, 10"; (B) Obs. 4, 9,

14, 20, 22, 1", 6", 12", 15", 20" ; (C) Obs. 1, 2, 3, 5, 6, 8, 10,

11, 12, 13, 15, 18, 19, 21, 23, 24, 2", 3", 4", 5", 6", 8", 9", 11", 14", 16", 17", 18", 19", 22".

Mathieu : (B) Obs. 1, 15, 18, 26 ; (C) 2, 3, 4, 5, 6, 7, 8', 9, 10, 11,

12, 13', 14, 16, 17, 19-25'.

Stern : (B) Obs. 1, 2, 3, 4, 20, 21, 27 ; (C) Obs. 5, 6, 7, 8, 9', 10-19,

22-26, 28-34. Rouhier : (C) Obs. 1, 2. Barbet and Bouvet : (A) Obs. 18 ; (B) Obs. 20, 22, 26 ; (C) Obs.

13, 14, 15, 16, 17, 19, 21, 23, 24, 25. Didier : (C) Obs. 1-8.

Gatelier : (A) Obs. 2 ; (B) Obs. 5; (C) Obs. 1, 3, 4, 6-11. Abadie : (A) Obs. 1 ; (B) Obs. 2 ; (C) Obs. 3-5', 6-15. Bouvillois: (A) Obs. 10, 11, 13; (B) 37-43, 45-52, 80; (C) Obs. 44, 47-49, 53-105, 121, 123, 124 (numbers of these inter- ventions relate to almost dying cases). Simonin: (A) Obs. 1 ; (B) Obs. 2, 3, 4, 10, 12 ; (C) Obs., 5-9, 11,

13-20.

Tisserand : (B) Obs. 5; (C) Obs. 3, 4, 8, 9, 10, 11. Cotte and Latarjet : (B Obs. 9, 15; (C) Obs. 4, 5, 8, 13, 14. Delay and Lucas- Champi onniere : (A) Obs. 2, 16; (B) Obs. 9, 17, 18;

(C) Obs. 3-8, 10, 11, 13, 14, 15, 19-22. Murard : (B) Obs. 3; (C) Obs. 1, 2.

The observations marked with a (') concern the manifestly hopeless cases, operated on chiefly in order to apply intervention without exception in every case, to have complete statistics, or to cases in which the surgeon himself declares that he will not operate again on such apparently dying cases. We count them, neverthe- less, to avoid all subtlety of discussion and to arrive at a distinct formula.

TREATMENT TO ADOPT IS LAPAROTOMY 139

	japarotomy useless, perhaps injurious.	Laparotomy may be useless.	Laparotomy neces- sary or powerless.
—	A.	'~~ B.	C.
	No. of Cases.	Re- coveries.	No. of Cases.	Re- coveries.	No. of Cases.	Re- coveries.
Sencert	_			—	3
Dupont and Kendirdjy Ghavannaz	~	—	3	3	8
Gosset Vertraeghe Schwartz . Bouvier & Caudrelier (I)	2	2	3 1 1	3 1 1	10 8 23	2 2 7
Goinard .	—	—	—	—
Duter and Hallez	—	—	1	1		•^
Petit Bichat .		~	1 6	1 6	14	3 j
Pascalis .	—	—	2
Pellot Bouvier &Caudrelier(II)	~9	~9	13	13	43	13 5
Tartois . Schwartz & Mocquot Mathieu . Stern	4	~3	10 4	10 4 6	13 32 27 2	4 2 8 1
Bouhier . Barbet and Bouvet	1	1	3	3	10	4
Didier	—	—	—	—		4
Gatelier .	1	—	1	1		4
Abadie . Rouvillois Simonin . Abadie (not publishe ) Cotte and Latarjet Tisserand .	1 3 1	1 3 1	1 13 5 2 2 1	12 5 1 2 1	58 14 15 5 6	7 2 4 2 2
Chalier .		— —	—	' '
Delay and Luca - Championniere Murard .	2	2	3 1	3	15 2	5
	24	22	91	87	367	89

We complete this table to-day by adding all the cases since published at the Chirurgical Society, or that we have found sutti- ciently detailed in other publications.

Before drawing conclusions from the foregoing, we must specify the cause of the three deaths that we find in the categories A and B :

(A) The death of one of Schwartz and Mocquot's wounded (Obs. 17) was caused on the day following the operation by pneumothorax, dyspnoea, and asphyxia, for which neither the laparotomy itself nor the anaes- thesia could be held answerable.

Gatelier's patient (Obs. 3) had a thoraco-abdominal

140

WOUNDS OF THE ABDOMEN

association ; he died on the 31st day from hepatisa- tion of the right lower lobe, and from gangrene of the pulmonary tissue. Laparotomy had nothing to do with this, and if anaesthesia by ether can be suspected of aggravating the pulmonary complication, that is an argument for rejecting ether, but not against laparotomy.

(B) The same remark applies to Stern's patient (Obs. 1) who was placed under a window always kept open, who got up, and died from pneumonia on the

following day.

The case of Rouvillois (Obs. 80) lends itself to discussion, but the fact of our placing it in category B proves that we admit the possibility o f spontaneous healing. It was a case of an abund- ant hsemoperito- neum caused by a wide laceration of the anterior border of the liver, extending from the vesi- cular notch to the falciform lig- ament ; a frag- m e n t of the liver as large as two thumbs was almost entirely detached ; there was also a wide perforation of the gall-bladder, and a second wound 5 cm. long in the inferior surface of

FIG. 25. — Deaths by abstention. Sencert [2]. To compare with the preceding figure.

TREATMENT TO ADOPT IS LAPAROTOMY 141

the right lobe of the liver. The sutures only held partially. Death on the fourth day was caused by a well-localised focus of sub-hepatic peritonitis. Con- sidering the good general condition of the patient, before intervention (Pulse 64), and the diminution of pain, is it possible that he might have recovered, in spite .of the blood in the peritoneum and the bile in the peritoneum ? Still, intervention does not appear to have caused the peritonitis, as the latter remained localised to the liver, without spreading to the rest of the peritoneal

cavity when the explorations were extended to the latter. One conclusion to be drawn from this case is that it is ad- visable to be more cautious in making sur- gical interven- tion in the region of the liver.

The same con- clusion as re- gards the colon is drawn from our own unfor- tunate case (see its case-report on p. 226). A late- ral wound of the ascending colon,

FIG. 26. — Recoveries by abstention. Sen- cert [»]. To compare with the following figure.

a tunnel- wound caused by a bullet, with very localised reaction, was treated by lateral laparotomy ; we found the rent in the middle of a sanguineous infiltration of

142

WOUNDS OF THE ABDOMEN

the meso-colon ; at that very moment intestinal contents escaped. The patient died of peritonitis, which perhaps would not have occurred without inter- vention, as the closure of the laceration seemed established. In any case, a mistake of operative

procedure had been made ; be- fore the lapa- rotomy, as the passage was so lateral, and the intra- perito- neal penetra- tion of the colon was not cer- tain, I ought to have ex- plored the course of the wound and confined myself to a freeopen- ing-up of the extra-perito- neal focus : we are well aware of the difficulty and the uncer- tainty of extra - peritoneal su- tures of the large intestine! From the cases that I have just col- lected and ana- wounded who,

j. y kjv^v*. *w .*. v ^ **»-. *- ~ • \ "~ /

without laparotomy, would certainly have recovered

P. Faecal Fistula.

FIG. 27. — Recoveries by abstention, ob- tained from a total of 121 cases of Sencert, Cadenat, and Chevassu (retaining only the penetrating wounds admitted by Tuffier and Quenu). Of the three wounds in the umbilical zone, two were accompanied by no reaction, and the third gave rise to a fascal fistula. This diagram should be compared with the follow- ing figure.

lysed it results : (1) That the

TREATMENT TO ADOPT IS LAPAROTOMY 143

from their abdominal lesions, recover also in spite of laparotomy ;

(2) The wounded who, without laparotomy, might perhaps have recovered, will almost certainly recover with laparotomy ;

(3) Of the wounded who, without laparo- tomy, would certainly have died, a consider- able proportion recover in conse- quence of lapa- rotomy ; that ri7v*'///mrw#//A proportion is jffHBBL**. here 25%.

To put it some- what roughly, and in extreme terms : " If we are mistaken, we do not kill any one ; when we operate on the condemned, we save a quarter of them ! "

Therefore (and bearing in mind that, so far, we do not see any possibility of its practical realisa- tion), the preferable treatment of penetrating abdominal wounds is laparotomy.

FIG. 28. — Recoveries by laparotomy drawn from a total of 125 penetrating wounds of Bouvier and Caudrelier, Schwartz and Moc- quot. We see that they include recoveries from wounds of the umbilical region. This diagram should be compared with the pre- ceding, Fig. 27.

Are there not cases in which this treatment

144 WOUNDS OF THE ABDOMEN

should or may 'be discarded, or should or may be deferred ? ^

No doubt there are. And we shall logically return to this in the chapter on diagnosis, in discussing therapeutic indications.

But these exceptions to the general rule evolve so naturally from the observation of the recoveries left to the credit of abstention, that we must discuss them now. First, here are two diagrams (Figs. 25 and 26) ; they represent, for the same observer and the same method (medical treatment), in one the deaths and in the other the recoveries. We see the relative rarity of the latter, and in what regions of the abdomen they are situated. Only one wound is found situated in the umbilical zone ; the notes state that only a slight abdominal reaction was found (Obs. 23) ; it is therefore probable that it was an example of one of those wounds that we have mentioned, where the pro- jectile glides between the coils without perforating them.

Two other diagrams (Figs. 27 and 28) compare the recoveries obtained on the one hand by abstention, on the other by laparotomy. Both concern a number of almost similar cases : 121 in the first instance (Sencert 58, Cadenat 11, Chevassu 52), 125 in the second (Bouvier and Caudrelier 84, not counting the parietal wounds, Schwartz and Mocquot 41).

With regard to abstention, we should note the fre- quency of recovery in lumbar wounds (of which the peritoneal or visceral penetration is far from being always proved), and in wounds of the upper region. In the umbilical zone, we have already noted the slight reaction presented by Sencert's patient (Obs. 23) ; it is the same with Catenat's patient (Obs. 1, right sub- umbilical opening.) The two wounds marked F, in which the small intestine was certainly involved, healed by spontaneous faecal fistula.

Laparotomy also shows distinctly a larger number

TREATMENT TO ADOPT IS LAPAROTOMY 145

of recoveries for penetrating wounds in the right colic region and the upper region, but the cases are numerous where penetration took place in the umbilical zone or was situated in the most central region of the iliac fossae with tendency of the projectile towards the mass of the small intestine.

Lastly, if we recall the great relative frequency of bullet- wounds among the recoveries due to abstention, we shall arrive at the following practical conclusion :

In war, as in peace, operative results confirm our view that there is emphatically a preferable treatment for penetrating abdominal wounds, and that treatment is LAPAEOTOMY !

10

PART II

UNDER WHAT CONDITIONS AND SURROUND- INGS IS THIS PARTICULAR TREATMENT APPLICABLE ?

147

CHAPTER VI

CONDITIONS AND SURROUNDINGS NECESSARY FOR LAPAROTOMY

LET us picture the surgeon and his assistant, the equipment, the distance from the front, and the difficulties.

I. THE SURGICAL STAFF

This must be trained and homogeneous. A surgeon cannot be improvised ; still less can one successfully plunge into laparotomy for a deep-seated wound without a previous mastery of abdominal surgery ; no operation of an urgent surgical nature is more full of unexpected accidents, or calls for more prompt decisions and more rapid execution ; it demands at the same time both experience and manual skill. In a minor degree, the same requirements are necessary in the surgeon's assistant. Qu6nu asserted with per- fect justice : " The idea that one can train an assist- ant in a few months seems to me a gross heresy."

The anaesthetist must be equally experienced, for it is necessary to produce steady anaesthesia (a condition important in rapid surgery) with the minimum amount of anaesthetic.

The nurses ought to be perfectly familiar with what is required of them. It is easy to obtain intelligent and active military nurses. The surgeon must train them efficiently if he wishes to have trustworthy and reliable assistance.

149

150 WOUNDS OF THE ABDOMEN

II. EQUIPMENT

We will consider this, successively, under the three conditions in which laparotomy has to be performed : in the ordinary ambulance ; in the automobile surgical ambulance (the autochir, to speak briefly and in the language of the hour) ; and in the advanced surgical station near the front line. And as we have to do with a matter which may be left to the initiative of the army surgeon, we will describe in detail one type of each class.

A. The ordinary ambulance. — It is obvious that we have not to consider the case of a "travelling ambu- lance " (i.e. an unspecialised regimental or divisional ambulance). The very example which Picque quotes is the best proof of this : In September 1914, in spite of a stream of 3,735 wounded in eleven days, he was able to operate in all cases of those wounded in the abdomen, where they seemed to him to be suitable for operation, and 9 laparotomies were thus undertaken among 135 operations. We have nothing but praise for those who showed such activity, but it is evident that the conditions under which the operations were performed would have been infinitely better if the 3,725 wounded had been sorted out at the same time, if Picque's ambulance had performed three or fou times the number of operations, and had occupied itself with operations only — that is to say, if it had been specialised only for surgery.

Laparotomy, with the necessary safeguards, will never be feasible except in a special surgical ambulance. We need also suitable special equipment and situation. An enviable example is described by Picque. " A site, as large as possible, having been chosen for an ambu- lance station, we must consider also the general appear- ance of the premises, and in accordance with these make a logical arrangement of the cases, separating head wounds, and wounds of the chest and abdomen,

CONDITIONS AND SURROUNDINGS 151

from those of the limbs only ; then make room for the formation of an operating-theatre and its offices. It is then possible to arrange immediately, in any place, a sufficiently aseptic room by using the surgical van for the first few hours as a preliminary sterilising station. The addition to our ambulances of the older type of two automobile cars for sterilisation and radio- graphy, provides us to-day with an excellent portable, aseptic operating-theatre, and with the immediate help of X-rays."

This description, together with that where Picque gives the details of the transformation which he had been able to effect in one of his ambulance wagons,* excites admiration and envy. Everything is evidently perfect. . . . '

But, writing for the ordinary surgeons of the army zone, we think it best to warn them to consider as very exceptional circumstances which would enable them also to obtain similar transformations and additions. Generally speaking, the equipment of their ambulance will be gradually added to ; an autoclave, a hot air steriliser, and instruments for laparotomy ; and at every change of place one must carefully set up new premises in lieu of a portable equipment for immediate use. What a long way off appears the seductive mirage of " an instantaneous equipment," and how rarely will one find oneself provided with " a site as large as possible " ! It would need hours and hours, running into days, before one dare to open the abdomen !

What we must insist on in every case is, that when called on to perform operations for abdominal wounds, an operating-room should be set apart specially for such cases. In my opinion this is a condition of supreme importance. It is not so much in order to comply with the demand for strict asepsis (when in times of peace one has to perform any kind of urgent operation in any kind of country place, we know that * See Bull, et Mem. Soc. de Chir., 1915, p. 1792.

152

WOUNDS OF THE ABDOMEN

it is always possible to arrange for surgical cleanli- ness), as to have available immediately an "instru- ment ready for use " automatically without hesitation, preparation, or delay, and without unnecessary mental strain to the operator. The size of the premises matters little ; in our last installation, we only set apart in our

FIG. 29. — Compartment reserved for laparotomies in our principal operating-room by means of a wooden partition prolonged upwards by stretched sheets. (Hopital de 1'Ecole Margaine, Sainte-Mene- hould.)

ordinary operating-theatre a compartment, 3 metres long, by 2 broad, made by a wooden partition 2 metres high, carried up to the ceiling by means of stretched sheets (Figs. 29 and 30). But at any moment there were ready, for instant use, the operating-table, two tables for instruments, on which were already boxes

CONDITIONS AND SURROUNDINGS 153

of sterilised bandages and instruments sterilised by hot air, just waiting to be taken out of their boxes, sterilised gloves, a basin with sterilised brushes, the anaesthetist's accessories, phials, and bottles of saline ; in short, all that nurses as well as surgeons ought to be certain of finding ready so that the opera-

r

FIG. 30.— Laparotomy taking place.

tion can be prepared for and carried out as automati- cally as possible. For we are not talking here of being to perform, in an exceptional manner, an opera- to which one has leisure to give every conceivable are, but of the case when one must be able at any me, above all at periods of great surgical stress, to perform with the greatest rapidity and with the mini-

154

WOUNDS OF THE ABDOMEN

mum of nervous fatigue, a delicate operation which will have been preceded and will also be followed by an uncertain number of other operations.

It is the surgeon's duty to obtain and to set up such an installation.

B. The automobile surgical ambulance. — -Here, on the other hand, everything one could wish for carrying

FIG. 31. — Arrangement of an operating-room in an advanced surgical post, near the front. Boigey [80].

out the most delicate surgical operations is found ready in advance. But the arrangements of the operating-theatre and its accessories are, however, vari- able, and will allow of special adaptation for a series of laparotomies. Roubillois'* model gives a very satisfactory arrangement of the different parts of the ambulance, because it provides for a strictly aseptic room reserved for abdominal operations.

* Bull. Soc. Chir., 1915, pp. 1453, 1454.

CONDITIONS AND SURROUNDINGS 155

C. Advanced stations for surgical operations in the neighbourhood of the front line. — These stations, being definitely intended for those wounded in the abdomen, for vascular wounds accompanied by profuse haemor- rhage, and for broken limbs, contain everything neces- sary for urgent abdominal operations.

We will suggest three examples which surgeons at

Fia. 32. — Transportable sterilisation apparatus in an advanced surgical post, near the front. Boigey [80],

the front could, as occasion offers, imitate or modify : those of Mignon [79], of Boigey [80], and of Tisserand. The first and second form part of the same institution due to the generosity of Mme Fould.* It consists of a complete transportable equipment which can be set up within any four walls : an aseptic operating-theatre as well as a sterilisation

* It is in this station that Bouvier and Caudrelier, and after- wards Lucas- Championnie re and Delay, obtained the results they have published.

156

WOUNDS OF THE ABDOMEN

annexe ; the walls, ceiling, and floor of an operating- room, an electric light plant, sterilising apparatus, operating equipment, and a radiographical outfit, which altogether weigh only 5,400 kilogrammes. The whole is transportable by an automobile lorry. Figs. 31 and 32 give some idea of the installation after it has been set up.

FIG. 33. — Mode of protection of a shelter for the performance of urgency operations in an advanced post near the front.

Then we have to find on the spot a house ; and a house which can be protected from artillery fire. The story of the unit which we have described above, which on two successive occasions had to leave the sites where it was at work, shows that these conditions cannot always be permanently assured.

It is this fact which gives special interest to Tis- serand's description [4 ']. This shows us a subterranean shelter (of which we give a section, Fig. 33) where the surgeon has been ingenious enough, in the absence

CONDITIONS AND SURROUNDINGS 157

of any plant, to supply its place and then prepare an aseptic operating-theatre.

Is a radioscopic installation necessary ? — It is often useful, never indispensable. We shall see, indeed, in the following chapters, that the information furnished by X-rays may be influential both in determining the operation (by helping the diagnosis as to the depth of the wound and the lesions), and in the actual con- duct of the operation by enabling the surgeon to deter- mine beforehand the position of the projectile which it is almost always advantageous to remove.

But we shall see also that the data furnished by the radioscope are rarely sufficient in themselves to furnish indications either for or against an operation, which have not already been in a great measure, established clinically. We must remember also that the aim of the operation is the reparation of the lesion, not the removal of the projectile. A radioscopic equipment is found in the autochirs, and in the advanced transport- able stations we have already mentioned.

Picque was able to attach a radioscopical car to his ambulance; but even in the fixed surgical units, which we have seen around us, a radioscopical car comes only on a fixed day and for an hour or two, and it is therefore only a coincidence if the radiographer is there to give the surgeon pre-operative indications in the most interesting cases, i.e. in those of the abdomen and head.

We repeat what we have already written. Is a radio- scopic installation useful ? Yes, but not indispensable.

III. DISTANCE FROM THE FRONT — DELAY IN OPERATING

The influence of the distance from the front on the development of abdominal wounds in general, and especially on the results obtained by laparotomy, is proved by two concordant pieces of evidence.

158 WOUNDS OF THE ABDOMEN

The farther a man with an abdominal wound is carried before he can be allowed to remain quiet in one spot (which, whether he is to be operated on or not, is an essential condition of cure) the worse are the conse- quences. Here is a proof of this : when, for strategical reasons, for example, one is obliged to evacuate all the wounded to a distance, one sees, as one goes from an advanced unit to one farther behind the lines, that the number of abdominal cases rapidly decreases, Those with abdominal wounds do not easily stand being moved ; among them excessive evacuation produces a very high mortality.

The later an operation is made for an abdominal wound, the more disappointing are the results.— All surgeons are unanimous with regard to this impression, and it it is confirmed by statistics. Given equality of lesions, recoveries are more frequent the sooner the operation takes place. We must note the " equality of the lesions," and not limit ourselves to contrasting the number of deaths in the very early stages with those which follow at a later period. In the early stages, in fact, the coefficient of mortality is very high ; this is due to the fact that the surgeon, especially if he is in the habit of operating systematically whatever the degree of gravity of a case, is led to operate on cases which are almost hopeless ; death or a rapid aggravation of their condition would have swept them away natur- ally if they had only reached the surgeon's hands at a later period. But after the fifth or the sixth hour the figures again assume their significance ; the result! are less and less favourable the more the operation is delayed.

For this reason one may say, therefore, that con- sidered with regard to other injuries, abdominal wounds deserve special consideration. For the majority cases of ordinary wounds the tendency is to follow the plan of establishing at 15, 20, or 25 kilometres from the fighting lines large " surgical centres " and

CONDITIONS AND SURROUNDINGS 159

to aim at bringing the wounded to these in auto- mobiles as soon as possible. These centres, out of reach of the guns, free as a rule from the local or momentary variations of the front, compensate largely, by means of complete and regular attention, and security of rest, for the relative disadvantage of an additional transport of some kilometres. This plan is intermediate between evacuating every one as far as possible to the hospitals at the base — a practice which seemed logical when the conviction was held that most wounds remained aseptic when covered by a single protective dressing — and the practice of sur- gery in the ambulances at the front which seemed for a time an ideal method on account of the great fre- quency of shell or trench-mortar wounds, and the constantly septic condition of such wounds. The most recent bacteriological results, however, have shown that septicaemia only sets in after the sixth hour ; surgical centres from 15 to 25 kilometres behind the front line sometimes allow operations to be performed within this period ; it is, therefore, a case for rapid eva- cuation. For penetrating abdominal wounds, such & distance from the front is unacceptable. This is on account of two consequences which it involves : first, the time which must pass between the wounding and the operation, and secondly transport. The second is undoubtedly the more important ! With a given intensity of lesions and the risk of haemorrhage or infection, it would be better to operate at the tenth hour on a wounded man who had not been moved, rather than at the second on a man who had been disturbed, pulled about in various ways to be got out of the trenches, then shaken, in spite of every care, by the jolting of an automobile, and whose disturbed intestines cause a flow of blood and septic fluids into the abdominal cavity from themselves or the surround- ing tissues.

Of two solutions which present themselves — one,

160 WOUNDS OF THE ABDOMEN

to cany the wounded to the surgeon by rapid trans- port, the other, to bring the surgeon to the wounded, the first has been shown to be impracticable.

Doubtless under all circumstances we ought to try to make transport as quick as possible (we shall see how later on), but one cannot with impunity rush a man wounded in the abdomen over long distances, and it is sufficient to have seen men arriving ten or twelve kilometres behind the lines, wounded in their limbs, and suffering from the shock of transport, to be able to imagine how much more injurious still would be such transport for a man with an abdominal wound. " Two or three kilometres more or less in an ' auto,' why, that's nothing at all ! " people have been in the habit of saying. That's true enough for almost all the wounded, even for chest wounds ; but it is altogether false as regards deep-seated abdominal wounds. A fortiori, we cannot accept the statement of Chavannaz that, if necessary, one may transport a man with an abdominal wound 50 kilometres in order to find a perfectly equipped hospital unit. The only solution evidently is to bring the surgeon to the wounded. But there are various degrees of necessity.

Although Fiolle * was able to conduct successfully, under a shelter actually within a trench, a laparotomy which did him the greatest credit, one cannot deduce from that a general method of procedure ; and all the more so because a surgeon without the necessary apparatus is rendered powerless.

It was this leading idea which led to the creation of the autochir. To Marcille, to whom belongs the credit for the original idea, and to the other surgeons whom civil practice in peace-time had taught what is the necessary minimum for the performance of emer- gency surgery, and especially of abdominal opera- tions, the question was one of obtaining the conditions necessary for a successful operation. Without going

* Quenu, Bull. Soc. Ghir., 1915, p. 1886.

CONDITIONS AND SURROUNDINGS 161

outside our subject we cannot here trace the history of the autochirs, nor show how it was possible to find fault both with their composition and also with their actual usefulness as representing only " the realisation ot hall of a very good notion."

Since they were to a large extent created for the purpose of enabling laparotomies to be made in the immediate neighbourhood of the fighting line, let us limit ourselves to the consideration of how close it is possible for them to approach. They cannot get nearer than ten or twelve kilometres; in the first place, because they are too heavy and form too complex and too important a unit (13 cars, including 4 large wagons) ; and also because it is not practically possible or them to give the surgical output one has the right to demand from them unless they are attached to a small hospital building already constructed, for even it portable the necessary huts have first to be erected One comes to the conclusion, in fact, that, in spite of he mobility of their actual vehicles, the autochirs themselves are not very mobile.* From the point of view, therefore, of distance from ie iront, the autochirs are exactly in the same category as divisional ambulances or army ambulances directly intended for surgery. (Later on we will consider their comparative output.)

It remains, therefore, to make a comparison between on the one hand, advanced surgical stations which •ring the surgeon as near as possible to the wounded and on the other hand, stationary ambulances from six to twelve kilometres from the front, whether they be automobile or not. *

At the advanced station the operation is performed

under the best conditions for success. Bouvier and

Jher operated on the wounded during the very

typlcal CaS6S' which we have see* »nd noted

es with a reference to p< Delbet

11

162 WOUNDS OF THE ABDOMEN

first hours ; but the full advantage of this is only gained if the station is absolutely safe from bombardment and if both the operating surgeon and the patient can

FIG. 34.— Trench stretcher (Eybert).

be ensured, not perhaps absolute, but comparative quiet during the days which follow an operation.

If these conditions are not secured, if severe fighting alters the front line, if the uncertainty of the next hour or even of the next day adds to the anxieties of the operator and exposes the wounded to a sudden evacua-

CONDITIONS AND SURROUNDINGS 163

tion, in short if the station becomes " unhealthy both for the wounded and their attendants," it is indisput- ably better to take the wounded at once to a surgical unit farther off which will assure him a longer and more restful stay in hospital after the operation.

Wherever he is to be operated on, near or far, there is one stage to be got over in the case of an abdominal wound to which too much attention cannot be paid, for it is of the ut- most gravity — that is the evacuation from the trench, and the transport to the point where he will be placed in an automobile. This is often a veritable Calvary, lasting perhaps two hours or more, in- terrupted by all sorts of shocks and difficulties ! This is the most injuri- ous time for the wounded.

The surgeon may use his influence to

enable him to use the evacuation trench for the wounded ; such trenches or galleries are to be found almost everywhere ; but before using them it is wise always to ascertain their size. Gatelier declares that in his sector the commandant had caused special large galleries to be constructed for this purpose, and that

Fia. 35. — Immobilising stretcher (Martignon).

