of the spine or the lung substance, no interference is advisable. When,
on the other hand, the bullet as viewed by the X-rays is seen to be in
the pleural cavity, and any symptoms of its presence exist, it may be
justifiable to remove it. I saw this done in one case for the removal of
a shrapnel bullet from the lower reflexion of the pleura on account of
fixed pain and tenderness complained of by the patient. The bullet, a
shrapnel, had perforated the arm, which the patient was sure was by his
side at the moment of injury, and the X-rays showed it to lie at the
bottom of the pleural cavity, where we assumed it had fallen. When,
however, the bullet was removed by Mr. Watson, he found that the fixed
pain and tenderness had been the result of a fracture of a rib from the
inner side, not involving loss of continuity; hence the actual
indication for the operation had been a delusive one, since the bullet
had not fallen, but expended its last force in injuring the rib. The
patient made an excellent recovery, and rejoined his regiment at the end
of six weeks. I saw several cases in which the bullet was lodged in
either the lung or bones of the spine do well with no interference. The
great disadvantage of primary removal in inducing an artificial
pneumo-thorax and in laying open a hæmothorax is obvious.
In case of lodgment of the bullet in the lung, bearing in mind the
infrequency of untoward symptoms, the latter should be watched for prior
to interference.
The following cases illustrate some typical instances of wound of chest
accompanied by the development of hæmothorax:--
[Illustration: TEMPERATURE CHART 3.--Primary Hæmothorax, with rise of
temperature. Secondary rise, with fresh effusion and pneumonia.
Spontaneous recovery. Case No. 154]
(154) _Severe hæmothorax. Spontaneous recovery._--Wounded at
Modder River at a distance of 30 yards. _Entry_, at the
junction of the left anterior axillary fold with the
chest-wall; _exit_, immediately to the left of the seventh
dorsal spinous process. The patient arrived at the Base with
signs of an extensive hæmothorax, accompanied by a temperature
which reached 102° on the fourth day, and on the evening of the
tenth 103°. The man was very ill, and an exploring needle was
inserted, by which about an ounce of blood was evacuated. The
signs of fluid in the left pleura were accompanied by those of
consolidation over the lower fourth of the right lung, and the
sputa were rusty. Evidence of perforation of the left axillary
artery existed in feebleness of the radial pulse; and there was
musculo-spiral paralysis.
After the preliminary puncture, the man refused any further
operative treatment, although a second rise of temperature
commenced on the fifteenth day, culminating in a temperature of
103.2° on the eighteenth. The further treatment of the patient
consisted in the ensurance of rest and the alleviation of pain.
A steady fall in the temperature extended over another three
weeks, together with diminution in the signs of fluid in the
pleura. At the end of seventy-four days the man was sent home,
some slight dulness at the left base, and contraction of the
chest sufficient to influence the spine in the way of lateral
curvature, being the only remaining signs.
[Illustration: TEMPERATURE CHART 4.--Primary Hæmothorax. Secondary rise
of temperature, with increase in the effusion. Spontaneous recovery.
Case No. 155]
(155) _Severe hæmothorax. Secondary effusion. Spontaneous
recovery._--Wounded at Koodoosberg Drift, at a distance of 200
yards. _Entry_, at angle of the right scapula; _exit_, at the
junction of the left anterior axillary fold with the
chest-wall. No signs of spinal cord injury. The patient was
brought in from the field twelve miles by an ambulance wagon on
the second day, and in crossing the Modder River he was
accidentally upset into the stream. For the first four days
there was no hæmoptysis, but for the succeeding nine days small
brightish red clots were expectorated. There was some
tenderness over the ribs from the fifth to the ninth in the
axillary line, and on the ninth day some gravitation ecchymosis
appeared over the same region. Cough was an early troublesome
symptom in this case, and when admitted to the Base hospital,
about the seventh day, there was evidence of fluid extending
about a third of the way up the back.
On the tenth day after admission a pleural rub was detected at
the upper margin of the dulness, and the latter shortly
extended upwards over a little more than half the back.
Meanwhile, there was no further hæmoptysis, respiration was
fairly easy, 24 per minute, but accompanied by slight
dilatation of the alæ nasi, and the temperature, which had been
ranging from 99° to 100°, began to rise steadily, on the
fifteenth day reaching 102.5°. The patient refused even an
exploratory puncture, and was treated on the expectant plan.
