(165*) Wounded at Graspan, sustaining a compound fracture of the fibula. While being carried off the field, a second bullet (Lee-Metford) entered immediately outside the left posterior superioriliac spine, perforated the pelvis, and emerged 1½ inch within the left anterior superior spine. The patient was then put down and left on the field ten hours; later he was carried to shelter for the night, and arrived at Orange River on the second day. He suffered with some pain in the abdomen, especially during the journey in the train, but was not sick; the bowels were confined.When seen on the third day at 6p.m., some pain was complained of in the abdomen, which moved freely in the upper part, but was motionless below the umbilicus. No distension. Tenderness around wound of exit and some rigidity. The bowels had acted four times during the day; motions loose, dark brown, and containing no blood. Face not anxious, eyes bright, temperature 102°. Pulse 96, regular, and of good strength. Tongue moist and little furred.The abdomen was opened at 5a.m.on the fourth day, as the local signs had become more pronounced, and the patient had passed a restless night in great abdominal pain. A local incision was chosen, as the wound was presumably in the sigmoid flexure. The sigmoid flexure was adherent to the abdominal wall opposite the wound of exit, and a dark ecchymosed patch was found, but no perforation could be detected. Foul pus and gas escaped freely from the pelvis, but no wound of the large bowel could be discovered here. On enlarging the incision upwards three openings were found in a coil of jejunum, probably that about five feet from the duodenal junction usually provided with the longest mesentery. No fourth opening could be found. The openings were circular, about 1/3 inch in diameter, clean cut, with a ring of everted mucous membrane, and the wall of the bowel in the neighbourhood was thickened. All three openings were included within a length of 2½ inches. There was no surrounding ecchymosis of the bowel wall. Very little escaped intestinal contents were found in the situation of the bowel. The latter had apparently been retracted upwards, and lay to the left of the lumbar spine. The wounds were readily closed by five Lembert's sutures, three crossing the openings, and one at each end. The belly was then washed out with boiled water and closed. The delay in finding the wounds due to the mistaken impression that they would be found in the pelvis materially prolonged the operation, which lasted an hour and a half. The patient never rallied, and died seventeen hours later. It is possible that a wound in the sigmoid flexure was present which had already closed at the time of operation.(166*) Wounded at Magersfontein.Entry(Mauser), oppositecentral point of left ilium;exit, 1½ inch above the centre of the right Poupart's ligament. Vomiting commenced soon after the injury, and this was continuous until the patient's arrival in the Stationary hospital on the fourth day, when the condition was as follows:—Face extremely anxious in expression. Temperature 101°, sweating freely. Pulse 110, fair strength. Tongue moist. Abdomen much distended, rigid, motionless, tympanitic throughout. Bowels confined. No urine had been passed for twenty-four hours, ℥ij in bladder on catheterisation, clear, and containing no blood.Abdominal section. Median incision. A considerable quantity of bloody effusion was evacuated. Intestine generally congested and distended. No lymph. Two wounds were found in the ileum on the opposite sides of one coil; the openings were circular, with the mucous membrane everted. No escape of fæcal matter was visible until the intestine was delivered, when intestinal contents spurted freely across the room. The openings were sutured with five Lembert's stitches. The bowel was punctured in two places to relieve distension, and then returned into the belly, after washing with boiled water.Four pints of saline solution were infused into the median basilic vein, and 1/30 grain strychnine sulph. was injected hypodermically.The patient did not rally, and died twelve hours after the operation.(167*) Wounded at Graspan.Entry(Lee-Metford), midway between the umbilicus and pubes;exit, 1 inch to the left of the fifth lumbar spine. The patient was seen on the third day in the following condition: in great pain, expression extremely anxious, vomiting constantly. Pulse 150 running, respirations 48. Temperature 100°, sweating freely. Great distension, rigidity, and general tenderness of immobile abdomen. No improvement followed the administration of brandy and hypodermic injection of strychnine 1/30 grain, and operation was deemed hopeless.In the evening the patient was apparently dying. Face blue and sunken and covered with sweat, eyes dull, speechless, pulse imperceptible, restlessness extreme, bowels acting involuntarily, no urine in bladder.The man was placed in a tent by himself, and to my surprise was alive and better the next morning; the expression was still anxious, but the face brighter and not sweating; the pulse onlynumbered 100, but was very weak, and the hands and feet were cold. The condition of the abdomen was unaltered, but the thoracic respiration had decreased in rapidity from 48 to 28.His condition still seemed to preclude any chance of successful intervention, but none the less life was retained until the morning of the seventh day, the state alternating between a moribund one and one of slight improvement. He was lucid at times, although for the most part wandering, and was so restless that no covering could be kept upon him. Vomiting was continuous, so that no nourishment could be retained; the bowels acted frequently involuntarily, and little or no urine was passed. Meanwhile, the abdomen became flat, then sunken, an area of induration and tenderness about 6 inches in diameter developing around the wound of entry. Slight variations in the pulse, and from normal to subnormal in the temperature, were noted, and death eventually occurred from septicæmia and inanition.(168*) Wounded at Driefontein.Entry(Mauser), above the posterior third of the left iliac crest, at the margin of the last lumbar transverse process (probably through ilio-lumbar ligament);exit, 1 inch below and to the left of the umbilicus.The patient was wounded at 3p.m., but not brought into the Field hospital until 9p.m., when the temperature of the tents was below 28°F. He was considerably collapsed, suffering much pain, and vomited freely. The abdomen was flat, but very tender. Bowels confined. The column had to move at 5a.m.the next morning, when the temperature was still near freezing, and during the day continuous fighting prevented any chance of operation. The man steadily sank during the day, and died thirty-six hours after the reception of the injury.Post-mortem condition.—Belly not distended, dull anteriorly in patches, and right flank dull throughout. When the belly was opened, extensive adhesion of omentum and intestine enclosing numerous collections of pus were disclosed, and on disturbing the adhesions a large collection of turbid blood-stained fluid was set free from the right loin. The great omentum was much thickened and matted, with deposition of thick patches of lymph; very firm recent adhesions also united numerous coils of small intestine. The pus was fœtid, but no appreciable quantity of intestinal contents was detected in it. The lower half or more of the small intestine was injected, reddened, and thickened. The wounds which were situated in the lower part of the jejunum and ileum were multiple, and seven perforations were detected;besides these the intestine was marked by bruises, and some gutter slits affecting the serous and muscular coats only. Considerable ecchymosis surrounded these latter. The clean perforations were circular, less than 1/4 inch in diameter, and for the most part closed by eversion of the mucous membrane. Intestinal contents were not apparent, but escaped freely on manipulation of the bowel.(169*) Wounded at Magersfontein.Entry(Mauser), over the eighth rib in the anterior axillary line;exit, 1 inch to the left of second lumbar spinous process, just below the last rib. Vomiting commenced almost immediately after reception of the injury, and the bowels acted frequently. This condition persisted until the fourth day, when the patient was brought down to Orange River, and the signs were as follows. Considerable pain in left half of abdomen, pulse 110, fair strength, temperature 101°. Some general distension of abdomen with complete disappearance of hepatic dulness. Some movement of right half of abdomen, left half immobile, dulness extending from the flank as far forwards as linea semilunaris. An incision was made in left linea semilunaris, and Oj blood evacuated from the left loin. There was no lymph on the intestines nor sign of inflammation. No perforation was discovered in either stomach or intestine, but on two coils of jejunum there were deep slits 3/4 inch long, extending through both peritoneal and muscular coats. Beyond these wounds, on other coils oval patches of ecchymosis, due to direct bruising, were present. The peritoneal cavity was sponged free of all blood and irrigated with boiled water; no bleeding point was discovered, and the abdomen was closed.The next morning the patient was comfortable; temperature 100.2°, pulse 100. Tongue clean and moist; he vomited once during the night.Some bloody discharge had collected in the dressing, and at the lower angle of wound there was a local swelling, apparently in the abdominal wall. The flank was resonant.During the afternoon the patient became faint, and when seen at 6p.m.was in a state of collapse, in which he shortly died.Death was apparently due to renewal of the previous hæmorrhage. Nopost-mortemexamination was made.(170*) Wounded at Magersfontein.Entry(Mauser), 1/2 inch to the left of the second sacral spine;exit, immediately below the left anterior superior iliac spine; the patient was kneeling at the time, and the same bullet traversed his left thigh in the lowerthird. When seen on the third day, the lower part of the abdomen was motionless, tumid, and tender. The bowels had been confined for three days; there had been no sickness, and the tongue was moist and clean. Temperature 100°, pulse 90, fair strength, respirations 38. The patient had once had an attack of acute appendicitis, and he himself said he was sure he now had 'peritonitis,' as he had pain exactly similar in the belly to that he had suffered in his previous illness.No further signs, however, developed under an expectant treatment, and he remained some two months in hospital, while the wound in the thigh and a third injury to the elbow-joint were healing.(171)Entry(Mauser), at the highest point of the left crista ilii;exit, through the right ilium, 2 inches horizontally anterior to the posterior superior spine. Absolutely no abdominal symptoms followed. The bowels were confined five days, and then opened by enema. The patient complained of some stiffness in the lumbo-sacral region, but the right synchondrosis was no doubt implicated in the track.