164 WOUNDS OF THE ABDOMEN

these saved an hour in the transport. We have also to consider the different methods and apparatus re- quired in bringing the wounded to the shelters, the gaps in the trenches, the corners, and to arrange for places where relays of wounded may pass each other.

Many doctors have devoted themselves to the con- sideration of the best kind of stretcher for trench- work. Gatelier has those wounded in the abdomen carried on a piece of tent-cloth with their knees raised ; others use a kind of carrying-chair with the patient in a sitting posture ; this has great advantages. Eybert's stretcher is of this type (Fig. 34). Matignon's stretcher keeps the trunk and the lower limbs as steady as possible (Fig. 35) ; the wounded man is " sausaged," that is to say he is packed up like a mummy and carried as if he himself were a stretcher or a hammock, or like a sack of corn carried on the back.

In spite of all these efforts, we must not forget that during an actual attack, in spite of the zeal and promptitude of the stretcher-bearers, the evacuation may be very slow, and a distance which ordinarily would be covered in two and a half hours will take in actual war-time six hours, or even more !

Transport from the first-aid station to the am- bulance is done by automobile. It is very rapid as a rule, and we cannot recommend greater speed in bringing the wounded to the surgeon ; on the contrary, more often than not, the surgeon advises the chauffeur to go more slowly so as to avoid too sudden shocks.*

Is this mode of transport " the perfection of smooth- ness," as Picque writes ? No. One has only to try such a journey for oneself, or, more simply still, to examine the wounded on their arrival, to discover that

* M. le me"decin inspecteur Follenfant is of opinion that the only way to obtain a reduced speed from the chauffeurs, and to oblige them not to exceed it, is to modify the gear-wheels and thus to diminish the ratio. The experiments already made in Morocco have been quite satisfactory.

CONDITIONS AND SURROUNDINGS 165

they are suffering from shock. But it must be owned that at the moment nothing better can be done.

What one should try to do, however, is to arrange that those suffering from abdominal wounds are not evacuated from the trenches in the same way as the other wounded. These are taken from the field-station to the sorting ambulance ; they are fetched twice during the day, and carried to the evacuation hospital or the hospital ambulance. It is absolutely necessary that the abdominal cases should be placed immedi- ately, direct from the trenches, in the automobile and taken at once to the surgeon without waiting for the ambulance to be fully loaded. Precious hours are thus gained.

To sum up : The problem presented by distance from the front can be solved in the following manner. In times of steady fighting and in periods of calm laparotomies should be undertaken in permanent advance stations ; in other than these rather excep- tional conditions laparotomies should be performed in stationary ambulances ten or twelve kilometres from the front, but with as rapid transport as can be obtained by means of special evacuation galleries and by direct transport to the surgical centre without any inter- mediate stopping-places.

IV. OVER-CROWDING

The sudden influx of large numbers of cases insepar- able from irregular fighting presents a distracting prob- lem to the surgeon, one which Sencert, Stern, and almost all those who have experienced it describe feelingly. It is no use treating it with sentimental arguments : it is a matter of cold calculation and pitiless arithmetic.

One abdomen, one laparotomy, means a whole hour devoted to an altogether uncertain result ; it means at most half a chance of saving one man ; an hour given to other severe wounds (heads, limbs, etc.) means that

166 WOUNDS OF THE ABDOMEN

you will save three at least.* Therefore, as the stream of wounded increases, one has to make a choice amongst the abdominal cases. And then it is that, quite rightly, one sets aside those which may possibly get cured to a certain extent without an operation ; i.e. cases of bullet-wounds or wounds which on clinical examination do not appear to be accompanied by clearly marked adverse symptoms. One operates on the others. But at last an hour comes when one hesitates no longer, when one abandons to their uncertain fate all those with abdominal wounds, hoping, in order to calm the revolt against one's own helplessness, that the very refusal to operate may be rewarded by some cures.

Are these over-crowding difficulties inevitable ? One might have thought that, thanks to the selection which is exercised in sending the wounded to them, and thanks to the perfection of their equipment, surgeons of the automobile ambulances might be able to avoid them ; but, according to Chevassu, they themselves own their helplessness, and, not content to resign them- selves to it, use it as an argument against the partisans of operation. It is well to remember what Qu6nu has demonstrated. Even on the day when the stream of wounded was greatest, all those taken to Chevassu could have had the advantage of the normal treatment for abdominal wounds — that is to say, of laparatomy when an operation seemed indicated — if two or three additional plants had been there ; if, for instance, one or two autochirs, not in use elsewhere (for that is the important fact) had been sent at this time to the point where they were undoubtedly needed.

For these reasons the Chirurgical Society is quite justified in the desire that it has recently expressed.

* " But," some will say, " a man with an abdominal wound once cured is completely restored, whilst the others are often left muti- lated ! " Granted, but from a social point of view (family, earning capacity, procreation) six mutilated men are worth more than one even with an abdomen completely healed.

CONDITIONS AND SURROUNDINGS 167

After having heard many facts as to the misuse of autochirs, it asks that "in order to secure for those wounded in the abdomen and also for all others seri- ously wounded, treatment in which the rapidity of the operation has a considerable influence on its success, the automobile ambulances should be concentrated at the point where the stream of wounded is greatest according to the need for them and for as long as is necessary " (May 10th, 1916).

To discuss here the question of the use of autochirs would be to go outside our subject. It is, however, useful to consider one point.

An autochir, a medium for urgency operations, cannot produce its maximum output — that is, its normal — un- less the evacuation of cases operated on, as soon as they are transportable, is kept also at a maximum. It follows, therefore, that every autochir (and even every surgical ambulance specially set aside for emergency operations during war) ought to be attached to a rail- way line. To place one of these units five or six kilo- metres from a railroad is to transform it at once into a hospital " for treatment," and this is not what it is intended for. Its role is to make it possible to evacuate by operations those wounded who cannot be evacuated before operation, and only to keep for a minimum time those whose wounds urgently demand treatment in a hospital on the spot. A surgeon, therefore, will permit those wounded in the thorax, head, or abdomen to travel to a surgical station, or even to the base, and will even consent to a twelve hours' journey, provided this be made by rail, whereas he will firmly refuse to sanction such a journey if it has been preceded by even three or four kilometres in an automobile !

So here we have a source of rapid overcrowding. To secure a prompt, regular, and safe evacuation is to more than double the output of every advanced surgical station ; especially does it give the surgeon oppor- tunities for operating on and attending to abdominal

168 WOUNDS OF THE ABDOMEN

wounds. Thus the necessity for proximity to a rail- way is obvious.

Can one imagine a factory without a rail to take away the goods ? A surgical station is a " factory'' There are brought to it the " raw products," the wounded not fit for evacuation ; the station transforms them into "manufactured goods," the wounded ready for evacuation.

This we must admit as a fundamental idea, and always bear it in mind, for from it arise consequences rich in results, advantages of concentration which allow of more complete general services with less fatigue, necessary specialisation, and a rigorous use of depart- ments according to their differentiation, a general ten- dency for work to go on automatically, and the organ- isation of everything connected with the surgeon, the chief " instrument " on whom depends the output, etc.

Another idea strikes us as a complement to the first. Surgery is not only a science, an art, but also a sport ; the expenditure of physical force ought to be reduced to a minimum by making the movement automatic, and also by saving the operator himself from outside worries ; the organisation, the actual working, the collaboration of each assistant, ought to come into the game auto- matically at moments of high pressure. Finally, the surgeon at the front ought always to be thinking more about the wounded who may be brought to him rather than of those on whom he has already operated and attended to ; to do his duty to the wounded who may come from the front lines to-morrow, he must know how to get rid of the wounded of yesterday.

And now for those matters which concern the surgeon much more directly. In any kind of surgical unit whatever, if one wants to make a series of laparo- tomies, one must have a unit specially intended for abdominal operations, and for those only ; a complete staff, so that the surgeon, before deciding to operate, will never have to weigh their relative usefulness for

CONDITIONS AND SURROUNDINGS 169

abdominal or other wounds, but who are assigned solely to a specific task (but not therefore necessarily less interesting or less common).

In a surgical automobile ambulance, internal or- ganisation, and division of labour are of the utmost importance ; of the three or four units of which it is composed one can be set aside for laparotomies.

In a surgical centre where there are many ambulances working at the same time an effort should be made to concentrate all abdominal wounds in one department.*

In all ambulances the question is a difficult one, for there are at most only one or two surgeons, and each has enough to do when from 100 to 150 inevacuable wounded arrive in the twenty-four hours f ; each doctor does his utmost to the limit of his endurance, and that may last for two, three, occasionally even four days. Then follows a period of calm, and then it is that one makes the returns of the abdominal cases which remain or have vanished !

At this moment of stress, then, there should be available a supplementary unit — perhaps two, but one at least which should be strictly kept for abdominal wounds. And when I say a unit, I mean a complete unit : surgeon, assistant, anaesthetist, orderly, and everything that is necessary : instruments, operating plant, sterilisation plant, and all kinds of dressings. This unit should not have to borrow anything from the ambulance which it comes to help and relieve, nothing but two stretcher-bearers (working almost continu- ously) and some kind of premises. And if no kind of

* In June and July 1915, when I was the only surgeon in our ambulance, I was able, with the help of my confreres, to examine 943 wounded in a month, and to operate personally on 627, an average of 20 a day, with on three occasions a maximum of 62 and 60 a day. We were only dealing with grave cases of men not able to be evacuated, and the operations were under general anaesthesia.

f Some recent changes have proved that the specialisation of services, the direct and rapid transport of the wounded, and im- provements in outfit can be obtained even without being asked for.

170

WOUNDS OF THE ABDOMEN

Fig. 56.

fl p i Orders HfSpj iCbmparbjmcnl

I <=

Flap Scat

FIGS. 36, 37, and 38. — Surgical automobile for operations close to the front. (Abadie.)

premises are available (four walls and a roof), one must con- sider the possi- bility of the re- inforcing unit bringing with it a portable ope- rating-theatre. " But you are describing, then, a n automobile surgical ambu- lance ? That al- ready exists ! " No, certainly not ! What is needed in an emergency is an

FIG. 36. — Chassis 20 h.p., 8 cylinders seen from above.

FIG. 37. —Bight side view.

FIG. 38.— Left side view.

CONDITIONS AND SURROUNDINGS 171

arrangement for immediate reinforcement, simple, pliant, and mobile. (It is not possible to confuse the two things.) Two automobiles (not wagons) would be enough ; perhaps even one only.

In a survey made in December 1914,* I described, with all the details of its arrangement, an automobile which should allow a surgeon to travel quickly to any given point with what I call " his ordinary operating outfit " (Figs. 36, 37, 38). In my opinion this survey lost nothing on account of the practical side which I endeavoured to give it. No operating-theatre was provided for, however ; and one might be useful. There are two ways of solving the difficulty : either by adding to the weight of this surgical automobile by panels necessary for the construction of an operating- theatre (that would necessitate turning it into a heavy and slow wagon), or, by adding, if necessary, to the automobile already described another light car which would carry the constituent parts of an operating- theatre, and finally one could add a radiological plant, as in the unit given by Mme Fould and described by Boigey.

These different units, the surgeons and autos, would in the ordinary way be at the disposal of the Director- General of Army Medical Service who could thus rein- force any particular over-worked ambulance by sending it a supplementary unit.

It has been objected that such a unit would not always be well received, and that the wounded whom it could treat for only two or three days, and would then have to turn over to the care of the ordinary am- bulance, would receive less interest and attention. . . .

To think this is, I believe, to fail to realise the state of mind of an overworked surgeon who feels the stream of wounded behind him growing greater and greater, who will no longer venture outside the operat- ing-theatre, so painful to him is the sight of the anxious

* Presse medicale, February 1915; supplement, p. 38.

172 WOUNDS OF THE ABDOMEN

eyes turned towards him, and who, transformed into an operating machine for hours and hours, has but one desire — to make only those movements which are abso- lutely necessary, so as to gain time, and to economise his own strength that he may last out. How would it be possible not to welcome joyfully those who come to help you to care for the poor waiting men before it is too late ? And how, later on, would it be possible not to look after, as if they were one's own, the cases of laparotomy which have had the exceptional luck to be saved by an opportune operation ?

It is objected also that the laparotomy cases will crowd up the hospital wards of the ambulance. Not more so, once operated on, than by waiting there to be cured without operation ; ... at least, not unless it is suggested that in the cases of no operation a greater number of beds will soon be emptied of their occupants !

" But," it is asked further, " what will be the output of a unit entirely occupied with laparotomies ? " One can allow, I think, that without any considerable strain (at any rate, for eight or nine days), a unit in working order can put in twelve hours a day of work at high pressure ; the number of laparotomies which a surgeon can do in a day is between eight and twelve. If, in conformity with the statistics of results furnished by laparotomy, a unit has the satisfaction at the end of the day of having saved four or five wounded who would otherwise have been condemned to death, its labour will not have been in vain.

The desire for mobile units is not new.

We have seen them suggested in the course of previous wars (Chap. II.). And the necessity for specialisation * is also proved by many surgeons of our Army — men who are not mere plagiarists, but

* Evidently it is a long way removed from the usual tendency of having men, methods, units, all interchangeable ; it is much less simple than having passe-partout (master-key, to fit any lock) Field Hospitals, or passe-partout doctors, who will be limited to the passe-partout operation — Murphy's !

CONDITIONS AND SURROUNDINGS 173

who, having worked at the front and known its exigencies, are quite agreed on this point ; amongst them are Leriche, Delay, Simonin, Gregoire, and quite recently Monprofit.*

Agreed ! That is all very well in trench warfare, in the " abnormal " war which we are passing through. What will happen to all these improvements in a war of movement ?

For here we have the double notion generally ad- mitted of which R. Picque f has made himself the exponent : " There are two kinds of military surgery : the false, that of preparation or stationary conditions which permit the application of all the surgical prin- ciples of peace-time ; and the true, that of active conditions during which, in spite of all that can be done, those wounded in the abdomen will probably suffer."

It may be objected that this conception of a true war (that of movement) and of a false war (that of the trenches) ought to be relegated to those other attitudes of mind which the present war has shown to be out of date.

" We are not able to believe," wrote Humbert in the Journal, "that this long immobility of armies face to face in entrenchments blocking all the available space from the sea to the mountains is merely an accident, a more or less abnormal phenomenon, destined never- theless to come to an end some day, to give place to the real war, a war of movement, the doctrine taught by the professors of Napoleonic tactics. No, this stagnation, these interminable bombardments, this mechanical pounding at human lives, this is war, the war of to-day, the war in which we are engaged, the war which we have to carry on ! "

The differences of opinion about this matter vary little. Stationary warfare has shown itself to be long

* Soc. de Chir., May 10th, 1916; Butt., p. 1159.

f September 13th, 1915 (Presse medicate), Fifth Army.

174 WOUNDS OF THE ABDOMEN

enough and wasteful enough of men for us to realise that every kind of organisation which has been able to diminish the waste (even if attached to special tactical conditions) will be amply justified !

But will a war of movement really invalidate all the conclusions at which we have arrived ? No, certainly not. It will oblige us still more to make the autochirs independent and mobile, and, thanks to their mobility, to concentrate them at the points where the influx of wounded is greatest and to make them work in connection with the railways. It will necessitate for the ordinary ambulance an equipment which will make quick surgical work possible. It will show the still greater need for mobile units to reinforce the others. The main thing will be to use wisely those resources which we actually have at present.

There will perhaps be room also for an arrangement, so far non-existent, although previous wars have shown its necessity : viz. the surgical train. During the Russo-Japanese War operating-theatres were impro- vised in railway carriages ordinarily used for passengers or goods, and at the moment when peace was concluded a train of this type was ready in every important rail- way-station.

Hautefort [8a] describes an arrangement of this kind. How often has many a surgeon at the front ardently wished that he could operate actually in the train itself ! Then the wounded, thus become evacuable, would pass directly from the operating-theatre (so easy to arrange in a railway carriage) to the train which would carry them away ! More than three- quarters of those operated on are ready to go away at once ; the others would go to the hospital huts in the neighbourhood. How much greater rapidity, both in attention and in evacuation ! What simplifi- cation of transhipment ! What delay and shaking spared to the wounded ! What economy, in fact !

CONDITIONS AND SURROUNDINGS 175

Once more the axiom would be verified that " the railroad is the beginning and the end of the military medical service during the battle " (Follenfant). So many simplifications which would, as a natural conse- quence, set free many units and premises for the rational treatment of abdominal wounds.

Conclusions. — Study of the conditions necessitated by the application of laparotomy to penetrating abdominal wounds leads us to two kinds of conclusions ; one concerns the general organisation, the other that of the conduct of the surgeon himself.

Is it not the part of those who are working and ob- serving in the front zones to give by facts, impressions, and arguments suggestions for the consideration of the organisers themselves and for those who, from head- quarters, preside over the general arrangements ? To them we say :

1. Abdominal wounds are by no means negligible ; on the contrary, both by reason of their frequency and by the statistics of possible recoveries, they claim that special means should be devised by which the good results can be still further increased.

2. The specific treatment is laparotomy. " Every argument opposed to this encourages inertia and error ; it is pregnant with dangerous consequences and con- trary to surgical truth."

3. Neither insufficient equipment nor delay in trans- port are obstacles to the practice of laparotomy if :

(a) The ambulances set apart for surgical use are regularly provided with the equipment necessary for rapid work wherever they may be ;

(6) Autochirs are used as they ought to be ;

(c) The specialisation of departments is organised ;

(d) Mobile units for reinforcements are created. And, above every other consideration relative to the

wounded man himself, there are two reflections which ought to guide the personal conduct of the surgeon.

176 WOUNDS OF THE ABDOMEN

1. The surgeon at the front ought to try by every means in his power to obtain those general operative conditions which alone can make possible the best treatment for abdominal wounds, which both in war as in peace is laparotomy.

2. But if he has any doubt of himself, any distrust of his assistants, if he has not both the necessary instru- ments for the operation and the means of sterilisation ; if he can only operate with anxiety with regard to these matters, or if he is placed in such circumstances that a laparotomy will prevent him from attending in time to one or more other wounded whose cases are urgent, not only can the surgeon at the front be excused for not performing laparotomy, but indeed it is his duty not to operate, and it is not on him that the responsibility for this helplessness lies.

PART III

OF THE METHODS TO BE ADOPTED IN THE PRESENCE OF A DEEP-SEATED ABDO- MINAL WOUND

12

CHAPTER VII

DIAGNOSIS OF THE LESIONS— INDICATIONS FOR OPERATION

H- - wounded November 30th, 1915, had a "seton " (tunnel-wound) of the right flank by the splinter from a shell found in the dressing ; on account of its very oblique direction, although its centre was nearly 5 cm

SZS fn, this '<Set°n" appeared to us laterol peritoneal, but not deep-seated. T 37° • P 93

Healed

Here is an abdominal wound on which we did not operate. Why? Because clinical examination showed almost certainly that there was no penetration.

Br--, wounded May 1st, 1916, showed an ab-

dominal wound from a shell-splinter which entered by

1Jgr axillary line opposite the tenth rib ; explora-

tion led ^ obliquely towards the right anterior superior

^ "" °

He was operated on • exploration of the track led to actual contact with the peritoneum and its

erit ; Pr°eCte WaS ^ged outside

normal m; counter-°Pening J drain; healing

Here we made an incision. Why? Because indi- cations and symptoms were contradictory, there was

179

180 WOUNDS OF THE ABDOMEN

doubt as to the penetration. (The operation was, however, stopped at the intact peritoneum.)

• • • • •

D , September 26th, 1915, had a deep-seated

wound below and to the left of the umbilicus made by some small projectile ; the probe went easily through the wall. But there was no abdominal pain ; the abdomen was supple ; general condition excellent. T. 38°' 4 (101-1° Fahr.); P. 96.

Besides, the wound was received thirty-six hours before. No operation. Cured. The radioscope showed a small shell-splinter projecting on the left of the vertebral column in the lumbar region and at the same depth as the vertebrae.

In this case the penetration was undoubted. Why was there no operation ? Because there was complete absence of abdominal symptoms and because the absence of all reaction was the more significant when thirty-six hours had already elapsed.

L , March 31st, 1916, had a penetrating wound

at the side of the right flank ; the right half of the abdomen was painful ; general condition good ; T. 38°' 2 (100-75° Fahr.); P. 120. The operation showed that the wound went right into the abdominal cavity ; There was found a perforation of the colon and besides that an appendix just on the point of suppurating ! Recovery.

Why the operation ? Abdominal penetration was certain, it is true ; but the seat of the wound in the flank and side would have made it legitimate not to operate, and all the more so as the general condition was good and the abdominal symptoms localised. But there, again, there was doubt as to the nature of the visceral injury ; it was better to operate.

• • » . •

M , September 17th, 1915, had a deep-seated

DIAGNOSIS AND INDICATIONS 181

wound from a shell-splinter 6 cm. above the right iliac spine. The abdomen was very painful ; parietal rigidity very marked ; no flatus, face drawn, pale, nose cold. T. 38° (100'4° Fahr.) ; P. 100. Immediate laparotomy disclosed two extensive and irregular longitudinal lacerations of the small intestine and a perforation of the caecum. Recovery.

There was no hesitation possible here. There was penetration ; there were undoubtedly serious visceral injuries ; the patient was in good condition. Prompt laparotomy was successful.

H , April 29th, 1915, had an extensive wound in

the buttock near the anus ; blood, faeces, and urine were flowing from it. The abdomen was painful. There was intense shock ; the patient was bloodless, respiration faint, cold, pulse hardly detectible. One would have thought any operation impossible. But an injection of caffeine citrate, camphorated oil, warmth and rest restored the patient ; two hours later one felt justified in making an incision. It was a complicated case ; two perforations of the small intestine, a vast laceration of the bladder, and a laceration of the rectum were disclosed. After many ups and downs, the man recovered (see p. 255).

Here we have a case of abdominal wound with serious lesions inoperable on account of shock, where it is necessary to delay the operation ; preceded by an active tonic treatment, an operation later on may meet with unexpected success.

L , January 14th, 1916, received a deep-seated

wound from a bullet which entered at the level of the ensiform process of the sternum and went out at the posterior axillary line between the eighth and ninth ribs. A little fluid of a bilious nature trickled from the gastric orifice. P. 76; T. 37°'5 (99*5° Fahr.).

182 WOUNDS OF THE ABDOMEN

No abdominal reaction ; slight thoracic haemorrhage at the back. Recovery.

The indications were against operation, as this was an dbdomino-ihoracic wound without any alarming symptom either of haemorrhage or of visceral lesion.

L , on the contrary, April 22nd, 1916, showed a

large " seton " extending from the thorax to the right side of the abdomen, with a wide opening in the pleura between the tenth and eleventh ribs, hernia of a loop of the colon with the omentum and wound of the liver and constant haemorrhage. Incision made, the pleural cavity was closed by pressing up the diaphragm to the pleural wall, and the colon and omentum were cleaned. Nevertheless, death took place in a few hours. (See Fig. 27.)

Here the situation was almost desperate, but an operation might possibly give a chance of recovery, so the incision was made.

As a final example : P , September 26th, 1915,

had a large abdominal wound, to the left of the umbilicus, from which several loops of intestine were hanging, many of them perforated. The man was cold, hardly answered when spoken to, had no pulse. No treatment succeeded in overcoming the shock. Death.

What would be the use of attempting a laparotomy predestined to failure ? One simply does not operate.

The clinical examples we have chosen range from deliberate non-operation to non-operation due to impotence, and from laparotomy performed unhesi- tatingly to laparotomy undertaken " to satisfy one's conscience." We have purposely contrasted these, one with the other. These are, in fact, typical cases round which are grouped the different contingencies

DIAGNOSIS AND INDICATIONS 183

with which the medical man may have to deal. But it is noticeable that in each case there are very distinct reasons for determining the action to be taken ; this is a clear proof of the interest which attaches on the one hand to the clinical diagnosis of the lesions, and on the other to the discussion of the indications for or against operation.

Here is an abdominal case. The examination must be brief, the decisions clear.

The interrogation consists of eight questions :

1. Time when wound received (note on label).

2. Cause of wound (ditto).

3. Position. Then follow :

4. Pain ?

5. Vomiting ?

6. Stools ?

7. Flatus ?

8. Micturition ? That is all.

The examination includes :

1. Inspection of the orifice or orifices made by

the projectile (the position, form, contents, discharge). The investigation of :

2. The pain produced and the contraction due to

rigidity, general or local.

3. Are hepatic resonance or dullness in the iliac

fossae and flanks present ?

4. Pale face, discoloured mucous membranes, cold

nose, dark rings round eyes ;

5. Cold extremities.

6. Dyspn&a, restlessness.

7. Pulse (frequency, compressibility).

8. Temperature ; sometimes probing of the wound,

catheterisation of the bladder, examination by the rectum, and pulmonary auscultation.

184 WOUNDS OF THE ABDOMEN

This done, the surgeon asks himself two essential questions, and two only :

First. — Is the wound a penetrating one ?

Second. — Are the viscera (especially the small intes- tine) injured ?

The clinical diagnosis of the injuries is limited to these points because these are sufficient to determine the course of the treatment.* One factor alone can now modify the decision as regards operation, based on the state of the wound ; that is, the general condition of the patient.

Is there shock ? Laparotomy may be perhaps deferred with advantage.

Is there haemorrhage ? The operation should be made without delay, and any such wound as seemed likely to do well without operation calls for an immediate interference.

This concludes the therapeutic indications.

A. CLINICAL DIAGNOSIS OF THE LESIONS

The first question is :

1. Does the Wound penetrate the Cavity of the Abdomen ?

In certain cases there can be no doubt ; when through one of the orifices there is hernia of the omentum or of a loop of the intestine either full or empty.

Or perhaps there trickles from a gaping hole, large or small, a stream of blood sometimes mixed with in- testinal fluid ; the exploring forceps or the finger goes freely into the abdominal cavity.

There, again, penetration is evident.

But, for the most part (and these are just the most

* One might ask oneself also : Is peritonitis present ? But this question has no practical value. Peritonitis certainly exists, but in a variable degree whenever one operates for an abdominal wound ; at this stage it is only an additional symptom which does not in any way affect the decision already taken, and where general peritonitis is verified, when it is sure enough to make an operation useless, this operation has already been made impossible on account of the delay between the reception of the wound and its examination.

DIAGNOSIS AND INDICATIONS 185

interesting cases because they afford much greater scope for effective treatment), the injury is slight, already plugged by a clot of blood or by the super- position of the muscular and aponeurotic tissues. On what shall we rely to establish penetration ?

(a) On the course of the projectile. — A passage ending in two orifices would seem to give absolute certitude. Often it does, but sometimes it does not ; for instance, oblique passages near the groins, and the hypochondria, and where the orifices are close together. The further off the wounds are from one an- other the more likelihood there is of penetra- tion ; but one must take into consideration the thickness of the wall (which one thinks of sometimes as much thinner than it really is ; Fig. 39 gives the proportions) ; one must also take into ac- count obliquity in the vertical direction which lends itself to long tangential tracks (Fig. 40). Certain positions involving torsion of the thorax, and muscular protuberances, explain paradoxical occurrences. After the parts affected have been straightened out a course of the projectile, however rectilinear, would show an improbable path.

In fact, even with the modern projectiles, if they are at the end of their flight, the passage might be bent inwards by cleavage of layers of muscles ; these

FIG. 39. — Horizontal section of the abdo- men showing the respective dimensions of the walls and of the peritoneal cavity. One sees that the tangential passages may correspond (as regards the projectiles) to orifices of en- trance and of exit at great distances from each other.