The temperature slowly subsided, with a steady improvement in
the physical signs, and at the end of about ten weeks he left
for home with only slight dulness and incapacity for active
exertion remaining. (Now again on active service.)
[Illustration: TEMPERATURE CHART 5.--Hæmothorax, primary and secondary
rises of temperature, on each occasion falling on the evacuation of the
blood. Case No. 156]
(156) _Severe hæmothorax. Recurrent secondary effusion. Tapping
on two occasions. Cure._--The patient was wounded at
Paardeberg, and arrived at the Base on the eighteenth day.
_Entry_, below the first rib, just external to its junction
with the costal cartilage; _exit_, through the ninth rib, just
within the posterior axillary line. The whole right side of the
chest was dull, with signs of the presence of fluid, the heart
being displaced to the left. There was considerable distress;
the respirations averaged 40, the pulse 100, and the
temperature reached 101.5° the first evening after arrival.
On the nineteenth day the thorax was aspirated (Mr. Hanwell)
and 50 ounces of dirty red-coloured fluid, half clot, half
serum, were evacuated. Considerable relief was afforded; the
respirations became slightly less frequent; the heart returned
to a normal position, and distant tubular respiration was
audible. The temperature dropped to normal the third day after
evacuation of the fluid, but on the sixth day it again
commenced to rise, and meanwhile fluid again began to collect.
On the twenty-sixth day a second aspiration resulted in the
evacuation of 35 ounces of bloody fluid in which flakes of
lymph were found. Three days later the temperature became
normal. The respirations fell to 22, and the patient made an
uninterrupted recovery.
[Illustration: TEMPERATURE CHART 6.--Wound of Lung. Secondary
development of Hæmothorax, with rise of temperature. Spontaneous
recovery. Case No 157]
(157) _Moderate hæmothorax. Secondary effusion at the end of
twenty days. Spontaneous recovery._--Wounded at Paardeberg;
range from 700 to 1,000 yards. _Entry_, in the centre of the
second right intercostal space, anteriorly; _exit_, at the
level of the sixth rib posteriorly, through the scapula, close
to its vertebral margin.
The patient arrived at the Base on the sixth day; he said he
expectorated some blood at the end of about ten minutes after
being shot, and experienced a 'half-choking sensation.' A small
quantity of phlegm and occasional clots had been expectorated
since. He had walked about a good deal; movement occasioned
cough, and he became 'blown' very rapidly.
On admission there were signs of fluid in the lower third of
the pleural cavity, but no general symptoms beyond an evening
rise of temperature to an average of 99°. About the twentieth
day the temperature commenced to rise, and on the twenty-third
and four following evenings reached 102°. The fever was
accompanied by some distress, and a well-marked increase in the
physical signs of the presence of fluid in the chest. The pulse
rose to 96, and the respirations considerably above the average
of 24, which was at first noted. A strictly expectant attitude
was maintained, and the temperature steadily fell in a curve
corresponding to the rise, gradually reaching the normal at the
end of a week. The physical signs at the base steadily cleared
up, and at the end of six weeks the patient returned to England
convalescent.
CHAPTER XI
INJURIES TO THE ABDOMEN
Perhaps no chapter of military surgery was looked forward to with more
eager interest than that dealing with wounds of the abdomen. In none was
greater expectation indulged in with regard to probable advance in
active surgical treatment, and in none did greater disappointment lie in
store for us.
Wounds of the solid viscera, it is true, proved to be of minor
importance when produced by bullets of small calibre; but wounds of the
intestinal tract, although they showed themselves capable of spontaneous
recovery in a certain proportion of the cases observed, afforded but
slight opportunity for surgical skill, and results generally deviated
but slightly from those of past experience. Such success as was met with
depended rather on the mechanical genesis and nature of the wounds than
upon the efforts of the surgeon, and operative surgery scored but few
successes.
It is true that to the Civil Surgeon accustomed to surroundings replete
with every modern appliance and convenience, and the possibility of
exercising the most stringent precautions against the introduction of
sepsis from without, abdominal operations presented difficulties only
faintly appreciated in advance; but this alone scarcely accounted for
the want of success attending the active treatment of wounds of the
intestine when occasion demanded. Failure was rather to be referred to
the severity of the local injury to be dealt with, or to the operations
being necessarily undertaken at too late a date. Many fatalities, again,
were due to the association of other injuries, a large proportion of the
wound tracks involving other organs or parts beyond the boundaries of
the abdominal cavity.
