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INTESTINAL RUPTURE FOLLOWING NON-PENETRATING INJURY
649 SUMMARY
Production of antitoxin continues for months or years after the last injection of antigen. It is suggested that cells bearing antigen must multiply, as patterns by which new antitoxic globulin is formed. It should be possible to devise a course of immunisation for children which would confer lifelong immunity. Levels of antitoxin in both guineapigs and horses are maintained better if the secondary stimulus is toxoid rather than alum-precipitated toxoid (A.P.T.). Large-scale experiments on volunteers are needed to test the efficiency of different methods of immunisation. It is suggested that medical students would be useful subjects for observation for five years. -
’
REFERENCES
Production of Antibodies. Melbourne. Cannon, P. R. (1942) J. Immunol. 44, 107. Ehrich, W. E., Harris, T. N. (1942) J. exp. Med. 76, 335. Holt, L. B. (1947) Lancet, i, 282. McMaster, P. D., Hudack, S. S. (1935) J. exp. Med. 61, 783.
INTESTINAL
press.
RUPTURE FOLLOWING
NON-PENETRATING INJURY GEOFFREY FLAVELL F.R.C.S., M.R.C.P. FIRST
ASSISTANT,
local or general. Leucocytosis and rectal tenderlate signs-often too late. When much leakage has taken place, gas is often seen below the diaphragm if the patient is radiographed in the erect position ; but, on the other hand, such gas may be trapped below the transverse mesocolon in which case radiography is not a safe guide. An abdomen completely silent on auscultation, the presence of release " pain, or an area of persistent local rigidity which begins to extend justifies immediate laparotomy.
rigidity,
ness are
"
Barr, M., Glenny, A. T. (1947) Lancet, ii, 647. Burnet, F. M., Freeman, M., Jackson, A. V., Lush, D. (1941) The
Oakley, C. L., Warrack, G. H., Batty, I. (1949) in the Pauling, L. (1940) J. Amer. chem. Soc. 62, 2643.
may last long enough for a plastic exudate to seal off the rent. After the patient has recovered from the primary shock, or stimulates peristalsis anew by taking food, leakage and consequent peritoneal symptoms will occur. This is the explanation of that " delusive calm " which so often deceives the surgeon and delays intervention. After such accidents there may be no superficial wound of the abdomen. At first there may be no
peristalsis of lymph
THE LONDON HOSPITAL
Aristotle said : "A slight blow will cause rupture of the intestine without injury to the skin." Since Aristotle’s time about 1500 instances of similar, injuries have been published : 1313 collected by Counsellor and McCormack (1935) ; 163 by Poer and Woliver (1942) ;
by O’Callaghan (1942) ; 13 by Kelly (1943) ; 5 by Bunch (1944) ; 4 by Hunt and Bowden (1944) ; 4 by Metheny (1944) ; and 18 by Ficarra (1944). Of these recorded cases by far the greater number have resulted from comparatively violent causes-traffic accidents, and kicks in the belly during fights, or football. Some were due to ill-judged hernial taxis, and others followed falls, usually of ill or aged people. The fatality-rate for such injuries was, and is, appalling. Curtis (1887) found 100% mortality in 116 patients. Gage (1902) stated it as 80% and wisely said : " Operate and operate early should be the rule whenever an intestinal rupture is suspected." Counsellor and McCormack (1935), reviewing all the available records, calculated the fatality-rate at 73.4%. Poer and Woliver (1942) say it was 61-3% of 163 persons. In the latest series described the rates have been 56% (Ficarra 1944), 50% (Metheny 1944), 33% (Packer 1939), 40% (Bunch 1944), and 69% (Kelly 1943). The explanation of these figures must be sought in the factors which lead to late diagnosis ; in the deceptive integrity of the abdominal 2
wall ; in the delusive calm, or latent period, which often follows injury ; and, in some instances, to the comparative triviality of the blow. The regions of the bowel most commonly injured are said to be those which are fixed by peritoneum, such as the third part of the duodenum, and the portion near the ligament of Treitz ; and those which may most easily be compressed against bony promontories, such as the ileum proximal to the ileocsecal valve where the vertebral column is nearest the anterior wall. But to these anatomical considerations must be added an essential element : the abdomen must be taken by surprise, the blow unexpected, and the muscles relaxed and unguarded. Zachary Cope (1914) pointed out that after such a blow, when rupture has taken place, a reflex inhibition of
CASE-REPORT