186

WOUNDS OF THE ABDOMEN

Rxiv

Rx(Lap.)

passages, following the contours of the thorax or the abdomen, were more frequent with the old-fashioned projectiles.

Although very exceptional, it is not impossible for the two orifices to be situated nearly at the ends of an antero-posterior diameter and for the wound to be

tangential. Quenu, in a case where the en- trance wasfound near the ante- rior median line and the exit at a distance of a breadth of four fingers from the posterior me- dian line, cut into it along its whole extent and ascertained that the whole of the walls, with the excep- tion of the peri- toneum, were involved. In the transverse direction the same fact may be observed. Rouvillois was thus led to make an exploratory laparotomy, this being the only means of verifying that a bullet going in at the right flank and coming out at the left, at a symmetrical point, had remained intrapa-

FIG. 40.— A— Abadie. B— Bouvier and Caudrelier. R — Rouvillois. Parietal wounds, not penetrating, operation performed. Notice the very great distance which often separates the two orifices without, however, the perito- neal cavity being involved.

DIAGNOSIS AND INDICATIONS

187

rietal during the whole of its course. (See also Quenu [«].)

Severe injuries may lay bare the peritoneum with- out perforating it, and allow the underlying viscera to show through ; if forced out by coughing, they form a large, tight hernia ; we have several times seen wounds of this type. On the other hand, it may be necessary, in order to understand it, to separate the

Gluteal artery

R = Rectum AS=Sfgmoid flexure

FIG. 41. — Horizontal section of the pelvis showing the usual passage of deep-seated wounds in the buttocks. Some of them cause profound hsematomata, others perforate the pelvic viscera.

contused lips of the wound which by their approxi- mation conceal the depth of the gap.

When there is only one orifice, and not two, the diagnosis becomes more difficult. Where is the pro- jectile ? We do not know its depth nor even the direction of its course. Probing will only occasionally give information ; the too sharp point of the director, or Kocher's forceps, even the blunt point of a clamp, straight or curved, otherwise preferable, can only with difficulty pierce through the layers of the abdominal wall. One conies to an end or allows oneself to be

188

WOUNDS OF THE ABDOMEN

deceived by a false passage. And more often than f not the position of the projectile remains unknown. I One will be considered intra-abdominal though it really remained outside the peritoneum. (These are ' the cases which serve so largely to swell the statistics ; of the " abstentionists " !) And another will be con- 1

side red purely I parietal though j it has really j pierced the peri- I toneum. But! if it is only ; slightly mislead- ing to suppose a i wound deep- seated when it is not, even if this leads one to an explora- tory laparoto- my, it is more serious not to recognise a deep wound, the tardy discovery of which will be too late to allow of a successful treatment.

Since we are talking of wounds with only one aper- ture, we cannot insist too often on the frequency

CIP= Post-sup, iliac spine. R*= Rectum.

FIG. 42. — Typical deep-seated wounds of the buttocks. — (1) Path of projectile injuring the gluteal artery or one of its branches ; haema- toma, infection. (2) Path of projectiles en- tering by the sciatic notch, injuries of the higher part of the rectum and of the sigmoid flexure or of the small intestine. (3) Passage of projectile which may remain extra-perito- neal but injure the rectum, the bladder, and perhaps the bony walls of the pelvis.

of abdominal penetration in wounds of the buttock. * This * This fact should be noted in connection with the invariable

DIAGNOSIS AND INDICATIONS 189

penetration is often unrecognised ; then peritonitis discloses the seriousness of a little harmless-looking opening ; it is too late, and the patient dies, for I have scarcely ever seen a buttock wound with abdominal penetration cured by " abstention." One must, there- fore, be particularly on one's guard against it.

We must be on the look-out for it, too, in the case of long tracks across the buttocks ! In " two cases," says Rouvillois, " the projectile had gone right through the bases of the two buttocks above and behind the great trochanter. It was only the autopsy which showed us, in the one case, a perforation of the rectum on a level with Douglas's pouch, with ecchymosis in the sigmoid flexure, and in the other a lesion of the rectum clearly intraperitoneal."

(6) Is the abdominal syndrome sufficient and suffi- ciently constant to complete or supply the place of knowledge of the course of the projectile ?

Spontaneous abdo'minal pains, tenderness on pres- sure, defensive contracture of the muscles of the abdomen, stoppage of fseces and vomiting, rapid pulse and a poor or bad general condition, clearly constitute a series of probabilities which, taken together, entitle us to diagnose almost certainly a peritoneal lesion.

All these different indications, however, have not the same demonstrative value.

The most constant is the rigidity of the abdominal walls. This has the advantage of being one of the

gravity of wounds of the buttock, which go deeper than the skin. When fragments, especially of shells, bombs, or grenades enter the muscular masses, beneath a cutaneous orifice sometimes little more than a puncture, we find serious damage ; muscles pulped, hsematomata, rupture of the gluteal or sciatic arteries, even detachment of the rectum. If this amount of destruction be compared with neighbouring wounds due to the fragments of the same shell, it would appear that the muscular masses of the buttocks offer scarcely any resistance. Practically we might say " Bulging wound of buttock, hcematoma ; look out for pulped muscles and gan- grene, beware of rupture of th» gluteal or sciatic vessels t But with a wound of the buttock without evidence of projectile, flat buttocka, beware of abdominal penetration I " (See Figs. 41 and 42.)

190 WOUNDS OF THE ABDOMEN

first symptoms ; but it is not really conclusive unless it is general all over the abdomen. If local it only enables one to diagnose penetration when the localisa- tion is some distance from the entrance of the projectile

Absence of flatus comes second. Every time that a patient is able, after the accident, to expel gas by the anus, one can be positive that there is no penetrating abdominal wound. The contrary is not true, at least m the early stages, and the absence of wind is not sumcient to allow us to diagnose penetration.

Spontaneous pains are a symptom of great proba- bility, but are liable to be slow in developing • when a man is just removed from an ambulance, one hardly knows whether or not to attribute these pains merely to the journey in the automobile. Whenever a wounded man complains incessantly of his abdomen wound °St °ertainly suffering fr°m a penetrating

From the general condition it is difficult to draw immediate conclusions. One slight wound may be accompanied by a grave general condition; with another the pulse and skin are little altered, although there are extrusion of the viscera and extensive wounds of the colon and small intestine. Practically, however one must own that a bad colour, with weak and sinking pulse, which do not rapidly improve under morphia are signs of a severe penetrating wound

Vomiting has little diagnostic value, as it accom- panies wounds of the thorax, and head, and even of e hmbs Its persistence or recurrence becomes significant, but only in the later stages.

The same may be said of the absence of voluntary micturition. In fact, there are signs suggestive of pene- tration of which some have a very real significance • none of them is pathognomonic, but when taken alto- gether they are conclusive.

But one must never forget that the whole series may only be roughly indicated or incomplete during the first

DIAGNOSIS AND INDICATIONS 191

hours — that is to say, just when the decision to operate or not may be most useful. And one could not defer the operation in order to wait until they were all developed.

Another cause of mistakes. — All these symptoms, isolated or grouped, may be found with abdominal wounds which are not penetrating. This has been called the " paraperitoneal syndrome."

Our case 1 ["] is typical in this respect.

Rouvillois in the case of a wound caused by a small projectile which had entered above the pubic sym- i physis, observed general abdominal pains with resist- ance of the walls and slight tympanites ; vomiting and pulsation of the nostrils were observed ; pulse 120, and a poor general condition. But an operation i took away a small shell-splinter from the wall of the abdomen and some bits of clothing ; the abdominal symptoms disappeared rapidly.

Jean Quenu [60] has collected, in a very interesting study, nine observations of the same kind — that is to say, of parietal wounds with peritoneal symptoms.

But the " paraperitoneal syndrome " may also accompany wounds seated elsewhere than in the abdomen.

First of all, in the loins. And this is often caused by an injury to the genito-abdominal nerves.

In the same way thoracic injuries may lead one to a wrong conclusion. Why should we be astonished ? Are we not familiar with false peritonitis, and the false appendicitis which accompanies pneumonia ? The same thing happens with injuries, and the following case-report is characteristic in this respect.

A shell-splinter entered in the left axillary line, the width of two fingers above the lower margin of the ribs. The patient's abdomen was painful on pres- sure, especially towards the right side, and slightly distended, breathing difficult and distressed ; no flatus, pulse 88, temp. 37° (98*6° Fahr.) the absence

192 WOUNDS OF THE ABDOMEN

of vomiting and spontaneous micturition were morl reassuring. The projectile was removed from immejj diately below the inferior costal cartilage. Neithe\ pleura nor peritoneum was injured. (Rouvillois [S6~ Obs. xiv.)

But one may be obliged to perform laparotomy ii order to dispel all doubts ; Clermont did this at leas j twice.

The grazing of the wall of the diaphragm by a pro I jectile free in the pleural cavity produced in one of Picque's patients a general contraction of the ab '• dominal walls, although on one side this was slight.

Finally I will cite a case of my own which is quitt* exceptional.

Wounded in the lumbar region, the patient com- 1 plained of violent pains in the abdomen — so violent as to make him cry out ; the least touch increased the]1 pains ; there was distention ; no flatus ; no micturition^ P. 92; T. 38*2° (100'75° Fahr.). But surgical ex- ploration led to the transverse processes of the second; lumbar vertebra ; shattered by a shell-splinter which! was still in contact with them, they pressed on the] posterior fibres of the spinal cord. Thence came the! visceral crises which were only one element in a com-\ plete syndrome reminding one of tabes. After laminectomy we observed daily improvement.

Lastly, we must remember that the rigidity of the1 abdominal walls may be due to injection of antitetanic serum.

To sum up : Diagnosis of penetration is generally! easy when we know the course of the projectile, apart from the existence of the abdominal syndrome, but properly speaking a warning symptom does not exist.

Rigidity of the abdominal wall is the most trustworthy symptom, especially if it is general ; it is the symptom which must be looked for and analysed with the greatest care. The diagnosis may remain undecided. In these cases a direct exploratory surgical examination

DIAGNOSIS AND INDICATIONS

193

is necessary, and, if free opening up is anatomically impossible, an exploratory laparotomy may be the last resource ; one must not hesitate to employ it. A superfluous laparotomy is not a very serious matter ; an unrecognised penetration is only too often fatal.

2. What Viscera are injured? Is the small Intestine affected ?

It would seem more instruc- tive to pass or- gan after organ in review and note how each one "pro- claims" its wounds. But does the sur- geon eliminate organ after or- gan like this ? No ! He infers the possibility of the injury of one organ rath- er than of an- other, by the actual position of the wound.

A topographical FIG. 43.— Diagram of the abdominal regions.

classification Topographical distribution of abdominal

J — _* J '_ ^_ j_ ^ J_T ^_ • Jl

guides his in- vestigation. We will follow the same plan.

Here are

some cases where the diagnosis is easy. A visceral hernia shows at once what lesions are present, such as laceration or wound of the liver or the spleen, 13

wounds according to their seriousness and their varying tendency to spontaneous re- covery. Wounds in the clear or slightly shaded region give the best chance of recovery; those in the darkly shaded region are the most serious.

194 WOUNDS OF THE ABDOMEN

perforation of the stomach, perforations in parts of the small intestine, or of the colon. But it would be a dangerous mistake to suppose that all the injuries received are visible and that a given artificial anus is providential ; one will almost always find in the abdomen other and more serious in- juries, and it is necessary to make a surgical ex- ploration. In the same wray, because the omentum alone is exposed, one must not conclude that there are no internal injuries ; only too often there exist deep- seated visceral wounds which need examination, and the plug formed by the omentum, which closes up the abdominal cavity, is neither beneficial nor re- liable !

Let us now go back to the diagram which the study of anatomical injuries has led us to adopt and which divides the abdominal walls into regions of varying importance (Fig. 43).

(a) A penetrating wound involves the umbilical region : one can almost certainly infer lesions of the small intestine and the transverse colon. In this case the transverse colon should be considered separately from the rest of the large intestine ; the variations of its level in different patients, its very great mobility, and its exclusively intra-peritoneal situation, make it analogous, from the point of view of the injuries, to a loop of the small intestine. Doubt- less there exist verified cases of projectiles having traversed the umbilical region from one end to the other or having remained loose in the abdominal cavity without any injury being done to the intestine. Wallace's diagram furnishes examples of these, on which we have already dwelt in Chapter IV. (see p. 72). But such cases are so exceptional as to be practically negligible. It would be subjecting the patient to too great risks if one dared to refuse to operate because of the possibility of such a providential coincidence ; only the most complete absence of all abdominal

DIAGNOSIS AND INDICATIONS 195

symptoms would justify such action. That is to say, it would hardly ever occur !

As a matter of fact, injuries in the umbilical region are regularly accompanied by a typical peritoneal syndrome, generalised pains, parietal rigidity, stop- page of faeces and wind, vomiting, and rapid and feeble pulse — that is to say, all the symptoms which we have shown accompany penetration.

If certain of these are accentuated it enables us some- times to conjecture the seriousness of any given visceral wound. Continuous and intense spontaneous pains often accompany extensive laceration, actual section, or many perforations of the intestine. General rigidity of the whole abdominal wall, with heavy expirations (as if the patient " was sawing wood ") indicate severe visceral wounds sometimes accompanied by great loss of blood.

Absence of flatus is almost constant.

Repeated vomiting is an unfavourable symptom . But, above all, it is the pulse that one must watch ; its frequency up to 120 and above, its low tension, its intermittence, especially if the face is pale and the features drawn. These are all indications of a serious wound.

And if these signs persist after the pain has been subdued by morphia, the diagnosis is quite clear.

Temperature is of no special importance unless very low or very high ; 36'5° or 39'5° (97*7°— 103° Fahr.) are new indications of gravity. From a temperature of 38-5° (101-5° Fahr.) one can deduce nothing.

Prehepatic resonance is a well-known indication of intestinal perforation with free gas ; it is, however, of very rare occurrence. If, however, the causes of the wound are known, then the rigidity and pain would make this sign unreliable.

The same is true of the dullness of the flanks and ^l^ac fossce, which is a logical but frequently absent sign of extravasation and haemorrhage.

196 WOUNDS OF THE ABDOMEN

In one case of a wound in the small intestine Schwartz and Moquot detected a sort of splashing in the right iliac fossa.

With the exception of this symptom and the pre- hepatic resonance, other symptoms are those of simple penetration.

To sum up : In practice a penetrating wound in the umbilical region will always be supposed to have injured the small intestine, or the transverse colon, either alone or associated with other viscera. And, without operation, the prognosis will always be con- sidered hopeless ; even after operation it is still very serious.

(b) The hypogastric region, with the inner parts of the iliac fossae, comes second as regards gravity. Here, again, it is the small intestine which is very frequently injured. The seriousness is a little less because the pelvis, " the main drain," is nearer, and gives occa- sionally opportunities for spontaneous localisation. But here, too, we find the peritoneal syndrome as in the umbilical region.

In the neighbourhood of the pubes the bladder should be suspected. A urinary fistula may very quickly develop. But, as a matter of course, if the patient cannot pass water the bladder must be caiheterised, and the character of the flow noted. Bloody, red urine, sometimes containing clots and passed with difficulty, indicates a small but not gaping perforation of the bladder.

A slow, frothy flow of blood mingled with urine, or one which falls drop by drop like the discharge from the ureter, indicates a large wound of the bladder which drains into either the pelvis, the region round the rectum, or the rectum itself.

One must also make an examination of the rectum^ for the rectum is very frequently injured, either in the peritoneal portion or lower down.

The usual position of the ilio-pelvic colon is in the

DIAGNOSIS AND INDICATIONS 197

left iliac fossa, near the median line. Here, again, the colon presents the same features as we have seen in the transverse colon. Its position as an intra-peritoneal organ varies according to the patient and its state of mobility. Hence the seriousness of its perforation, all the more so because the contents of the colon are very highly septic. One fairly frequent symptom is the red stool — after abundant evacuation ; but this is slow to appear, and is not of any great practical value.

To sum up: An injury above the pubes suggests a perforation of the bladder, of the rectum, or a loop of the small intestine ; an injury in the upper part of the hypogastric region, or the iliac fossae, suggests the small intestine and the colon, more especially the ilio-pelvic colon. These wounds have a very grave prognosis with or without an operation ; as a matter of fact, one should look upon them as quite as dangerous as those of the umbilical region.

(c) The flanks and the outer parts of the iliac fossae represent the vertical boundaries of the regions of the colon. Here a very clear distinction can be made between the different kinds of injuries.

A tangential breach with gaping lips and lateral perforation of the colon forms a traumatic false anus, of slight gravity. A lateral and oblique tunnel wound with entirely localised symptoms and with no involve- ment of the general condition leads one to conjecture an extraperitoneal perforation of the colon : prognosis favourable. The same is true when a single very lateral wound produces no abdominal symptoms.

But a wound with only one orifice accompanied by abdominal symptoms, or a wound near the umbilical region, ought to be considered as penetrating the viscera and as serious wounds because they lead either to the small intestines or to the colon in its free peritoneal portion, and also because here there is a danger of highly septic matter finding its way into the abdomen.

198 WOUNDS OF THE ABDOMEN

(d) The upper part of the abdomen comprises three parts.

The right hypochondrium is the region of the liver ; every penetrating wound in this region will certainly injure it.

The left hypochondrium is occupied by the stomach, the spleen, and the upper end of the descending colon. The central epigastric triangle leads on the right to the liver and the gall-bladder, on the left, to the stomach.

Are there any absolutely sure symptoms of hepatic penetration ? The continuous oozing of dark blood is strong presumptive evidence; a discharge of bile immediately or during the next day or two is a positive symptom.

With regard to the stomach, local pains and vomiting are frequent, but not constant ; haematemesis is a positive symptom, but is rather unusual.

Perforation of the spleen produces no other symp- toms than haemorrhage. Generally speaking, one may consider that penetrating wounds of the upper part of the abdomen have a favourable prognosis.

Quenu only considers as benign wounds whose course is quite above the horizontal line of the costal margin. Certain reservations, however, must be made.

As regards the stomach, there is danger of escape of faeces into the main abdominal cavity; if the wound occurred soon after the patient had taken food, the stomach would be distended and there would be signs of general peritoneal reaction. There might be danger, also, of double perforation with haemorrhage in the posterior cavity of the omen turn (the diagnosis is difficult, but is suggested if there are indications of haemorrhage and sharp, deep-seated pains, with increasing swelling in the sub-gastric region), or there might be actual section of the vascular liga- ments of the stomach, or of the arteries which surround it (signs of haemorrhage). In the case of the liver and

DIAGNOSIS AND INDICATIONS 199

spleen, the danger arises from profuse and prolonged haemorrhage.

In the case of all these organs a common cause of aggravation is the existence of injuries to other hollow viscera, such as the transverse colon, or the small intestine, or to the large blood-vessels.

From all these contingencies, and from the anatomical characters which differentiate the liver, the spleen, and the stomach (fixedness of the first, friability and mo- bility of the second, the hollow nature of the third), it follows that, generally speaking, wounds of the left hypochondrium are more serious than those of the right, and also equally more serious than those of the epigastric region.*

But here we note a very common complication of penetrating wounds in the upper part of the abdomen to which we attach great importance ; that is, the co-existence of thoracic injuries. Thoraco-abdominal wounds are found under two very different conditions.

The passage of the projectile through the abdomen has not produced any serious injuries ; there is neither a large wound, nor visceral hernia, nor symptom of intestinal laceration, nor sign of haemorrhage ; the whole diagnosis is dominated by the thoracic

* An autopsy happens to demonstrate an anatomical arrangement of the parts which shows how variable are the relations of the gut to the parietes. Examination of two photographs of Plate I, shows that, in certain subjects, the transverse colon descends to the neighbourhood of the umbilicus, or even below it, and that numerous coils of small intestine may be found beneath the transverse colon. The photograph, which represents the transverse colon held up, shows clearly three coils of small intestines situated to the left between the stomach and the still visible bed of the transverse colon on the intestinal mass. We see, therefore, how illusory is the topographical barrier of the " colic frame " ! It should further be noted that, in this subject, the colon is nowhere sessile, but furnished in its vertical portions with a meso-colon at least ten centimetres long. Besides, the transverse meso-colon was adherent to the omentum between the colon and the stomach, thus realising the diagram in Chapter VIII. (p. 244). The resulting layer, not very thick, would render impossible the method proposed by Pauchet for reaching the lesser cavity of the peritoneum.

200 WOUNDS OF THE ABDOMEN

symptoms. While considering these one neglects the abdominal injury ; it is a thoracic wound one has to attend to and not an abdominal one.

The prognosis is that of a penetrating wound of the chest.* But there is strong presumption in favour of an intestinal perforation, or of a serious gastric laceration, or of severe hepatic or splenic haemorrhage; the immedi- ate danger is to the abdomen. And therefore we know at once that the prognosis is always extremely serious.

It is more serious still when the injuries are wide- spread and the wound gaping, in the thorax as well as in the abdomen (see p. 114). We must be on the look-out for visceral hernias through the diaphragm. When a thorax wound has closed up, these hernias may be cured or may require operation at a later stage, f but if the opening in the thorax is large, or if there is strangulation at the diaphragmatic orifice^ death is almost certain.

* Chaput (15) mentions examples of thoraco-abdominal wounds benign in appearance, but which nevertheless required a pleurotomy for infected haemo-thorax, and, later, an opening through the diaphragm for sub-phrenic abscess. Doubtless, a wound which is at the same time thoracic and abdominal has a perfect right to develop as a thoracic injury and cause a haemothorax which nothing can prevent from becoming infected, and to evolve as an abdominal wound and determine a collection of pus which is only a process of recovery. This shows that such cases need closely watching in both stages; but, from the point of view of immediate treatment, we cannot conclude from it that a laparotomy has preventive utility ; and we do not agree with the advice which Chaput gives, to make a systematic exploratory laparotomy in order to verify the fact of penetration.

t Four months after a bullet wound Duval (63) performed resec- tion of the seventh rib, which had been fractured and consolidated; the omentum which was found beneath the skin adherent to the parietal pleura, was caught in an opening in the diaphragm 2 cm. long by 5-6 cm. wide ; after partial resection it was replaced in the abdomen through the orifice in the diaphragm; the splenic angle and the spleen were found adherent to one another ; the spleen seemed to have been perforated by a bullet. After suture of the diaphragm, the thorax was completely closed, and the air in the pleural cavity aspirated. Complete recovery.

J See our cases (Figs. 20 and 21) and that of Legrain and Qu6nu, whose drawing we have reproduced (Fig. 22).

PLATE I

FIG. A. — Abdomen widely opened, the organs in situ. Between the stomach and the transverse colon, the omentum and the meso- colon tightly joined together, form a thin veil through which are seen several loops of the intestine situated high up.

FIG. B. — Same subject : the colon has been raised; the curved depression of its "bed" across loops of small intestine is seen; above are three projecting loops of small intestine. Subject was ptosic, with all the mesenteries elongated and pedunculated.

200]

DIAGNOSIS AND INDICATIONS 201

(e) The lumbar region gives access to the kid- neys ; haematuria is very frequent ; as a rule it quickly diminishes ; but abundant flow, its persistence, pain- fulness, and signs of increasing haemorrhage, suggest rupture of the kidney, always a most serious injury. Projectiles which enter through the loins often damage the whole intestinal viscera, both small intestine and colon. We must remember this when we find abdomi- nal symptoms.

As a rule, injuries in the lumbar regions are not so serious.

(/) Quite the contrary is the case with injuries to the buttocks. All penetrating abdominal wounds through the buttocks are very serious indeed. The projectiles may injure the bladder or the rectum, or may break the sacrum or the iliac bones, aU of which lie close together in the same horizontal plane. There is every cause for grave prognosis. Entering by an oblique vertical line, the projectiles go straight into the whole intestinal mass to cause numerous lacerations and perforations throughout it. Death is almost inevitable. (See Figs. 41 and 42.) All these wounds ought to be examined with great care, the bladder must be emptied and the rectum examined. Openings near the sacrum or in the neighbourhood of the anus can conveniently be examined in the position advocated by Depage — that is to say, like an inverted V (A), the head and legs hanging down, and the sacrum upwards ; this position gives the best light.

B. THERAPEUTIC INDICATIONS

Now the moment for a decision has arrived. The course to follow is determined by the examination we have just made, and by the estimation of the seat and probable nature of the injuries to the viscera.

But there are still two factors which may intervene,

202 WOUNDS OF THE ABDOMEN

although they are of less importance : (1) the general condition of the patient, (2) the nature of the pro- jectile.

Let us then consider the therapeutic indications from the point of view of the wound, the patient, and the projectile.

1. As regards the Wound.— There are cases where an operation is absolutely essential, others where it is equally clearly forbidden, others where it is doubtful.

(a) Cases in which operation is imperative. — Laparo- tomy is advisable for all penetrating abdominal wounds with visceral hernia or hernia of the omentum only.

In all cases of wounds in the umbilical region (there is one very rare exception, i.e. when there is absolutely no sign of abdominal reaction).

All injuries of the hypogastrium and of the inner wall of the iliac fossae (one rare exception is that of a small supra-pubic wound with lateral or closed vesical lesion) ; all deep-seated abdominal wounds through the buttocks ; injuries to the flank adjoining the umbilical region, whether directed forwards to the umbilicus itself, or simply suspected to be intra- peritoneal, and wounds in the lumbar region with abdominal symptoms. In all these cases the surgeon should have no hesitation.

(b) Cases which should not be operated on. — These are wounds which are almost certainly non-penetrating on account of their position and of the complete absence of abdominal reaction.

Thoraco-abdominal wounds without serious injury to the abdomen.

Wounds of the right hypochondrium without severe haemorrhage. Small epigastric wounds without symp- toms of reaction or signs of haemorrhage.

Lateral wounds of the various colic regions with closed orifices, with no reaction, or gaping largely and letting the intestinal contents flow away freely—

DIAGNOSIS AND INDICATIONS 203

that is to say, almost solely tangential wounds outside the peritoneum.

In my opinion these are the only cases where one should deliberately avoid operation.

(c) Doubtful Cases. — -There is every reason to hesitate in the following cases :

A wound probably not penetrating, but with the peritoneal syndrome. Penetrating wound of the stomach.

Wound in the left hypochondrium.

In each of these cases laparotomy runs the risk of being useless or even injurious.

To solve these doubts by means of a clinical examina- tion alone will often be impossible, and here tempera- ment and individual diagnostic instinct come in.

Rouhier, for example, always tries to avoid any unnecessary laparotomy, and the benefit of the doubt in his case would lead rather to a decision not to operate ; others, on the contrary, and these are the majority, judge by averages and think that mistakes are likely to prove more costly if they lead to absten- tion, after which nothing can be done, than if they lead to an aseptic laparotomy steadily carried out.

Here are two cases, amongst others, where the balance is in favour of operation : a penetrating but small wound in the stomach in the case of a patient who had just had a meal ; and a penetrating wound of the left hypochondrium with slight symptoms of re- action or signs of haemorrhage. In all other cases the prescription most advantageous to the patient appears to us to be, in war-time as in peace : When in doubtt operate ! if you hesitate, perform laparotomy !

2. As regards the Patient. — Should one operate on all patients with abdominal wounds having regard only to the nature of the wound and whatever be the general condition of the patient ?

Both theories have their partisans.