The frequent association of wounds of the thoracic cavity with those of
the abdomen afforded many of the most striking examples of immunity from
serious consequences as a result of wound of the pleura. It must be
conceded that in a large number of such injuries only the extreme limits
of the pleural sac were encroached upon, yet in some the tracks passed
through the lungs, although without serious consequences. Under the
heading of injury to the large intestine a somewhat special form of
pleural septicæmia will be referred to.
It may at once be stated that such favourable results as occurred in
abdominal injuries were practically limited to wounds caused by bullets
of small calibre, and that, although in the short chapter dealing with
shell injuries a few recoveries from visceral wounds will be mentioned,
I never met with a penetrating visceral injury from a Martini-Henry or
large sporting bullet which did not prove fatal.
_Wounds of the abdominal wall._--It is somewhat paradoxical to say that
these injuries possessed special interest from their comparative rarity
of occurrence, since they were not of intrinsic importance. Their
infrequency depended on the difficulty of striking the body in such a
plane as to implicate the belly wall alone, and their interest in the
diagnostic difficulty which they gave rise to.
In many cases the position of the openings and the strongly oval or
gutter character possessed by them were sufficient proof of the
superficial passage of the bullet; in others we had to bear in mind that
the position of the patient when struck was rarely that of rest in the
supine position, in which the surgical examination was made, and
considerable difficulty arose. Some superficial tracks crossing the
belly wall have already been referred to in the chapter on wounds in
general and in that dealing with injuries to the chest, in which the
above characters sufficed to indicate that penetration of the abdominal
cavity had not occurred. In other instances a definite subcutaneous
gutter could be traced, and often in these a well-marked cord in the
abdominal wall corresponding to the track could be felt at a later date.
Again, limitation to the abdominal wall was sometimes proved by the
position of the retained bullet, or sometimes by the presence in the
track of foreign bodies carried in with the projectile. See case 160.
Fig. 84 illustrates an example where the limitation to the abdominal
wall was evident on inspection. Here the division of the thick muscles
of the abdominal wall had led to the formation of a swelling exactly
similar to that seen after the subcutaneous rupture of a muscle, and two
soft fluctuating tumours bounded by contracted muscle existed in the
substance of the oblique and rectus muscles.
[Illustration: FIG. 84.--Wound of Abdominal Wall (Lee-Metford). Division
of fibres of external oblique and rectus abdominis muscles. Case 159]
The cases which presented the most serious diagnostic difficulty in this
relation were those in which the wound was situated in the thicker
muscular portions of the lower part of the abdominal and pelvic walls.
Such a case is illustrated in the chapter on fractures (see fig. 55, p.
191). I saw one or two such instances, in which only the exploration
necessary for treatment of the fracture decided the point. In many of
the wounds affecting the lateral portion of the abdominal wall the
question of penetration could never be definitely cleared up, as wounds
of the colon sometimes gave rise to absolutely no symptoms.
In a certain proportion of the injuries the peritoneal cavity was no
doubt perforated without the infliction of any further visceral injury,
and in these also the doubt as to the occurrence of penetration was
never solved.
(158) _Wound of belly wall._--Wounded at Modder River. _Entry_
(Mauser), 2 inches below the centre of the left iliac crest;
_exit_, 1-1/2 inch above and internal to the left anterior
superior iliac spine. The patient was on horseback at the time
of the injury and did not fall; he got down, however, and lay
on the field an hour, whence he was removed to hospital.
Probably the track pierced the ilium, and remained confined to
the abdominal wall. There were no signs of visceral injury.
(159) Cape Boy. Wounded at Modder River. _Entry_ (Lee-Metford),
immediately above and outside right anterior superior spine;
_exit_, 1-1/2 inch below and to right of umbilicus. A
well-marked swelling corresponded with division of the fibres
of the oblique muscles and of the rectus, and on palpation a
hollow corresponding with the track was felt. The abdominal
muscles were exceptionally well developed (fig. 84).
(160) Wounded at Magersfontein while lying prone. _Entry_,
irregular, oblique, and somewhat contused, over the eighth left
rib, in the anterior axillary line; _exit_, a slit wound
immediately above and to the left of the umbilicus. The bullet
struck a small circular metal looking-glass before entering,
hence the irregularity of the wound. The patient developed a
hæmothorax, but no abdominal signs; the former was probably
parietal in origin, secondary to the fractured rib, and the
whole wound non-penetrating as far as the abdominal cavity was
concerned.