(172) Wounded at Paardeberg (range 800 yards).Entry(Mauser), 2 inches diagonally below and to the right of the umbilicus;exit, not discoverable. For the first two days the patient had to lie out with the regiment; on the fourth he was removed to the Field hospital. During the first three days the patient vomited (green matter) frequently, and the belly was hard and painful; as biscuit was the only available food, no nourishment was taken. The bowels acted on the second night. At the end of a week the patient was sent by bullock wagon (three days and nights) to Modder River, and then down to Capetown, where he walked into the hospital on the thirteenth day, apparently well.Two days later the temperature rose to 104°, and enteric fever was diagnosed, no local signs pointing to the injury existing. The patient made a good recovery.(173) Wounded at Colenso.Entry(Mauser), at junction of outer 2/5 with inner 3/5 of line from right anterior superior iliac spine to umbilicus;exit, at upper part of right great sacro-sciatic foramen, in line of posterior superior iliac spine. Advancing on foot when struck; he then fell and crept fifty yards to behind a rock, where he remained seven and a half hours. For two days subsequently he vomited freely; the bowels acted nine hours after the injury, and then became constipated. No further symptomswere noted, and at the end of three weeks the abdomen was absolutely normal. The man is now again on active service.(174*) Wounded at Modder River while retiring on foot.Entry(Mauser), at highest point of right iliac crest;exit, 2½ inches to right of and 1/2 inch above level of umbilicus. The injury was not followed by sickness, and the bowels remained confined. During the first two days 'pain struck across the abdomen' when micturition was performed.When the patient came under observation on the third day the condition was as follows:—Complains of little pain, temperature normal, pulse 72, respirations 24, tongue moist, bowels confined. Rigidity of abdominal wall and deficient mobility of nearly whole right half of belly, the whole lower half of which moves little with respiration. No track palpable in abdominal parietes. No dulness, no distension. The temperature rose to 99.5° at night. On the fourth day the bowels acted freely, the pulse fell to 60, the respirations were 24, and the temperature normal.Tenderness and rigidity persisted in the right flank to the end of a week, after which time no further signs persisted.(175*) Wounded at Modder River while lying on right side. Range 500 yards. Walked 400 yards after injury.Entry(Mauser), at the junction of the posterior and middle thirds of the right iliac crest;exit, 3 inches to right of and 1/2 inch below the level of the umbilicus. The injury was followed by no signs of intra-abdominal lesion; on the third day the temperature was normal, pulse 80, and the tongue clean and moist. Some soreness at times and tenderness on pressure were complained of, but the man was discharged well at the end of one month.(176*) Wounded while doubling in retirement at Modder River.Entry(Mauser), immediately above the junction of the posterior and middle thirds of the left iliac crest;exit, 1 inch below costal margin (eighth rib), 3 inches to the right of the median line. The bullet was lying in the anterior wound, whence it was removed by the orderly who applied the first dressing on the field. The patient remained on the field seven and a half hours, and when brought into hospital at once commenced to vomit. The ejected matter, at first green in colour, during the next forty-eight hours changed to a dirty brown. Meanwhile, the abdomen was somewhat painful. When seen on the third day he had ceased to vomit for three hours. The face was slightly anxious, and thepatient lay on the ground with the lower extremities extended. Temperature 99°, pulse 72, fair strength. Respirations 32, shallow. Tongue moist, lightly furred, bowels not open for four days. He slept fairly last night. Abdomen soft, moving well with respiration, no distension, slight tenderness below and to the right of the umbilicus, and local dulness in right flank.The next day the pulse fell to 60 and the bowels acted, but there was no change in the local condition. The man looked somewhat ill until the end of a week, but was then sent to the Base, and at the expiration of a month was sent home well.(177*) Wounded at Modder River. Two apertures ofentry(Mauser); (a) below cartilage of eighth rib in left nipple line; (b) 2 inches below and 4½ inches to the left of the median line. No exit wound discovered, and no track could be palpated between the two openings, which were both circular and depressed. When seen on fourth day there was tenderness in the lower half of the abdomen, and the left thigh was held in a flexed position. Respirations 20, respiratory movement confined to upper half of abdominal wall. Pulse 70, temperature 99°. Tongue moist, covered with white fur; bowels confined since the accident; no sickness. The patient remained under observation thirteen days, during which time pain and difficulty in movement of the left thigh persisted, also slight tenderness in the lower part of the abdomen; but at the end of a month he was sent to England well, but unfit to take further part in the campaign. I thought the bullet might be in the left psoas, but it was not localised.(178*) Wounded at Modder River.Entry(Mauser), 3½ inches above and 1½ inch within the left anterior superior iliac spine;exit, 1½ inch to the right of the tenth dorsal spinous process. The same bullet had perforated the forearm just above the wrist prior to entering the abdomen. No local or constitutional signs indicated either bowel injury or perforation of liver. The man, however, was suffering from a slight attack of dysentery, passing blood and mucus per rectum with great tenesmus. He was sent to the Base at the end of a week, and returned to England well three weeks later. He attributed his dysentery to the wound, as the symptoms did not exist prior to its reception; but as the disease coincided exactly with what was very prevalent amongst the troops at the time, I do not think there was any connection between it and the injury.(179) Wounded near Thaba-nchu.Entry, over the centre of the sacrum at the upper border of fourth segment;exit, 1½ inchabove left Poupart's ligament, 2 inches from the median line. Aperture of entry oval, with long vertical axis. Exit wound a transverse slit, with slight tendency to starring (see fig. 19, p. 58). One hour after being shot the patient vomited once. There was some evidence of shock and considerable pain. The bowels acted involuntarily simultaneously with the vomiting, and incontinence of fæces and retention of urine persisted for four days. The vomit was bilious in appearance; no blood was seen either in it or the motions.Forty-six hours after the injury the condition was as follows: Face slightly anxious and pale; skin moist, temperature 100.4°; pulse 116, regular and of fair strength; respirations 24; abdomen slightly tumid; tenderness over lower half, especially on left side; the lower half moves little with respiration.Twenty-four hours later the patient had improved. He was comfortable and hopeful; slept well with morphia 1/3 grain hypodermically. Tongue moist, covered with white fur; has been taking milk only, ℥ij every half-hour. No sickness. Temperature99°. Pulse 104. Respirations 24. Abdomen flatter; general respiratory movement; tenderness now mainly localised to an area 2½ inches in diameter, to the left of the umbilicus, above exit wound.The patient continued to improve, and on the fifth day travelled six hours in a bullock wagon to Bloemfontein. Soon after arrival his temperature was normal: pulse 80, respirations 16, with good abdominal movement. Local tenderness persisted in the same area, but was less in degree. Tongue rather dry, bowels confined. Micturition normal. Two drachms of castor oil and an enema were given.On the ninth day patient was practically well, except for slight deep tenderness. He remained in bed on ordinary light diet, but at the end of the third week he was seized by a sudden attack of pain, the temperature rising to 103° and the pulse to 140, the abdomen becoming swollen and tender. He was then under the charge of Mr. Bowlby, who ordered some opium, and the symptoms rapidly subsided. Although this wound crossed the small intestine area, it is probable that the symptoms may have been due to an injury of the rectum or sigmoid flexure.
(165*) Wounded at Graspan, sustaining a compound fracture of the fibula. While being carried off the field, a second bullet (Lee-Metford) entered immediately outside the left posterior superioriliac spine, perforated the pelvis, and emerged 1½ inch within the left anterior superior spine. The patient was then put down and left on the field ten hours; later he was carried to shelter for the night, and arrived at Orange River on the second day. He suffered with some pain in the abdomen, especially during the journey in the train, but was not sick; the bowels were confined.
When seen on the third day at 6p.m., some pain was complained of in the abdomen, which moved freely in the upper part, but was motionless below the umbilicus. No distension. Tenderness around wound of exit and some rigidity. The bowels had acted four times during the day; motions loose, dark brown, and containing no blood. Face not anxious, eyes bright, temperature 102°. Pulse 96, regular, and of good strength. Tongue moist and little furred.
The abdomen was opened at 5a.m.on the fourth day, as the local signs had become more pronounced, and the patient had passed a restless night in great abdominal pain. A local incision was chosen, as the wound was presumably in the sigmoid flexure. The sigmoid flexure was adherent to the abdominal wall opposite the wound of exit, and a dark ecchymosed patch was found, but no perforation could be detected. Foul pus and gas escaped freely from the pelvis, but no wound of the large bowel could be discovered here. On enlarging the incision upwards three openings were found in a coil of jejunum, probably that about five feet from the duodenal junction usually provided with the longest mesentery. No fourth opening could be found. The openings were circular, about 1/3 inch in diameter, clean cut, with a ring of everted mucous membrane, and the wall of the bowel in the neighbourhood was thickened. All three openings were included within a length of 2½ inches. There was no surrounding ecchymosis of the bowel wall. Very little escaped intestinal contents were found in the situation of the bowel. The latter had apparently been retracted upwards, and lay to the left of the lumbar spine. The wounds were readily closed by five Lembert's sutures, three crossing the openings, and one at each end. The belly was then washed out with boiled water and closed. The delay in finding the wounds due to the mistaken impression that they would be found in the pelvis materially prolonged the operation, which lasted an hour and a half. The patient never rallied, and died seventeen hours later. It is possible that a wound in the sigmoid flexure was present which had already closed at the time of operation.