Certain surgeons have always systematically per-

204 WOUNDS OF THE ABDOMEN

formed, laparotomy for all penetrating wounds, how- ever desperate the case might appear. There was a reason for this : it was necessary to be able to con- trast the total results of one method with the results of another, and thus to learn by experience the most extreme limits when laparotomy could effectively be used. At the present moment opinion is clear on these two points, and we can legitimately set aside the cases which are clearly beyond surgical aid. Extensive injuries with many lacerations or actual sections of the intestine, wide-spread tearing of the mesentery, blood and faecal matter in the abdomen, leave no hope of a cure ; the same is true of large thoraco-abdominal wounds with or without visceral hernia and extensive visceral extrusions above or below the umbilical region. It is to the interest of the other patients not to waste time, at their expense, in attempts which one knows cannot produce any satisfactory result, and it is also merciful to allow these poor fellows to die in peace under the influence of morphia.

The same thing is true of old wounds which date back at most thirty-six hours. From about the twelfth hour, the chances of cure by laparotomy decrease hourly very rapidly. After twenty-four to thirty-six hours any chance of recovery exists only in exceptional cases, which examination may show are not already rendered hopeless by a rapidly developing peritonitis.

But, this period once passed, one must acknowledge that there is only room for two types of wounded : those with acute general peritonitis, and those whose lesions show signs of local reaction only and still have some chance of spontaneous recovery. For either case laparotomy is at best useless, and more often than not will be injurious.

In these cases Murphy's operation may be useful. If we have refused to compare this with laparotomy as the special treatment to be preferred, we ought

DIAGNOSIS AND INDICATIONS 205

in justice to remember that it has produced some pleasant surprises (Didier, Murard). And it will be justifiable to use Murphy's supra-pubic buttonhole for penetrating wounds of the abdomen more than about twenty-four hours old and in which the clinical examination does not promise a favourable result.

But it is on the question of shock that the advocates for or against immediate operation chiefly disagree.

Shock is characterised by : a rapid, weak, and even uncountable pulse, paleness of face, with nose cold and drawn, sunken eyes ; general coldness of the body, but particularly of the extremities ; mental torpor, with resigned euphoria, or, on the contrary, excitement and loquacity.

Its frequency varies according to the different conditions of the sections of the front line, perhaps also according to the interpretation of the surgeons. Amongst our wounded, evacuated from a distance of 12 kilometres, we observe it very often, especially at night. Sencert also notices this point.

Shock is by no means confined to wounds of the abdomen, but often accompanies serious injury to the limbs, such as high amputations of a limb or numerous and bilateral wounds of the lower limbs. There is no question here of peritoneal infection as a cause.

Anaemia, considered as the only cause by Cotte and Latarjet, and Bouvier and Caudrelier, was perhaps the predominant cause of shock in the case of wounded brought in immediately and not carried for several kilometres, and getting chilled on the journey.

But, amongst the wounded whose cases we are con- sidering, there would seem to be little connection between the intensity of the shock and the seriousness of the deep-seated injuries.

Besides haemorrhage, nervous shock certainly comes into play (intensity of the injury, previous emotional exhaustion, the shaking up of the abdominal viscera during the automobile journey over rough roads).

206 WOUNDS OF THE ABDOMEN

Haemorrhage which is not severe enough to prevent a patient being carried for a distance of 12 kilometres is never so bad that it cannot be temporarily checked by injections of saline and adrenalin (otherwise the patient will die during or immediately after the opera- tion). On the other hand, the nervous shock will undoubtedly be lessened by the tonics we have men- tioned.

Here, then, is our programme : immediate injection of camphorated oil, ether, even of morphia if the patient is in great pain, but above all a copious injec- tion of saline with 1 milligramme of adrenalin ; if in- travenous injection seems advisable, use at least a litre ; shivering and shock will not be more marked than

FIG. 44. — Simple apparatus with electric lamps for warming patients when suffering from shock (lamps with carbon filaments).

with a small injection, and it has the advantage of keeping the blood-vessels full. Then, if within an hour

DIAGNOSIS AND INDICATIONS 207

FIG. 45. — Stretcher for warming patients. (Poucel [88].)

the patient does not begin to improve, no operation is likely to be in time to be successful, either on account of haemorrhage too severe to be checked, or because of

the nerv-

ous shock [I from too great a " nervous h ae m o r- rhage." If, on the contrary, the pulse beco mes s tronger, and the patient be- gins to improve, one may operate without further delay ; but the subcutaneous injection of saline must be continued during the operation.

This, then, is the method which we follow for severe wounds to the limbs ; often after some hours' rest an extensive operation for the removal of splinters, or even an amputation of the thigh, becomes possible and may do well ; which would have caused immediate death if the patient had not been rested, warmed, and revived.

We reproduce here two models of apparatus for warming a patient ; one (Fig. 44) uses electric lamps (we had one made quite easily in our ambulance) ; the other (Fig. 45) employs petrol or methylated spirit, and so can be used anywhere.

3. From the Point of View of the Projectile. — It is generally admitted that bullet-wounds are less serious than those from shell-splinters, but in the list of the first 15 cases which we published were found : 4 bullets with 3 deaths and 1 recovery ; 11 shell-frag- ments with 6 deaths and 5 recoveries — figures which

208 WOUNDS OF THE ABDOMEN

would seem to prove the greater seriousness of bullet- wounds. This explains itself. In our section of the

— ^ — j V,»V,JL o/nj' open iigiiiing, it is a between trenches very close together ; bullet wounds therefore, are very rare, and such as occur are usually very severe on account of the short range

The mam thesis, therefore, is still correct, but one must not try to draw too precise therapeutic deductions

To know that a wound has been caused by a buUM will doubtless strengthen the decision already taken not to operate when the case is already following a normal course, but will never cause one to refrain trom operating when operation is plainly indicated by the clinical examination.

On the other hand, even a small shell-splinter which is almost always irregular and mixed up with pieces of clothing makes an operation still more imperative fi To sum up: The nature of the projectile adds con- i armatory evidence to that already obtained from an examination of the patient, but is never decisive when I considered, alone.

H^1S 1S ^tme alsJ° °f its size' The seriousness of> deep-seated wounds is never in proportion to the •t the projectile, nor is the importance of the injury done in proportion to the size of the wound where the projectile entered ; one ought not, therefore, to follow the ^examples of Gosset or of Pellot, who var^ their methods according as they are dealing with a small or a large projectile.

RADIOSCOPY

There has been no mention in this chapter on diagnosis of the help to be obtained from X-rays This is intentional.

Not all army surgeons have a radioscopic equipment under their control; most of them have only at their disposal from time to time, and for a short period a

DIAGNOSIS AND INDICATIONS 209

travelling radioscopic unit which pure chance may bring their way at the moment when an abdominal wound is being examined !

In times of pressure, even with a permanent equip- ment, the surgeon will often be obliged to decide on an operation without having time to use the X-rays at all.

Then the clinical examination must suffice him ; so it is on this alone that we have based our observations in the preceding pages.

Are we to conclude, then, that in the diagnosis of deep-seated abdominal wounds X-rays may not play a very important part ? Certainly not. For it gives us additional information of a very exact nature in all those cases which we know to be most difficult of diagnosis : those ivounds with only one opening.

In determining the site of the projectile, the radio- scope shows also in the simplest way the course of such a projectile of which we know the openings both of its entrance and exit. Still further, it shows us the shape and size of the projectile. Sometimes, indeed, it shows us that a projectile supposed to be embedded in the tissues has really gone straight through the body.

Thus the radioscope helps us more easily to answer the two questions which sum up the whole clinical examination : Is the wound penetrating ? Is there a visceral injury ?

Here, for instance, is a case where the X-rays had helped to confirm a hesitating diagnosis :

April 20th, 1916, R had three small penetrating

wounds at the base of the left thigh, another on the crural arch, another under the left anterior superior iliac spine.

Pains in the abdomen. T. 38° (100-4° Fahr.). But the pulse (92) was strong ; voluntary micturition ; two stools, of which one was copious ; skin normal ; localised pain in the right iliac fossa.

The radioscope showed us at once that the projectile was not in the abdomen, but on the left iliac margin. 14

210 WOUNDS OF THE ABDOMEN

There was no operation, and uninterrupted convales- cence followed.

Note that the clinical examination alone had already made us decide not to operate ; the X-rays only gave us additional confidence.

In one of Rouvillois's cases they gave greater corro- borative evidence ; the clinical examination led one to consider the possibility of operating for a wound in the lumbar region complicated by hsematuria with great rigidity of the abdomen ; under the X-rays a tiny shell-splinter was discovered moving up and down with the diaphragm ; no operation was performed, and the patient recovered.

Such cases are fairly exceptional at this stage, and the radioscope can only modify the indications of the clinical examination if these are rather doubtful, and if the situation of the projectile in and moving with any organ is clearly indicated.

For the known depth of the projectile does not allow us to state that it is actually inside the abdomi- nal cavity. One has often a very false idea of the thickness of the walls of the whole posterior part of the trunk in comparison with the total thickness of the body, and one often believes the projectile to be right inside the abdominal cavity when it is really in the posterior muscles. (See Fig. 39.)

With regard to this, case 676 of Chevassu is inter- esting : because a projectile, protruding from the left margin of the image (on the screen) of the fourth lumbar vertebra, was 9 cm. from the anterior wall, the total thickness at this level being 20 cm., one wasinclined to conclude that the projectile was in the small intestine. It was, on the contrary, much more probable that it was in the posterior wall, because the vertebral column is not 9 cm. from the walls in a subject whose diameter is 20 cm. !

But there is still more to be said. A projectile may be found on a plane the depth of which places it really

DIAGNOSIS AND INDICATIONS 211

Ei the confines of the abdominal cavity, and yet it intra-peritoneal. We note the following example.

B — • — -, April 26th, 1916, besides many other wounds, had a penetrating wound in the right lumbar region, with neither haematuria nor abdominal symptoms. Medical treatment.

The radioscope showed, next day, a shell fragment 4 cm. long, projecting on the right side of the umbilicus on a diagonal reaching the hypochondrium and 8 cm. in depth from before backwards.

On May 2nd there was a copious discharge from the posterior orifice, a clamp was cautiously introduced in a posterior-anterior di- rection, and at a dis- tance of 14 cm. from the aperture the pro- jectile was felt and taken out carefully (Fig. 46) ; it was ac- companied by shreds of clothing. Recovery FIG. 46. — Splinter of shell situated normal 8 cm- from the a-nteri°r walls and at

the same time extra-peritoneal. ( Case

This projectile, there- B, p. 211). fore, was right inside the

abdomen, but it was certainly neither intravisceral nor intraperitoneal ; very probably it had split the mesen- tery or the transverse colon ! Therefore, whatever may be the mathematical precision given by the radio- scope, the interpretation of what is seen still leaves an inevitable opportunity for error. And when there is disagreement between the clinical examination and the radioscope, we give precedence to the former. Rouhier [28] arrived at similar conclusions.

What will be the best methods of localising intra- abdominal projectiles ?

It is generally sufficient to localise the depth from a fixed point marked on the parietes.

All the methods suggested by the double projection

212 WOUNDS OF THE ABDOMEN

on the screen, after moving the X-ray tube, are accept- able. The method of Haret, the "planchette" of Hirtz, the "skia- metre " of Vialet j [•*], etc., all give rapid indications. Such circum- stances as mo- I bility, with the [> respiratory move- ment sand induced j] movements, help the anatomical 1 diagnosis of the i position of the j projectile.

We give here a| surgical " com- pass," of our own I design, which has the advantage not J only of giving very j rapidly on the screen, without any calculation or* tables, the depth! of the projectilej (a fixed point of the apparatus at-j tached to the) screen is substi- ! tuted in the place j previously occu- 1 pied by the pro-| jecbile), but also^

Fia. 47. — Surgical compass, with direct controls under the X-ray screen. (The author's invention, patented.)

j V*. -" f J

of being adjusted directly under the screen in such a

DIAGNOSIS AND INDICATIONS 213

ty as to allow, if necessary, an exact localisation of le projectile during the operation. A short descrip- ion of the

method of using

the apparatus

(see Figs. 47

and 47 bis) is

sufficient.

(1) The pa- tient is placed under the ra- dioscope, the existence of the projectile verified, and the approxi- mate situation determined by a right-angled projection.

(2) Three

guiding surface-marks are noted on the skin, the three points of the com- pass are placed in contact with these (position A), and a first right-angled projection of the projec- tile is marked on the screen. A second pro- jection is marked accord- ing to the known displace- ment of the tube. The patient is then taken away.

(3) The bar C (position B) is placed in the compass. The X-ray tube being placed in the original position, the image of 0 is brought to coincide with the first

FIG. 47 bis. — Surgical compass, with direct controls under the X-ray screen. (The author's invention, patented.)

214 WOUNDS OF THE ABDOMEN

image of the projectile, the X-ray tube is displaced as before ; the bar E is lowered until the image of 0 coincides with the second image of the projectile. 0 clearly occupies in relation to the screen the same position in space which was originally occupied by the projectile ; further, the image thus directly corresponds to the three points of the fixed compass — that is to say, with the three guiding surface-marks on the body.

(4) If we now bring the point of the indicator into the socket 0 (position C) and if we take away the arm (7, now unnecessary, the compass is arranged for the surgical operation and the examination of the pro- jectile (position D).

If we note the eight figures which determine (1) the space between the arms, (2) the position of the one point, (3) the position of the other point, (4) the position of the socket 0, we can at any moment remove the compass or replace it just as it was before.

The procedure is still shorter if one simply wishes to measure the depth of the projectile. The arm C being in position over the patient, we place 0 on the skin, projecting it on to the screen at the same point as the projectile in the right-angled position ; we note its height on the scale ; then we proceed as above (2) and (3). The distance between the two positions of 0 give the position and depth of the projectile from the skin.

Conclusions. — The multiplicity of cases we have considered, all of which were necessary for the complete discussion of the problem of diagnosis, may have the disadvantage of misleading us as to their relative im- portance and of leaving on the mind an impression of a confused and indecisive clinical examination, just where, on the contrary, we must have a very clear, and definite idea of the course to be followed.

We therefore think it wiser to correct this analytical

DIAGNOSIS AND INDICATIONS 215

examination by a general summing up. Our conclu- sions are as follows :

(1) In the majority of cases, the character of the wounds and the clinical syndrome indicate deep-seated wounds of the abdomen and viscera ; laparotomy must be performed. The only cases in which we decide not to operate (which we have already dis- cussed) demand such a complete knowledge of the course of the projectile that they are exceptional, and can hardly occur unless there are two orifices, one of entry and one of exit, or an orifice of entry and localisation by the radioscope of the projectile.

(2) A single abdominal wound, wherever it be, calls for operation, unless there is complete absence of abdominal symptoms.

(3) A small wound does not mean that the lesions are negligible. Too often, on the contrary, one finds that they are extensive and serious.

(4) Resistance of the abdominal wall and the pulse are the most useful symptoms for confirming the need for operation and guiding the prognosis.

(5) It is never admissible to put off the diagnosis or the special treatment : " watchful expectation is a meaningless expression" (Quenu).

A superfluous exploratory laparotomy is preferable to the risks of delay.

Hesitation in diagnosis must not mean hesitation in the treatment, for, if one hesitates, it is clear that opera- tion is necessary.

CHAPTER VIII

LAPAROTOMY FOR PENETRATING WOUNDS OF THE ABDOMEN

LAPAROTOMY for penetrating wounds of the abdomen is the type of operation which ought to be conducted rapidly, and it should be simple and methodical : simple as to its equipment and the choice of its techni- cal procedure, and methodical in its execution ; for, even when performed under unexpected conditions, a strict and almost invariable plan should be followed.

Preliminary surgical examination of the openings with treatment of any hernia which may be found ;

Laparotomy properly so called ;

Rapid inspection or exposure of the principal seat of the lesions ;

Treatment of these lesions ;

General overhauling of the other viscera ;

Cleaning up and draining of the peritoneum ;

Suture.

We will now review these various processes. Instruments and Material. — The following are sufficient (see Figs. 48 and 49) :

1 scalpel.

2 pairs of scissors (one for aseptic, the other for

septic use) ;

3 dissection forceps (2 aseptic and 1 septic) ;

1 curved needle with handle (Doyen's pattern) ; 216

PENETRATING WOUNDS

217

12 Doyen's short-bladed forceps (or 6 Doyen and

6 Terrier) ; 8 Kocher's forceps * ;

* We give these different types of forceps because they are sup- plied by our medical service ; in our personal practice for many years now we have used only one kind of forceps — that of Delageniere.

218 WOUNDS OF THE ABDOMEN

2 long haemostatic clamps (these will serve, as a rule, to carry the swabs to the deep parts and to fix the drainage-tubes, but they will be equally valuable should we be obliged to clamp a renal or splenic pedicle) ;

6 bowel forceps * ;

FIG. 49. — Instruments reserved for intestinal work and placed upon the small transverse table (second set).

4 intestinal forceps with handles (Chaput's pat- tern) ;

1 Doyen's sub-pubic valve for placing between the thighs ;

1 self-acting retractor f for the abdominal wall ;

* The simplest are Hartmann's straight elastic clamps; those issued by the Service de Sant6 are Doyen's curved clamps ; very convenient for the stomach, they are, for the intestine, unnecessarily long and not conveniently curved. Their curvature is not suffi- ciently long to isolate a segment of intestine and allow the suturing to be done ; it is inconvenient for the approximation and parallel alignment of the intestinal segments.

t The tri-valve model of the Service de Sante has two great

PENETRATING WOUNDS

219

1 valve (Legueu's pattern) or a metallic tongue- depressor ; (for certain recesses, to lift up and inspect the posterior surface of the bladder by gently slipping the instrument above its folds) ;

1 strong double-hooked retractor (Ollier's pat- tern) * ;

6 sets of 2 straight sewing-needles preferably threaded two together at each end of the same loop of thread ; this should be 50 cm. long ; these needles are stuck into a little roll of gauze and the loop of thread is rolled round it ; if we pull the end of the loop, everything unrolls evenly. These sets of needles are sterilised with the dres- sings or by themselves in separate tubes. (The loops of thread with two needles reduce to a minimum any delay or stop- page in order to re-thread the needles. If we should want a needle threaded on a single thread, nothing is easier

FIG. 50. — Autostatic retractor (author's pattern).

disadvantages ; it is not fixed, and turns round. The heads of the screws which adjust the valves catch up compresses and sutures. Much more simple and stable is Gosset's autostatic retractor, large size, or that supplied by Gentile, which is seen on the right in Fig. 48.

For exploring small parietal lesions or exploratory laparotomies, we are accustomed to use the autostatic retractor which is repre- sented in Fig. 50. We have always employed in general surgery, in laying open wounds, ligaturing, and cranial trephining. By its aid we can systematically do anything, except laparotomies and some of the more delicate ligatures (carotid, sub-clavian, etc.).

* Or Hartmann's S- shaped retractor, of steel wire.

220 WOUNDS OF THE ABDOMEN

than to cut the loop and two separate needles

are ready) ;

2 cylindrical curved needles ; 2 curved triangular needles for stitching in the

Fio. 6 1 . — Double clamps, permitting different positions, for entero • anastomoses (author's pattern).

deeper parts. (Inserted in one of Doyen's short-bladed forceps they enable one to do

PENETRATING WOUNDS

221

without special-handled (Aiguilles a pedale) needles. These are rarely used, however, if we know how to make the usual sewing- needles and needles with a handle serve our purpose).

Metal wire previously cut into lengths of 20 cm. One can add if desired :

1 heart-shaped forceps (to seize a particular organ, notably the bladder in order to expose the posterior side) ;

1 double forceps for intestinal anastomoses ; Temoin's forceps, for example. We show here a new model of our own, which has the advan- tage over that of Temoin of allowing for vary- ing obliquity of the area of grip of the forceps, and therefore makes it easier to do the sutur- ing of the posterior serous surfaces without being disturbed by the mass of overlying intes- tines (the forceps are placed in the position shown on the left) and to do the same for the anterior serous surfaces without straining the tissues (here the forceps are placed in position shown on the right, Fig. 51). These double forceps save a great deal of time when used for lateral anastomoses, they give absolute stability to the parts which have to be joined together and also complete bowel closure ;

1 forceps (Liston's pattern) or one sharp cutting- forceps for dividing the metal wire ; the scissors will be all the better for this !

These instruments are divided into two sets, of which one is reserved for use in the intestinal regions, and is placed on a little T-shaped table which can be drawn across the legs of the patient ; by this arrange- ment one secures great security and rapidity. By the side of the assistant there are some forceps, an Ollier's retractor, and some swabs ; that is all. (See Fig. 30.)

222 WOUNDS OF THE ABDOMEN

It is necessary to have two or three large swabs, 0*75 metre square ; soaked in hot saline, these cover over and support the loops of the intestine during the operation ; they are useful also for shutting off the different sectors of the abdominal cavity.

We also employ medium-sized swabs from 0*20-0'25 me'tre and others from 0*10 metre square and in four thicknesses. These two last types will be found in the medical outfit.

For making sutures I use only linen thread or fine silk, which slips more easily and holds well ; for needles, ordinary sewing-needles. For intestinal surgery catgut is either too fine and too rapidly absorbed or too coarse for the needle to make rapid fine sutures which will not injure the tissues.

As a matter of course, one must operate in rubber gloves*

Pre-operative Precautions. — These consist in the treatment of the wounded for shock (which we have described above) in cases where the operation is de- layed for varying periods. In other cases, as a matter of course, we prepare 10 cc. of camphorated oil, J cgm. of morphia, some adrenalin or not according to the blood pressure, and we operate as a rule with a continuous hypodermic injection of saline.

The patients are carefully covered, wearing woollen operation stockings and a thick flannel vest.

Anaesthesia. — Spinal ancesthesia is not advisable. The conditions here are not comparable to those in ordinary surgery, the patient habituated to the thought of an operation, reassured as to spinal anaesthesia, by the conversations of the nurses or of other patients, the topographical extent of the operation already

* Generally speaking, I have never understood the uses of cotton gloves ; when they become soaked with blood, they cannot isolate the tissues ; when soaked with pus, they disseminate infection and contaminate the surgeon's hands. This never happens with rubber gloves, which keep the sensitiveness of the finger-tips intact.

PENETRATING WOUNDS 223

:nown, etc. Here, on the contrary, the patient has only just come out of the hell of actual fighting ; one cannot ask of him either the calm necessary for the success of this form of anaesthesia or the effort neces- sary to acquire and maintain such a calm ; further, we have a patient already in a depressed state from anaemia or shock, and spinal toxins have a well-known depressant effect. Besides, we do not know the extent of the injuries; we may have to work up to the dia- phragm and even above it ; this would necessitate large doses or high injections, and therefore dangerous ones ; finally, it takes longer and is more inconvenient on account of having to make the spinal injections oneself and to await the results than to hand over to an assistant the complete care of the anaesthetic. Moreover, the attempts which have been made are not encouraging. Against one success recorded by Leriche in the case of a simple wound in the stomach we must reckon two deaths before the operation could even be begun, observed by Cotte and Latarjet, and other failures necessitating the use of chloroform noticed by Rouvillois as well as by myself.

Briefly, spinal anaesthesia seems best rejected.

There remains general anaesthesia. But should this be by ether or chloroform ? Ombredanne's apparatus gives such absolute safety in the employment of ETHER by controlling the absorption and diminishing the quantity absorbed, that many surgeons employ it regularly in the visceral surgery of the abdomen ; they have not noticed that it causes any more thoracic complications than does chloroform. But here the conditions are not normal ; the patients are already cold, perhaps already suffering from unrecognised or neglected affections of the thorax ; the operating stations and hospitals have varying and inconstant temperatures. Ether finds out all these disadvantages. Finally Ombredanne's apparatus does not form part of the ordinary outfit, and, if it has been supplied to

224 WOUNDS OF THE ABDOMEN

certain privileged units, the greater part have had no share in this liberality !

Here, then, is the result of an examination of facts. Schwartz and Mocquot gave up ether to return to chloroform. Stern, a partisan of ether, noted a death from pneumonia after three days, and this was from a simple penetrative wound ; it is probable that the anaesthetic was responsible for this accident. In another case one of Gatelier' s patients died of pneu- monia on the thirty-first day (this, it is true, was a thoraco-abdominal wound).

In order, therefore, to avoid thoracic complications, Gatelier and his collaborators rub the chest with alcohol after the operation, and make the patient breathe through a compress during the hours which follow. For this purpose they have arranged at one end of their huts a sort of post-operation room separated by a half-partition with cloths stretched over it ; the rest of the ward is heated to excess " with a Gadin stove on which is placed a saucepan of boiling water to prevent the air becoming too dry." Do you think that such complicated installations and attention are compatible with the pressure of work, and all the emergencies that face the army surgeons ?

It is for exactly this reason that we prefer the usej of Chloroform. For our own part, we have never noticed the frequent syncopes nor the jaundice of which Gatelier speaks. Generally speaking, all war-patients (except certain alcoholic subjects) yield quickly and quietly to the anaesthetic if it is given slowly at first.

In practice we begin administering the anaesthetic! as soon as the painting with iodine is finished, and' the interfemoral V-support is adjusted, in order that the patient may not have to be moved again. The arrangement of the instruments, forceps, clamps, etc.,, for operation, and the simple inspection of the wounds fill in the time while the patient is being anaesthetised ; it is advisable for anaesthesia to be complete before any

PENETRATING WOUNDS 225

operative act is begun, otherwise the patient is sensitive, moves, and struggles ; the anaesthetist increases the dose ; no time has been gained, and the patient absorbs in the end a larger quantity of chloroform.

Stern advises interrupted anaesthesia in order that the control of the intestinal mass may be aided by the pressure of abdominal resistance and also beca.use movements of the intestines are not very painful.

We think that it is an advantage to work as quickly as possible, and, thanks to a complete and steady anaesthesia, this can be done. At the same time it is so exceptional to be able to treat visceral herniaTbefore having made a survey of the deep-seated injuries, that to begin with that before anaesthesia is established seems to us an inadvisable practice with very rare exceptions.

It is obvious that steady and complete anaesthesia does not mean " chloroform by the pint," but that, on the contrary, the patients ought to take as little chloro- form as possible.

THE OPERATION

Preliminary exploration of the openings. — This is always essential when there is but one orifice. It ought then to consist in freely opening, verification of the penetration, and treatment of the lips of the wound by scraping the contused tissues, and freshening of the skin. In doubtful cases it is this exploration alone which enables one either to make sure of the penetrating nature of the wound, or helps one to decide that laparotomy would be useless, or at any rate should be limited to a purely exploratory incision.

Here is an example :

M •, wounded June 7th, 1915, was injured by a

shell-splinter below and within the right anterior- superior iliac spine. There was an orifice the size of one's thumb leading under the crural arch. The abdo- 15

,£26 WOUNDS OF THE ABDOMEN

minal pains localised in the right side were accompanied by a very strong parietal resistance in the iliac fossa. T., 39-6° (102-2° Fahr.), P. 112. Sub-peritoneal laparo- tomy"led to the peritoneum ; we were still uncertain ; an . incision was made in the peritoneum ; there was no haemorrhage, the general appearance was normal. We immediately stitched up at two levels. Free .opening ,u£ of the track and sub -peritoneal drainage was setup. Recovery. (Abadie [33], Obs. 1).

The direction of the course of the projectile verified by the finger may give useful help for further examina- tion of the injuries; pieces of clothing embedded in the walls had better be removed, and the bruised tissues dressed ; in short, the wound will have already received surgical treatment, whether it is to be included in the coming incision or is to become an opening for * drainage.

Exploration also is necessary in the case of two openings near together, especially in the flanks. It enables us to perceive that a penetrating wound may remain extra-peritoneal, and will enable us to decide on a sub-peritoneal laparotomy or- even on a simple external incision. Because we failed to do this, we had one fatal case which the more prudent method would have saved.

