Downloaded from http://jramc.bmj.com/ on May 5, 2017 - Published by group.bmj.com
Br Med J 1917;321–30.
The authors of this paper were both Captains in the Royal Army Medical Corps (RAMC) and submitted the paper to the BMJ to confirm a change in their opinion and practice based on the clinical and experimental data they present. As the title suggests, the paper is divided into two parts: a description of a series of animal experiments investigating abdominal trauma, and a review of clinical cases from the Western Front. Theirs is one of the first research publications detailing the military management of penetrating intestinal trauma, a series of work completed at Porton Down 80 years later;1 2 the later work simply confirming the observations of our predecessors. The first experiment was an investigation into the optimal anastomotic technique comparing end-to-end with side-to-side construction. They found that in-line anastomoses were inferior as they became oedematous resulting in obstruction and leakage, whereas the wider side-to side anastomoses fared much better. They compared iso- and anti-peristaltic joins, and although they found no difference in leakage, favoured the antiperistaltic joins when they observed less faecal trapping by using feed laced with lead shot. This method is now the recommended configuration when using linear staple devices. The second experiment was an investigation of the degree of devascularisation which the small intestine and colon could survive. Again, using small mammals the authors found that the colon could survive major arterial disruption due to a marginal colonic artery, whereas similar injuries to the small bowel mesentery usually resulted in necrosis of the bowel. They concluded that both large and small bowel could survive significant vascular injuries, with the colon faring better than the ileum. They could therefore recommend primary repair of the bowel, with or without resection. Having previously observed at laparotomy that intestinal perforations had often been sealed with minimal leakage by the omentum, their third experiment was to investigate omental function. Using cats, they divided the omentum from its attachments but left it in the abdomen. Unsurprisingly, the animals died ( probably of sepsis from the necrotic fat) but when they repeated the procedure and abraded the bowel, the animals survived. At autopsy, they noted that the omentum had acquired a secondary blood supply from the injured bowel around which it had wrapped. Their final experiment was to compare transverse and longitudinal injuries with the bowel having observed clinically that injuries along the bowel were associated with a greater degree of faecal contamination. Their experiments supported the clinical findings, and taking things further, they wrapped omentum around lacerated but unrepaired bowel. They found that the
omentum contained colonic injuries but not those in the small bowel, and suggested that early leakage was greater from the fluid containing ileum than the colon which contains more solid stool. The second part of the paper describes the results and observations in the management of war wounded by the authors. The authors discussed in detail the management of each organ injured and gave advice which is relevant to surgeons today. Their results are summarised in Table 1. They stressed the importance of:
Similarly, wounds of the small intestine are easily missed as they observe:
and conjecture that there is:
They report that injuries to the mesenteric border of the gut is a serious injury usually requiring resection, and that simple gut perforations without need for resection have an excellent prognosis (100% of nine such cases survived). Duodenal injuries rarely survived to reach the surgeons. The very high mortality was:
Those who reached surgery had suffered lateral injuries to the second part of the duodenum which were amenable to suture. The recommendation of duodenal mobilisation (after Kocher) and the need to consider gastro-enterostomy are still taught today.4 Colonic injuries are likened to small bowel injuries, but the authors admit their management of the injured colon changed during the war. The authors draw on their clinical and experimental experience regarding the use of colostomy:
Edwards DP. J R Army Med Corps 2014;160(Supp 1):i33–i35. doi:10.1136/jramc-2014-000309
i33
Downloaded from http://jramc.bmj.com/ on May 5, 2017 - Published by group.bmj.com
Table 1 Surgical outcomes for penetrating abdominal trauma3
Stomach Small intestine Duodenum Colon Rectum Bladder Kidney Spleen Liver
No of cases reported
‘Recoveries’
Mortality (%)
24 96 6 85 10 14 29 14 33
10 37 1 37 3 4 17 9 19
54 61 83 56 70 71 41 36 42