(166*) Wounded at Magersfontein.Entry(Mauser), oppositecentral point of left ilium;exit, 1½ inch above the centre of the right Poupart's ligament. Vomiting commenced soon after the injury, and this was continuous until the patient's arrival in the Stationary hospital on the fourth day, when the condition was as follows:—
Face extremely anxious in expression. Temperature 101°, sweating freely. Pulse 110, fair strength. Tongue moist. Abdomen much distended, rigid, motionless, tympanitic throughout. Bowels confined. No urine had been passed for twenty-four hours, ℥ij in bladder on catheterisation, clear, and containing no blood.
Abdominal section. Median incision. A considerable quantity of bloody effusion was evacuated. Intestine generally congested and distended. No lymph. Two wounds were found in the ileum on the opposite sides of one coil; the openings were circular, with the mucous membrane everted. No escape of fæcal matter was visible until the intestine was delivered, when intestinal contents spurted freely across the room. The openings were sutured with five Lembert's stitches. The bowel was punctured in two places to relieve distension, and then returned into the belly, after washing with boiled water.
Four pints of saline solution were infused into the median basilic vein, and 1/30 grain strychnine sulph. was injected hypodermically.
The patient did not rally, and died twelve hours after the operation.
(167*) Wounded at Graspan.Entry(Lee-Metford), midway between the umbilicus and pubes;exit, 1 inch to the left of the fifth lumbar spine. The patient was seen on the third day in the following condition: in great pain, expression extremely anxious, vomiting constantly. Pulse 150 running, respirations 48. Temperature 100°, sweating freely. Great distension, rigidity, and general tenderness of immobile abdomen. No improvement followed the administration of brandy and hypodermic injection of strychnine 1/30 grain, and operation was deemed hopeless.
In the evening the patient was apparently dying. Face blue and sunken and covered with sweat, eyes dull, speechless, pulse imperceptible, restlessness extreme, bowels acting involuntarily, no urine in bladder.
The man was placed in a tent by himself, and to my surprise was alive and better the next morning; the expression was still anxious, but the face brighter and not sweating; the pulse onlynumbered 100, but was very weak, and the hands and feet were cold. The condition of the abdomen was unaltered, but the thoracic respiration had decreased in rapidity from 48 to 28.
His condition still seemed to preclude any chance of successful intervention, but none the less life was retained until the morning of the seventh day, the state alternating between a moribund one and one of slight improvement. He was lucid at times, although for the most part wandering, and was so restless that no covering could be kept upon him. Vomiting was continuous, so that no nourishment could be retained; the bowels acted frequently involuntarily, and little or no urine was passed. Meanwhile, the abdomen became flat, then sunken, an area of induration and tenderness about 6 inches in diameter developing around the wound of entry. Slight variations in the pulse, and from normal to subnormal in the temperature, were noted, and death eventually occurred from septicæmia and inanition.
(168*) Wounded at Driefontein.Entry(Mauser), above the posterior third of the left iliac crest, at the margin of the last lumbar transverse process (probably through ilio-lumbar ligament);exit, 1 inch below and to the left of the umbilicus.
The patient was wounded at 3p.m., but not brought into the Field hospital until 9p.m., when the temperature of the tents was below 28°F. He was considerably collapsed, suffering much pain, and vomited freely. The abdomen was flat, but very tender. Bowels confined. The column had to move at 5a.m.the next morning, when the temperature was still near freezing, and during the day continuous fighting prevented any chance of operation. The man steadily sank during the day, and died thirty-six hours after the reception of the injury.
Post-mortem condition.—Belly not distended, dull anteriorly in patches, and right flank dull throughout. When the belly was opened, extensive adhesion of omentum and intestine enclosing numerous collections of pus were disclosed, and on disturbing the adhesions a large collection of turbid blood-stained fluid was set free from the right loin. The great omentum was much thickened and matted, with deposition of thick patches of lymph; very firm recent adhesions also united numerous coils of small intestine. The pus was fœtid, but no appreciable quantity of intestinal contents was detected in it. The lower half or more of the small intestine was injected, reddened, and thickened. The wounds which were situated in the lower part of the jejunum and ileum were multiple, and seven perforations were detected;besides these the intestine was marked by bruises, and some gutter slits affecting the serous and muscular coats only. Considerable ecchymosis surrounded these latter. The clean perforations were circular, less than 1/4 inch in diameter, and for the most part closed by eversion of the mucous membrane. Intestinal contents were not apparent, but escaped freely on manipulation of the bowel.
(169*) Wounded at Magersfontein.Entry(Mauser), over the eighth rib in the anterior axillary line;exit, 1 inch to the left of second lumbar spinous process, just below the last rib. Vomiting commenced almost immediately after reception of the injury, and the bowels acted frequently. This condition persisted until the fourth day, when the patient was brought down to Orange River, and the signs were as follows. Considerable pain in left half of abdomen, pulse 110, fair strength, temperature 101°. Some general distension of abdomen with complete disappearance of hepatic dulness. Some movement of right half of abdomen, left half immobile, dulness extending from the flank as far forwards as linea semilunaris. An incision was made in left linea semilunaris, and Oj blood evacuated from the left loin. There was no lymph on the intestines nor sign of inflammation. No perforation was discovered in either stomach or intestine, but on two coils of jejunum there were deep slits 3/4 inch long, extending through both peritoneal and muscular coats. Beyond these wounds, on other coils oval patches of ecchymosis, due to direct bruising, were present. The peritoneal cavity was sponged free of all blood and irrigated with boiled water; no bleeding point was discovered, and the abdomen was closed.
The next morning the patient was comfortable; temperature 100.2°, pulse 100. Tongue clean and moist; he vomited once during the night.
Some bloody discharge had collected in the dressing, and at the lower angle of wound there was a local swelling, apparently in the abdominal wall. The flank was resonant.
During the afternoon the patient became faint, and when seen at 6p.m.was in a state of collapse, in which he shortly died.
Death was apparently due to renewal of the previous hæmorrhage. Nopost-mortemexamination was made.
(170*) Wounded at Magersfontein.Entry(Mauser), 1/2 inch to the left of the second sacral spine;exit, immediately below the left anterior superior iliac spine; the patient was kneeling at the time, and the same bullet traversed his left thigh in the lowerthird. When seen on the third day, the lower part of the abdomen was motionless, tumid, and tender. The bowels had been confined for three days; there had been no sickness, and the tongue was moist and clean. Temperature 100°, pulse 90, fair strength, respirations 38. The patient had once had an attack of acute appendicitis, and he himself said he was sure he now had 'peritonitis,' as he had pain exactly similar in the belly to that he had suffered in his previous illness.
No further signs, however, developed under an expectant treatment, and he remained some two months in hospital, while the wound in the thigh and a third injury to the elbow-joint were healing.
(171)Entry(Mauser), at the highest point of the left crista ilii;exit, through the right ilium, 2 inches horizontally anterior to the posterior superior spine. Absolutely no abdominal symptoms followed. The bowels were confined five days, and then opened by enema. The patient complained of some stiffness in the lumbo-sacral region, but the right synchondrosis was no doubt implicated in the track.
(172) Wounded at Paardeberg (range 800 yards).Entry(Mauser), 2 inches diagonally below and to the right of the umbilicus;exit, not discoverable. For the first two days the patient had to lie out with the regiment; on the fourth he was removed to the Field hospital. During the first three days the patient vomited (green matter) frequently, and the belly was hard and painful; as biscuit was the only available food, no nourishment was taken. The bowels acted on the second night. At the end of a week the patient was sent by bullock wagon (three days and nights) to Modder River, and then down to Capetown, where he walked into the hospital on the thirteenth day, apparently well.
Two days later the temperature rose to 104°, and enteric fever was diagnosed, no local signs pointing to the injury existing. The patient made a good recovery.
(173) Wounded at Colenso.Entry(Mauser), at junction of outer 2/5 with inner 3/5 of line from right anterior superior iliac spine to umbilicus;exit, at upper part of right great sacro-sciatic foramen, in line of posterior superior iliac spine. Advancing on foot when struck; he then fell and crept fifty yards to behind a rock, where he remained seven and a half hours. For two days subsequently he vomited freely; the bowels acted nine hours after the injury, and then became constipated. No further symptomswere noted, and at the end of three weeks the abdomen was absolutely normal. The man is now again on active service.
(174*) Wounded at Modder River while retiring on foot.Entry(Mauser), at highest point of right iliac crest;exit, 2½ inches to right of and 1/2 inch above level of umbilicus. The injury was not followed by sickness, and the bowels remained confined. During the first two days 'pain struck across the abdomen' when micturition was performed.
When the patient came under observation on the third day the condition was as follows:—Complains of little pain, temperature normal, pulse 72, respirations 24, tongue moist, bowels confined. Rigidity of abdominal wall and deficient mobility of nearly whole right half of belly, the whole lower half of which moves little with respiration. No track palpable in abdominal parietes. No dulness, no distension. The temperature rose to 99.5° at night. On the fourth day the bowels acted freely, the pulse fell to 60, the respirations were 24, and the temperature normal.