^TnTs case deserves to be reported on account of the lessons-it contains.

H , was wounded May 19th, 1916, by a rifle- bullet ^which went into the right flank 5 cm. under the. end of the tenth rib on the mid-axillary line, and came out. just by the posterior middle line between the third and fourth lumbars. Abdominal resistance slight and confined to the right flank, One attack of vomiting. Urine clear. T. 39° (102-2° Fahr.), P. 68. Twelve hours afterwards a lateral laparotomy outside the external v-edge of the rectus muscle showed the abdominal cavity to be intact ; but the mesocolon was raised by a large suffusion of blood. By a longitudinal

PENETRATING WOUNDS 227

cision detaching the colon we discovered two lateral m ^forat^ons of the colon connected with each other whence issued only a mixture of blood and intes- tinal contents. I protected the wound with swabs soaked m ether. I closed up the two perforations with fficulty by sutures on two different planes, besides e general suturing : at this level there was no perito- leum. The whole area was washed out with ether, the ateral detachment fixed in place, and tube for drainage placed m position. Suturing was on one plane

The patient died May 23rd. The autopsy showed the mesocolon contained some very foetid pus illuhtis) and circumscribed peritonitis, but with foetid nuid in the recto-vesical pouch.

Conclusions.— 1st, that we ought to have laid oDen the wound, and, seeing that the lesion was extra-peri- toneal, we should not have performed laparotomy nless the operation had been subperitoneal, and by 3 gaping wound might have established a focal ula ; 2nd, the recto-vesical pouch ought to have been drained ; 3rd, the infection of the mesocolon is an example of retroperitoneal cellulitis on which Wallace laid stress (see p. 106).

Preliminary treatment of visceral hernias.— As a rule t is best only to clean them, wash them in hot serum! mark the already existing injuries, and cover them with hot compresses ; the lips of the wound can be attended to afterwards. But we must wait lor a complete examination and verification of the intra- abdominal injuries before suturing, resecting etc th intestinal loops which have come out of the abdo- men. If we neglect such an examination we risk wasting time on unnecessary local work ; for instance . loop of the intestine carefully made good may have to be removed again because there are lesions in its neighbourhood which may affect it. It would be •etter to lsolate it carefully with warm saline swabs then carry out laparotomy at once.

228

WOUNDS OF THE ABDOMEN

In certain cases, hernia of the viscera can be treated at once.

The omentum may be exposed by itself ; we can resect, and if the incision for laparotomy does not pass through the actual opening, the stump of omentum can presently be drawn out of the abdomen itself.

FIG. 52. — The various incisions for laparotomy. (1) Transverse incision from orifice to orifice ; (2) sub-umbilical median laparo- tomy ; (3) supra- umbilical median laparotomy ; (4) lateral laparo- tomy, outside the rectus ; (5) oblique iliac laparotomy; (6) lateral laparotomy (extreme) ; (7) horizontal laparotomy ; (8) sub-costal laparotomy; (9 and 10) incisions for a mobile costal flap. (Auvray- Baudet.)

We pursue the same course when a parietal opening has tangentially abraded the tissues and the peri- toneum, allowing the loops of the intestine to protrude whether they are injured or not ; if one is sure that

.

:

PENETRATING WOUNDS 229

there are no other intra-abdominal injuries they can e repaired at once. Under other circumstances it

better to verify the extent and position of such

juries in the preliminary investigation.

If there is persistent haemorrhage it may be impor- tant to stop this at once ; in our own case (p. 255) we thus removed the ruptured kidney, which was bleeding profusely, before repairing the colon, which presented at the wound.

The incision (Fig. 52). — If we know the probable position of the greater part of the lesions — that is to say, if the two openings determine the course of the projectile — -the incision ought to lead towards these lesions in the most convenient way. Thus, if the track is transverse or oblique the incision may with advantage divide the parietal wall between the two orifices, because the lesions are thus exposed. If the track is clearly antero-posterior the incision will be vertical and will pass through the anterior opening ; and we shall come down on to the injuries arranged one above the other from front to back. If the passage is somewhat oblique, it might be more advan- tageous to leave the orifice out of the question in making the incision and to make a median or lateral laparotomy in such a manner as to bring the explora- tory incision towards the plane of the posterior orifice of exit.

If we do not know the position of the injuries — that is to say, if there is but one orifice — we must choose an incision which gives the best opportunities for explora- tion. This will be, as a rule, supra- and sub-umbilical median laparotomy and without regard to the orifice.

In certain cases of lumbar wounds or wounds of the flanks or of the epigastric region it may be convenient to make a horizontal or transverse laparotomy. But, with the exception of these special cases, this incision gives a smaller area for exploration than the median vertical, even with Mayo's pad.

230 WOUNDS OF THE ABDOMEN

Here, for instance, it allowed us to repair not only a perforation of the ascending colon, but also to treat a suppurating appendix at the same time.

L , wounded March 31st, 1916, had a penetrating

wound in the right flank ; abdomen painful on the right side ; T. 38'2° (100-7° Fahr.), P. 120. By means of horizontal laparotomy I found an intra-peritoneal perforation of the lower third of the ascending colon ; sutures in two stages. But liquid pus flowed spon- taneously from the region of the caecum and I exposed a large, turgid appendix, bathed in pus, surrounded by a zone of inflamed loops of the small intestine ; excision of the appendix ; two large drain- age-tubes. " Drop by drop." Patient placed in the right lateral decubitus. Recovery.

In order to examine lateral wounds more easily, we must not hesitate to add to the incision already made (vertical, for example) another one either horizontal or oblique parallel to the edge of the false ribs.

We shall see later on what particular type of incision is best for the exposure of the liver or of the upper part of the stomach or of the spleen.

As a general rule, the laparotomy ought to be exten- sive and give complete opportunity for exploration ; the median sub-umbilical incision ought generally to be immediately prolonged above the umbilicus. And as soon as the abdomen has been opened up as far as the pubis it is advisable to place the supra-pubic valve in position, as this gives fuller exposure and avoids having to make inconvenient manoeuvres.

Detection of the principal focus of the lesions. — As a rule, the abdomen is copiously filled with blood or with blood and intestinal contents. Without handling the viscera as yet, we must soak up the blood with swabs. The character of the effusion gives us at once some useful hints.

If very copious and dark the blood probably comes from the liver or the spleen ; if of a brighter colour it

PENETRATING WOUNDS 231

comes from the mesentery or the posterior abdominal wall, and one often sees also hsematomata of blocd pushing up or separating the substance of the mesentery or the meso-colon. When blood is mingled with in- testinal fluids it indicates an injury to the small intestine. And this is certainly the case if one should find worms in it, as I once did myself !

Half-digested food and odourless gases suggest a perforation of the stomach.

Faecal matter and a faecal odour are signs of injury to the large intestine.

Pus is the proof that peritonitis has already set in ; we detected its presence less than twelve hours after a wound in the buttock !

But here is the most familiar picture : distended loops of the small intestine are collected in congested masses ; some are even showing perforations or lacerations. On the other hand, the rest of the small intestine is composed of loops in a normal condition, with irregular contractions, of a pale colour — "dogs' intestines." The lesions are in the distended loops, and one should begin by attending to these.

TREATMENT OF THE LESIONS

(a) The Small Intestine. — Before treating the lacera- tions or perforations individually, we must make an inspection of the whole of the suspected part, and of all the distended loops.* We mark off in some degree the injured points by pressure forceps which ensure copro- stasis ; we clean them up at the same time and isolate them under hot saline swabs ; one sees at once which perforations ought to be sutured separately, and which require removal of a portion of the intestine.

A simple punctiform perforation is closed with a purse-string stitch. A more extensive perforation with irregular edges will be freshened by a cut in the shape of a lozenge with two snips of the scissors and sutured in two stages transversely.

232 WOUNDS OF THE ABDOMEN

A^ longitudinal wound may necessitate resection of a wedge-shaped piece of intestine ending at the edge of the mesentery, with end-to-end anastomosis.

Complete sections of the intestine perpendicular to the axis will be sutured end to end, after putting the cut ends in order, if necessary. In certain cases everything is cut except the musculo-serous membrane over a certain area; this "bridge" will be left untouched, and by a complete circular suturing the repair of the sero-serous membrane will be completed.

Resection is clearly necessary for a segment of the intestine cut longitudinally for a considerable extent (explosion) or ruptured and torn away from the mesen- tery.

There are also cases in which we must deliberately remove quite a long segment ; many perforations succeed each other without leaving enough tissue between them to allow of the stitches being sufficiently deep to make a firm suture, or perhaps the tissues appear to be badly injured ; the perforations are numerous and their individual reparation would take too long ; there may be also holes in the mesentery or rents at its point of insertion. (See Figs. 9 and 10.)

There must be no hesitation ; the corresponding segments of the intestine are liable or even doomed to secondary necrosis ; resection is absolutely neces- sary.

But here is a contingency which? is open to discussion. The lesions are grouped in such a manner as to necessi- tate a preliminary resection of from 10 to 30 cm., there follows a second resection, and, between the two, there will remain a piece of sound intestine from 30 to 50 or even 75 cm. long. Will it be better to make each excision separately, leaving the intermediate piece of sound intestine intact or to take out the whole segment and thus make only one extensive resection ? One of our cases which we will report is rather in favour of the second decision.

PENETRATING WOUNDS 233

G •, on May 2nd, 1916, was injured by multiple

fragments from a grenade of which one entered half- way up the rectus muscle ; a small opening, hernia of the omentum and no visible exit. The abdomen pain- ful ; neither flatus nor stools ; urine clear. Pallor, shock. T. 38-90° (102-0° Fahr.)3 P. 132, feeble; 1,000 grams of saline with adrenalin.

Operation (twelfth hour). — A median sub-umbilical laparotomy which by a transverse incision was joined to the aperture where the splinter entered ; resection of the surrounding muscular tissue, excision of part of the omentum. Blood, red and copious ; the pelvis was filled with it. In the area underneath the parietal opening the distended and crimson loops of the intes- tine contrasted vividly with the rest of the intestine which was normal and contracted. We contented our- selves with drawing these loops outside and found that they showed the following lesions : (a) two small con- nected perforations of which one was at the level of the mesenteric insertion (closed with purse-string stitch) ; (b) two perforations of which one was the size of a pea (one of them closed with purse-string stitch, the other with two rows of stitches) ; (c) four perforations close together with jagged edges on a morbid-looking loop (excision of 5 cm., end-to-end anastomosis) ; at this level two or three loops of the small intestine were stuck together and we found two pro- jectiles (Fig. 53), half buried in the intestine, with debris of cloth- ing ; (d) at about 30 cm. from here a complete section with clean- cut edges ; end-to-end suture after it has been straightened up ; (e) two small perforations of the mesentery P FlG- 53- ~~ Grenade

TVT . ,. i fragments taken from

JMo evisceration necessary here. G— , p. 233,

Ether; pelvic drainage. Suture

with a bronze wire in one stage, incomplete on account

of the traumatic section and suspected infection of the

234 WOUNDS OF THE ABDOMEN

rectus muscle. In addition laying open of numerous wounds of both lower limbs, a penetrating wound in the left sub-pectoral region, with hsematoma ; the removal of a small splinter fixed in the right edge of the sternum. Finally injections of Leclainche and Vallee's serum. The after-effects were exceedingly interesting. Two days later gas gangrene in the recti muscles (in spite, let us note, of the preventive injection of Leclainche and Vallee's serum) ; we took out all the metal sutures ; the crnentum, which had been carefully spread out, appeared normal and covered up the intes--; tinal mass. Dressing with ether.

On May 6th a natural stool, and from that time onwards there was normal progress as far as the intes- tines were concerned. The abdominal wound was- gaping widely ; after treating with hot air and helio- therapy we were able little by little to bring the lips of the wound together by means of lateral strips of adhesive plaster with hook-attachments ; the edges were brought together by a catgut lace.

After a period of profuse diarrhoea with rapidly increasing exhaustion, assimilation improved and his food was increased by degrees.

Meanwhile general bilateral bronchitis set in. On May 31st the patient was evacuated to Paris (Pan- theon Hospital, under Leriche).

During the whole of June he got rapidly better ; the extraction of the numerous splinters still embedded in the wound caused the suppurations spread all over the two lower limbs to dry up and the patient visibly put on flesh.

Quite suddenly at the end of June intestinal obstruc- tion declared itself, and seemed to be about to prove fatal. But suddenly an intestinal fistula appeared, half-way between the pubis and the umbilicus, and an abundant evacuation of foetid intestinal contents greatly improved the situation. On July 5th, in passing through Paris, I myself examined the patient ;

PENETRATING WOUNDS 235

le night before they had extracted by means of the stular opening a scrap of dead tissue containing a thread of silk (?) and I myself removed a portion of dead intestine 25 cm. long with a corresponding piece of mesentery. Another abundant stool followed the removal of this foreign body which formed an artificial stoppage ; the condition of the patient improved ; the temperature fell to 38° (100-4° Fahr.), P. 120, and hope was renewed.

But the fistula was high up ; particles of food passed without being digested ; and weakness became more and more marked. Death came on July 16th, two months and a half after the wound.

How can we explain this case ? Clinically ?IK! anatomically the sloughing of this long segment of intestine can only be explained by septic arterial thrombosis, the segment affected was probably that which separated the resection and the complete section. It would not perhaps have occurred if the whole segment had been taken away by resection, the whole extent of which was not sufficiently large to be by itself a new and serious factor.

It appears to us, therefore, that in similar cases, especially if the injuries to the mesentery, which even though small are always septic, can affect the blood supply, it would be best to excise the intermediate section.

Some surgeons have tried to obliterate confluent or extended perforations by joining up a neighbouring loop (Stern), but these attempts never gave good results. They are best left alone. In all these cases, resection seems to be the safest, most rapid and least injurious method.

Only as a last extremity ought one to have recourse to making an artificial anus of a ruptured loop of the small intestine. For either this is the only lesion and it is inconceivable that we should not find time to attend to it, or there are many lesions of which the very-

236 WOUNDS OF THE ABDOMEN

multiplicity would lead us to adopt a similar course ; it would be better then to risk a possible death under a complete operation which might even result in recovery rather than to court certain death by exhaus- tion.*

The method to be followed for intestinal resection.— Latero-lateral anastomosis undoubtedly takes more time ; we therefore prefer the circular, end to end. We never employ Murphy's button ; a neatly made suture in two rows is much quicker.

Here are brief details of the method which experience has shown us to be the best.

Two clamps ; section of the intestine for a length of 3 cm. on the inner side.

Section in an obtuse V of the mesentery leaving 1 cm. of mesentery projecting inside the intestinal section. The vessels are ligatured with catgut ; the threads are left hanging down, by placing them oppo- site each other and tying them from slit to slit ; once the intestinal suture is made, one can effect the closing of the mesenteric breach rapidly, and as a rule with- out overs titching. The two ends of the intestines are brought together like the barrels of a gun and kept in place by two Chaput's forceps, mesenteric edge to mesenteric edge, and free border to free border. Then we make a complete overstitching beginning in the middle of the posterior semicircle, with a loop of thread on two needles knotted. The left thread does the oversewing on the mesenteric side, turns carefully at the level of the angle, and comes to the front ; in the same way the right-hand thread makes the stitches on the free edge and is tied to the first thread, in the centre of the anterior semicircle.

* One of Tisserand's patients had eight perforations on one loop of the small intestine, which was resected. The patient's condition not allowing an anastomosis, the two ends were joined to the skin. The patient recovered from the operation very well, but died on the seventh day from rapid wasting ; the excised loop was very close to the duodenum.

PENETRATING WOUNDS

237

L iver_ _

Stomach

One may then begin the suturing of the serous sur- faces, which is done from right to left, and from front to back ; one of the needles goes through the mesen- tery (take care not to prick the small arteries !) con- tinuing the deep suturing, and the two threads are tied together at the back.

One more point. We never make X-shaped stitches (called stops), because wre find them useless, and because they make the suturing less regular and less tight.

We tie together two by two the ligatures of the mesenteric sec- tions. For latero-lat- eral anastomosis we always find it very convenient to use the double forceps (Te- moin-Abadie). We have too often seen the vessels bleeding at the edges of the area flattened out by the "ecraseur" to advise its being used on the intestine.

After every suture the intestine is washed

with ether, then placed under a swab soaked in saline until it is put back in its place.

(b) The Large Intestine.— There are two segments particularly difficult of access — the two angles, and the left even more so than the right.

The sub-hepatic angle is generally exposed during an operation which involves the liver, such as Auvray's incision prolonged vertically downwards to its outer extremity, a sub-costal incision also prolonged ver- tically outwards, and Kehr's extensive incision (excep-

-[Colon

'iOmentum

"•^.Small intestines

FIG. 54. — Exposure of the right angle of the colon and the neighbouring organs after Kehr's laparotomy.

238 WOUNDS OF THE ABDOMEN

tional) which gives a wide exposure of the whole region as shown in Fig. 54.

The splenic angle is most conveniently reached by a sub-costal incision with an external vertical prolon- gation (Fig. 55).

When the colon has a long mesentery over its whole extent or in those parts which are generally wrell

\J

FIG. 55. — Left sub-costal laparotomy with vertioarprolongation. The stomach, the upper part of the spleen, and the splenic angle of the colon are brought into view. The dotted line shows the incision for effecting the detachment of the colon. (Borrowed from Guibe.)

provided with pedicles (the transverse colon and the sigmoid flexure), the method of reparation is nearly the same as that for the small intestine. The greater extent of the insertion of the mesentery is, however, always a cause of difficulty. If the appendices epi-

PENETRATING WOUNDS 239

ploicae are in the way, it is no waste of time to tie them nrmly at the base and remove them from the area of operation.

In the cases where the shortness of the mesentery is source of inconvenience in preventing the organs be examined and treated, from being easily *awn outside, we must not hesitate to make a " lateral Detachment " by dividing the peritoneum longitudinally the whole length of the mesentery and pressing back nwards the colon and its vascular layer. Its mobility is thus considerably increased. It does t seem advisable here to re-attach the colon to the walls by suture ; it would be better to leave this coalescence to be established later, and not to run the risk of infection of the area of cleavage, which is sep and has no outlet. On the other hand if the enetrating wound is posterior and leads, after being freely laid open, to the focus of the lesions and allows »i easy communication and good posterior drainage we may nnd it very advantageous to suture the external parietal edge of the cut peritoneum, to the anterior .rface of the colon ; in this way the whole external posterior surface of the colon is exposed and separated from the peritoneal cavity. Infection of the area or nstula would not in this case be very serious We owe a recent success to this method.

End-to-end anastomoses of the colon are always

ifficult, especially when it is sessile on account of

the length of the suture where the enclosed portion

s not m the serous layer. When possible it is best to

>egm in these cases by a strong posterior back-tc-back

iture before doing the complete circular overstitch-

But this operation is always delicate and uncer-

n and much more tiresome because we have to use

curved needles, and the surrounding tissues are soaked

>lood. If by good luck we have the necessary

material to make two deep rows of sutures we must

not hesitate to do so. A plastic of the omentum is

240

WOUNDS OF THE ABDOMEN

very useful in giving additional strength to these delicate sutures. Yet in spite of all our care a faecal fistula very often supervenes, but this is not really alarming, for as a rule it will gradually disappear of its own accord.

The uncertainty of the sutures and the frequency of fistula are reasons which make us prefer to treat the

FIG. 56. — Auvray's method for reaching the upper surface of the liver (Guibe). (A) Parietal incision ; the dotted curve shows the line of section of the costal cartilages ; (B) the scalpel applied closely to the deep surface of the cartilaginous flap to avoid the pleura and detach the diaphragm.

large intestine by exposing it and making the artificial anus, which we have condemned as regards the small intestine. Such results as have been published are, as a rule, highly unsatisfactory. But the high mortality is due to the fact that this expedient is only resorted

PENETRATING WOUNDS

241

o when every moment gained is very valuable, that is to'say when the general condition of the patient is very ^serious. What we have to remember is that, as Quenu advises, we should make the special lumbar incision, through which the loop to be exposed will

FIG. 56. — (C) The diaphragm being incised as well as the perito- neum, the hand hooks up the liver to permit access to its upper surface.

pass, as far back as possible. The preliminary detach- ment of the mesentery might be advantageous.

In a case of urgency we might equally well have recourse to the following procedure : resection of a seg- ment of the colon, closing up and enclosure of the distal 16

242 WOUNDS OF THE ABDOMEN

end, and opening of the csecal end at the skin (Bouvier and Caudrelier, two cases, two deaths). Unilateral exclusion of this kind and the entero-anastomoses which accompany them are only to be resorted to under exceptional circumstances.

(c) Liver. — Easy access to the dome of the liver is obtained by Auvray's method, of which we will give a brief description (Fig. 56). An incision leading from the xiphoid cartilage to the tip of the eleventh rib passing by a finger's breadth above the costal margin ; laying bare of the costal cartilages, incision by the bistoury, beginning at the xiphoid, dividing the eighth cartilage on the inner side, separating it from the seventh, then making a fresh incision on the inner side of the chondro-costal articulation, finally dividing the ninth and tenth cartilages ; we keep close to the deeper surface to make quite sure of avoiding the pleura ; the diaphragm and the transverse colon are detached, and the peritoneum opened.

In the case we are considering, this line of access is generally used to complete a median supra-umbilical laparotomy, or else an incision going from one orifice to the other.

The following case is an example : — •

B — • — , on June 19th, 1915, was struck by a bullet which caused a large tunnel-wound near the false ribs on the right side with diffuse hsematoma, hernia of the transverse colon and of a loop of the small intestine, extrusion of the omentum and hepatic haemorrhage. The patient lost a lot of blood and was very pale. He was operated on ten hours afterwards. The tunnel was converted into a trench ; the abdominal cavity was thus opened extensively ; resection of the costal cartilages exposed the dome of the liver ; we pressed back the transverse colon, the omentum, the small intestine and then the liver, and found a deep lacera l tion 4 cm. long. Suture, by means of U-stitches in coarse catgut ; drain ; restoration of the walls stage

PENETRATING WOUNDS 243

244

WOUNDS OF THE ABDOMEN

The treatise by Forgue and Jeanbrau * is the best to study on this question.

The upper part of the stomach is most easily reached by a similar incision and a similar method on the left to those which have been described for the liver on the right. Baudet recommends the following procedure : division of the seventh costal cartilage near the sternum, section of the eighth and seventh ribs in the nipple line ; one thus obtains a kind of movable flap, which can

FIG. 57. — Section, vertical and sagittal, to show the routes to the lesser sac of the peritoneum and the posterior surface of the stomach : (I. 1) Trans-mesocolic route ; (2) inter- gastrocolic route ; (3) Inter- colo-omental route. (II) Anatomical arrangement of the parts which renders impracticable the inter-colo-omental route by reason of the extensive and fenestrated adhesions of the omentum and the mesocolon (A).

be lifted up to allow a view of the spleen, the left lobe of the liver, and the upper part of the stomach (Fig. 63). f

* Forgue and Jeanbrau, " Gunshot Wounds of the Stomach " Rev. de Chir. Sept. Oct. Nov. 1903.

f In spite of the fact that text-book descriptions represent the pleural cavity as being slightly higher on the left side, nevertheless the greatest care must be taken in dividing the cartilages and in uncovering the flaps from behind, for one may find abnormalities ; in the patient whose case we have represented on Plate IV the pleura is within a finger's breadth of the edge of the thorax.

PENETRATING WOUNDS

245

K valve or a powerful retractor will raise the costal lework. This line of approach gives an extensive exposure of the stomach and spleen.

The posterior surface of the stomach should be syste-

FIG. 58. — Gastro-colic means of approach, through the omentum, to the posterior surface of the stomach. After section of the omen- turn, the two edges of the wound which are marked by the forceps which are effecting hsemostasis, the stomach is tilted from below up- wards. A perforation, even if quite high up, is thus readily sutured (after Forgue and Jeanbrau).

matically examined even when only a single perfora- tion has been found on the anterior surface.

These methods of procedure now bring us quickly to the lesser cavity of the peritoneum, that is to say to the posterior surface of the stomach (Fig. 57 and Plates II and III).

246

WOUNDS OF THE ABDOMEN

The first consists in making an opening through the transverse mesocolon as in gastro-enterotomy.

In one instance where laparotomy allowed us to suture a small perforation of the stomach in front of and above the greater curvature (F — — • , March 17th,

FIG. 59. — Access to the posterior surface of the stomach by the inter- colo-omental route. " The abdomen is open, the Gosset retractor keeps the walls apart ; the scalpel is seen with its point scratching the transverse colon at the insertion of the great omen- turn" (Pauchet [73]).

1916), it was necessary to examine the posterior sur- face : an opening rapidly made through the transverse

PLATE II

FIG. D. — A. r. Renal artery. F. Fragment detached by ex- plosion.

Root of ^sentery.

mall in- testine.

Caecum, opendix.

FIG. E.

Transverse colon.

Transverse colon.

Sigmoid flexure.

Left kidney.

Rectum.

Explosive lesions of the liver, produced by bullets (Fig. C-Vp, Portal vein. Vb, bile duct) and of the right kidney (D) with extan- sive laceration of the pelvis ; complete section of the angle of the ascending colon ; perforation of the vertebral column, with lacera- tion of the spinal cord. Bullet entered under the right costal margin ; went out in the left lumbar region. (Part of post-mortem on a wounded man brought in dead.) The following abnormalities were also found : the descending colon, the splenic angle of which was against the vertebral column, passed under the root of insertion of the mesentery ; it emerged at the level of the right iliac fossa, and the rectum descended to the right of the sacrum. Finally, the left kidney was at the level of the upper outlet of the pelvis (E). 246]

PENETRATING WOUNDS

247

mesocolon showed that the posterior cavity of the omentum (lesser cavity of the peritoneum) was sound ; the projectile had probably remained in the stomach. The abdomen was completely closed up again. The wound healed by first intention.

FIG. 60. — " The inter-colo-omental detachment, commenced with the scalpel, following the black line, is continued with the aid of a pair of forceps holding a gauze swab. It will be noticed that the mesocolic vessels allow themselves to be separated readily with the great omentum without haemorrhage." (Pauchet [73].)

But, this route being narrow and long, though it would suffice once in a way for an examination, is awkward for suturing a perforation. We will, there- fore, disregard it.

248

WOUNDS OF THE ABDOMEN

The second passes through the great omentum at the level of the greater curvature (Fig. 58 and Plate II) ; we divide the omentum above the arterial arch, liga-

FIG. 61. — "The great omentum, completely separated from the transverse colon, has been detached, and drawn up with the stomach. The gastric perforation will be easy to suture. The pancreas presents between the mesocolon and the stomach ; the duodenum can be seen as far as the pyloric vein." (Pauchet [73].)

turing one after the other branches which descend into the omentum ; this incision can be extended if , neces-

PLATE III

FIG. F.— Abdominal cavity widely opened by removal of the anterior wall. The organs seen in situ. Note the curve of the sigmoid flexure and the extensive overlapping of the gut bv the omentum. J

FIG. G.— Line of access between the transverse colon and stomach across the omentum, to the posterior surface of the stomach The omentum is divided below the perigastric arterial circle- foreepl are placed on the omental arteries.

248]

PENETRATING WOUNDS

249<

sary ; the posterior cavity is now completely open ; the stomach is now tipped from below upwards in order to discover the perforation and suture it. Then the opening in the omentum is sewn up. This method is- inconvenient because haemostasis is required.

, 'i??/"1*0^ gastric perforation is sutured. This one has-

been obliterated by four separate perforating sutures- a portion

the great omentum has been placed in contact and fixed by some separate stitches. The rest of the colon is going to be placed behind the omentum. The transverse colon will be sutured

ctly to the greater curvature of the stomach." (Pauchet [*»].)