- all the essential and the patient was under my observation from the moment the blow was struck until his recovery. A young airman of good physique, began to bat in a unit cricket match at 5 P.M. The third ball of the over did not seem to be particularly fast but broke to leg, glanced up, and struck the batsman just below his umbilicus. He dropped the bat, clasped his belly, and sat down. By the time I reached the crease he was up again and said that he was just winded for a moment." He was not given out, continued to bat, and made ten runs without mishap. At the end of his innings I saw him again, and this time examined his abdomen. He felt perfectly well but " a bit bruised where he had been hit. No abrasion or bruise was visible, and there was no local or general rigidity, though he was
following history includes ingredients of one of these injuries, The
"
"
tender over a point some 2 in. below and to the left of his navel. He left me to have his supper. At 7 after a meal of tea and rissoles, he was attacked by burning abdominal pain, reported sick,_and was admitted to hospital. On examination he was not shocked and had not vomited. There was local rigidity in the left lower abdominal quadrant, local tenderness, and " release " pain. Peristalsis could be heard on auscultation. I decided however to operate, and opened his abdomen (about three-quarters of an hour later) through a subumbilical paramedian incision. Free fluid was not found, but on the antimesenteric surface of the ileum, some 18 in. from the ileocaecal valve, was a patch of peritoneal soiling round a longitudinal rent 1 in. long. This was repaired with a two-layered Lembert stitch, and the abdomen was closed without drainage. The patient made an uneventful recovery. COMMENTS
illustrated the apparently trivial but abdominal blow ; the absence of external the latent period, ended by taking food ; and followed by early, but not quite unequivocal, signs of a ruptured bowel. The moral in such event must be that a blow on the abdomen should be watched with no less attention than is a blow on the head ; and on reasonable suspicion of perforation the belly should unhesitatingly be explored. Here
are
unexpected wounding ;
REFERENCES
Bunch, J. R. (1944) Sth. med. J. 37, 717. Cope, V. Z. (1914) Proc. R. Soc. Med. 7, 86. Counseller, V. S., McCormack, C. J. (1935) Ann. Surg. 102, 365. Curtis, B. F. (1887) Amer. J. med. Sci. 94, 321. Ficarra, B. J. (1944) Surgery, 15, 465. Gage, H. (1902) Ann. Surg. 35, 331. Hunt, G. H., Bowden, J. N. (1944) Arch. Surg. 49, 321. Kelly, E. C. (1943) Surgery, 14, 163. Metheny, D. (1944) West. J. Surg. 52, 34. O’Callaghan, D. (1942) Brit. J. Surg. 30, 107. Packer, B. D. (1939) Miss. Vall. med. J. 61, 218. Poer, D. H., Woliver, E. (1942) J. Amer. med. Ass. 118, 11.
Production of antitoxin continues for months or years after the last injection of antigen. It is suggested that cells bearing antigen must multiply, as patterns by which new antitoxic globulin is formed. It should be possible to devise a course of immunisation for children which would confer lifelong immunity. Levels of antitoxin in both guineapigs and horses are maintained better if the secondary stimulus is toxoid rather than alum-precipitated toxoid (A.P.T.). Large-scale experiments on volunteers are needed to test the efficiency of different methods of immunisation. It is suggested that medical students would be useful subjects for observation for five years. -
’
REFERENCES
Production of Antibodies. Melbourne. Cannon, P. R. (1942) J. Immunol. 44, 107. Ehrich, W. E., Harris, T. N. (1942) J. exp. Med. 76, 335. Holt, L. B. (1947) Lancet, i, 282. McMaster, P. D., Hudack, S. S. (1935) J. exp. Med. 61, 783.
INTESTINAL
press.
RUPTURE FOLLOWING
NON-PENETRATING INJURY GEOFFREY FLAVELL F.R.C.S., M.R.C.P. FIRST
ASSISTANT,
local or general. Leucocytosis and rectal tenderlate signs-often too late. When much leakage has taken place, gas is often seen below the diaphragm if the patient is radiographed in the erect position ; but, on the other hand, such gas may be trapped below the transverse mesocolon in which case radiography is not a safe guide. An abdomen completely silent on auscultation, the presence of release " pain, or an area of persistent local rigidity which begins to extend justifies immediate laparotomy.
rigidity,
ness are
"
Barr, M., Glenny, A. T. (1947) Lancet, ii, 647. Burnet, F. M., Freeman, M., Jackson, A. V., Lush, D. (1941) The
Oakley, C. L., Warrack, G. H., Batty, I. (1949) in the Pauling, L. (1940) J. Amer. chem. Soc. 62, 2643.
