The Goulstonian Lectures on Insanity in Relation to Cardiac and Aortic Disease and Phthisis
Authors: Wm. J. Mickle
Journal: BMJ (1888)

The post-nortemn examination was made by Mr. Bilton Pollrd, whose notes contain the following facts.Thes m.-l intestinI Were very inuchl-distendefl, 'especially in the ulmbilical (r'g:inex there was no gas, lympl, or pus anywhere in thd abdominal cavity, buit the.coils of -the -bowel'-iii th& disteiAded' ureA; WVere slightly greasv.The large intestine was hot at' §I'l' 4itended; itnd seemed out of'the' area of 'inflamtnation, whieh.hadc ifected 'lhe small intestine solely.'Tlhe latter 'it the'neighboufliooddf tlhe wound was more adherent than elsewlher&' Thi' portion of bowel stutured, whichl was in the ileum about three feet'fom the ctchm vtas in a perfectly satisfactory condition."Uni6oh had takien place thoroughly betweeni the cut ends, and the" boel; waS hiot 'ob- structed in any way.Tested with'61orfide'blb pressure it 'Wag perfectly air and witter tight.There ,were about two.drahms of blood-stained fluid, in the recto-vesic%l pouch, 'aboit' half EL drachih in the right flank, and three drachms in the left.There were a few spots of extravasated blood in the omentuni, Whi'ch occupied its normal-position, but was adherent to"'the edge of the wound by recent 'lymph.There wat Wiiich hpostatic pneumonia in both lungs, especially OnI the riglht side; the otlher organs wete healthy.It wilI be seen from these notes that the caise of death.wes a very moderate amouint of peritoniitis limited to' the" small intesw tine, and in'addition no doubt the hypostatic ptheunionia told un- favourably.Indeed, there was so little to be founld in the abd6- men indicatiing )eritonitis, except the distended coils of bowel, that there wais solme hesitatioil in accepting this as the cause of dteath.Butt the absence of any otlher lesion' except 'the' pneu- monia, left no alternative.A septic condition, 'iti the ordinary use of the term, lid not exist; the spleen was quite normal and other evidences also failed: in short; one turhed 'a''ay from 'this necropsy witlh an intensified feeling'of disappoihtinent, because the patient lhadl so very nearly recovered.' These two cases appear to mne to possebs'each its own special interest.In the first there can be but little doubt that a fatal peritonitis would have occurred had 'not the bullet, its wad and the clots whiclh surrounded it,.been removed from the folds of dhe omentum by abdominal section.Againi laparotomy enabled us to exclude from consideration all other injuries of 'zisdera:, without subjecting the patient to any special risk in explorAtioA."The case is also of interest in being the first successful lapa'ttotoim.forgunshotwoound of the abdomen recorded in this country."I trust it may encourage other surgeons to very prompt attioft in! similar cases, so that the conclusions artrived at in America, an to the pro- priety of immnediate laparotomy in a11 cases where penetration of the abdomen is proved, may be jistified by our experience too.The seco'nd case, although a Asource of' the keenest disappoint- ment to me, has in no wise shaken mny belief in the rule that every case of the kind should be treated' irumeditely 'by abdbminal sectioin; indeed, it strengtllens 'that belief in everV Wa ./''What little peritonitis there was no doubt Atarted freoii !sfie spot in the peritoneum not tlhoroughly cleilunsed; from matters' escaped from the wounded bowel.Wlhether, a mrie perfect 'ahtisepsiS could 'have been carried ouit by a 'median"icision and ft+igAtioq 'naylbe a question of opinion, but I am' strongly inclined to' thinik'that it could, thouglh at the time I decided that tho extra time and Strfati upon the patieint's powers involved in a double incision and-its concomitants would be too dear a pThce toput ThAt the median incision should be the rule in the-vast majorty, 6f su1h 'Wounds of the abdomen I am convinced, and this -1eir 'Will 'be ghated'by everyonie who carefully studies the litetature of the subject.This literature is now becoming a large one.Sir William Mlac Cdrinac's classical monograph sufficiently attests 'this by the 'numerous cases there quoted.But even'in' 'the slort' Interval of only a few months which lhas elapsed since he' publish ed hlis col- lection of thirty-two operatiohs for gunshftWund' 'of 'tho abdo- men, almost an equal number of cases have been ptut'on record, chliefly in America, and nume.rousdiscussioht'have takei place on this subject.These cases I bave been at'the pains to coll0et' tincI tabulate.A study of the results of these operations is 'most encouraging.They shfow a greatly le.'sened Thortality, eaar'by year, and also that much more desperate cases may besaved by'iurgical interference than has hitherto been supposed.T giVe'theni 'as fully as is possible in sucll a table, and allow, them to 'speak for them- sel-ves with only one comnient.It will be seen that -yhereas out of the 32 laparotomiesi for gunshottinjury of tlih abdomen included in Sir W. Mac Cormac's list, only 7 reeovered, lhe-a're here col-; lected 26 fresh cases of the same kind" with 16 recoveries and 10! 1 In the reprint of the article published in the JouRmL (May llth, 1887), SirIV. Mac Cormac added two cases, making a total of 32.' dentb .'ombinngn the two tables, we.ha,ve,b&eaLs c witlii 23 r vevie, dn u dba1is.The nimbers strt in this ,table where Air;W.Mao Co(omaG's end, that is -at 2.. o,,,gjl;;e ,.,