Pauchet ['»] suggests reviving the method of detach- ment of the inter-colic om,entum ; we reach the posterior cavity by lifting up the omentum and making an incision (splitting it) above the colon. The figures

250

WOUNDS OF THE ABDOMEN

Liver. _

Stomach --

Spleen

given here and the notes under them do away with any necessity for further description (Figs. 60 to 63 and Plate III).

This method, seductive as it may be, is not always possible, and on two occasions (notably on that repre- sented on Plate IV) we have found on the dead subject, between the stomach and the colon, an omentum already penetrated because the coalescence of the constituent layers, instead of being arrested only below

the anterior edge of the transverse colon, went up much higher, almost to the edge of the stomach.

However, this ar- rangement is not un- known, and we find a -Colon mention of it in Testut and Jacob, vol. ii., p. 84, as well as the dan- gers to which we are exposed in attempting an opening of the pos- terior cavity (Fig. 57, Plate II).

FIG. 63.— Access to the left edge W The Spleen. — - If of the stomach, the spleen, and the we are dealing with splenic angle of the colon after lapa- the spleen alone, and rotomy with the resection of a carti- >£ -,

laginous flap in the thorax. " we nave not to ex-

amine the whole of the

left hypochondrium, we may make either a sub-costal or directly horizontal incision. But this is an ex- ceptional case ; generally the spleen is involved in lesions of the left hypochondrium. which therefore we must examine carefully, or it may be injured by a thoraco-abdominal wound.

In the first case we get access to the spleen by the same means as we have just used for the upper part

PLATE IV

FIG. H. — Abdominal cavity as in Fig. F, after raising the omen- turn and the transverse colon.

FIG. I. — Line of access between the omentum and colon, by section and detachment of the omentum and the transverse colon.

250]

PENETRATING WOUNDS 251

of the stomach (Fig. 63), but in order to examine the spleen properly we must prolong the incision backwards in a horizontal direction and even vertically towards the iliac crest.

The existence of a thoraco-abdominal wound may lead to two different methods of action which Delore .and Kocher [76] have very clearly compared. They distinguish two clinical types : the respiratory, and the abdominal, each of which has its own preferable line of access ; the diaphragmatic route in the first case, the abdominal route in the other.

They say that the diaphragmatic route will have manifest advantages whenever the blood coming from the spleen has flowed copiously into the pleura, whilst the peritoneum has received scarcely any (don't forget a, rectal examination ! ) . But if there is no blood , or only •a little, in the pleura the abdominal route is to be chosen (a sub-costal incision enlarged, by means of the resection of two or three of the left costal cartilages). It has the advantage of limiting manipulations of the pleura, which is always more liable to infection than is the peritoneum.

The following is a short account of three cases, which may be said to indicate the various therapeutic methods.

First Case. — Thoraco-abdominal wound with injury to the spleen. No operation took place and at the •end of two months and a half the patient succumbed to diffuse suppuration, and chronic peritonitis, in spite of many incisions to drain off the constantly collecting pus in the regions of the spleen, pelvis, left iliac fossa, etc.

Second Case. — -A small wound 3 or 4 cm. long under- neath the angle of the left scapula ; more abdominal than thoracic symptoms, (a) Resection of the eighth rib, which was fractured ; no blood in the pleura ; wound closed (afterwards it was necessary to remove 100 grammes of serous liquid by puncture) ; (b) left

252 WOUNDS OF THE ABDOMEN

sub-costal laparotomy prolonged by a vertical incision to the iliac crest ; splenectomy. Recovery.

Third Case. — Penetrating wound of left axilla at the level of the ninth rib. An oblique incision on to the rib and resection ; a great deal of blood in the pleura ; a hole as big as the thumb in the diaphragm led to a wound in the spleen ; the whole rib was excised and the orifice in the diaphragm was en- larged, and by means of this, splenectomy was performed. The opening was closed by suturing the upper edge of the diaphragmatic wound to the thoracic pleura and thus the pleural cavity was closed (small drain) ; at the same time the lung was secured in the costal diaphrag- matic sinus by two catgut stitches ; then the diaphragm and finally the peritoneum were closed. Recovery.

Plugging the spleen for a bleeding wound is generally deceptive, and it would be better to take away the organ altogether.

Considered as abnormally serious and constantly fatal in military surgery in consequence of some obser- vations by Willems [23], splenectomy deserves that we should challenge such a condemnation. The two successes of Delore which we have just described in detail, one by Lammory, quoted by Quenu, another by Barbet and Bouvet, and four published by Depage [41]} show that the after-effects of splenectomy are serious in proportion as the already existing haemorrhage and the injuries of the other organs have threatened the patient's life ; 12 cases operated on by Depage or his. collaborators resulted in 4 recoveries, and in 4 cases, where the spleen alone was involved there were 3- recoveries .

The method for excision of the spleen has nothing very special about it, and can be summed up as follows : draw it outside by detaching the mesentery, place two firm clamps in position, cut, and above all ligature the pedicle very carefully.

In all the operations on the hypochondria and the

PENETRATING WOUNDS 253

dgastric region, we should remember the comfort given ~by Mayo Robson's cushion, in making the deep-seated ;ans more prominent and more easily accessible. (/) The Kidney. — The kidney can be reached by a, trans-peritoneal route in the course of either an .anterior laparotomy or of a lateral or transverse lumbar Japarotomy (see following case). Plugging ought only to be used for small wounds with slight haemorrhage. Otherwise we must have recourse to nephrectomy.

The technique should be simple and rapid ; the same remarks apply here as those we have made on the subject of the spleen. If combined with the treat- ment of other injuries of the abdominal viscera, nephrectomy is always serious. Recoveries are un- usual ; we have, however, seen one.

J , wounded April 29th, 1916, by a bullet which

•entered just to the left of the umbilicus and came out in the left lumbar region with hernia of the omen turn and of the descending colon. General appearance of haemorrhage. T. 38'4 (100'4° Fahr.), P. 140. At the eighth hour direct horizontal laparotomy. Excision of the omentum ; we staunched the blood, which flowed •copiously from the region of the kidneys ; we made & large opening in the peritoneum and examined the bleeding kidney ; it was ruptured and brittle (Figs. 16 and 17) ; two clamps were placed on the pedicle, nephrec- tomy ; afterwards the descending colon was found to have been divided transversely ; end-to-end anastomosis after cleaning up the cut ends. Drainage. Suture in one layer. On May 2nd a bronze-coloured infiltration was found in the flank ; all the stitches were taken out ; the lips of the wound were gangrenous, with a foetid odour, and there was gas ; all the gangrenous tissue was removed, and ether dressings applied.

After this operation some amount of sloughy tissue was eliminated, but the general condition of the patient was excellent and the wound healed up without faecal fistula.

254 WOUNDS OF THE ABDOMEN

(g) The Bladder.^We have described above how the extra-peritoneal, lower part of the bladder can be conveniently reached by an opening in the perineo- sacral or gluteal region, by placing the patient in JJepages position (ventral decubitus with the legs hanging down, in the shape of an inverted V).

Examination of the bladder will be made during a laparotomy after the pelvis has been completely dried, and a large swab placed as a barrier, the patient being arranged in a slightly exaggerated Trendelenburg's position. Now we have a very anxious moment Perforation in the folds of the peritoneum can easily be missed, we must go slowly, carefully smoothing out all the corners, while the fundus of the bladder is taken and held by large heart-shaped forceps. Perforation once detected, we must open up the perforated peri- toneum more widely still in order to get at the bladder Ought we to be contented with closing up, even on two levels, perforation of the bladder ?

Experience has shown us that we must at the same time systematically open the bladder in the hypogastric region by cystotomy, with a large drainage-tube from the upper part. A siphon with a glass tube (as in pros- tatectomy) will prevent the patient from being flooded with urine. If the fundus of the bladder is also injured a long drain will go from the hypogastrium to the perineum. Not until much later on, when these wounds are nearly healed, will it be necessary to tie m a catheter. The co-existence of bladder injuries, with other wounds, greatly increases the seriousness of the prognosis.

We can ignore the case of Tartois' patient who re- covered ; he had only a simple sub-mucous tunnel- wound without perforation of the bladder. The wounded described by Dupont and Kendirdjy (Case 2), Schwartz and Mocquot (Cases 3 and 11), Stern (Cases 22 and 32), etc., died. The same fate overtook seven of our own cases, and that is easily understood when we

PENETRATING WOUNDS

255

notice that they were nearly all cases of wounds in the buttocks or in the region of the sacrum where the per- foration had been overlooked (hence the operation was too late) or that they were complicated by extensive lacerations and complex lesions of the rectum, the sigmoid flexure, the pelvic bones, etc.

In one case, how- ever, we succeeded in obtain- ing a re- covery in spite of the seriousness

and extent

of the dam- age. As far

as we know,

this is the

only case

which has

been pub- lished. It

deserves

p ublica-

tion, not so

much on

account of

the lessons

to be learnt

u!, 64-— Sma11 projectile which has perforated bladder, rectum, small intestine, and pubis The larger projectile remains sub-peritoneal.

from the point of view of the wounds, as from the method of operation and after-care.

H ' wounded by shell-splinter April 29th, 1915

in the night, was brought to us the same day at nine o clock. On the left buttock about 3 cm. behind the anus, and invading the region of the sacrum, there was a wound 12cm. long losing itself in the fold between

256 WOUNDS OF THE ABDOMEN

the buttocks ; copious bleeding. Catheterism of the bladder, a few drops of blood ; no urine, abdomen painful, severe shock ; bloodless, respiration very faint, pulse uncountable, cold. Thought to be beyond •operation.

Injections of saline, caffeine, ether, and campho- rated oil. Two hours later the patient revived. P. 160.

Operation. — About twelve hours after the injury. 'Continuous injection of saline. Chloroform ; severe syncope at the beginning of the operation, which was continued, however, in spite of the apparently desperate situation. Sub-umbilical median laparotomy ; copious bleeding from the left posterior surface of the bladder, which was ruptured for a length of 25 mm. with sub- peritoneal haematoma and laceration of the bleeding peritoneum ; suture of the bladder, large drainage- tube pushed in at the back of the wound towards the buttock and coming out at the hypogastrium ; the psritoneum was closed again above, thus shutting off the cavity from the rest of the abdomen. Examination of the intestine ; two perforations of the small intestine close together, one cm. in length ; suture by purse- stitch. The loops of the intestine were washed with a solution of sea-salt, strength 140 in 1,000 ; 200 grms. -of the same solution were put into the abdomen ; a large drain into the pelvis ; stitching up in one layer only ; catheter tied in. Length of operation, fifty-five minutes.

After-effects. — Flatus on the second day, natural ,stool on the fourth, From the day after the operation, T. 36° (96-8° Fahr.), P. 130, and then fell to 120. On the sixth day urine by the hypogastrium ; the catheter constantly obstructed by pus from the bladder; on the tenth day it was left out. May 16th faecal matter in the hypogastrium ; immediate removal of the large drainage-tube ; in two days the discharge of faecal matter ceased, and then that of urine. v Urine

PENETRATING WOUNDS 257

and faecal matter then passed by the gluteal wound. Frequent lavage of the bladder and the wounds. May 25th, micturition normal.

May 26th, faeces no longer discharged except by the rectum.

May 28th, evacuated with general condition very good ; the posterior wound rapidly filled up.

Radiography (May 27th). — First, a splinter 15 mm. long projected into the inner angle of the left obturator foramen. Secondly, a large foreign body was clearly visible in the left flank, against the caecum, having glanced off laterally, it would appear, to the horizontal level of the posterior iliac crest ; but the most vigorous handling did not produce any visible reaction nor any abnormal projection. A radiogram taken seme days afterwards at Bar-le-Duc confirmed the radioscopic examination. (Fig. 64.)

After-effects. — Recovery was uneventful.

Latest Report. — The patient has just been operated on by laparotomy at Guincamp by 13 r. Aragon, for the extraction of a large shell fragment (40 grammes of cast-iron) enclosed in a fold of the peritoneum between the caecum and the lateral external and posterior wall ; the appendix was removed at the same time. After- effects excellent. Complete recovery in all other respects. (Abadie (33), Case 15.)

(h) Rectum. — Isolate if possible from the peritoneum, leave a large opening from the perineum and from the sacrum by opening up the posterior wound, pack with gauze and drain all the corners ; this seems to us to be the general method to be followed.

(k) Omentum, Mesentery, Posterior Peritoneum.— The omentum contaminated by or perforated with possibly septic tissue should be resected in all the injured parts. The haemostasis must be watched. The mesentery is often the seat of haemorrhage ; the rup- tured vessels must be carefully searched for. This is often difficult, for a haemorrhagic infiltration divides 17

258 WOUNDS OF THE ABDOMEN

the folds and prevents us from finding the origin of the haemorrhage.

The perforations and lacerations are sutured after cleaning up and checking the haemorrhage at the edges of the wound.

We have already seen under which circumstances it is necessary to make the various intestinal resections for lacerations, perforations, and injuries at points of insertion.

Posterior retro-peritoneal haemorrhage looks like a red tumour. It is useless to seek for the origin of the blood ; the most one can do is to plug the region whence it comes. Sometimes one may be induced to lift up the posterior peritoneum and suture it to the edges of the exploratory peritoneal incision, in such a way as to isolate the peritoneal cavity and so effect extra-peritoneal plugging. (C. Wallace.)

(I) Thoraco- Abdominal Wounds. — Thoraco-abdominal wounds which call for operation are, as a rule, large openings involving two regions, the thoracic and the abdominal, piercing the partition of the diaphragm, which separates them, and penetrating also the walls of the thorax (see Fig. 21).

The edges must be repaired and the costal section made sound by removal of bone-splinters or by resec- tion.

A visceral hernia through the diaphragm should be verified, reduced after the viscera have been cleaned up and repaired, and, if the condition of the patient allows, the operation should be completed by an exploratory laparotomy. In the case- report on p. 113 (Fig. 20), we could not do this ; we had closed up one perforation of the stomach, but there remained another, unnoticed, as well as some intestinal injuries.

If the hernia is confined to the omentum it is wiser to leave it alone, as it forms a natural plug, even at the risk of having to perform laparotomy if there are accompanying symptoms of a deep abdominal wound.

FOR PENETRATING WOUNDS 259

It will be advisable, as a rule, to isolate the pleural cavity by joining up the edges of the parietal opening to those of the diaphragmatic opening as we suggest in the case on p. 114, then it is emptied by aspiration.

The Miculicz pleural treatment, according to Depage, has resulted in several cures in the case of large wounds in the thorax, with a complete pneumothorax. The treatment might produce good results in a thoraco- abdominal association.

GENERAL EXAMINATION OF THE ABDOMINAL VISCERA

When the zone of the injuries is not clearly marked or when there is an impression of a wide area of injuries (and this case is frequent when there is no reliable information as to the course of the projectile), one must at once make a full and methodical inspection of the intestinal mass, and then, if necessary, of the whole viscera.

This exploratory examination is also necessary when the various injuries have been repaired, and the pro- jectile has not been removed at the same time. Unless this is done we are liable to overlook some injuries.

Briefly : the cases in which we can do without making a complete visceral examination appear to us to be very few.

The intestine, as one goes on methodically exposing it, is wrapped up in a large compress soaked in hot saline solution. The injuries are isolated, one after the other, as they are discovered and grouped together, under compresses, on the side away from the whole intestinal mass, which is on the left near the assistant, while the lesions are on the right near the operator. They are not treated until later on, otherwise we run the risk of obscuring many perforations, and being forced, after a fuller examination, to resect some loop which we have already repaired with difficulty.

260 WOUNDS OF THE ABDOMEN

The swabs which surround them are sprinkled with hot saline. Depage obtained a continuous sprinkling by a jet of saline from an adjacent receiver ; this arrangement cannot always be made sufficiently aseptic in installations at the front ; but we can always put two or three thicknesses of compresses over the exposed mass and pour over them from time to time hot saline at a temperature of 40° to 45° C. (104° to 113° Fahr.).

In the examination we must not neglect the region of the colon, still less the bladder.

Removal of the Projectiles. — Here we see the advantage of those equipments which, thanks to the radioscope, are able in a preliminary examination to determine the number and seat of the projectiles.

Though the surgeon must avoid any prolongation of an operation which is not intended primarily to remove projectiles, but to repair the injuries that they have produced, he will have done a more satisfactory piece of work if he has been able to remove the foreign bodies at the same time.

Without information from the radioscope, he will sometimes pass quite close to a shell-splinter without suspecting it, although he would have been only too glad to get hold of it, and so relieve the patient of it at once.

Rochard has carefully elaborated this point and Stern's statistics show a doubled mortality when the projectile is left in the body. How much quicker and simpler would have been the operative results in

E 's case, if we had been able to remove at once

a shell-splinter which, by the abscesses which it caused, jeopardised the recovery of the patient for some days !

November 2nd, 1915, E • was injured by a shell- splinter above the right anterior superior iliac spine ; a median sub-umbilical laparotomy (at the twelfth hour) allowed the mopping-up of an effusion of foetid

PENETRATING WOUNDS 261

liquid and of intestinal contents which came from a perforation of the small intestine which was sutured. No projectile was found. Ether. Double drainage.

November 6th. Normal stool.

On November llth, pieces of clothing and some pus came away through the upper drain.

November 15th, to the right of the umbilicus, a large deep-seated abscess was opened. Under the radioscopic screen the forceps easily found the projectile, but a loop of the intestine probably came in the way. On December 2nd the projectile was taken away ; it was a 2 cm. cube. From that moment the healing was normal, and in January the wound was entirely closed. (Abadie [3S], Case 3.)

Briefly. When, without lengthening the operation too much, we can find and remove the projectiles, it is best to do so.

Cleansing and Draining the Peritoneum. — The swabbing-up of the abdominal cavity is necessary, especially in the three parts which slope downwards, the flanks and the pelvis. This has to be taken in hand from the very beginning of the operation, and continued in order to make sure that there is no further haemorrhage.

The organs and tissues near the perforations have been cleansed with ether during the operations for repairs and then covered over with swabs wet with saline. It has become the custom to pour a small quantity of ether into the abdomen after the operation, before closing it up again. Not more than 100-150 grammes 'must be used.

This proceeding is not without some drawbacks, and one must at once watch for any change of pulse and respiration. The general cold due to the ebullition and the rapid evaporation of the ether must be taken into consideration.

Are we to suppose that no harm comes from the fact that " bathing with ether has the effect not only

262 WOUNDS OF THE ABDOMEN

of lubricating and drying up the peritoneum, but also of completing the general narcosis and especially of relaxing the loops of the intestines, opening up to the laparotomist, as cocaine-adrenalin does to the rhinologist, a wider field of exploration ? " (Picque).

For our own part, we have always had more faith in the action of swabs soaked in very hot salt saline which surrounds or gently wipes the loops ; the colour improves at once. The circulation becomes stronger and the whole appearance is more normal than after ether has been employed ; we can correct the former method by the latter ; by the first we obtain tem- porary asepsis in a limited area, by the second we stimulate contractility and adhesive power — both indications of normal vitality ; in a very short time the peritoneum will begin to adhere to the swabs.

It is not until the operation is at an end that we leave a small quantity of ether in the pelvis ; its vapour circulating in this particularly septic region may be useful. Moreover, we must mention that, in two cases, we substituted for the ether hypertonic saline solution, 140 in 1,000; one of these cases (see p. 255) is perhaps the most successful of the series.

The replacement of the intestinal coils has never seemed to us a difficulty ; it must be done methodi- cally, taking care to avoid any twisting which might lead to obstruction.

Shall we drain or not ? Only in cases of strictly limited injuries easily repaired, and without soiling of the general abdominal cavity, ought we to close up without drainage. Such conditions are exceptional.

We think it wiser to place one drainage-tube in thej pelvis and sometimes another near the lesions.

Certain post-mortem findings would incline us to' a systematic drainage of the pelvis, in the case of sub-umbilical wounds and of high laparotomy as well as in the case of low laparotomy, if there is proved to

PENETRATING WOUNDS

263

ive been haemorrhage or effusion of fluids from a septic area pouring into the downward sloping parts of the abdomen.

This drainage takes very little time, only a minute or two, and allows of the exit of this suspicious effusion. Examination of the rectum may give, with regard to this, some very useful information, by revealing before operation on the middle or upper part of the abdomen an effusion into the recto-vesical pouch.

Certain operators pack with gauze, at the same time using drainage-tubes, and Stern describes cases where the injured gut was literally swathed in gauze, packed into the point where the gut was absolutely intact ; in the centre a drainage tube serves the purpose of allowing daily douches of ether. These swabs are intended to facilitate adhesion. Adhesions between themselves and the intestine, certainly ; and this accounts for the almost constant appearance of subsequent fistulas ! But one is right to ask oneself why should we set up a barrier of adhesions in addition to that of the swabs ? It is very probable that these adhesions (which do not need swabs to produce them) will, on the contrary, be pulled about and injured in the daily cleaning up and dressing with gauze. As to the idea of trying to keep the injured loops near the wound itself it is impossible with widely dissemin- ated lesions, and above all we must avoid abnormal torsion of the gut.

We should do better to push down the injured loop or loops into the pelvic cavity and to cover up the rest of the small intestine very carefully with the omentum ; the omentum forms a very useful covering if the sutures of the incision give way spontaneously, or if the wound is deliberately reopened by the surgeon. (See cases on pp. 93 and 255.)

Closure of the Abdomen. — Every one is agreed as to this ; close up on one plane with a strong metal wire, either brass or silver. With these, we can use horse-

264 WOUNDS OF THE ABDOMEN

hair threads or Michel's clips, to bring together the cutaneous edges.

The employment of a steel wire in the case of isolated hidden stitches is suggested by Clermont ; some years ago I used this method in aseptic surgery ; as, how- ever, the elimination was often very slow, I gave up the practice. If we use it after an operation for a penetrating abdominal wound we shall meet with many drawbacks.

Two precautions must be taken : always clean the wound itself very carefully if it is included in the incision, and if possible do not reunite, at this level — • leave plenty of space round the drainage tubes and the gauze used for plugging, so as not to compress them unduly.

Treatment of Accompanying Wounds. — We will not dogmatise, and say that we must always perform laparotomy and treat the patient's other wounds at the same time ; it is a case of diagnostic intuition and of appreciation of the power of resistance in the patient.

But it is very desirable that multiple wounds should be laid open and cleansed, that any accessible foreign bodies should be removed, and the dressings carefully done so that the patient need not be moved for several days.

This method is particularly necessary for wounds in the lower limbs, which, more than any others, are liable rapidly to develop septic complications, notably gas gangrene.

Dressing. — We shall note only the advantage to be obtained by setting up an external siphonage for supra-pubic cystotomy and in certain cases of hypo- gastric drainage.

Post-operative care — immediate treatment. — As soon as the patient has been warmed, rubbed if necessary, and restored by all the usual means after anaesthesia, the essential points are :

PENETRATING WOUNDS 265

Absolute immobility ; Folder's position ; Nothing by mouth.

These form a therapeutic triad which we will con- sider in detail under " medical treatment."

At the same time we give daily injections of camphorated oil (10 cc.) ; of adrenalin in doses of 2 or even 3 milligrammes decreasing to £ a milligramme, which is continued as long as there is low arterial tension.

Finally, if there should be pulmonary congestion, strychnine.

Usually, we give the patients small doses of morphia : | centigramme morning and evening.

(One ought to be able to isolate in a separate room.)

Operative after-treatment. Dressings. — We will give an outline of four different types.

With some patients everything follows a normal course. From the second day recovery would appear to be almost certain ; pulse slower and fuller, the face calm and the eyes brighter, no restlessness of any sort, nor the calm induced by torpor. On the third to the sixth day flatus or natural stools appear, the stitches are removed, and union takes place from the outset.

In a quite contrary case the weakness remains or increases ; after the operation, the pulse quickens, the features are drawn, dyspnoea increases and the end comes rapidly in the first thirty-five or forty-eight hours. A fatal development of this kind occurs in the large majority of these unfortunate cases ; and against it we are utterly helpless.

Others, less frequently, are carried off in four to six days by typical general peritonitis, acute no doubt, but with a relatively slow development. And we are almost powerless.

In a great many cases recovery is only obtained at the price of a sustained struggle* No other kind of

266 WOUNDS OF THE ABDOMEN

patient demands such assiduous care and such atten- tive observation of detail in order to discover the com- plication in time. Laparotomy for abdominal wounds derives more benefit from the " dodges " for treat- ment which the surgeon's own personal experience will suggest than any other operation.

The day after the operation it will be wise to look over the dressings in case it is necessary to move or change the gauze plugging or to draw off the serous fluid in the pelvis by means of a Nelaton catheter introduced right into the opening of the drainage tube, or to examine the line of suture ; in cases where the incision passes actually into the wound itself, be on the look-out for gas gangrene ! If one day be lost, it will be too late ! And if the edges of the wound are turgid, or if when a stitch is taken away we notice that the tissues are violet or green, we must not hesi- tate to open the wound again ; there will be protrusion as a matter of course, but it is only at such a price that some hope of a cure can be retained (see pp. 233 and 255.

Dressings should be done every day, or at least every two days. We cannot go into every detail, but one or two points must be insisted on.

The respiration must receive special attention ; from the moment that we have ascertained the existence of pulmonary congestion, we must use cupping, mustard poultices and strychnine.

If there is regurgitation, sickness or distention, the stomach should be washed out. This gives instant relief. In the case of supra-pubic cystotomy one must not hastily tie in a catheter, but wait until the hypogastric opening is almost closed. Unless this is done the urethra and the bladder will both be fatally infected. Sometimes a tied-in catheter is quite unnecessary and, as after prostatectomy, micturition will re-establisJ itself naturally. It may be useful to arrange a tinuous irrigation of the recto-vesical pouch ; to d<

PENETRATING WOUNDS 267

this one passes a Nelaton catheter the whole length of the pelvic drain. One of our patients began to improve in a few hours after a triple system of instilla- tion tubes had been set up ; instillation in the bladder by means of a fixed catheter with supra-pubic drainage ; instillation in the pelvis with hypogastric siphonage and rectal instillation.

When there is distension we apply the wet compress of Priessnitz, in preference to ice. We shall come back to this in dealing with medical treatment.

When the patient is convalescent we apply helio- therapy to the wounds themselves, and the abdominal walls.

In the case of protrusion a strip of adhesive plaster to the borders of which hooks have been sewn is stuck along each edge ; above the swabs of gauze protecting the wound, a piece of catgut, silk, or elastic draws the hooks together, and thus the edges of the wound are united. The diameter of the drainage tubes is gradually diminished and then they are shortened.

The cases we have quoted above (see pp. 93 and 233) give examples of various kinds of operative results.

Every surgeon must surely remember patients whom he has not only saved in the first instance by laparo- tomy but for whom he has afterwards fought with death for a long time ; the surgeon must be stubborn and never allow that he is beaten ; the patient must also "hang on" to life, and struggle with confidence and resolution.

Evacuation. — This much-debated question is entirely dominated by one fact : for patients who have under- gone visceral laparotomy, there is always a critical period from the sixth to about the fifteenth day ; it is at this time that the sutures are liable to come apart, that fistulas appear and that the abdominal walls give way.

Experience confirms this.

One of Goinard's patients got up on the ninth day

WOUNDS OF THE ABDOMEN

to go and get a drink of water ; he developed dis- quieting peritoneal symptoms.