Tenderness and rigidity persisted in the right flank to the end of a week, after which time no further signs persisted.
(175*) Wounded at Modder River while lying on right side. Range 500 yards. Walked 400 yards after injury.Entry(Mauser), at the junction of the posterior and middle thirds of the right iliac crest;exit, 3 inches to right of and 1/2 inch below the level of the umbilicus. The injury was followed by no signs of intra-abdominal lesion; on the third day the temperature was normal, pulse 80, and the tongue clean and moist. Some soreness at times and tenderness on pressure were complained of, but the man was discharged well at the end of one month.
(176*) Wounded while doubling in retirement at Modder River.Entry(Mauser), immediately above the junction of the posterior and middle thirds of the left iliac crest;exit, 1 inch below costal margin (eighth rib), 3 inches to the right of the median line. The bullet was lying in the anterior wound, whence it was removed by the orderly who applied the first dressing on the field. The patient remained on the field seven and a half hours, and when brought into hospital at once commenced to vomit. The ejected matter, at first green in colour, during the next forty-eight hours changed to a dirty brown. Meanwhile, the abdomen was somewhat painful. When seen on the third day he had ceased to vomit for three hours. The face was slightly anxious, and thepatient lay on the ground with the lower extremities extended. Temperature 99°, pulse 72, fair strength. Respirations 32, shallow. Tongue moist, lightly furred, bowels not open for four days. He slept fairly last night. Abdomen soft, moving well with respiration, no distension, slight tenderness below and to the right of the umbilicus, and local dulness in right flank.
The next day the pulse fell to 60 and the bowels acted, but there was no change in the local condition. The man looked somewhat ill until the end of a week, but was then sent to the Base, and at the expiration of a month was sent home well.
(177*) Wounded at Modder River. Two apertures ofentry(Mauser); (a) below cartilage of eighth rib in left nipple line; (b) 2 inches below and 4½ inches to the left of the median line. No exit wound discovered, and no track could be palpated between the two openings, which were both circular and depressed. When seen on fourth day there was tenderness in the lower half of the abdomen, and the left thigh was held in a flexed position. Respirations 20, respiratory movement confined to upper half of abdominal wall. Pulse 70, temperature 99°. Tongue moist, covered with white fur; bowels confined since the accident; no sickness. The patient remained under observation thirteen days, during which time pain and difficulty in movement of the left thigh persisted, also slight tenderness in the lower part of the abdomen; but at the end of a month he was sent to England well, but unfit to take further part in the campaign. I thought the bullet might be in the left psoas, but it was not localised.
(178*) Wounded at Modder River.Entry(Mauser), 3½ inches above and 1½ inch within the left anterior superior iliac spine;exit, 1½ inch to the right of the tenth dorsal spinous process. The same bullet had perforated the forearm just above the wrist prior to entering the abdomen. No local or constitutional signs indicated either bowel injury or perforation of liver. The man, however, was suffering from a slight attack of dysentery, passing blood and mucus per rectum with great tenesmus. He was sent to the Base at the end of a week, and returned to England well three weeks later. He attributed his dysentery to the wound, as the symptoms did not exist prior to its reception; but as the disease coincided exactly with what was very prevalent amongst the troops at the time, I do not think there was any connection between it and the injury.
(179) Wounded near Thaba-nchu.Entry, over the centre of the sacrum at the upper border of fourth segment;exit, 1½ inchabove left Poupart's ligament, 2 inches from the median line. Aperture of entry oval, with long vertical axis. Exit wound a transverse slit, with slight tendency to starring (see fig. 19, p. 58). One hour after being shot the patient vomited once. There was some evidence of shock and considerable pain. The bowels acted involuntarily simultaneously with the vomiting, and incontinence of fæces and retention of urine persisted for four days. The vomit was bilious in appearance; no blood was seen either in it or the motions.
Forty-six hours after the injury the condition was as follows: Face slightly anxious and pale; skin moist, temperature 100.4°; pulse 116, regular and of fair strength; respirations 24; abdomen slightly tumid; tenderness over lower half, especially on left side; the lower half moves little with respiration.
Twenty-four hours later the patient had improved. He was comfortable and hopeful; slept well with morphia 1/3 grain hypodermically. Tongue moist, covered with white fur; has been taking milk only, ℥ij every half-hour. No sickness. Temperature
99°. Pulse 104. Respirations 24. Abdomen flatter; general respiratory movement; tenderness now mainly localised to an area 2½ inches in diameter, to the left of the umbilicus, above exit wound.
The patient continued to improve, and on the fifth day travelled six hours in a bullock wagon to Bloemfontein. Soon after arrival his temperature was normal: pulse 80, respirations 16, with good abdominal movement. Local tenderness persisted in the same area, but was less in degree. Tongue rather dry, bowels confined. Micturition normal. Two drachms of castor oil and an enema were given.
On the ninth day patient was practically well, except for slight deep tenderness. He remained in bed on ordinary light diet, but at the end of the third week he was seized by a sudden attack of pain, the temperature rising to 103° and the pulse to 140, the abdomen becoming swollen and tender. He was then under the charge of Mr. Bowlby, who ordered some opium, and the symptoms rapidly subsided. Although this wound crossed the small intestine area, it is probable that the symptoms may have been due to an injury of the rectum or sigmoid flexure.
3.Wounds of the large intestine.—Injuries to every part of the large bowel were observed, and spontaneous recoveries were seen in all parts except the transverse colon, which,as already remarked, is near akin to the small intestine with regard to its position and anatomical arrangement.
The only case of perforation of the vermiform appendix that I heard of, one under the care of Mr. Stonham, died of peritoneal septicæmia. Several cases of recovery from wounds of the cæcum and ascending colon are recounted below. The only points of importance in the nature of the signs of these injuries were their primary insignificance, and the comparative frequency with whichlocalperitoneal suppuration followed them. The absence of a similar sequence in some of the cases in which wounds of the small intestine were assumed, was, in my opinion, one of the strongest reasons for doubting the correctness of the diagnosis. It is also a significant fact that injuries of the ascending colon—that is to say, of the portion of the large bowel which perhaps lies most free from the area occupied by the small intestine—were those which most frequently recovered.
The following cases afford examples of the course followed in a number of injuries to the large intestine, and illustrate both the uncomplicated and the complicated modes of spontaneous recovery.
No. 180 affords a good example of an extra-peritoneal injury, and of the especially fatal character of such lesions. This case was also one of my surgical disappointments.
Nos. 182, 183 are of great interest in several particulars. First, the aperture of exit was large and allowed the escape of fæces, not a very common feature in wounds not proving immediately fatal. Secondly, in neither were any peritoneal signs observed. Thirdly, in each the exit wound communicated with the pleura, and the patients died from septicæmia mainly due to absorption from the surface of that membrane (Pleural septicæmia).
No. 190 is a most striking instance of spontaneous cure, since no doubt can exist that both rectum and bladder were perforated.