vascular injuries dying on the battlefield. Now we see the reverse; rapid evacuation to Role 3 has resulted in significant organ and vascular injuries with poor prognosis reaching the operating room, and antibiotics with post-operative anaesthetic support has greatly reduced the mortality of penetrating intestinal trauma. They advocate a period of 1–2 h delay of surgery from arrival at the hospital to stabilise the patient (unless there is evidence of ongoing haemorrhage) and stress it is important that
recognising hypothermia as a third of the lethal triad (hypothermia, acidosis and coagulopathy). They even allude to damage control surgical principles:
(of the injured colon) due to concerns about the viability of the repair, but later
This lesson seems to have been lost in the subsequent years as by the end of World War II colostomy was mandated for colonic injury, and it was not until the late 20th century that surgical doctrine changed back to primary repair following results of further experimental2 and clinical5 research. The management of rectal injuries has changed little since World War I. Intra-peritoneal rectal injuries if repaired primarily were usually covered with a temporary colostomy, and extensive wounds were resected with formation of an end colostomy. Extra-peritoneal wounds were drained and covered with a stoma. That the authors recognised that a transverse colostomy was superior to a sigmoid stoma when
more readily has been lost to subsequent generations of trauma surgeons (although the transverse colostomy and ileostomy are favoured by colorectal surgeons6). Bladder injuries when intra-peritoneal were repaired with a draining urethral catheter to prevent over-distension and strain on the repair (although the value of measurement of urine output in trauma was not recognised). Extra-peritoneal injuries were managed as they would be today—by suprapubic catheter drainage. The management of renal injuries differs considerably from that now advocated. A lumbar approach to the kidney was advised, with a separate laparotomy for associated intraperitoneal injuries. Perhaps this related to the familiarity rather than the utility of the posterior approach in the early days of general anaesthesia. Injuries to the other solid organs (spleen and liver) are modern, with splenectomy and liver suture and packing advocated (although the sub-costal incisions used in World War I would not now be recommended). The authors conclude with some general remarks regarding abdominal penetrating trauma. They advocate the use of the long midline incision for most cases. They observed cases of acute gastric dilatation for which they recommended the use of nasogastric tube drainage. They observe that hollow viscus injuries have a worse prognosis than solid organ injuries due to peritoneal contamination with enteric content and the slower evacuation to field hospital probably resulted in major solid organ and i34
Perhaps the most pertinent comment the authors make relate to post-operative treatment which a 100 years ago probably proved to be the greatest impediment to survival. They recommend:
intravenous infusions were not available so the choice of rectal administration of a non-sterile fluid was pragmatic. Although by modern standards the mortality appears high, it must be remembered that routine laparotomy for abdominal injury was advocated only a few years earlier during the Boer wars.7 General anaesthesia was in its infancy; endotracheal intubation was developed in the 1910s; abdominal muscle relaxation was achieved by either deep anaesthesia with very volatile agents or spinal blockade (muscle relaxants were not introduced until the 1940s) and intravenous agents had not been introduced. While antiseptics were used, antibiotics would not be available for another 20 years and sepsis following gastrointestinal injury was the major cause of post-operative death. Surgeons at this time had very limited equipment; sutures were gut, silk or linen and not sterile and needed to be threaded onto reusable needle. Stapling devices, electrocautery, haemostatic agents and prosthetic vascular grafts commonly used today in theatres did not exist. It is therefore remarkable that the surgeons on the Western Front had any success, and those who survived surgery for abdominal injury owed their lives to the skill of their surgeons. Now nearly 100 years old, this paper still has much to teach modern trauma and military surgeons, both in general principles of emergency surgery for abdominal trauma and specific guidance for particular organ injuries. That the authors rescued so many injured soldiers with limited equipment and postoperative surgical support is a credit to their phenomenal skills.