A patient of Schwartz at the sixth day got up in the night to see a fire ; a fatal attack of peritonitis resulted.

l^our patients on whom Proust performed laparo- tomy were evacuated from Aubigny to Paris between the sixth and the twelfth day : one died ; the second developed distension of the abdomen, vomiting and diarrhoea, and the other two were very exhausted.

Quenu insists then quite rightly on the injuriousness of all transport during this period.

The question of evacuation therefore maybe summed up thus :

// the wounded who have been operated on at the advanced stations are unable to remain in hospital on the spot for at least fifteen days, they ought to be evacuated during the first four days to the nearest stationary surgical ambulance, that is to say one about 12 kilometres from the front. It was in this way that we received Bouvier's and Caudrelier's patients in our hospital at Sainte-Menehould ; they made per- fectly normal progress towards recovery.

The patients operated on in the stationary surgical ambulances ought to stay in the same place for at least fifteen days or longer still if they should develop any complications. Only in a case of urgent neces- sity should a laparotomy patient be moved between the sixth and the fifteenth day ; he will run great risks but not actually great enough to be equivalent to a death sentence.

How shall evacuation to the hospitals of the interior be carried out ? Stern and Eochard propose short stages by hospitals situated at places only a few hours apart We can understand the advantages of having only such a short journey to make in going from a stationary ambulance to the farthest hospital centre. But it would appear to be better to leave the patient there ) rest three or four days longer, and then send him

PENETRATING WOUNDS 269

direct to the final hospital, rather than take him to two or three more supplementary stopping-places under the pretext of not giving him more than three hours on a railway. In doing so we are overlooking the shiftings inseparable from every new journey ; dressing, placing in the automobile, transference from auto to train, transference from train to auto, journey in automobile, unloading, and undressing. If "three removals are as bad as a fire," three transhipments are worse than one long railway journey ! From the line of communications, the patient ought to go directly to his ultimate destination.

Finally the possibility of future complications ought to cause us to hesitate in making premature estimates as to recovery. It is only in the final hospital that any safe prognosis can be made.

CHAPTER IX

MEDICAL TREATMENT — EXCEPTIONAL OPERATIONS- DEFERRED OPERATIONS

THE medical treatment for penetrating wounds of the abdomen may be stated as briefly and clearly as an equation ; this has the advantage of enabling it to be applied automatically by those in charge of the wounded.

'Absolute immobility ;

Abdominal

Nothing by mouth ;

Fowler's position ;

wounds J Rectal injection « drop by drop"; without T> • .. i 11

Pnessmtz s cold compress ; operation Morphia .

.Camphorated oil.

Let us review these various factors and notice the rare cases from which they would be excluded, and above all the details of application.

Absolute immobility. — This allows of no relaxation. The less the patient moves or is moved, the better it will be. Complete isolation, if it could be procured, would be the ideal treatment.

Nothing by mouth. — An equally obvious precept. But intense thirst and dryness of the mouth when they do not yield to injections of saline and a rectal injec- tion may lead to some relaxation of this rule. But a spoonful of cold water every two hours is all that can be allowed ; sensible patients will be content with only rinsing their mouths with this water. If there is the

270

MEDICAL TREATMENT

271

Lst tendency to vomiting even this slight relaxation tust be withdrawn.

At the end of four or five days, if the recovery is

>llowing a normal course, the dose of liquid may be

icreased at longer intervals ; tea with rum hot or

cold, as the patient prefers, and whichever agrees best

with his stomach ; then broth and aerated water, and

FIG. 65. — Showing arrangement in Fowler's position with the help of two inclined planes fixed together.

then milk mixed with Vichy water ; finally, light purees and custards, etc.

Fowler's position. — This is produced by means of an inclined plane and long cushions or a mattress, or better still with two inclined planes hinged together, of which one, intended for the seat, is shorter than that supporting the back. We find this arrangement more convenient and more resilient than a framework of two inclined planes in one piece. Fig. 65 shows a

272

WOUNDS OF THE ABDOMEN

side-view of this arrangement. A long cushion may be added to support the loins and make the patient comfortable whilst resting in this position.

In certain flank wounds the lateral decubitus will have to be substituted for Fowler's position and the

FIG. 66. — Drop- counter for control- ling the " drop- by- drop" rectal instilla- tion. Extemporised by means of an am- poule for hypodermic injections aud a glass tube in which catgut ligatures are stored.

II'1

FIG. 67.— Control of the " drop-by- drop " apparatus by means of a fun- nel (Stern).

FIG. 68. — Regula- tion of the " drop- by-drop " instillation by progressive pres- sure on a rubber tube, under a piece of wood tightened up by a screw-ring. (The piece of wood may be placed horizontally, which would

do away with the need for supporting the rubber tube by a V-shaped iron wire.)

dorsal decubitus for penetrating wounds of the upper region.

Rectal injection " drop by drop." This is obtained by means of a Nelaton catheter connected with a douche can.

To regulate this we may use many little devices.

MEDICAL TREATMENT

273

Regulation by means of a simple ebony stop-cock without control is one of the most difficult. We may apply control either by the insertion of a drop-counter (see Fig. 66) connected with a hypodermic injection ampoule and a glass catgut tube, or by using Stern's method with a funnel (Fig. 67). Regulation can never be effective unless it is obtained slowly with the help of a tightening screw. The indiarubber tube can be tightened by degrees (Fig. 68). On the other hand, it is possible to reduce the pressure on the branches of a Tripier's dilator Heister's gag or a nasal speculum by the constriction due to a rubber ring (piece of tubing) bringing the ends of the branches together.

Provised arrangements to exert gradual ber tube and thus to obtain easily a

We show above all the improvised arrangements which are m daily use and do not require any patent dropping tube.

^ What quantity of liquid ought to be absorbed?

r £0 76 6S a day seems to us a maximum, and a

w P ^7lr°P inJection of 15 to 20 Htres seems question-

What we want to procure is absorption. Of

what use could it possibly be to induce a repletion which

18

274 WOUNDS OF THE ABDOMEN

produces evacuations from the rectum, and which may cause unnecessary and even injurious contractions of the intestine ? In addition we might consider the question of perforated mattresses and the patient's uncomfortable position. But we are speaking of medical treatment during war.

Priessnitz' 's compress. — -We prefer to use this rather than ice. This is not only on account of its practical utility, though we ought to remember how rare it is, under war conditions, to be able to obtain ice, while it is very simple at all times to surround the abdomen and the loins with wet swabs. But for some years past we have entirely given up the use of ice in pelvic peritonitis, and even in appendicitis itself, and we believe we have obtained better results with Priess- nitz's method.

The wet compresses ought not to be confined to the abdomen, but ought to be arranged all round the waist. Two napkins soaked in cold water and wrung out, or a large dressing saturated with water, are placed round the abdomen and the kidneys ; we then cover over everything with waterproof and keep it in position with a bandage round the body. This ' ' pack " is renewed every twelve hours.

Morphia should be given in small doses, but the patient must be kept continuously under its influence ; two daily injections of J centigramme or even up to 1 centigramme will be enough.

Camphorated oil is an excellent heart tonic ; but this must be given in large doses : 1 gramme of camphor a day as a rule or even up to 2 grammes.

This is the principal treatment. But we must not hesitate to add (according to the symptoms) sub cutaneous injections of saline in addition to the rectal injection, or to have recourse to adrenalin in the presence of marked reduction of tension.

Possible after-effects. — After this treatment three contingencies may follow :

MEDICAL TREATMENT 275

(a) Either at once, or after seme days during which the pulse and temperature have remained high and the signs of abdominal reaction are marked, the general condition improves, the peritoneal syndrome subsides, flatus is emitted voluntarily, and recovery gradually takes place uninterruptedly.

(6) The initial peritonitic condition declares itself frankly as peritonitis ; and is followed by increased contracture, distension, bilious vomit, becoming dark and brown, weak pulse, agitation, and dyspnoea.

Death takes place between the third and the eighth day.

(c) After a period of abdominal reaction of a variable but temporary intensity, the development appears favourable, and there is a decided improve- ment. Recovery seems certain, but towards the sixth, seventh or eighth day the general condition be- comes less good ; the face is again drawn, and the pulse rapid ; but the feverish complexion, and the agreement between the pulse and the temperature, which has risen to 39° C. ( 102-2° Fahr.), show that the patient is putting up a good fight and defending himself. Deep abdomi- nal pain, diffused or localised, leads us to make a new and searching examination, and we discover localised peritonitis, or even a collection of pus in the iliac fossa, the pelvis or under the diaphragm.

And in this case we should perform, not perhaps laparotomy but one of the operations which we still have to describe : Murphy's supra-pubic drainage, lateral drainage, or multiple drainage.

The evacuation of patients with abdominal wounds which are under medical treatment necessitates the same precautions as for those who have undergone laparotomy, and there is the same critical period from the sixth to the fifteenth day during which evacua- tion should not be thought of. This period once over, all now depends upon the regularity of de- velopment.

276 WOUNDS OF THE ABDOMEN

UNUSUAL OPERATIONS

Murphy's supra-pubic drainage. — In order to get the best out of this operation, we must avoid general anaesthesia either with chloroform or ether. In the last extremity we may have recourse to general anaes- thesia with kelene or ethyl-chloride, but given pro- gressively and slowly in small doses and not much at a time ; otherwise the patient will often struggle and highly dangerous effects due to movement and strain may result. It is undoubtedly best therefore to use local anaesthesia with novocaine or stovaine ; anaes- thesia of the skin for 6 cm. on the median line and subcutaneous injections of 1 c.c. in both recti.

The whole operation scarcely takes two minutes.

The bladder having been emptied, an incision 5 cm. long is made in the skin along the median line ; the aponeurosis between the two recti is cut open, and we make a horizontal cut with the scissors of about 1 cm. in length, in each tendon of the insertion of the recti ; a small autostatic retractor or two of Fara- boeuf's retractors expose the peritoneum, which is then seized by two Kocher's forceps ; an incision is made, and we use a retractor or simply the closed scissors to lift up the loops of the small intestine, and a long curved clamp, holding a wide-bore drainage tube between its points, is used to introduce the tube gently into the recto-vesical pouch. It will be advis- able to suture it with horsehair to one of the lips of the wound.

The drainage tube carries away blood, intestinal fluids, bile, foetid serous matter, and pus.

Certain authors advise injection through the drain, of ether or camphorated oil. But the most important thing seems to us to be steadily to get rid of the septic fluid collected under pressure.

That the evacuation of such fluids may be as com- plete as possible, the simplest method is to- fit the

MEDICAL TREATMENT 977

drain with a siphon tube plunged into a bottle filled a quarter of the way up with antiseptic solution Aspiration is as complete and more continuous than wnen done by a syringe.

Murphy's operation ought to be followed by medical treatment.

In addition the patient must be regularly examined We have mentioned that the early formation of Ihesions soon frustrates drainage of the abdominal cavity by the recto-vesical pouch. We must then the areas of local peritonitis in time and operate in order to drain them. Chalier was thus led • make a right lateral laparotomy on the thirteenth day in order to drain a large sub-phrenic abscess which contained 3 litres ; death followed nevertheless

-he dram is removed gradually, first by diminishing s calibre and then by reducing its length in proportion t discharges less and thinner pus, that is to sav •etween the sixth and the tenth day.

Multiple drainage.— Sencert insisted, at the Congress of Surgery in 1900, on the value of multiple drainage m the hypogastrium and in the iliac fossae He pro- posed " small » peritoneal incisions, as they would dram better than the larger ones on account of the abdominal pressure.

Ileostomy.--Colostomy.--A™stomosis of a loop of small intestine to the skin may be made in the 36 oi a laparotomy which, owing to the general

condition of the patient, has not followed a normal

course.

wW* , ^ a, lo°P already Perforated and

where the false anus is already established : it will be

nlarged either naturally by the sloughing of a strangu- lated loop, or by an incision with the cautery made by the surgeon. Deliberate ileostomy as recommended by Mjramond de la Eoquette for the sole reason of

lowing the easy evacuation of the contents of the >owels, and thus diminishing the distension of the

278 WOUNDS OF THE ABDOMEN

loops, is quite different. We have said (p. 123) what we think of this operation. Without a technical descrip- tion we cannot represent it exactly.

Iliac colostomy is a useful addition to an operation in certain cases of injuries to the rectum when we desire to isolate it in order to facilitate subsequent disinfection and reparation. Granted that the case is not one of immediate evacuation, the simplest method, and therefore the best, is to separate off the gut with a packing of gauze or a simple drain passed underneath it. Next day or the day after it is opened.

Drainage of localised peritoneal abscesses. — Collec- tions of pus due to encysted peritonitis should be opened the moment they are discovered. We may distinguish :

(a) Sub-phrenic abscesses following wounds of the stomach, spleen, and liver.

(6) Sub-hepatic abscesses from wounds in stomach, spleen and liver.

(c) Abscesses in the iliac fossae which are reached by the incision for acute appendicitis or for the ligature of the external iliac.

(d) Abscesses round the bladder, opening on to the hypogastrium or by way of the rectum.

(e) Abscesses pointing in the buttocks or the peri- anal region.

(/) Pelvic cellulitis which may necessitate an opera- tion by means of the methods of perinea! prostatec- tomy, or a sub-peritoneal laparotomy or a rectal incision or even sacral resection.

(g) Abscesses round the kidneys reached by the incision used ordinarily in nephrectomy.

(h) Collections of pus behindflthe colon, in which Wallace has shown the danger of early gaseous infec- tion, progressive septic infiltration or septicaemia. Here also lumbar laparotomy is called for.

(i) Abscesses in the lesser sac of the peritoneum caused by suppurating hsematoma ; these are difficult

MEDICAL TREATMENT 279

abscesses to diagnose, and will necessitate a complete laparotomy.

DEFERRED OPERATIONS

Deferred operations are those which deal with the results left behind by penetrating wounds of the abdomen, or by the laparotomy which they have required.

Delayed removal of the projectiles requires a searching preliminary radioscopic examination ; this may dis- close hitherto unsuspected foreign bodies, whose ap- pearance is a real surprise. One of the most curious instances is that of one of Delore's patients [87] in whose body a pile of six louis d'or was found, which had been forced through his waist-belt by the pro- jectile, carried into the abdomen and thence had fallen into the recto-vesical pouch.

Gouilloud and Arcelin [7S] have written an article on "mobile and stationary bullets in the abdominal cavity," from which we have taken the two drawings of shrapnel bullets embedded in the omentum. A rifle bullet removed by Quenu [n] had entered the abdominal cavity by the sacral region, without affect- ing any visceral organ ; it had become encysted in the omentum. The fluid of the cyst, though its viru- lence lessened, did not become quite sterile ; even after a year, it still contained staphylococci.

In one of our own observations, the discovery of a large shell splinter in the right iliac fossa was an equally surprising result due to the radioscope.

Mauclaire [60] took away, at the level of the ileo- caecal angle, some fragments of a bullet, which were causing persistent pain, from a patient who had under- gone Murphy's treatment.

The method of these operations varies for each case.

Protrusions of the intestines are frequent after laparotomy ; either because we have had to leave openings large enough for plugging or because it has

280 WOUNDS OF THE ABDOMEN

been thought wise not to close up a penetrating wound with contused and septic edges, or because the edges of a laparotomy wound have become separated.

Very few cases have as yet been published. We will quote, however, a case by Walther [70] relating to a very large left sub-costal intestinal protrusion.

A bullet which went in above the left iliac crest came out at the front under the costal margin after having gone through the colon, as was shown by a fsecal fistula lasting for five months. Dissection showed the orifice of the hernia to be from 8 to 10 cm. broad, and 5 cm. high. It was repaired by a series of U- stitches in double horsehair, independently of the suturing of the peritoneum by catgut.

The closing of an artificial anus following on an abdominal wound is easily managed, as Quenu [66] remarks, by the following method : free the edges of the anus, separate the two edges of the abdominal wound and lay bare the aponeurosis of the external oblique muscle. Then the two fragments of the intestine are seen in the shape of two cylinders covered externally with fat ; we anastomose them by passing non-perforating threads from one to the other, and doubling this first plane of sutures by a second which passes through the muscular and fatty tissue of the in- testine. If the peritoneum has been opened in setting free the intestine it is sewn up by a purse-stitch ; the two sutured fragments are pushed behind the muscular- aponeurotic plane of the walls and a catgut suture is made leaving just room enough for a small drain whose end is placed in contact with the intestine. This is a safety drain ; on the eighth or ninth day it may occasion a slight discharge with a faecal odour, but this is of no importance. Thus the cure of an artificial anus by operation is generally effected at the first attempt and is quite without danger.

P. Duval [64] has, for a large lumbar wound with multiple colic fistulae, deliberately used the method

MEDICAL TREATMENT 281

:

»f exclusion of the large intestine on the right, and then excision of the right colon.

Finally, here are two examples of complex operations

ich we may be obliged to perform to counteract unexpected symptoms due to stenosing cicatrices.

One of Gosset's patients [72] was injured by a bullet which went in above the right nipple and came out outside the left anterior superior iliac spine. He was treated by Murphy's process, which resulted in a dis- charge of blood, and then he recovered. But four months afterwards he gradually developed progressive jaundice, which was complicated by septic biliary symptoms which from time to time became very serious. At first a simple drainage of the gall bladder was effected by cholecystotomy ; three months later the flow of bile into the duodenum was re-established by cholecysto-gastrotomy. According to evidence ob- tained from the operation, it does not appear that the bile duct was ever injured by the wound ; jaundice did not appear until three months later, but the duct, as a secondary consequence, had been enclosed in an area of plastic sub-hepatic peritonitis, itself a result of a probable perforation of the duodenum.

In the case of a patient operated on by Pauchet [74], the stomach, pierced by a bullet, was enclosed in a layer of perigastritis, on its anterior and sub-hepatic surfaces. After the adhesions had been broken down, the interposition of the coli comentum prevented any further adhesions being made.

In the months and years to come many other un- foreseen cases will doubtless show that the management of penetrating abdominal wounds is not concerned with the immediate treatment alone ; at the same time we must insist that the most arduous and fascinating task is that of winning the battle during the early hours, and for this, as we have seen, laparo- tomy offers us the best weapon.

BIBLIOGRAPHY

Only papers relating to events in the present war are men- tioned in this bibliography.

Those marked with an asterisk contain full or abstracted case reports.

The numbers in brackets in the text refer to the corre- sponding numbers in the bibliography.

(The works prior to the present war which we have consulted, especially for Chapters I and II, are indicated in the footnotes, our object having been to make our bibliography serve as a guide to all, or almost all, the works which have appeared on a given question after a definite date. It stops at June 1, 1916).

PARIS CHIRURGICAL SOCIETY

[x] 1914. — DUPONT et KENDIRDJY (Rapporteur : BATJDET).

- Contribution a 1' etude du pronostic et du traitement

des plaies penetr antes de T abdomen en chirurgie de

guerre. Soc. de chir., 18 nov. 1914. — Bulletins, 1914,

p. 1207.

[2] 1915. — *SENCERT. — Le traitement des plaies penetrantes de 1'abdomen dans une ambulance de 1'avant (58 obser- vations). Soc. de chir., 6 Janvier 1915. — Bulletins, 1915, p. 22.

[3] TH. WEISS et GROSS. — Notes de chirurgie de guerre. Soc. de chir., 27 Janvier 1915. —Bulletins, 1915, p. 157.

[4] *DUPONT et KENDIRDJY (Rapporteur : BAUDET). — Plaie penetrante de 1'abdomen, laparotomie et suture de 5 perforations intestinales, guerison (4 observations). Soc. de chir., 3 fevrier 1915. — Bulletins, 1915, p. 276.

[5] HALLOPEATT (Rapporteur : ROUTIER). — Fonctionnement d'un service chirurgical mobile et depla9able sur le front des armees. Soc. de chir., 3 fevrier 1915. — Bulletins, 1915, p. 283.

[6] *CHAVANNAZ. — A propos du traitement des plaies de 1'abdomen (13 observations). Soc. de chir., 24 feVrier 1915. — Bulletins, 1915, p. 539.

283

284 BIBLIOGRAPHY

[7] DEVEZE (Rapporteur : TUFFIEB). — Sur la therapeutique des plaies de 1' abdomen dans les ambulances de 1'avant. Soc. de chir., 3 mars 1915. — Bulletins, 1915, p. 603.

[8] *GOSSET. — A propos du traitement des plaies de 1' ab- domen (7 observations). Soc. de chir., 24 mars 1915. - Bulletins, 1915, p. 759.

[9] *VEBTBAEGHE (Rapporteur : TUFFIEB). — Contr. a 1'etude des plaies de 1' abdomen dans les ambulances de 1'avant (3 observations). Soc de chir., 28 avril 1915. — Bulletins, 1915, p. 977.

j-ioj *CADENAT (Rapporteur : HABTMANN). — Quelques re- flexions sur la chirurgie de guerre (11 observations). Soc. de chir., 26 mai 1915. — Bulletins, 1915, p. 1138.

[n] *SCHWABTZ (Rapporteur : QUENU). - • Traitement des plaies de 1'abdomen dans les ambulances de 1'avant (9 observations). Soc. de chir., 16 juin 1915. — Bulletins, 1915, p. 1257.

[12] *BOUVIEB et CAUDBELIEB (Rapporteur : QUENU). - Trente-trois laparotomies pratiquees sur des blesses de 1'abdomen par balles, eclats de bombes et d'obus. Soc. de chir., 16 juin 1915. — Bulletins, 1915, p. 1262.

[13] *GOINABD, POIBET et ROLLAND (Rapporteur : QUENU). — Plaie penetrante de 1'abdomen par balle de fusil ; perforations intestinales et sections vasculaires multiples ; Laparotomie : Guerison (1 observation). Soc. de chir., 16 juin 1915. — Bulletins, 1915, p. 1291.

j-u-j *DUTEZ et HALLEZ (Rapporteur : QUENU). — Deux obser- vations de laparotomie retardee pour plaies penetrantes de 1'abdomen. Soc. de chir., 23 juin 1915. — Bulletins, 1915, p. 1308.

[15] CHAPUT. — Traitement des plaies abdominales de guerre. Soc. de chir., 7 juillet 1915. — Bulletins, 1915, p. 1410.

[16] HEITZ-BOYEB (Rapporteur : QUENU). — Essai sur les indications operatoires dans la zone des armees. Soc. de chir., 21 juillet 1915. — Bulletins, 1915, p. 1495.

[17] *PETIT (Rapporteur : QUENU). — Plaies penetrantes de 1'abdomen traitees par la laparotomie (2 observations). Soc. de chir., 22 sept. 1915. — Bulletins, 1915, p. 1816.

[18] *BICHAT (Rapporteur : QUENU). — Traitement des plaies penetrantes de 1'abdomen en chirurgie de guerre (26 observations). Soc. de chir., 22 sept. 1915. — Bulletins, 1915., p. 1819.

[19] *PASCALIS (Rapporteur : QUENU). — . 15 observations de plaies abdominales. Soc. de chir., 22 sept. 1915. — Bulle- tins, 1915, p. 1823.

[20] *PELLOT (Rapporteur : QUENU). — Des plaies penetrantes

BIBLIOGRAPHY 285

de 1'abdomen (24 observations). Soc. de chir., 22 sept. 1915.

- Bulletins, 1915, p. 1825.

[21] *BOUVIEB et CAUDBELIEB (Rapporteur : QUENU). — Plaies abdominales traitees par la laparotomie (66 observations). — Soc. de chir., 22 sept. 1915. — Bulletins, 1915, p. 1832.

pa] *TABTOIS (Rapporteur : P. DUVAL). - - Trente-quatre plaies penetrantes de 1'abdomen traitees dans une ambu- lance divisionnaire du front. Soc. de chir., 13 oct. 1915.

- Bulletins, 1915, p. 1937.

[-23] *WILLEMS. — Gravite de la splenectomie en chirurgie de guerre (5 observations). Soc. de chir., 27 oct, 1915. - Bulletins, 1915, p. 1990.

[24] *SCHWABTZ et MOCQUOT (Rapporteur : QUENU). — Plaies de 1'abdomen traitees par la laparotomie (46 observa- tions). Soc. de chir., 24 nov. 1915. — Bulletins, 1915, p. 2207.

pa] *MATHIETJ (Rapporteur : QUENU). — Plaies de 1'abdomen traitees par la laparotomie (26 observations). Soc. de chir., 24 nov. 1915. — Bulletins, 1915, p. 2229.

[28] MARQUIS. — Sur la methode abstentionniste dans les plaies de 1'abdomen. Soc. de chir., ler decembre 1915. — Bulletins, 1915, p. 2276.

[27] *STEBN (Rapporteur : ROCHARD). — Notes cliniques et therapeutiques sur les plaies de 1'abdomen en chirurgie de guerre (38 observations). Soc. de chir., ler dec. 1915. — Bulletins, 1915, p. 2301.

[28] 1916. *ROUHIEB (Rapporteur : QUENU). — Note sur la localisation d'urgence des projectiles abdominaux (5 observations). Soc de chir., 5 Janvier 1916. — Bulletins, 1916, p. 115.

[29] *BABBET et BOUVET (Rapporteur : QUENU). — Vingt-six cas de plaies penetrantes de 1'abdomen par projectiles de guerre. Soc. de chir., 5 Janvier 1916. — Bulletins, 1916, p. 117.

j-soj *DIDIEB (Rapporteur : QUENU). — Quelques observations de plaies penetrantes de 1'abdomen par projectiles de guerre (20 observations). — Soc. de chir., 5 Janvier 1916.

- Bulletins 1916, p. 122.

[31] *GATELIER (Rapporteur : QUENU). — Note sur vingt-trois cas de plaies penetrantes de 1'abdomen traitees dans une ambulance divisionnaire du front. Soc. de chir, 5 Janvier 1916. — Bulletins, 1916, p 128.

[32] PBOUST (Rapporteur : QUENU). — Statistique integrate des plaies de 1'abdomen observees a 1'Ambulance chir- urgicale automobile n° 1. Soc. de chir., 5 Janvier 1916. — Bulletins, 1916, p. 136.

286 BIBLIOGRAPHY

psj *ABADIE. — A propos du traitement des plaies pene- trantes de 1'abdomen (16 observations). Soc. de chir., ler mars 1916. — Bulletins, 1916, p. 489.

[34] R. PICQTJE. — Evolution du traitement des blessures de 1'abdomen dans une ambulance de 1'avant. Soc. de chir., 8 mars 1916. — Bulletins, 1916, p. 545.

[36j CHEVASSU (Rapporteur : TTJFFIER). — Etude sur 210 cas de plaies de 1'abdomen observees en 15 jours d'offensive dans une ambulance chirurgicale automobile, et en par- ticulier sur les resultats heureux des methodes absten- tionnistes. Soc. de chir., lecture, le 17 nov. 1915 ; rapport le 15 mars 1916. — Bulletins, 1916, p. 646.

pe] *ROUVI:LLOIS. — Etude clinique et therapeutique sur les plaies de 1'abdomen en chirurgie de guerre (132 observa- tions). Soc. de chir., 22 mars 1916. — Bulletins, 1916, p. 708.

[87] QU^NU. — Du traitement des plaies abdominales. A propos du rapport de M. Tuffier sur la communication de M. Chevassu. Soc. de chir., 5 avril 1916. — Bulletins, 1916, p. 883.

[38] *SIMONIN (Rapporteur : QUENU). -- Vingt observations de plaies de 1'abdomen par projectiles de guerre. Soc. de chir., 17 avril 1916. — Bulletins, 1916, p. 988.

[-39j *TUFFIER. — A propos des plaies de 1'abdomen. Discus- sion : QUISNTJ, DELBET, SOULIGOUX, ROCHARD, TUFFIER, MONPBOFIT, BBOCA (100 observations). Soc. de chir., 10 mai 1916. — Bulletins, 1916, p. 1136.