may last long enough for a plastic exudate to seal off the rent. After the patient has recovered from the primary shock, or stimulates peristalsis anew by taking food, leakage and consequent peritoneal symptoms will occur. This is the explanation of that " delusive calm " which so often deceives the surgeon and delays intervention. After such accidents there may be no superficial wound of the abdomen. At first there may be no
peristalsis of lymph
THE LONDON HOSPITAL
Aristotle said : "A slight blow will cause rupture of the intestine without injury to the skin." Since Aristotle’s time about 1500 instances of similar, injuries have been published : 1313 collected by Counsellor and McCormack (1935) ; 163 by Poer and Woliver (1942) ;
by O’Callaghan (1942) ; 13 by Kelly (1943) ; 5 by Bunch (1944) ; 4 by Hunt and Bowden (1944) ; 4 by Metheny (1944) ; and 18 by Ficarra (1944). Of these recorded cases by far the greater number have resulted from comparatively violent causes-traffic accidents, and kicks in the belly during fights, or football. Some were due to ill-judged hernial taxis, and others followed falls, usually of ill or aged people. The fatality-rate for such injuries was, and is, appalling. Curtis (1887) found 100% mortality in 116 patients. Gage (1902) stated it as 80% and wisely said : " Operate and operate early should be the rule whenever an intestinal rupture is suspected." Counsellor and McCormack (1935), reviewing all the available records, calculated the fatality-rate at 73.4%. Poer and Woliver (1942) say it was 61-3% of 163 persons. In the latest series described the rates have been 56% (Ficarra 1944), 50% (Metheny 1944), 33% (Packer 1939), 40% (Bunch 1944), and 69% (Kelly 1943). The explanation of these figures must be sought in the factors which lead to late diagnosis ; in the deceptive integrity of the abdominal 2
wall ; in the delusive calm, or latent period, which often follows injury ; and, in some instances, to the comparative triviality of the blow. The regions of the bowel most commonly injured are said to be those which are fixed by peritoneum, such as the third part of the duodenum, and the portion near the ligament of Treitz ; and those which may most easily be compressed against bony promontories, such as the ileum proximal to the ileocsecal valve where the vertebral column is nearest the anterior wall. But to these anatomical considerations must be added an essential element : the abdomen must be taken by surprise, the blow unexpected, and the muscles relaxed and unguarded. Zachary Cope (1914) pointed out that after such a blow, when rupture has taken place, a reflex inhibition of
CASE-REPORT
- all the essential and the patient was under my observation from the moment the blow was struck until his recovery. A young airman of good physique, began to bat in a unit cricket match at 5 P.M. The third ball of the over did not seem to be particularly fast but broke to leg, glanced up, and struck the batsman just below his umbilicus. He dropped the bat, clasped his belly, and sat down. By the time I reached the crease he was up again and said that he was just winded for a moment." He was not given out, continued to bat, and made ten runs without mishap. At the end of his innings I saw him again, and this time examined his abdomen. He felt perfectly well but " a bit bruised where he had been hit. No abrasion or bruise was visible, and there was no local or general rigidity, though he was
following history includes ingredients of one of these injuries, The
"
"
tender over a point some 2 in. below and to the left of his navel. He left me to have his supper. At 7 after a meal of tea and rissoles, he was attacked by burning abdominal pain, reported sick,_and was admitted to hospital. On examination he was not shocked and had not vomited. There was local rigidity in the left lower abdominal quadrant, local tenderness, and " release " pain. Peristalsis could be heard on auscultation. I decided however to operate, and opened his abdomen (about three-quarters of an hour later) through a subumbilical paramedian incision. Free fluid was not found, but on the antimesenteric surface of the ileum, some 18 in. from the ileocaecal valve, was a patch of peritoneal soiling round a longitudinal rent 1 in. long. This was repaired with a two-layered Lembert stitch, and the abdomen was closed without drainage. The patient made an uneventful recovery. COMMENTS
illustrated the apparently trivial but abdominal blow ; the absence of external the latent period, ended by taking food ; and followed by early, but not quite unequivocal, signs of a ruptured bowel. The moral in such event must be that a blow on the abdomen should be watched with no less attention than is a blow on the head ; and on reasonable suspicion of perforation the belly should unhesitatingly be explored. Here
are
unexpected wounding ;
REFERENCES
Bunch, J. R. (1944) Sth. med. J. 37, 717. Cope, V. Z. (1914) Proc. R. Soc. Med. 7, 86. Counseller, V. S., McCormack, C. J. (1935) Ann. Surg. 102, 365. Curtis, B. F. (1887) Amer. J. med. Sci. 94, 321. Ficarra, B. J. (1944) Surgery, 15, 465. Gage, H. (1902) Ann. Surg. 35, 331. Hunt, G. H., Bowden, J. N. (1944) Arch. Surg. 49, 321. Kelly, E. C. (1943) Surgery, 14, 163. Metheny, D. (1944) West. J. Surg. 52, 34. O’Callaghan, D. (1942) Brit. J. Surg. 30, 107. Packer, B. D. (1939) Miss. Vall. med. J. 61, 218. Poer, D. H., Woliver, E. (1942) J. Amer. med. Ass. 118, 11.