(180*)Injury to the cæcum and ascending colon.—Boer, wounded at Graspan while sheltering behind a rock, lying on his back.Entry(Lee-Metford), in right thigh, 3 inches below and 1 inchwithin anterior superior spine of ilium;exit, in back, on a level with the fourth lumbar spinous process and 3 inches from that point.Half an hour after the wound the patient commenced to suffer severe stabbing pain; he lay on the field one hour; later he was taken to a Field hospital, and on the second day was sent by train a distance of twenty-five miles.When seen at the end of fifty hours the condition was as follows. Face anxious, complexion dusky. Great abdominal pain, especially about the umbilicus. Vomiting frequent and distressing; bowels confined since the accident; tongue dry and furred. Urine scanty. Pulse full and strong, 125; respirations, entirely thoracic, 30.Abdomen generally distended and tympanitic, wall rigid and motionless. Dulness in right flank, together with superficial œdema and emphysema.Abdominal section fifty-three and a half hours after accident. Incision in right linea semilunaris. Great omentum adherent to ascending colon, which was covered with plastic lymph. Gas and intestinal contents escaped from an opening at the line of reflexion of the peritoneum from the ascending colon; retro-peritoneal extravasation and emphysema extended the whole length of the ascending colon and around duodenum, the wall of the colon itself exhibiting subperitoneal emphysema. The colon was freed and the rent sewn up with interrupted sutures. About ℥iv of foul fæcal fluid were evacuated from loin, and a free counter-opening made. The opening in the ilium by which the bullet had entered the abdomen was found at the brim of the pelvis; the loin and peritoneal cavity were sponged dry and flushed with boiled water; no lymph was seen on the small intestine. A large gauze plug was inserted into the posterior wound, one end of the plug being brought out of the operation incision.During the succeeding six days progress was not unsatisfactory: the abdomen became soft, moved with respiration, there was no sickness, and the bowels acted. The pulse fell to 90, respirations to 20, and the temperature did not exceed 102° F. The wound suppurated freely, however, and although there were no further signs of peritoneal septicæmia, it was evident that general infection had taken place, and on the sixth day a parotid bubo developed on the right side, which was opened.On the seventh day the patient suddenly commenced to fail rapidly; vomiting was almost continuous—at first curdled milk, later frothy watery fluid—and on the eighth day he died. Theabdomen remained soft, sunken, and flaccid, and death no doubt resulted from general septicæmia rather than from peritoneal infection, absorption taking place from the large foul cavity behind the colon. As the cavity in part surrounded the descending duodenum, this possibly accounted for the attack of vomiting which preceded death.(181*)Ascending colon.—Wounded at Graspan while lying in prone position.Entry(Mauser), over ninth rib in line of right linea semilunaris;exit, in right buttock, just below and behind the top of the great trochanter.The injury was followed by little abdominal pain, but a strange sensation of local gurgling was noted. The bowels acted as soon as the patient reached camp, some hours after being wounded. There was no sickness and nothing abnormal was noted in the motions, except that they were loose and light-coloured.On the evening of the third day the patient came under observation in the ambulance train for Capetown. He looked somewhat anxious and ill, but he complained of little pain; the temperature was 102°, pulse 88, fair strength, soft and regular. There was local dulness, tenderness, and deficiency of movement in the right iliac region. As it was night, he was removed from the train and an operation was performed the next morning.Prior to operation the condition was as follows: Pulse 84, temperature 100°; respiration easy, 20. Tongue moist, but thickly coated in centre. Abdomen moves fairly, and is resonant, except in right lower quadrant. No distension. Dulness, tenderness, and rigidity in right iliac region, marked to outer side of cæcum. Entry wound nearly and exit quite healed. Cannot flex right thigh. The following operation was performed. Appendix incision, about ℥j of fæcal fluid and fæces in a localised cavity on outer and anterior aspect of cæcum evacuated; adhesions very firm. Cavity sloughy throughout and cæcum covered with dull grey lymph. The opening in the bowel was not localised, and it was considered wiser to treat the case like one of perforation from appendicitis than to run the risk of breaking down adhesions. A small awl-like opening was found in the ilium with powdered bone at its entrance leading to the wound of exit.The after-treatment of the case gave rise to no anxiety, but healing of the resulting sinus was slow; fæcal-smelling pus escaped for some days, and a number of small sloughs came away. On the twelfth day the patient was sent down to Wynberg, where he remained twelve weeks. A counter-incision was needed in theloin to drain the suppurating cavity three weeks after the primary operation, and five weeks after the operation an escape of gas and fæces took place from the anterior wound, while the bowels were acting, as a result of a dose of castor oil. No further escape of fæces occurred, and he left for England with a small sinus only. No extension of inflammation into the original wound track ever occurred, both openings and the canal healing by primary union.The sinus remained open, and occasionally discharged for a further period of six months, and then healed firmly; since when the patient has been in perfect health.(182*)Splenic flexure, descending colon.—Wounded at Magersfontein.Entry(Mauser), in sixth left intercostal space in mid-axillary line;exit, in left loin, below last rib, at outer margin of erector spinæ. The patient remained in the Field hospital three days, during which time he exhibited no serious abdominal symptoms, but during the journey to Orange River (53½ miles) he was sick. He remained at Orange River two days, and while there an enema was administered, producing a normal motion. The abdomen was slightly distended; it moved fairly, there was slight rigidity, but little tenderness. Temperature 100.8°, pulse 120. No appearance of fæces in wound.When seen on the sixth day the condition was as follows:—Patient cheerful and not in great pain. Temperature 99.2°; pulse 120; respirations 48, very shallow. Abdomen soft, moving freely, no distension or general tenderness. Fluid fæces escaping in abundance from the wound in loin. Redness of skin and swelling below level of wound, and cellular emphysema above. Fæcal-smelling fluid was also escaping from the thoracic wound.The wound was enlarged, but the patient rapidly sank, and died of septicæmia on the seventh day.(183*) An exactly similar case came under observation from the battle of Modder River, except that the opening in the loin was somewhat larger, and earlier and freer escape of fæces took place from it. In this also fæcal matter passed freely into the left pleural cavity, and fæcal matter was expectorated, while there was an almost complete absence of abdominal symptoms. Death occurred on the fourth day.Nopost-mortemexamination was made in either case, but I believe in both the extra-peritoneal aspect of the colon was implicated and that the septicæmia was in great part due to absorption from the pleural rather than the peritoneal cavity, since in neither case were the abdominal symptoms a prominent feature.(184)Possible wound of cæcum.—Wounded at Spion Kop. Bullet (Mauser) perforated the right forearm, then entered belly.Entry, 3 inches from the right anterior superior iliac spine, in the line of the supra-pubic fold of the belly wall (a transverse slit);exit, in right buttock, on a level with the tip of the great trochanter and 2 inches within it. The wound was received immediately after breakfast had been eaten. There was retention of urine and constipation for three days, but no sickness. Local pain and tenderness were severe, and at the end of three weeks there was still local tenderness, slight induration, and dragging pain on defæcation. The patient returned to England at the end of a month well, except for slight local tenderness.(185)Possible wound of colon.—Wounded at Paardeberg; range 200 yards. Walking at time. The bullet (Mauser) perforated the left forearm, just below the elbow-joint.Entry, into belly 1 inch anterior to the tip of the left eleventh costal cartilage; no exit.The injury was followed by pain in the left half of the abdomen and vomiting, which continued for two days. The bowels acted on the third day; no nourishment was taken for two days, but a small quantity of water was allowed. No further symptoms were noted, and at the end of a fortnight the patient was well, except for slight local tenderness. The bullet could not be detected with the X-rays.(186)Wound of cæcum.—Wounded at Paardeberg.Entry(Mauser), 2 inches diagonally above and within right anterior superior iliac spine;exit, immediately to the right of the fifth lumbar spinous process; the patient was lying on his left side when struck. A burning pain down the right thigh immediately followed the accident, and lasted some days. There was no sickness, the bowels were confined three days, and there was pain across the back and down the thigh.On the tenth day he arrived at the Base, when he was lying on his back suffering considerable pain. The temperature ranged to 101°. There was diarrhœa and cystitis, with a considerable amount of pus in the urine, which was very offensive. A small fluctuating spot existed on the back, just to the right of the original exit wound which was firmly healed. The abdomen moved fairly with respiration in its upper part, but was motionless below, especially in the right iliac fossa; some induration was to be felt here. The right thigh was kept flexed.During the next few days the pus disappeared from the urine,and with this change the induration in the right iliac fossa increased. An incision (Mr. Gairdner) was made into the fluctuating spot behind, and pus evacuated. The patient recovered.(187)Possible wound of cæcum.—Wounded outside Heilbron.Entry(Mauser), in the right loin, 2½ inches above the iliac crest, at the margin of the erector spinæ;exit, 1½ inch above and within the right anterior superior spine of the ilium. There was little shock. The patient was brought six miles in a wagon into camp, and slept comfortably with a small morphia injection. Prior to the accident the patient was suffering from diarrhœa, but afterwards the bowels were confined. The next morning there had been no sickness and little pain. The tongue was moist and clean, the pulse 80, the respirations 24, the belly moved generally, although inspiration was shallow; the temperature was 99°. Slight tenderness in the belly to the inner side of the exit wound, but no dulness.The patient was starved for the first thirty-six hours, a little warm water then being allowed. No symptoms developed, and a perfect recovery followed.(188)Colon,liver.—Wounded outside Heilbron.Entry(Mauser), midway between the last right rib and the crista ilii;exit, below the eighth costal cartilage in nipple line. There were no serious primary symptoms, but ten days after the accident the temperature rose, swelling and pain developed in the right loin, and on the fourteenth day a large tympanitic abscess was opened (Dr. Flockemann, German Ambulance.) Fæcal-smelling gas and pus were evacuated. There was no extension of the abscess forwards. A week later the patient had much improved, although there were evident signs of general absorption, and the discharge from the abscess cavity was abundant and very foul. On the thirteenth day a serious hæmorrhage occurred from the loin wound, which was opened up, but no evident source was discovered; hæmorrhage was repeated the next day, and the man died.At thepost-mortemexamination a large quantity of chocolate-coloured fluid was found free in the abdomen and pelvis. A chain of small local abscesses was found surrounding the ascending colon, and a larger one over the front of the cæcum. The wall of the ascending colon was generally thickened, and from this, in three places, openings with rounded margins connected the abscess cavities with the lumen of the bowel. One of the openings, larger than the others, was possibly theaperture of entry of the bullet; the others were apparently spontaneous.At the anterior border of the right lobe of the liver an abscess cavity existed in connection with the wound of the liver, and this was continuous with the aperture of exit, although not discharging. The aperture of exit was plugged by a tag of omentum (see fig. 89). No obvious source of the hæmorrhage was forthcoming, but it probably originated in one of the large branches of the vena cava. The bullet had struck the transverse process of the lumbar vertebra, but had not given rise to any signs of spinal concussion.(189*)Ascending colon.—Wounded at Modder River.Entry(Mauser), midway between the tip of the tenth right rib and the iliac crest. Bullet retained. A second wound existed over the centre of the left sterno-mastoid, and the bullet here was also retained and never localised. The patient stated that he brought up blood at short intervals for half an hour immediately after he was wounded. This might have been explained by the wound in the neck, but no difficulty in swallowing was noted. The bowels acted the day after he was shot, and, except for some local tenderness and immobility, no abdominal signs were noted. Three weeks later a swelling was obvious to the right side of the umbilicus, and a tympanitic abscess developed; this was opened, and a deformed Mauser bullet extracted. Foul pus, but no fæcal matter, was evacuated, and after discharging for a fortnight the wound closed, and the man was sent home as 'well.' In this case I assumed a wound of the ascending colon had occurred.(190*)Rectum and bladder.—Wounded at Graspan, while retiring at the double.Entry(Mauser), 1 inch to the right of the coccyx;exit, 1 inch above the junction of the middle and outer thirds of left Poupart's ligament. The man suffered with some pain in the abdomen, and for first two days with retention of urine. The urine was drawn off with the catheter, and contained blood. During the next five days micturition was hourly or more frequent; gas was passedper urethram, and the urine was very foul, containing evident fæcal matter. Micturition continued frequent, with purulent cystitis for one month. Local tenderness, pain, and immobility developed over the lower quarter of the abdomen, extending to the right iliac fossa. A local abscess pointed a little to the right of the mid line, and 2 inches above the symphysis, and from this foul-smelling pus, but no fæces, was discharged for three months, during which period the surrounding dulness andinduration gradually decreased and the sinus healed. When the patient left for England there was still occasional slight discharge from the original wound of entry, and there was slight discomfort on micturition, but he was otherwise well.A year later the man had resumed active duty, and, except for occasional pain on stooping, considered himself well.