(161) Wounded at Magersfontein. _Entry_ (Mauser), 1-1/2 inch
external to and 1/2 inch below the left posterior superior
iliac spine; _exit_, 1 inch internal horizontally to the left
anterior superior spine.
No signs of intra-peritoneal injury were noted, but free
suppuration occurred in left loin; the ilium was tunnelled.
The same patient was wounded by a Jeffrey bullet in the hand;
the third metacarpal was pulverised, although the bullet, which
was longitudinally flanged, was retained.
(162) Wounded outside Heilbron. _Entry_, below the eighth right
costal cartilage; _exit_, below the eighth cartilage of the
left side. The wound of entry was slightly oval; that of exit
continued out as a 'flame'-like groove for 2 inches. A week
later the wound track could be palpated as an evident hard
continuous cord.
_Penetration of the intestinal area without definite evidence of
visceral injury._--This accident occurred with a sufficient degree of
frequency to obtain the greatest importance, both from the point of view
of diagnosis and prognosis, and as affecting the question of operative
interference. Amongst the cases reported below a number occurred in
which it was impossible to settle the question whether injury to the
bowel had occurred or not, and I will here shortly give what explanation
I can for the apparent escape of the intestine from serious injury.
We may first recall the general question of the escape of structures
lying to one or other side of the track of the bullet. I believe that
there can be no doubt as to the accuracy of the remarks already made as
to the escape of such structures as the nerves by means of displacement,
and that the occurrence of such escapes is manifestly dependent on the
degree of fixity of the nerve or the special segment of it implicated.
The general tendency of the tissues around the tracks to escape
extensive destruction from actual contusion has also been referred to,
and is, I think, indisputable.
If these observations be accepted, I think there can be no difficulty in
allowing that the small intestine is exceptionally well arranged to
escape injury. First of all, it is very moveable; secondly, it is so
arranged that in certain directions a bullet may pass almost parallel to
the long axis of the coils; thirdly, it is elastic, capable of
compression, and light, and hence offers but a small degree of
resistance to the passage of the bullet across the abdominal cavity.
Certain evidence both clinical and pathological supports the contention
that the small intestine may escape injury from the passing bullet.
First of all, the fact may be broadly stated that injuries to the small
intestine were fatal in the great majority of certainly diagnosed cases,
while, on the other hand, many tracks crossed the area occupied by the
small intestine without serious symptoms of any kind resulting.
Secondly, experience showed that when the bullet crossed the line of the
fixed portions of the large intestine the gut rarely escaped, and that,
although a considerable proportion of these cases recovered
spontaneously, in a large number of them immediate symptoms, or
secondary complications, clearly substantiated the nature of the
original injury. As far as my experience went, however, I never saw any
instance in which an undoubted injury of the small intestine was
followed by the development of a local peritoneal suppuration and
recovery, a sequence by no means uncommon in the case of wounds of the
large intestine. Although, therefore, I am not prepared to deny the
possibility of spontaneous recovery from an injury to the small
intestine, under certain conditions which will be stated later, I
believe that in the immense majority of cases in which a bullet crossed
the small intestine area without the supervention of serious symptoms,
the small intestine escaped perforating injury.
Beyond the clinical evidence offered above, certain pathological
observations support the view that the intestine escapes perforation by
displacement. Most of my knowledge on this subject was derived from the
limited number of abdominal sections I performed on cases of injury to
the small intestine, and may be summed up as follows.
The small intestine may present evidence of lateral contusion in the
shape of elongated ecchymoses, either parallel, oblique, or transverse
to its long axis. These ecchymoses resemble in extent and outline those
which ordinarily surround a wound of the intestinal wall produced by a
bullet (see fig. 87, p. 418).
The wall of the small intestine may be wounded to an extent short of
perforation, either the peritoneal coat alone being split, or the wound
implicating the muscular coat and producing an appearance similar to
that seen when the intestine is dragged upon during an operation, but
without so much gaping of the edges (see fig. 85, p. 416).
I met with these conditions in association with co-existing complete
perforations of the small intestine, and in one case of intra-peritoneal
hæmorrhage in which no complete perforation was discoverable (No. 169,
p. 432).