[40] *ROUHIER (Rapporteur : M. Pozzi). — Note sur 46 obser- vations de plaies de 1'abdomen par projectiles de guerre. Soc. de chir., 6 juin 1916. — Bulletins, 1916, p. 1274.

[41] *DEPAQE. — Note sur 12 cas de splenectomie pour bles- sures de guerre. Soc. de chir., 1916, 31 mai. — Bulletins, 1916, p. 1293.

PAPERS NOT CONNECTED WITH THE CHIRURGICAL SOCIETY

[42] *LERICHE. — Necessite d'operer systematiquement les plaies de 1'abdomen (4 obs. tres resumees). Presse medi- cale, 24 juin 1915, p. 221.

j-43j *DELORE. — Notes sur la chirurgie abdominale dans une ambulance de 1'avant (15 observations). Lyon chirurgical, ler sept. 1915, p. 230.

[44] *COTTE et LATARJET. — Quelques considerations sur les plaies de 1'abdomen par projectiles de guerre (15 observa- tions). Lyon chirurgical, 1" sept. 1915, p. 240.

[45] *MURARD. — De 1' intervention immediate dans les plaies penetrantes de 1'abdomen par projectiles de guerre (28 obs.). Lyon chirurgical, ler oct. 1915, p. 548.

t BIBLIOGRAPHY 287

] VIGNABD. — Essai sur les indications operatoires dans les plaies penetrantes de 1'abdomen. Lyon chirurgical, d£c. 1915. ] TISSEBAND. — Pourquoi, comment et ou faut-il inter- venir dans les plaies de 1'abdomen ? (13 observations).

Lyon chirurgical, dec. 1915. j-48j *CHALIEB. -- Notes sur le traitement des plaies pene-

trantes de 1'abdomen par projectiles de guerre (51 obser- vations). Lyon chirurgical, dec. 1915. [49] *DELAY et LUCAS-CHAMPIONNIEBE. — Un mois de chi-

rurgie abdominale au front (22 observations). Paris

medical, 1915, p. 511. [50] *QUENU (JEAN). — Des symptomes peritoneaux observes

dans les plaies non penetrantes de 1'abdomen par armes

a feu (9 observations). Paris medical, 17 juillet 1915,

p. 189. ' [51] QUENU. — Note sur le traitement des plaies de 1'abdomen

par projectiles de guerre. Academic de medecine, 26 oct.

1915. — Bulletins, 1915, p. 466. [52] WALLACE. — The early operative treatment of gunshot

wounds of the alimentary canal. The Lancet, 18 dec.

1915, p. 1336.

[53] GAUDIER. — Traitement des plaies penetrantes de 1'ab- domen. VIe Armee. In Presse medicale, 1916, p. 22. [54] PELLOT, puis MOCQTJOT, VOTJZELLE, BBECHOT, POTHERAT,

SEJOUBNET. — Plaies de 1'abdomen. IV8 Armee. In Presse

medicale, 1916, pp. 29 et 53. [55J GOBSE. — Au sujet du traitement des plaies de 1'abdomen.

Xe Armee. In Presse medicale, 1916, p. 46. j-56-j *CLEBMONT. — Sur le traitement des plaies penetrantes

de 1'abdomen (18 observations). X* Armee. In Presse

medicale, 1916, p. 180. [57] GBEGOIBE. — La chirurgie abdominale a 1'avant. Paris

medical, 1916, p. 419. [58] ABADIE. — A propos du traitement des plaies penetrantes

de 1'abdomen. Presse medicale, 27 avril 1916.

ISOLATED CLINICAL FACTS OF QUESTIONS OF DETAIL

[5»] *TOUSSAINT. — Fracture de cote et anus lombaire suite d'dclatement du colon par balle ; gu6rison avec hernie de J.-L. Petit consecutive. Soc. de chir., 16 feVrier 1915. - Bulletins, 1915, p. 417.

[60] *MAUCLAIBE. — Fragments de balle au niveau de Tangle ileo-ccecal. Ablation. Soc. de chir., 24 mars 1915. — Bulle- tins, 1915, p. 768.

288 BIBLIOGRAPHY

[-61] *MATHIEU (Rapporteur : QUENU). - - Extraction d'un eclat d'obus sous le diaphragme (1 observation). Soc. de chir., 28 avril 1915. — Bulletins, 1915, p. 976.

[62] VIALET (Rapporteur : MAUCLAIRE). - - Localisation des projectiles de guerre par la methode radioscopique de la double image. Soc. de chir., 12 mai 1915. — Bulletins, 1915, p. 1065.

[6S] *DUVAL (P.). - - Plaie en seton, par balle de fusil, de 1'hypochondre et de la region thoracique gauches. Hernie epiploique thoracique (1 observation). Soc. de chir., 12 mai 1915. — Bulletins, 1915, p. 1043.

[64] *DUVAL. — Vaste plaie lombaire avec fistules coliques multiples, exclusion du gros intestin droit, extirpation secondaire du colon droit. Soc. de chir., 12 mai 1915. - Bulletins, 1915, p. 1047.

[65] *QuENU. — Deux observations de laparotomie retardee par plaies penetrantes de 1'abdomen (2 observations). Soc. de chir., 23 juin 1915. — Bulletins, 1915, p. 1308.

[69] * QUENU. — Plaie de 1'anse sigmoi'de avec evisceration de 1'anse. Gangrene et resection de 1'anse. Technique opera- toire pour la guerison de 1'anus inguinal consecutif (1 observation). Soc. de chir., 30 juin 1915. — Bulletins, 1915, p. 1349.

[67] *DELORE. — Corps etrangers du peritoine (Pile de six louis d'or prolabee dans le Douglas) (1 observation). Soc. de chir., 21 juillet 1915. — Bulletins, 1915, p. 1464.

[68] *CHARRIER (Rapporteur : QUENU). — Plaie penetrante thoraco-abdominale (1 observation). Soc de chir., 22 sept. 1915. — Bulletins, 1915, p. 1817.

[69] *WALTHER. — Plaie par balle de shrapnell ; projectile loge dans 1' epiploon. Soc. de chir. — Bulletins, 1915, p. 1978.

[70] *WALTHER. — Enorme eventration d'une cicatrice de plaie de 1'abdomen par balle. Cure radicale. Soc. de chir., 27 octobre 1915. — Bulletins, 1915, p. 2048.

[71] * QUENU. — Extraction du ventre d'une balle de fusil enkyst6e dans 1' epiploon, un an apres la blessure. Soc. de chir., 1916, 12 avril. — Bulletins, p. 1025.

[72j *GOSSET. — Cholecysto-gastrostomie pour obliteration du choledoque apres blessure de guerre. Soc. de chir., 3 mai 1916. — Bulletins, 1916, p. 1109.

,[78] PAUCHET. — Chirurgie de la face posterieure de 1'estomac. Methode de choix pour aborder les organes de 1'arriere- cavite des epiploons. Soc. de chir., 10 mai 1916. — Bulle- tins, 1916, p. 1128.

[-74] * PAUCHET. — Perigastrite par plaie de guerre (balle).

I BIBLIOGRAPHY 289

Guerison par interposition colo-epiploi'que. Soc. de chir., 21 juin 1916. — Bulletins, 1915, p. 1450. 75] *GOULLIOUD et ARCELIN. — Balles mobiles et balles fixes dans la cavite abdominale (2 observations). Lyon chirur- gical, dec. 1915. ™] *DELORE et KOCHER. — Les plaies thoraco-abdominales de la rato (3 observations). Revue de chir., 1915, dec., p. 458.

[77] *LEGBAIN, QUENIJ, RICHARD. — Un cas de hernie dia- phragmatique (1 observation). Paris medical, 1916, n° 7, p. 191.

DETAILS OF MATERIAL ORGANISATION

[78] SENCERT et SIEUR. — Sur 1' organisation et le fonctionne- ment technique d'une Ambulance chirurgicale de corps d'armee. Arch, de med. et de pharm. militaires, mars 1915, p. 356.

[79] MIGNON. — Une salle d'operations sur le front. Paris medical, 17 juillet 1915, p. 182.

[80] BOIGEY. — Un poste chirurgical de 1'avant pour blesses de 1'abdomen et interventions d'urgence. Arch, de med. et de pharm. milit., 1915, mars, p. 418.

[81] COSTANTINI. — De la chirurgie dans les postes chirurgicaux avances. Paris medical, 17 juin 1916, p. 575.

[82] HAUTEFORT (Rapporteur : HARTMANN). — Projet d'un train chirurgical annexe de 1'hopital d' evacuation fonc- tionnant a une gare origine d'6tapes. Soc. de chir., 14 avril

1915. — Bulletins, p. 888.

[83] MATIGNON. — Brancard-gouttiere immobilisateur pour le

transport des grands blesses dans les tranchees. Presse

medicale, suppl., 1915, 25 oct., p. 386. [8*] MIRAMOND DE LAROQUETTE. — Traitement des blesses

dans une ambulance de premiere ligne. Paris medical,

nov. 1915. j-85] *CARPANETTI. — Fonctionnement d'une ambulance divi-

sionnaire (2 obs.). Arch, de med. et de pharm. milit., mars

1916, p. 461.

[86-j EYBERT. — Note sur le brancard de tranchees (9 fig.).

Arch, de med. et de pharm. milit., mars 1916, p. 472. [87] REVEL (Rapporteur : QUBNU). — L'action chirurgicale

a 1'extreme-avant. Soc. de chir., 3 mai 1916. — Bulletins,

1916, p. 1097. [*8] POUGEL. — Le brancard chauffant. Presse medicale ,

13 mars 1916. Supplement, p. 114.

19

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THE PSYCHONEUROSES OF WAR. By Dr. G. Roussy, Assistant Professor in the Faculty of Medicine, Paris, and J. Lhermitte, sometime Laboratory Director in the Faculty of Medicine, Paris. Edited by Colonel William Aldren Turner, C.B., M.D., and Consulting Neurologist to the Forces in England. Translated by Wilfred B. Christopherson. With 13 full-page plates. Price 6/- net

"The Psychoneuroses of War" being a book which is addressed to the clinician, the authors have endeavoured, before all else, to present an exact semeiology, and to give their work a didactic character. After describing the general idea of the psychoneuroses and the methods by which they are produced, the authors survey the various clinical disorders which have been observed during the war.

THE CLINICAL FORMS OF NERVE LESIONS (Vol. I). By Mme. Athanassio Benisty, House Physician of the Hospitals of Paris (Salpetriere), with a Preface by Professor Pierre Marie. Edited with a Preface by E. Farquhar Buzzard, M.D., F.R.C.P., Captain R.A.M.C.(T.), etc. With 81 illustrations in the text, and seven full-page plates. Price 6/- net

In this volume will be found described some of the most recent acquisitions to our knowledge of the neurology of war. But its principal aim is to initiate the medical man who is not a specialist into the examination of nerve injuries. He will quickly learn how to recognise the nervous territory affected, and the development of the various clinical features ; he will be in a position to pronounce a precise diagnosis, and to foresee the consequences of this or that lesion.

THE TREATMENT AND REPAIR OF NERVE LESIONS (Vol. II). By Mme. Athanassio Benisty. Edited by E. Farquhar Buzzard, M.D., F.R.C.P., Capt. R.A.M.C.(T.), etc. With 62 illustrations in the text and four full-page plates. Price 6/- net

This volume is the necessary complement of the first. It explains the nature of the lesions, their mode of repair, their prognosis, and above all their treatment. It provides a series of particularly useful data as to the evolution of nerve-wounds— the opportunities of inter- vention— and the prognosis of immediate complications or late sequelae*

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"The importance of this comprehensive series can hardly be exaggerated. The French genius in its application to scientific medicine will be discovered here at its best and it will be found to be a distinct gain to have had this method of collaboration applied to so important an enterprise."

THE TREATMENT OF FRACTURES. By R. Leriche, Assistant Professor in the Faculty of Medicine, Lyons. Edited by F. F. Burghard, C.B., M.S., F.R.C.S., formerly Consulting Surgeon to the Forces in France. Vol. I. — " Fractures Involving Joints." With 97 illustrations from original and specially prepared drawings.

Price 6/- net

The author's primary object has been to produce a handbook of surgical therapeutics. But surgical therapeutics does not mean merely the technique of operation. Technique is, and should be, only a part of surgery, especially at the present time. The purely operative surgeon is a very incomplete surgeon in time of peace ; "in time of war he becomes a public disaster ; for operation is only the first act of the first dressing."

Vol. II.— "Fractures of the Shaft." With 156 illustrations from original and specially prepared drawings. Price 6/- net

Vol. I. of this work was devoted to Fractures Involving J lints \ Vol. II. (which completes the work) treats of Fractures of the Shaft > and is conceived in the same spirit— that is, with a view to the production of a work on conservative surgical theraptutics. The author strives on every page to develop the idea that anatomical conservation must not be confounded with functional conservation. The two things are not so closely allied as is supposed. There is no conservative surgery save where the function is conserved. The essential point of the treatment of diaphysial fractures consists in the early operative disinfection, primary or secondary, by an extensive sub-periosteal removal of fragments, based on exact physiological knowledge, and in conformity with the general method of treating wounds by excision. When this operation has been carefully performed with the aid of the rugine, with the object of separating and retaining the periosteum of all that the surgeon considers should be removed, the fracture must be correctly reduced and the limb immobilised.

FRACTURE OF THE LOWER JAW. By L. Imbert, National Correspondent of the Socie*te de Chirurgie, and Pierre Real, Dentist to the Hospitals of Paris. With a Preface by Medical Inspector- General FeVrier. Edited by J. F. Colyer, F.R.C.S., L.R.C.P., L.D.S. With 97 illustrations in the text and five full-page plates.

Price 6/- net

Previous to the present war no stomatologist or surgeon possessed any very extensive experience of this subject. Claude Martin, of Lyons, who perhaps gave more attention to it than anyone else, aimed particularly at the restoration of the occlusion of teeth, even at the risk of obtaining only fibrous union of the jaw. The authors of the present volume take the contrary view, maintaining the consolidation of the fracture is above all the result to be attained. The authors give a clear account of the various displacements met with in gunshot injuries of the jaw and of the methods of treatment adopted, the latter being very fully illustrated.

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THE SPECTATOR: "For our physicians and surgeons on active service abroad or in military hospitals at home these are the very books for them to dip into, if not to read through."

FRACTURES OF THE ORBIT AND INJURIES OF THE EYE IN WAR. By Felix Lagrange, Professor in the Faculty of Medicine, Bordeaux. Translated by Herbert Child, Captain R.A.M.C. Edited by J. Herbert Parsons, D.Sc., F.R.C.S., Temp. Captain R.A.M.C. With 77 illustrations in the text and six full-page plates.

Price 6/- net

Grounding his remarks on a considerable number of observations, Professor Lagrange arrives at certain conclusions which at many points contradict or complete what we have hitherto believed concerning the fractures of the orbit : for instance, that traumatisms of the skull caused by fire-arms produce, on the vault of the orbit, neither fractures by irradiation nor independent fractures ; that serious lesions of the eye may often occur when the projectile has passed at some distance from it. There are, moreover, between the seat of these lesions (due to concussion or contact) on the one hand, and the course of the projectile on the other hand, constant relations which are veritable clinical laws, the exposition of which is a highly original feature in this volume.

HYSTERIA OR PITHIATISM, AND REFLEX NERVOUS DISORDERS. By J. Babinski, Member of the French Academy of Medicine, and J. Froment, Assistant Professor and Physician to the Hospitals of Lyons. Edited with a Preface by E. Farquhar Buzzard, M.D., F.R.C.P., Captain R.A.M.C.(T.), etc. With 37 illustrations in the text and eight full-page plates. Price 6/- net

The number of soldiers affected by hysterical disorders is great, and many of them have been immobilized for months in hospital, in the absence of a correct diagnosis and the application of a treatment appropriate to their case. A precise, thoroughly documented work on hysteria, based on the numerous cases observed during two years of war, was therefore a necessity under present conditions. Moreover, it was desirable, after the discussions and the polemics of which this question has been the subject, to inquire whether we ought to return to the old conception, or whether, on the other hand, we might not finally adopt the modern conception which refers hysteria to pithiatism.

WOUNDS OF THE SKULL AND THE BRAIN. Clinical forms and medico-surgical treatment. By C. Chatelin and T. De Martel. With a Preface by the Professor Pierre Marie. Edited by F. F. Burghard, C.B., M.S., F.R.C.S., formerly Consulting Surgeon to the Forces in France. With 97 illustrations in the text and two full-page plates. Price 7/6 net

Of all the medical works which have appeared during the war, this is certainly one of the most original, both in form and in matter. It is, at all events, one of the most individual. The authors have preferred to give only the results of their own experience, and if their conclusions are not always in conformity with those generally accepted, this, as Professor Pierre Marie states in his preface, is because important advances have been made during the last two years ; and of this the publication of this volume is the best evidence.

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From THE TIMES : " A series of really first-rate manuals of medicine and surgery .... the translations are admirably made. They give us in English that clearness of thought and that purity of style which are so delightful in French medical literature and are as good in form as in substance."

LOCALISATION AND EXTRACTION OF PROJECTILES.

By Assistant Professor Ombredanne, of the Faculty of Medicine, Paris, and M. Ledoux-Lebard, Director of the Laboratory of Radi- ology of the Hospitals of Paris. Edited by A. D. Reid, C.M.G., M.R.C.S., L.R.C.P., Major (Temp.) R.A.M.C. With a Preface on Extraction of the Globe of the Eye, by Colonel W. T. Lister, C.M.G.. With 225 illustrations in the text and 30 full-page photo- graphs. Price 10/6 net

This volume appeals to surgeons no less than to radiologists. It is a summary and state- ment of all the progress effected by surgery during the last two and a half years. MM. Ombredanne and Ledoux-Lebard have not, however, attempted to describe all the methods in use, whether old or new. They have rightly preferred to make a critical selection, and — after an exposition of all the indispensable principles of radiological physics— they examine, in detail, all those methods which are typical, convenient, exact, rapid, or interesting by reason of their originality : the technique of localisation, the compass, and various adjust- ments and forms of apparatus.

WOUNDS OF THE ABDOMEN. By G. Abadie (of Oran), National Correspondent of the Societe* de Chirurgie. With a Preface by Dr. J. L. Faure. Edited by Sir Arbuthnot Lane, Bart., C.B., M.S., Colonel (Temp.), Consulting Surgeon to the Forces in England. With 67 illustrations in the text and four full-page plates. Price 7/6 net

Dr. Abadie has been enabled, at all the stations of the army service departments, to weigh the value of methods and results, and considers the following problems in this volume : (i) How to decide what is the best treatment in the case of penetrating wounds of the abdomen ; (2) How to instal the material organisation which permits of the application of this treatment, and how to recognise those conditions which prevent its application ; (3) How to decide exactly what to do in each special case — whether one should perform a radical operation, or a palliative operation, or whether one should resort to medical treatment.

WOUNDS OF THE BLOOD-VESSELS. By L. Sencert, Assistant Professor in the Faculty of Medicine, Nancy. Edited by F. F. Burghard, C.B., M.S., F.R.C.S., formerly Consulting Surgeon to the Forces in France. With 68 illustrations in the text and two full-page plates. Price 6/- net

Hospital practice had long familiarised us with the vascular wounds of civil practice, and the experiments of the Val-de-Grace School of Medicine had shown us what the wounds of the blood-vessels caused by modern projectiles would be in the next war. But in 1914 these data lacked the ratification of extensive practice. Two years have elapsed, and we have hence- forth solid foundations on which to establish our treatment. In a first part, Professor Sencert examines the wounds of the great vessels in general ; in a second part he rapidly surveys the wounds of vascular trunks in particular, insisting on the problems of operation to which they give rise.

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GLASGOW HERALD: "The whole series is heartily commended to the attention and study of all who are interested in and responsible for the treatment of the injuries and diseases of a modern war."

THE AFTER-EFFECTS OF WOUNDS OF THE BONES AND JOINTS. By Aug. Broca, Professor of Topographical Anatomy in the Faculty of Medicine, Paris. Translated by J. Renfrew White, M.B., F.R.C.S., Temp. Captain R.A.M.C., and edited by R. C. Elmslie, M.S., F.R.C.S.; Orthopaedic Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's Auxiliary Hospital, Roehampton; Major R.A.M.C.(T.) With 112 illustra- tions in the text. Price 6/- net

This new work, like all books by the same author, is a vital and personal work, conceived with a didactic intention. At a time when all physicians are dealing, or will shortly have to deal, with the after-effects of wounds received in war, the question of sequelae presents itself, and will present itself more and more. What has become — and what will become — of all those who, in the hospitals at the front or in the rear, have hastily received initial treat- ment, and what is to be done to complete a treatment often inaugurated under difficult circumstances ?

ARTIFICIAL LIMBS. By A. Broca, Professor in the Faculty of Medicine, Paris, and Dr. Ducroquet, Surgeon at the Rothschild Hospital. Edited and translated by R. C. Elmslie, M.S., F.R.C.S., etc. ; Orthopaedic Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's Auxiliary Hospital, Roehampton ; Major R.A.M.C.(T.). With 210 illustrations. Price 6/- net

The authors of this book have sought not to describe this or that piece of apparatus — more _ ed" — but to explain the anatomical, physiological, practical and technical conditions which" an artificial arm or leg should fulfil. It is, if we may so call it, a manual

or less " newfangled " — \

of applied mechanics written by physicians, who have constantly kept in mind the anatomical conditions and the professional requirements of the artificial limb.

TYPHOID FEVERS AND PARATYPHOID FEVERS (Symp. tomatology, Etiology, Prophylaxis). By H. Vincent, Medical In- spector of the Army, Member of the Academy of Medicine, and L. Muratet, Superintendent of the Laboratories at the Faculty of Medicine of Bordeaux. Second Edition. Translated and Edited by J. D. Rolleston, M.D. With tables and temperature charts.

Price 6/- net

This volume is divided into two parts, the first dealing with the clinical features and the second with the epidemiology and prophylaxis of typhoid fever and paratyphoid fevers A and B. A full account is to be found of recent progress in the bacteriology and epidemiology of these diseases, considerable space being given to the important question of the carrier in the dissemination of infection.

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From THE LANCET : «' The names of the editors are sufficient guarantee that the subject matter is treated with fairness and discrimination."

DYSENTERIES, CHOLERA, AND EXANTHEMATIC TY- PHUS. By H. Vincent, Medical Inspector of the Army, Member of the Academy of Medicine, and L. Muratet, Superintendent of the Laboratories at the Faculty of Medicine of Bordeaux. With an Introduction by Andrew Balfour, C.B., C.M.G., M.D., Lieut. -Col. R.A.M.C. Edited by George C. Low, M.A., M.D., Temp. Capt. I.M.S. Price 6/- net

This, the second of the volumes which Professor Vincent and Dr. Muratet have written for this series, was planned, like the first, in the laboratory of Val-de-Grace, and has profited both by the personal experience of the authors and by a mass of recorded data which the latter years of warfare have very greatly enriched. It will be all the more welcome, as hitherto there has existed no comprehensive handbook treating these great epidemic diseases from a didactic point of view.

ABNORMAL FORMS OF TETANUS. By MM. Courtois-Suffit, Physician of the Hospitals of Paris, and R. Giroux, Resident Pro- fessor. With a Preface by Professor F. Widal. Edited by Surgeon- General Sir David Bruce, K.C.B., F.R.S., LL.D., F.R.C.P., etc., and Frederick Golla, M.B. Price 6/- net

Of all the infections which threaten our wounded men, tetanus is that which, thanks to serotherapy, we are best able to prevent. But serotherapy, when it is late and insufficient, may, on the other hand, tend to create a special type of attenuated and localised tetanus ; in this form the contractions are as a general rule confined to a single limb. This type, how- ever, does not always remain strictly monoplegic ; and if examples of such cases are rare this is doubtless because physicians are not as yet very well aware of their existence. We owe to MM. Courtois-Suffit and R. Giroux one of the first and most important observations of this new type ; so that no one was better qualified to define its characteristics. This they have done in a remarkable manner, supporting their remarks by all the documents hitherto pub- lished, first expounding the characteristics which individualise the other atypical and partial types of tetanus, which have long been recognised.

WAR OTITIS AND WAR DEAFNESS. Diagnosis, Treatment, Medical Reports. By Dr. H. Bourgeois, Oto-rhino-laryngologist to the Paris Hospitals, and Dr. Sourdille, former interne of the Paris Hospitals. Edited by J. Dundas Grant, M.D., F.R.C.S.(Eng.) ; Major R.A.M.C., President, Special Aural Board (under Ministry of Pensions). With many illustrations in the text and full-page plates. Price 6/- net

This work presents the special aspects of inflammatory affections of the ear and deafness, as they occur in active military service. The instructions as to diagnosis and treatment are intended primarily for the regimental medical officer. The sections dealing with medical reports (expertises) on the valuation of degrees of disablement and claims to discharge, gratuity or pension, will be found of the greatest value to the officers of invaliding boards.

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GUY'S HOSPITAL GAZETTE : " The series is a most valuable addition to the medical literature of the war. . . . We deem it to be almost indispensable to a medical officer, and have no hesitation in unreservedly recommending it."

SYPHILIS AND THE ARMY. By G. Thibierge, Physician of the Hopital Saint-Louis. Edited by C. F. Marshall, F.R.C.S.

Price B/- net

It seemed, with reason, to the editors of this series that room should be found in it for a work dealing with syphilis considered with reference to the army and the present war. The frequency of this infection in the army, among the workers in munition factories, and in the midst of the civil population where this is in contact with soldiers and mobilised workers, makes it, at the present time, a true epidemic disease, and one of the most widespread of epidemic diseases. Dr. Thibierge, whose previous labours guarantee his peculiar competence in these difficult and important questions, has, in writing this manual, very notably assisted in this work. But the treatment of syphilis has, during the last six years, undergone con- siderable modifications ; the new methods are not yet very familiar to all physicians ; and certain details may no longer be present to their minds. It was therefore opportune to survey the different methods of treatment, to specify their indications, and their occasionally difficult technique, which is always important if complications are to be avoided. It was necessary before all to state precisely and to retrace, for all those who have been unable to follow the recent progress of the therapeutics of venereal diseases, the characters and the diagnostic elements of the manifestations of syphilis.

MALARIA IN MACEDONIA: Clinical and Hsematological Features. Principles of Treatment. By P. Armand-Delille, P. Abrami, G. Paisseau and Henri Lemaire. Preface by Profe«sor Lavern, Membre de 1'Institut. Edited by Sir Ronald Ross, K.C.B., F.R.S., LL.D., D.Sc., Lieut.-Col. R.A.M.C. With illustrations and a coloured plate. Price 6/- net

This work is based on the writers' observations on malaria in Macedonia during the present war in the French Army of the East. A special interest attaches to these observations, in that a considerable portion of their patients had never had any previous attack. The disease proved to be one of exceptional gravity, owing to the exceptionally large numbers of the Anopheles mosquitoes and the malignant nature of the parasite (Plasmodium falciparum). Fortunately an ample supply of quinine enabled the prophylactic and curative treatment to be better organised than in previous colonial campaigns, with the result that, though the incidence of malaria among the troops was high, the mortality was exceptionally low. Pro- fessor Laveran, who vouches for this book, states that it will be found to contain excellent clinical descriptions and judicious advice as to treatment. Chapters on parasitology and the laboratory diagnosis of malaria are included.

An early announcement will be made in regard to further volumes under consideration.

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