(180*)Injury to the cæcum and ascending colon.—Boer, wounded at Graspan while sheltering behind a rock, lying on his back.
Entry(Lee-Metford), in right thigh, 3 inches below and 1 inchwithin anterior superior spine of ilium;exit, in back, on a level with the fourth lumbar spinous process and 3 inches from that point.
Half an hour after the wound the patient commenced to suffer severe stabbing pain; he lay on the field one hour; later he was taken to a Field hospital, and on the second day was sent by train a distance of twenty-five miles.
When seen at the end of fifty hours the condition was as follows. Face anxious, complexion dusky. Great abdominal pain, especially about the umbilicus. Vomiting frequent and distressing; bowels confined since the accident; tongue dry and furred. Urine scanty. Pulse full and strong, 125; respirations, entirely thoracic, 30.
Abdomen generally distended and tympanitic, wall rigid and motionless. Dulness in right flank, together with superficial œdema and emphysema.
Abdominal section fifty-three and a half hours after accident. Incision in right linea semilunaris. Great omentum adherent to ascending colon, which was covered with plastic lymph. Gas and intestinal contents escaped from an opening at the line of reflexion of the peritoneum from the ascending colon; retro-peritoneal extravasation and emphysema extended the whole length of the ascending colon and around duodenum, the wall of the colon itself exhibiting subperitoneal emphysema. The colon was freed and the rent sewn up with interrupted sutures. About ℥iv of foul fæcal fluid were evacuated from loin, and a free counter-opening made. The opening in the ilium by which the bullet had entered the abdomen was found at the brim of the pelvis; the loin and peritoneal cavity were sponged dry and flushed with boiled water; no lymph was seen on the small intestine. A large gauze plug was inserted into the posterior wound, one end of the plug being brought out of the operation incision.
During the succeeding six days progress was not unsatisfactory: the abdomen became soft, moved with respiration, there was no sickness, and the bowels acted. The pulse fell to 90, respirations to 20, and the temperature did not exceed 102° F. The wound suppurated freely, however, and although there were no further signs of peritoneal septicæmia, it was evident that general infection had taken place, and on the sixth day a parotid bubo developed on the right side, which was opened.
On the seventh day the patient suddenly commenced to fail rapidly; vomiting was almost continuous—at first curdled milk, later frothy watery fluid—and on the eighth day he died. Theabdomen remained soft, sunken, and flaccid, and death no doubt resulted from general septicæmia rather than from peritoneal infection, absorption taking place from the large foul cavity behind the colon. As the cavity in part surrounded the descending duodenum, this possibly accounted for the attack of vomiting which preceded death.
(181*)Ascending colon.—Wounded at Graspan while lying in prone position.Entry(Mauser), over ninth rib in line of right linea semilunaris;exit, in right buttock, just below and behind the top of the great trochanter.
The injury was followed by little abdominal pain, but a strange sensation of local gurgling was noted. The bowels acted as soon as the patient reached camp, some hours after being wounded. There was no sickness and nothing abnormal was noted in the motions, except that they were loose and light-coloured.
On the evening of the third day the patient came under observation in the ambulance train for Capetown. He looked somewhat anxious and ill, but he complained of little pain; the temperature was 102°, pulse 88, fair strength, soft and regular. There was local dulness, tenderness, and deficiency of movement in the right iliac region. As it was night, he was removed from the train and an operation was performed the next morning.
Prior to operation the condition was as follows: Pulse 84, temperature 100°; respiration easy, 20. Tongue moist, but thickly coated in centre. Abdomen moves fairly, and is resonant, except in right lower quadrant. No distension. Dulness, tenderness, and rigidity in right iliac region, marked to outer side of cæcum. Entry wound nearly and exit quite healed. Cannot flex right thigh. The following operation was performed. Appendix incision, about ℥j of fæcal fluid and fæces in a localised cavity on outer and anterior aspect of cæcum evacuated; adhesions very firm. Cavity sloughy throughout and cæcum covered with dull grey lymph. The opening in the bowel was not localised, and it was considered wiser to treat the case like one of perforation from appendicitis than to run the risk of breaking down adhesions. A small awl-like opening was found in the ilium with powdered bone at its entrance leading to the wound of exit.
The after-treatment of the case gave rise to no anxiety, but healing of the resulting sinus was slow; fæcal-smelling pus escaped for some days, and a number of small sloughs came away. On the twelfth day the patient was sent down to Wynberg, where he remained twelve weeks. A counter-incision was needed in theloin to drain the suppurating cavity three weeks after the primary operation, and five weeks after the operation an escape of gas and fæces took place from the anterior wound, while the bowels were acting, as a result of a dose of castor oil. No further escape of fæces occurred, and he left for England with a small sinus only. No extension of inflammation into the original wound track ever occurred, both openings and the canal healing by primary union.
The sinus remained open, and occasionally discharged for a further period of six months, and then healed firmly; since when the patient has been in perfect health.
(182*)Splenic flexure, descending colon.—Wounded at Magersfontein.Entry(Mauser), in sixth left intercostal space in mid-axillary line;exit, in left loin, below last rib, at outer margin of erector spinæ. The patient remained in the Field hospital three days, during which time he exhibited no serious abdominal symptoms, but during the journey to Orange River (53½ miles) he was sick. He remained at Orange River two days, and while there an enema was administered, producing a normal motion. The abdomen was slightly distended; it moved fairly, there was slight rigidity, but little tenderness. Temperature 100.8°, pulse 120. No appearance of fæces in wound.
When seen on the sixth day the condition was as follows:—Patient cheerful and not in great pain. Temperature 99.2°; pulse 120; respirations 48, very shallow. Abdomen soft, moving freely, no distension or general tenderness. Fluid fæces escaping in abundance from the wound in loin. Redness of skin and swelling below level of wound, and cellular emphysema above. Fæcal-smelling fluid was also escaping from the thoracic wound.
The wound was enlarged, but the patient rapidly sank, and died of septicæmia on the seventh day.
(183*) An exactly similar case came under observation from the battle of Modder River, except that the opening in the loin was somewhat larger, and earlier and freer escape of fæces took place from it. In this also fæcal matter passed freely into the left pleural cavity, and fæcal matter was expectorated, while there was an almost complete absence of abdominal symptoms. Death occurred on the fourth day.
Nopost-mortemexamination was made in either case, but I believe in both the extra-peritoneal aspect of the colon was implicated and that the septicæmia was in great part due to absorption from the pleural rather than the peritoneal cavity, since in neither case were the abdominal symptoms a prominent feature.
(184)Possible wound of cæcum.—Wounded at Spion Kop. Bullet (Mauser) perforated the right forearm, then entered belly.Entry, 3 inches from the right anterior superior iliac spine, in the line of the supra-pubic fold of the belly wall (a transverse slit);exit, in right buttock, on a level with the tip of the great trochanter and 2 inches within it. The wound was received immediately after breakfast had been eaten. There was retention of urine and constipation for three days, but no sickness. Local pain and tenderness were severe, and at the end of three weeks there was still local tenderness, slight induration, and dragging pain on defæcation. The patient returned to England at the end of a month well, except for slight local tenderness.
(185)Possible wound of colon.—Wounded at Paardeberg; range 200 yards. Walking at time. The bullet (Mauser) perforated the left forearm, just below the elbow-joint.Entry, into belly 1 inch anterior to the tip of the left eleventh costal cartilage; no exit.
The injury was followed by pain in the left half of the abdomen and vomiting, which continued for two days. The bowels acted on the third day; no nourishment was taken for two days, but a small quantity of water was allowed. No further symptoms were noted, and at the end of a fortnight the patient was well, except for slight local tenderness. The bullet could not be detected with the X-rays.