THE AUTHORS Hamilton Drummond was born in 1882 and hailed from a wellconnected medical family, his father being an ex-president of the British Medical Association and Pro-Vice Chancellor of Durham University. He graduated from Durham in 1906 and acquired the Edinburgh Fellowship 6 years later. Following house jobs in Newcastle (for Rutherford Morrison) and in
Edwards DP. J R Army Med Corps 2014;160(Supp 1):i33–i35. doi:10.1136/jramc-2014-000309
Downloaded from http://jramc.bmj.com/ on May 5, 2017 - Published by group.bmj.com
London at St Marks and Great Ormond Street he returned as surgical registrar to Newcastle, once again under the auspices of Professor Morrison. While on an academic visit to the USA with his Professor, Drummond suffered appendicitis and was operated by Professor Morrison. At the outbreak of World War I Drummond departed to France with the Northumberland Yeomanry, seeing action at the first battle of Ypres (and being Mentioned in Dispatches) before being transferred to the RAMC where he continued to serve with distinction. He combined his surgical workload with research such as this paper and investigations into the management of gas gangrene and the introduction of flavine, proflavine and BIPP as topical antiseptics. Having survived the War and being elected to full consultant status at the Royal Victoria Hospital in Newcastle, he died after a car accident at the age of 43.8 His name is remembered still by colorectal surgeons for his description of the importance of the marginal artery of the colon.9 Born in 1885, John Fraser was a Scot whose career revolved about Edinburgh. He graduated MBChB from there in 1907, received his fellowship and MD from Edinburgh University and sat as Professor of Clinical Surgery from 1925 to 1944 before becoming the University’s Vice-Chancellor for three further years. His only appreciable absences were his war service, during which he was wounded and awarded the Military Cross, and a 3 month world tour in 1935 which was the same year he was appointed surgeon to His Majesty the King in Scotland. He was knighted in 1937 and made a Baronet in 1942.10 David P Edwards Correspondence to Lt Col David P Edwards, Colorectal Unit, Frimley Park Hospital, Portsmouth Road, Frimley, Surrey GU16 7UJ, UK; david.edwards@fph-tr. nhs.uk
The original article can be found online as supplementary file. To view please visit the journal online (http://dx.doi.org/10.1136/jramc-2014-000309). Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Edwards DP. J R Army Med Corps 2014;160(Supp 1):i33–i35. Accepted 15 April 2014 J R Army Med Corps 2014;160(Supp 1):i33–i35. doi:10.1136/jramc-2014-000309
REFERENCES 1
2 3 4 5 6
7 8 9 10
Edwards DP. J R Army Med Corps 2014;160(Supp 1):i33–i35. doi:10.1136/jramc-2014-000309
Howell GP, Ryan JM, Cooper GJ, et al. Assessment of the use of disposable skin staplers in bowel anastomoses to reduce laparotomy time in penetrating ballistic injury to the abdomen. Ann R Coll Surg Engl 1991;73:87–90. Edwards DP, Warren BF, Galbraith KA, et al. Comparison of techniques for the repair of experimental colonic perforations. Brit J Surg 1999;86:514–17. Fraser J, Drummond H. A Clinical and Experimental Study of Three Hundred Perforating Wounds of the Abdomen. BMJ 1917;321–30. Roberts P. ed. The British Military Surgery Pocket Book. London: HMSO, 2004. Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: is it necessary? J Trauma 1996;41:271–5 Edwards DP, Leppington-Clarke A, Sexton R, et al. Stoma related complications are more frequent after transverse colostomy than loop ileostomy a prospective randomised controlled trial. Brit J Surg 2001;88:360–1. Bennett JDC. Abdominal surgery in war—the early story. J R Soc Med 1991;84:554–7. Obituary. Hamilton drummond. BMJ 1925;2:181. Drummond H. Some points relating to the surgical anatomy of the arterial supply of the large intestine. Proc R Soc Med 1914;7(Surg Sect):185–93. http://www.archives.lib.ed.ac.uk/catalogue/cs/viewcat.pl?id=GB-237-Coll1296&view=basic (accessed 14 Apr 2014)
i35
Downloaded from http://jramc.bmj.com/ on May 5, 2017 - Published by group.bmj.com
David P Edwards J R Army Med Corps 2014 160: i33-i35
doi: 10.1136/jramc-2014-000309 Updated information and services can be found at: http://jramc.bmj.com/content/160/Suppl_1/i33
These include:
Supplementary Supplementary material can be found at: Material http://jramc.bmj.com/content/suppl/2014/05/20/160.Suppl_1.i33.DC1 References Email alerting service
This article cites 7 articles, 1 of which you can access for free at: http://jramc.bmj.com/content/160/Suppl_1/i33#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Br Med J 1917;321–30.