The implication and perforation of the small intestine are to some
extent influenced by the direction of the wound. A striking case is
included below, No. 201, in which a bullet passed from the loin to the
iliac fossa on each side of the body, approximately parallel to the
course of the inner margin of the colon, and I also saw some other
wounds in this direction in which no evidence of injury to the small
intestine was detected, and which got well. Again wounds from flank to
flank were, as a rule, very fatal; but I saw more than one instance
where these wounds were situated immediately below the crest of the
ilium, in which the intestine escaped injury (see case 171). A very
striking observation was made by Mr. Cheatle in such a wound. The
patient died as a result of a double perforation of both cæcum and
sigmoid flexure; none the less the bullet had crossed the small
intestine area without inflicting any injury.
The sum of my experience, in fact, was to encourage the belief that,
unless the intestine was struck in such a direction as to render lateral
displacement an impossibility, the gut often escaped perforation.
As a rule, the wounds of the abdomen which from their position proved
the most dangerous to the intestine were--
1. Wounds passing from one flank to the other were very dangerous, as
crossing complicated coils of the small intestine, and two fixed
portions of the colon. This danger was most marked when the wounds were
situated between the eighth rib in the mid axillary line and the crest
of the ilium; above this level the liver, or possibly liver and stomach,
were sometimes alone implicated, and the cases did well. Again, when the
wounds crossed the false pelvis the patients sometimes escaped all
injury to viscera.
2. Antero-posterior wounds in the small intestine area were very fatal
if the course was direct; in such the small intestine seldom escaped
injury.
3. Wounds with a certain degree of obliquity from anterior wall to
flank, or from flank to loin, were on the other hand comparatively
favourable, as the small intestine often escaped, and if any gut was
wounded, it was often the colon.
4. Vertical wounds implicating the chest and abdomen, or the abdomen and
pelvis, were on the whole not very unfavourable. For instance, when the
bullet entered by the buttock and emerged below the umbilicus, a number
of patients escaped fatal injury; this depended on the comparatively
good prognosis in wounds of the rectum and bladder. A good many
patients in whom the bullet entered by the upper part of the loin, and
escaped 1-1/2 inch within the anterior superior spine of the ilium, also
did well. The same holds good when the wounds either entered or emerged
under the anterior costal margin of the thorax, either prior to or after
traversing the thorax.
Wounds passing directly backward from the iliac regions were in my
experience very unfavourable; but I believe mainly as a result of
hæmorrhage from the iliac arteries.
_The occurrence of wounds of the abdomen of an 'explosive'
character._--The vast majority of the abdominal wounds observed in the
Stationary or Base hospitals were of the type dimensions. A certain
number of the abdominal injuries which proved fatal on the field or
shortly afterwards were described as explosive in character, and were
referred by the observers to the employment of expanding bullets.
A few words on this subject seem necessary, because it seems doubtful
whether such injuries could be produced by any of the forms of expanding
bullet of small calibre in use, unless the track crossed one of the
bones in the abdominal or pelvic wall. That this was sometimes the case
there is no doubt: thus I saw two cases in which the splenic flexure of
the colon was wounded, in which the external opening was large, and a
comminuted fracture of the ribs of the left side existed. One can well
believe that bullets passing through the pelvic bones might 'set up' to
a considerable extent, and although I never happened to see such a case,
an explanation of some of the wounds described by others might be found
in this occurrence.
In instances in which the soft parts alone were perforated, I am
disinclined to believe that bullets of small calibre, either regulation
or soft-nosed, were responsible for the injuries. I had the opportunity
of examining two Mauser bullets of the Jeffreys variety which crossed
the abdomen and caused death. In the first (figured on page 94, fig. 40)
very little alteration beyond slight shortening had occurred. In the
second the deformity was almost the same, except that the side of the
bullet was indented, probably from impact with some object prior to its
entry into the body. In each case the bullet was of course travelling at
a low rate of velocity; hence no very strong inference can be drawn
from either. In the case of the second specimen, which was removed by
Mr. Cheatle, a remarkable observation was made, which tends to throw
some light on one possible mode of production of large exit apertures.
This bullet crossed the cæcum, making two small type openings; but
later, when it crossed the sigmoid flexure, it tore two large irregular
openings in the gut. This might be explained on the ground that the
velocity was so small as only just to allow of perforation, which
therefore took the nature of a tear. I am inclined to suggest, as a more
likely explanation, that the spent bullet turned head over heels in its
course across the abdomen, and made lateral or irregular impact with the
last piece of bowel it touched. A slightly greater degree of force would
have allowed a similar large and irregular opening to be made in the
abdominal wall also.