(186)Wound of cæcum.—Wounded at Paardeberg.Entry(Mauser), 2 inches diagonally above and within right anterior superior iliac spine;exit, immediately to the right of the fifth lumbar spinous process; the patient was lying on his left side when struck. A burning pain down the right thigh immediately followed the accident, and lasted some days. There was no sickness, the bowels were confined three days, and there was pain across the back and down the thigh.
On the tenth day he arrived at the Base, when he was lying on his back suffering considerable pain. The temperature ranged to 101°. There was diarrhœa and cystitis, with a considerable amount of pus in the urine, which was very offensive. A small fluctuating spot existed on the back, just to the right of the original exit wound which was firmly healed. The abdomen moved fairly with respiration in its upper part, but was motionless below, especially in the right iliac fossa; some induration was to be felt here. The right thigh was kept flexed.
During the next few days the pus disappeared from the urine,and with this change the induration in the right iliac fossa increased. An incision (Mr. Gairdner) was made into the fluctuating spot behind, and pus evacuated. The patient recovered.
(187)Possible wound of cæcum.—Wounded outside Heilbron.Entry(Mauser), in the right loin, 2½ inches above the iliac crest, at the margin of the erector spinæ;exit, 1½ inch above and within the right anterior superior spine of the ilium. There was little shock. The patient was brought six miles in a wagon into camp, and slept comfortably with a small morphia injection. Prior to the accident the patient was suffering from diarrhœa, but afterwards the bowels were confined. The next morning there had been no sickness and little pain. The tongue was moist and clean, the pulse 80, the respirations 24, the belly moved generally, although inspiration was shallow; the temperature was 99°. Slight tenderness in the belly to the inner side of the exit wound, but no dulness.
The patient was starved for the first thirty-six hours, a little warm water then being allowed. No symptoms developed, and a perfect recovery followed.
(188)Colon,liver.—Wounded outside Heilbron.Entry(Mauser), midway between the last right rib and the crista ilii;exit, below the eighth costal cartilage in nipple line. There were no serious primary symptoms, but ten days after the accident the temperature rose, swelling and pain developed in the right loin, and on the fourteenth day a large tympanitic abscess was opened (Dr. Flockemann, German Ambulance.) Fæcal-smelling gas and pus were evacuated. There was no extension of the abscess forwards. A week later the patient had much improved, although there were evident signs of general absorption, and the discharge from the abscess cavity was abundant and very foul. On the thirteenth day a serious hæmorrhage occurred from the loin wound, which was opened up, but no evident source was discovered; hæmorrhage was repeated the next day, and the man died.
At thepost-mortemexamination a large quantity of chocolate-coloured fluid was found free in the abdomen and pelvis. A chain of small local abscesses was found surrounding the ascending colon, and a larger one over the front of the cæcum. The wall of the ascending colon was generally thickened, and from this, in three places, openings with rounded margins connected the abscess cavities with the lumen of the bowel. One of the openings, larger than the others, was possibly theaperture of entry of the bullet; the others were apparently spontaneous.
At the anterior border of the right lobe of the liver an abscess cavity existed in connection with the wound of the liver, and this was continuous with the aperture of exit, although not discharging. The aperture of exit was plugged by a tag of omentum (see fig. 89). No obvious source of the hæmorrhage was forthcoming, but it probably originated in one of the large branches of the vena cava. The bullet had struck the transverse process of the lumbar vertebra, but had not given rise to any signs of spinal concussion.
(189*)Ascending colon.—Wounded at Modder River.Entry(Mauser), midway between the tip of the tenth right rib and the iliac crest. Bullet retained. A second wound existed over the centre of the left sterno-mastoid, and the bullet here was also retained and never localised. The patient stated that he brought up blood at short intervals for half an hour immediately after he was wounded. This might have been explained by the wound in the neck, but no difficulty in swallowing was noted. The bowels acted the day after he was shot, and, except for some local tenderness and immobility, no abdominal signs were noted. Three weeks later a swelling was obvious to the right side of the umbilicus, and a tympanitic abscess developed; this was opened, and a deformed Mauser bullet extracted. Foul pus, but no fæcal matter, was evacuated, and after discharging for a fortnight the wound closed, and the man was sent home as 'well.' In this case I assumed a wound of the ascending colon had occurred.
(190*)Rectum and bladder.—Wounded at Graspan, while retiring at the double.Entry(Mauser), 1 inch to the right of the coccyx;exit, 1 inch above the junction of the middle and outer thirds of left Poupart's ligament. The man suffered with some pain in the abdomen, and for first two days with retention of urine. The urine was drawn off with the catheter, and contained blood. During the next five days micturition was hourly or more frequent; gas was passedper urethram, and the urine was very foul, containing evident fæcal matter. Micturition continued frequent, with purulent cystitis for one month. Local tenderness, pain, and immobility developed over the lower quarter of the abdomen, extending to the right iliac fossa. A local abscess pointed a little to the right of the mid line, and 2 inches above the symphysis, and from this foul-smelling pus, but no fæces, was discharged for three months, during which period the surrounding dulness andinduration gradually decreased and the sinus healed. When the patient left for England there was still occasional slight discharge from the original wound of entry, and there was slight discomfort on micturition, but he was otherwise well.
A year later the man had resumed active duty, and, except for occasional pain on stooping, considered himself well.
The following cases are appended as of some general interest. The first two (191, 192) illustrate extra-peritoneal injuries to the rectum. In neither did positive evidence exist of wound of the bowel, but the symptoms in each rendered this accident probable. Case 193 is an illustration of apparent escape of the anal canal in a wound in which from the position of the external apertures this escape would have appeared impossible.
Wounds of the extra-peritoneal portion of the rectum, as a rule, appeared to have a somewhat better prognosis than would have been expected; in any case, the prognosis was far better than that obtaining in wounds of the base of the urinary bladder. My experience on the subject of these wounds was, however, limited to the two cases quoted.
Case 194 is inserted as an example of the complicated nature of the abdominal injuries not so very unfrequently met with. It illustrates well the difficulty which may arise at any stage in the course of treatment of an injury, in the certain determination or exclusion of wound of a part of the alimentary canal.
(191) Wounded at Magersfontein.Entry(Mauser), in the right loin, immediately below the ribs in the mid-axillary line;exit, about the centre of the left buttock, on a level with the tip of the great trochanter. A second lacerated shell wound of back was present. All the wounds suppurated. For the first sixteen days following the injury all control was lost over the anal sphincter, and bloody fæces, and later slime, constantly escaped, but no fæcal matter ever escaped from the wound in the buttock. There was no history of previous dysentery, and rectal examination afforded no information. The buttock wound had to be opened up, disclosing a tunnel in the ilium.The wounds granulated slowly with continuous suppuration, but were healed, and the patient returned home at the end of fourteen weeks, the bowels acting normally.(192) Wounded at Paardeberg.Entry(Mauser), at the junction of the middle and posterior thirds of the left iliac crest; the bullet was retained, and removed (Mr. Pegg) from the back of the right thigh, 3 inches below the back of the great trochanter. After the injury retention of urine followed, with incapacity to control loose motions, though solid ones could be retained. The retention was treated by catheterisation, which was followed by cystitis. The power of micturition was slowly recovered, and three weeks later he could pass water, at times in a dribbling stream only; the cystitis had improved. The man returned to England very much improved, but not quite well, at the end of five weeks.(193) Wounded at Modder River.Entry, in the right buttock, near the outer border at the upper part;exit, at the lower part of outer border of left buttock. The line of the wound exactly crossed the position of the anus, but no sign of injury to the rectum could be discovered.(194) Wounded at Magersfontein.Entry(Mauser), 1/2 inch below the margin of the iliac crest, at the junction of its middle and posterior thirds, and on a level with the fifth lumbar spinous process;exit, below the cartilage of the eighth rib, just within the left nipple line. Struck while retiring; fell at once, and remained thirty hours on the field. Patient stated that he vomited 'blood like coffee grounds' six times while lying on the field, and twice after being brought in. His bowels were confined for three days. His right lower extremity was paralysed.On the fifth day there was considerable induration around the wound of exit, and the upper half of the abdomen was immobile and tender. The temperature rose to 100°, and the pulse was 96. Shortly afterwards a similar condition was noted in the lower half of the abdomen; the temperature continued to be raised and the pulse quickened, when on the thirteenth day a considerable quantity of pus was passed per rectum, and diarrhœa set in; this continued for three days, with marked improvement in the general symptoms. Micturition, which had been painful, became normal; the pulse and temperature fell, and the expression became less anxious. The patient continued to sleep badly, however, and complained of pain.At the end of the third week he still looked ill, but was easier. Temperature normal in the morning, 100° in evening, pulse 80. Tongue thickly furred, but moist. Still on milk diet; appetite bad; bowels irregular.The abdomen moved little in the lower half, induration persisted in the left iliac fossa, the left thigh continued flexed, and resonance was impaired to the left of the umbilicus.At the end of six weeks a distinct hard swelling in two parts, separated by a resonant area, was noted to the left of the umbilicus and in the left iliac fossa. The abdomen moved fairly, and there was little tenderness over the swelling. During the next week the swelling appeared to increase and to fluctuate; at the same time the temperature again began to rise to 100° and 101° at eve. The swelling was taken to be a localised peritoneal suppuration, and an incision was made over it; but this led down to a free peritoneal cavity, with a tumour pressing up from the posterior abdominal wall. The wound was therefore closed, and a fresh extra-peritoneal incision made, immediately above Poupart's ligament, when the swelling proved to be a large retro-peritoneal hæmatoma. As the cavity extended into the pelvis and up to the level of the costal margin, it was deemed wise only to evacuate a part of the blood-clot. The origin of the bleeding was not determined, and the wound was closed and healed by first intention. The man continued to improve, and left for home five weeks later.This patient has continued to improve since his return, but the left thigh is still somewhat flexed.