The authors of this paper were both Captains in the Royal Army Medical Corps (RAMC) and submitted the paper to the BMJ to confirm a change in their opinion and practice based on the clinical and experimental data they present. As the title suggests, the paper is divided into two parts: a description of a series of animal experiments investigating abdominal trauma, and a review of clinical cases from the Western Front. Theirs is one of the first research publications detailing the military management of penetrating intestinal trauma, a series of work completed at Porton Down 80 years later;1 2 the later work simply confirming the observations of our predecessors. The first experiment was an investigation into the optimal anastomotic technique comparing end-to-end with side-to-side construction. They found that in-line anastomoses were inferior as they became oedematous resulting in obstruction and leakage, whereas the wider side-to side anastomoses fared much better. They compared iso- and anti-peristaltic joins, and although they found no difference in leakage, favoured the antiperistaltic joins when they observed less faecal trapping by using feed laced with lead shot. This method is now the recommended configuration when using linear staple devices. The second experiment was an investigation of the degree of devascularisation which the small intestine and colon could survive. Again, using small mammals the authors found that the colon could survive major arterial disruption due to a marginal colonic artery, whereas similar injuries to the small bowel mesentery usually resulted in necrosis of the bowel. They concluded that both large and small bowel could survive significant vascular injuries, with the colon faring better than the ileum. They could therefore recommend primary repair of the bowel, with or without resection. Having previously observed at laparotomy that intestinal perforations had often been sealed with minimal leakage by the omentum, their third experiment was to investigate omental function. Using cats, they divided the omentum from its attachments but left it in the abdomen. Unsurprisingly, the animals died ( probably of sepsis from the necrotic fat) but when they repeated the procedure and abraded the bowel, the animals survived. At autopsy, they noted that the omentum had acquired a secondary blood supply from the injured bowel around which it had wrapped. Their final experiment was to compare transverse and longitudinal injuries with the bowel having observed clinically that injuries along the bowel were associated with a greater degree of faecal contamination. Their experiments supported the clinical findings, and taking things further, they wrapped omentum around lacerated but unrepaired bowel. They found that the
omentum contained colonic injuries but not those in the small bowel, and suggested that early leakage was greater from the fluid containing ileum than the colon which contains more solid stool. The second part of the paper describes the results and observations in the management of war wounded by the authors. The authors discussed in detail the management of each organ injured and gave advice which is relevant to surgeons today. Their results are summarised in Table 1. They stressed the importance of:
Similarly, wounds of the small intestine are easily missed as they observe:
and conjecture that there is:
They report that injuries to the mesenteric border of the gut is a serious injury usually requiring resection, and that simple gut perforations without need for resection have an excellent prognosis (100% of nine such cases survived). Duodenal injuries rarely survived to reach the surgeons. The very high mortality was:
Those who reached surgery had suffered lateral injuries to the second part of the duodenum which were amenable to suture. The recommendation of duodenal mobilisation (after Kocher) and the need to consider gastro-enterostomy are still taught today.4 Colonic injuries are likened to small bowel injuries, but the authors admit their management of the injured colon changed during the war. The authors draw on their clinical and experimental experience regarding the use of colostomy:
Edwards DP. J R Army Med Corps 2014;160(Supp 1):i33–i35. doi:10.1136/jramc-2014-000309
i33
Downloaded from http://jramc.bmj.com/ on May 5, 2017 - Published by group.bmj.com
Table 1 Surgical outcomes for penetrating abdominal trauma3
Stomach Small intestine Duodenum Colon Rectum Bladder Kidney Spleen Liver
No of cases reported
‘Recoveries’
Mortality (%)
24 96 6 85 10 14 29 14 33
10 37 1 37 3 4 17 9 19
54 61 83 56 70 71 41 36 42