In this relation the question will naturally be raised as to how far the
explosive appearances may have been due to high velocity alone on the
part of the bullet. I am disinclined from my general experience to
believe that explosive injuries of the soft parts were to be thus
explained. On the other hand, I believe that the possession of a low
degree of velocity very greatly increased the danger in abdominal
wounds. I believe that the bowel was, under these circumstances, less
likely to escape by displacement, and was more widely torn when wounded;
again, that inexact impact led to increase of size in the external
apertures, and the bullet was of course more often retained.
Mr. Watson Cheyne[19] published a very remarkable instance of one of the
dangers of an injury from a spent bullet, in which, in spite of
non-penetration of the abdominal cavity, the small intestine was
ruptured in two places.
I believe the majority of the wounds designated as explosive were the
result of the passage of large leaden bullets, either of the
Martini-Henry or Express type. The small opportunity of observing such
injuries in the hospitals of course depended on the fact that the
majority were rapidly fatal.
_Nature of the anatomical lesion in wounds of the intestine._--The
openings in the parietal peritoneum tended to assume the slit or star
forms, probably on account of the elasticity of the membrane. A diagram
of one of these forms is appended to fig. 89. In this instance the
opening in the peritoneum was made from the abdominal aspect, prior to
the escape of the bullet from the cavity, and on the impact of the tip,
the long axis of the bullet was oblique to the surface of the abdominal
wall.
In the intestinal wall the openings varied in character according to the
mode of impact.
In some cases the gut was merely contused by lateral contact of the
passing bullet. The result of this was evidenced later by the presence
of localised oval patches of ecchymosis. These were identical in
appearance with the patches shown surrounding the wounds in fig. 87.
[Illustration: FIG. 85.--Lateral Slit in Small Intestine produced by
passage of bullet. Slit somewhat obscured by deposition of inflammatory
lymph. (St. Thomas's Hospital Museum)]
More forcible lateral impact produced a split of the peritoneum, or of
this together with the muscular coat. Such a lateral slit is shown in
fig. 85, although the clearness of outline is somewhat impaired by the
presence of a considerable amount of inflammatory lymph.
Fig. 86 exhibits a lateral injury of a more pronounced form. The bullet
here struck the most prominent portion of the under surface of the
bowel, and produced a circular perforation not very unlike one produced
by rectangular impact, except in the lesser degree of eversion of the
mucous membrane. Here again the appearance is somewhat altered by the
presence of a considerable amount of lymph, but this is of less
importance in this figure because the lymph is localised to the portion
of the bowel in the immediate neighbourhood of the opening which had
suffered contusion and erasion.
[Illustration: FIG. 86.--Gutter Wound of Small Intestine caused by
lateral impact. Position of shallow portion of gutter indicated by
deposition of inflammatory lymph. Circular perforation. (St. Thomas's
Hospital Museum)]
Fig. 87, A B, illustrates a symmetrical perforation of the small
intestine; the aperture of entry (A) is roughly circular, and a ring of
mucous membrane protrudes and partially closes the opening. The aperture
of exit is a curved slit, again partially occluded by the mucous
membrane. The same amount of difference between the two apertures did
not always exist; in many cases both were circular, and apparently
symmetrical. Beyond this I have seen three apertures in close proximity,
two lying on the same aspect of the bowel, and the first of these was no
doubt an opening due to lateral impact similar to that seen in fig. 86.
In the recent condition little difference existed between the three
apertures.
The localised ecchymosis surrounding the apertures is quite
characteristic of this form of injury, and is a valuable aid to finding
the openings during an operation.
Fig. 88 shows the interior of the same segment of bowel, as fig. 87. It
shows the localised ecchymosis as seen from the inner surface, here
rather more extensive from the fact that the blood spreads more readily
in the submucous tissue.
[Illustration: FIG. 87.--Perforating Wounds of Small Intestine. A.
Entry; note circular outline and eversion of mucous membrane. B. Wound
of exit; curved slit-like character, eversion of mucous membrane. Note
the localised ecchymosis, more abundant round exit aperture. (St.