(191) Wounded at Magersfontein.Entry(Mauser), in the right loin, immediately below the ribs in the mid-axillary line;exit, about the centre of the left buttock, on a level with the tip of the great trochanter. A second lacerated shell wound of back was present. All the wounds suppurated. For the first sixteen days following the injury all control was lost over the anal sphincter, and bloody fæces, and later slime, constantly escaped, but no fæcal matter ever escaped from the wound in the buttock. There was no history of previous dysentery, and rectal examination afforded no information. The buttock wound had to be opened up, disclosing a tunnel in the ilium.
The wounds granulated slowly with continuous suppuration, but were healed, and the patient returned home at the end of fourteen weeks, the bowels acting normally.
(192) Wounded at Paardeberg.Entry(Mauser), at the junction of the middle and posterior thirds of the left iliac crest; the bullet was retained, and removed (Mr. Pegg) from the back of the right thigh, 3 inches below the back of the great trochanter. After the injury retention of urine followed, with incapacity to control loose motions, though solid ones could be retained. The retention was treated by catheterisation, which was followed by cystitis. The power of micturition was slowly recovered, and three weeks later he could pass water, at times in a dribbling stream only; the cystitis had improved. The man returned to England very much improved, but not quite well, at the end of five weeks.
(193) Wounded at Modder River.Entry, in the right buttock, near the outer border at the upper part;exit, at the lower part of outer border of left buttock. The line of the wound exactly crossed the position of the anus, but no sign of injury to the rectum could be discovered.
(194) Wounded at Magersfontein.Entry(Mauser), 1/2 inch below the margin of the iliac crest, at the junction of its middle and posterior thirds, and on a level with the fifth lumbar spinous process;exit, below the cartilage of the eighth rib, just within the left nipple line. Struck while retiring; fell at once, and remained thirty hours on the field. Patient stated that he vomited 'blood like coffee grounds' six times while lying on the field, and twice after being brought in. His bowels were confined for three days. His right lower extremity was paralysed.
On the fifth day there was considerable induration around the wound of exit, and the upper half of the abdomen was immobile and tender. The temperature rose to 100°, and the pulse was 96. Shortly afterwards a similar condition was noted in the lower half of the abdomen; the temperature continued to be raised and the pulse quickened, when on the thirteenth day a considerable quantity of pus was passed per rectum, and diarrhœa set in; this continued for three days, with marked improvement in the general symptoms. Micturition, which had been painful, became normal; the pulse and temperature fell, and the expression became less anxious. The patient continued to sleep badly, however, and complained of pain.
At the end of the third week he still looked ill, but was easier. Temperature normal in the morning, 100° in evening, pulse 80. Tongue thickly furred, but moist. Still on milk diet; appetite bad; bowels irregular.
The abdomen moved little in the lower half, induration persisted in the left iliac fossa, the left thigh continued flexed, and resonance was impaired to the left of the umbilicus.
At the end of six weeks a distinct hard swelling in two parts, separated by a resonant area, was noted to the left of the umbilicus and in the left iliac fossa. The abdomen moved fairly, and there was little tenderness over the swelling. During the next week the swelling appeared to increase and to fluctuate; at the same time the temperature again began to rise to 100° and 101° at eve. The swelling was taken to be a localised peritoneal suppuration, and an incision was made over it; but this led down to a free peritoneal cavity, with a tumour pressing up from the posterior abdominal wall. The wound was therefore closed, and a fresh extra-peritoneal incision made, immediately above Poupart's ligament, when the swelling proved to be a large retro-peritoneal hæmatoma. As the cavity extended into the pelvis and up to the level of the costal margin, it was deemed wise only to evacuate a part of the blood-clot. The origin of the bleeding was not determined, and the wound was closed and healed by first intention. The man continued to improve, and left for home five weeks later.
This patient has continued to improve since his return, but the left thigh is still somewhat flexed.
Prognosis in intestinal injuries.—This was of a most discouraging character compared with the prognosis in abdominal injuries as a whole. The cases were of two classes, however: those that died within twenty-four hours, and those that died at the end of from three days to a week.
Cases falling into the first category are obviously of little importance from the point of view of surgical treatment. Many of them died from the widespread nature of the injury, and the shock produced by it; others from hæmorrhage from the large abdominal vessels. It is unlikely that any could have been saved, even under the most satisfactory conditions.
In the following small table, therefore, I have included only the cases which have been already quoted, which survived long enough to be amenable to surgical treatment, and which were for some days under my own observation. Some of them, in fact almost all, I watched until they were either convalescent, or died, and in six I performed operations.
I am aware, and have short details of the histories of eight patients wounded in the same battles who died prior to the termination of the first thirty-six hours; but these are not included, for the reason stated above, and also because I am uncertain whether all the injuries were produced by bullets of small calibre.
Viscous woundedNumber of casesLocalised Secondary suppuration occurredRecoveredDiedStomach certain2—11Stomach possible1—1—Small intestine certain50—5Small intestine possible10010—Large intestine certain84[21]44Large intestine possible4—4—Bladder certain3312Bladder possible1—1—Liver6—6—Kidneys6—42Spleen3—21Total49[22]—3415
Included in the above table are thirty instances of intestinal injury, and these are divided up according to the segment of the intestinal canal implicated, and also as to whether the perforation was certain, or only assumed from the position of the external apertures and the presence of abdominal symptoms of a noticeable grade.
From this analysis it appears clear—
1. That wounds of the stomach have a comparatively good prognosis, and that they may recover spontaneously. It is true that only two examples are included in my table; but I was at various times shown patients with similar injuries and histories, and a number of cases which have been published appear to substantiate the opinion. From our experience of the occasional spontaneous recovery of gastric perforations from disease, I think we might be prepared to expect that the stomach would offer a comparatively favourableseat for these wounds. It may be pointed out, however, that hæmatemesis, the main feature in the symptoms pointing to wound, is by no means direct proof of more than contusion.
2. That perforating wounds of the small intestine are very fatal injuries; every patient in whom the condition wascertainlydiagnosed died.
3. That in the cases in which a perforation was inferred from the position of the external apertures and the symptoms, not one patient suffered from the secondary complications—e.g.local peritonitis and suppuration, which were common in the case of the large intestine, and which we are accustomed to see after perforation from disease. This renders the occurrence of actual perforation in the majority of the cases a matter of very grave doubt.
If spontaneous recovery does take place after this injury, it is only in cases in which the wounds are single, and slight in character.
4. That in eight cases in which perforation of the large intestine was certain, four recoveries took place; but in each instance suppuration occurred. I am, however, quite prepared to believe that perforation may have occurred in some or all of the other four cases included as 'possible,' provided the wounds were intra-peritoneal.
Wounds of the cæcum and ascending colon are those which have the best prognosis, and after these of the rectum. The comparatively good prognosis in these parts is what would be expected, on account of their greater fixity, and lesser tendency to be covered by the small intestine.
An extra-peritoneal wound of any of these portions of the bowel is more dangerous than an intra-peritoneal, and more likely to give rise to septicæmia.
Of the cases included in my table eighteen of the possible intestinal injuries were observed among the wounded of the four battles of the Kimberley relief force. These cases I saw early and followed to their termination, and I believe the list contains the great majority of all the patients who received intestinal wounds in those battles. On inquiry I could not learn of others from the officers of the Field hospitals; but no doubtsome patients died before their reception into hospital, and some may have been overlooked; again, I know of two cases in which death took place within the first week, but which went direct to the Base and did not come under my observation. These exceptions being made, we have a fairly complete series, from which some deductions may be drawn. The cases included are marked with an asterisk.
Of the eighteen cases, eight or44.4per cent. died. These were made up as follows:—Stomach, one case; this patient died at the end of fourteen days, as a result of secondary hæmorrhage and septicæmia. It was complicated by a severe wound of the liver and also one of the lung.
Small intestine, four certain cases; all died, two after operation in the stage of septicæmia, and one after operation from recurrent hæmorrhage, possibly from the mesentery. Of the other six cases one can only say that the position of the wounds was such as to render wound of the intestine possible, and that all suffered with abdominal symptoms of some severity.
Large intestine. Of six cases in which wound was certain, three died, one after operation. One recovered after operation, two recovered with local peritoneal suppuration. In one case the injury could only be returned as possible.
In connection with this subject I have received permission from Mr. Watson Cheyne to quote the statistics published by him[23]concerning the abdominal wounds observed after the fighting at Karree Siding, on March 29, which are as follows:—