vascular injuries dying on the battlefield. Now we see the reverse; rapid evacuation to Role 3 has resulted in significant organ and vascular injuries with poor prognosis reaching the operating room, and antibiotics with post-operative anaesthetic support has greatly reduced the mortality of penetrating intestinal trauma. They advocate a period of 1–2 h delay of surgery from arrival at the hospital to stabilise the patient (unless there is evidence of ongoing haemorrhage) and stress it is important that
recognising hypothermia as a third of the lethal triad (hypothermia, acidosis and coagulopathy). They even allude to damage control surgical principles:
(of the injured colon) due to concerns about the viability of the repair, but later
This lesson seems to have been lost in the subsequent years as by the end of World War II colostomy was mandated for colonic injury, and it was not until the late 20th century that surgical doctrine changed back to primary repair following results of further experimental2 and clinical5 research. The management of rectal injuries has changed little since World War I. Intra-peritoneal rectal injuries if repaired primarily were usually covered with a temporary colostomy, and extensive wounds were resected with formation of an end colostomy. Extra-peritoneal wounds were drained and covered with a stoma. That the authors recognised that a transverse colostomy was superior to a sigmoid stoma when
more readily has been lost to subsequent generations of trauma surgeons (although the transverse colostomy and ileostomy are favoured by colorectal surgeons6). Bladder injuries when intra-peritoneal were repaired with a draining urethral catheter to prevent over-distension and strain on the repair (although the value of measurement of urine output in trauma was not recognised). Extra-peritoneal injuries were managed as they would be today—by suprapubic catheter drainage. The management of renal injuries differs considerably from that now advocated. A lumbar approach to the kidney was advised, with a separate laparotomy for associated intraperitoneal injuries. Perhaps this related to the familiarity rather than the utility of the posterior approach in the early days of general anaesthesia. Injuries to the other solid organs (spleen and liver) are modern, with splenectomy and liver suture and packing advocated (although the sub-costal incisions used in World War I would not now be recommended). The authors conclude with some general remarks regarding abdominal penetrating trauma. They advocate the use of the long midline incision for most cases. They observed cases of acute gastric dilatation for which they recommended the use of nasogastric tube drainage. They observe that hollow viscus injuries have a worse prognosis than solid organ injuries due to peritoneal contamination with enteric content and the slower evacuation to field hospital probably resulted in major solid organ and i34
Perhaps the most pertinent comment the authors make relate to post-operative treatment which a 100 years ago probably proved to be the greatest impediment to survival. They recommend:
intravenous infusions were not available so the choice of rectal administration of a non-sterile fluid was pragmatic. Although by modern standards the mortality appears high, it must be remembered that routine laparotomy for abdominal injury was advocated only a few years earlier during the Boer wars.7 General anaesthesia was in its infancy; endotracheal intubation was developed in the 1910s; abdominal muscle relaxation was achieved by either deep anaesthesia with very volatile agents or spinal blockade (muscle relaxants were not introduced until the 1940s) and intravenous agents had not been introduced. While antiseptics were used, antibiotics would not be available for another 20 years and sepsis following gastrointestinal injury was the major cause of post-operative death. Surgeons at this time had very limited equipment; sutures were gut, silk or linen and not sterile and needed to be threaded onto reusable needle. Stapling devices, electrocautery, haemostatic agents and prosthetic vascular grafts commonly used today in theatres did not exist. It is therefore remarkable that the surgeons on the Western Front had any success, and those who survived surgery for abdominal injury owed their lives to the skill of their surgeons. Now nearly 100 years old, this paper still has much to teach modern trauma and military surgeons, both in general principles of emergency surgery for abdominal trauma and specific guidance for particular organ injuries. That the authors rescued so many injured soldiers with limited equipment and postoperative surgical support is a credit to their phenomenal skills.
THE AUTHORS Hamilton Drummond was born in 1882 and hailed from a wellconnected medical family, his father being an ex-president of the British Medical Association and Pro-Vice Chancellor of Durham University. He graduated from Durham in 1906 and acquired the Edinburgh Fellowship 6 years later. Following house jobs in Newcastle (for Rutherford Morrison) and in
Edwards DP. J R Army Med Corps 2014;160(Supp 1):i33–i35. doi:10.1136/jramc-2014-000309
Downloaded from http://jramc.bmj.com/ on May 5, 2017 - Published by group.bmj.com
London at St Marks and Great Ormond Street he returned as surgical registrar to Newcastle, once again under the auspices of Professor Morrison. While on an academic visit to the USA with his Professor, Drummond suffered appendicitis and was operated by Professor Morrison. At the outbreak of World War I Drummond departed to France with the Northumberland Yeomanry, seeing action at the first battle of Ypres (and being Mentioned in Dispatches) before being transferred to the RAMC where he continued to serve with distinction. He combined his surgical workload with research such as this paper and investigations into the management of gas gangrene and the introduction of flavine, proflavine and BIPP as topical antiseptics. Having survived the War and being elected to full consultant status at the Royal Victoria Hospital in Newcastle, he died after a car accident at the age of 43.8 His name is remembered still by colorectal surgeons for his description of the importance of the marginal artery of the colon.9 Born in 1885, John Fraser was a Scot whose career revolved about Edinburgh. He graduated MBChB from there in 1907, received his fellowship and MD from Edinburgh University and sat as Professor of Clinical Surgery from 1925 to 1944 before becoming the University’s Vice-Chancellor for three further years. His only appreciable absences were his war service, during which he was wounded and awarded the Military Cross, and a 3 month world tour in 1935 which was the same year he was appointed surgeon to His Majesty the King in Scotland. He was knighted in 1937 and made a Baronet in 1942.10 David P Edwards Correspondence to Lt Col David P Edwards, Colorectal Unit, Frimley Park Hospital, Portsmouth Road, Frimley, Surrey GU16 7UJ, UK; david.edwards@fph-tr. nhs.uk
The original article can be found online as supplementary file. To view please visit the journal online (http://dx.doi.org/10.1136/jramc-2014-000309). Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Edwards DP. J R Army Med Corps 2014;160(Supp 1):i33–i35. Accepted 15 April 2014 J R Army Med Corps 2014;160(Supp 1):i33–i35. doi:10.1136/jramc-2014-000309
REFERENCES 1
2 3 4 5 6
7 8 9 10
Edwards DP. J R Army Med Corps 2014;160(Supp 1):i33–i35. doi:10.1136/jramc-2014-000309
Howell GP, Ryan JM, Cooper GJ, et al. Assessment of the use of disposable skin staplers in bowel anastomoses to reduce laparotomy time in penetrating ballistic injury to the abdomen. Ann R Coll Surg Engl 1991;73:87–90. Edwards DP, Warren BF, Galbraith KA, et al. Comparison of techniques for the repair of experimental colonic perforations. Brit J Surg 1999;86:514–17. Fraser J, Drummond H. A Clinical and Experimental Study of Three Hundred Perforating Wounds of the Abdomen. BMJ 1917;321–30. Roberts P. ed. The British Military Surgery Pocket Book. London: HMSO, 2004. Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: is it necessary? J Trauma 1996;41:271–5 Edwards DP, Leppington-Clarke A, Sexton R, et al. Stoma related complications are more frequent after transverse colostomy than loop ileostomy a prospective randomised controlled trial. Brit J Surg 2001;88:360–1. Bennett JDC. Abdominal surgery in war—the early story. J R Soc Med 1991;84:554–7. Obituary. Hamilton drummond. BMJ 1925;2:181. Drummond H. Some points relating to the surgical anatomy of the arterial supply of the large intestine. Proc R Soc Med 1914;7(Surg Sect):185–93. http://www.archives.lib.ed.ac.uk/catalogue/cs/viewcat.pl?id=GB-237-Coll1296&view=basic (accessed 14 Apr 2014)
i35
Downloaded from http://jramc.bmj.com/ on May 5, 2017 - Published by group.bmj.com
David P Edwards J R Army Med Corps 2014 160: i33-i35
doi: 10.1136/jramc-2014-000309 Updated information and services can be found at: http://jramc.bmj.com/content/160/Suppl_1/i33
These include:
Supplementary Supplementary material can be found at: Material http://jramc.bmj.com/content/suppl/2014/05/20/160.Suppl_1.i33.DC1 References Email alerting service
This article cites 7 articles, 1 of which you can access for free at: http://jramc.bmj.com/content/160/Suppl_1/i33#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