Thomas's Hospital Museum)]
It will be noted that the main feature of the form of injury is the
regular outline and the small size of the wounds. Another feature not
illustrated by the figures should also be mentioned. In the ruptures of
intestine with which we are acquainted in civil practice the wound in
the gut is almost without exception situated at the free border of the
bowel, but in these injuries it was just as frequently at the mesenteric
margin. The importance of this factor is considerable, since wounds
near the mesenteric edge are much more likely to be accompanied by
hæmorrhage, and thus the opportunity for diffusion of infection is
considerably multiplied, to say nothing of the danger from loss of
blood.
Beyond these more or less pure perforations, long slits or gutters were
occasionally cut. I saw instances of these in the case of the ascending
colon, and in the small curvature of the stomach. The comparative fixity
of the portion of bowel struck is a matter of great importance in the
production of this form of injury.
[Illustration: FIG. 88.--The same piece of Intestine as that shown in
fig. 87, laid open to show the ecchymosis on the inner aspect of the
Bowel. The two indicating lines lead to the openings, which appear
slit-like, and are sunk at the bottom of folds. (St. Thomas's Hospital
Museum)]
It may be well to add that, although the figures inserted are all taken
from small-intestine wounds, the nature of the wounds of the
peritoneum-clad part of the large intestine in no way differed from
them, except in so far as fixity of the bowel exposed it to a more
extensive wound when the bullet took a parallel course to its long axis.
A more important point in the injuries to the large intestine was the
possibility of an extra-peritoneal wound. I saw several such lesions of
the colon, every one of which ended fatally. I became still more fully
convinced of the greater seriousness of extra- to intra-peritoneal
rupture of this portion of the gut than I was when I expressed a similar
opinion in a former paper.[20] It will be seen later that the results of
intra- and extra-peritoneal wounds of the bladder fully confirm this
view, as all extra-peritoneal injuries died, while many intra-peritoneal
perforations recovered spontaneously.
_Wounds of the mesentery._--I had little experience of this injury; in
fact, case 169, on which I operated, was my sole observation. It stands
to reason, however, that injuries to the mesentery would be much more
frequent proportionately to wounds of the gut than is the case in the
ruptures seen in civil practice, since the whole area of the mesentery
is equally open to injury. Viewing the extreme danger of hæmorrhage into
the peritoneal cavity in these injuries, I should be inclined to expect
that a considerable proportion of those deaths from abdominal wounds
which took place on the field of battle were due to this source.
_Wounds of the omentum._--Here, again, I am unable to express any
opinion, although the supposition that hæmorrhage from this source took
place is natural.
Prolapse of omentum was comparatively rare, except in cases with large
wounds; it was apparently seen with some frequency among patients who
died rapidly on the field of battle. I only saw it twice, and on each
occasion in shell wounds. The wounds from small-calibre bullets were as
a rule too small to allow of external prolapse.
Fig. 89, however, illustrates a very interesting observation. A patient
in the German Ambulance in Heilbron, under Dr. Flockemann, died as a
result of suppuration and hæmorrhage secondary to an injury to the
colon. At the autopsy a portion of the omentum was found adherent in the
wound of exit, but it had not reached the external surface. The chief
interest of the observation lies in the light it throws on the mechanism
of these injuries. It is impossible to conceive that a small-calibre
bullet coming into direct contact with the omentum could do anything but
perforate it. It, therefore, appears clear that in a displacement like
that figured, only lateral impact occurred with the omentum, which was
carried along by the spin and rush of the bullet into the canal of exit,
where it lodged.
[Illustration: FIG. 89.--Great Omentum carried by the bullet into an
exit track leading from the abdominal cavity. A. Outline of opening in
the peritoneum]
_Results of injury to the intestine._ 1. _Escape of contents and
infection of the peritoneal cavity._--I think there is little special to
be said on this subject. The escape of contents into the peritoneal
cavity was by no means free, unless the injury was multiple. Thus in one
case of injury to the small intestine, No. 166, on which I operated,
there was absolutely no gross escape until the bowel was removed from
the abdominal cavity, when the contents spurted out freely. In one case
of very oblique injury to the colon there was a considerable quantity of
fæcal matter in a localised space, but as a rule the ordinary condition
best described as 'peritoneal infection' from the wound was found. The
bad effect of anything like free escape was well shown in multiple
perforations; in these suppurative peritonitis rapidly developed and the
patients died at the end of thirty-six hours or less. A typical case is
quoted in No. 168.
2. _Peritoneal infection, and general septicæmia._--As is evident from
the results quoted among the cases, the degree which this reached varied
greatly. It may of course be assumed that in some measure it occurred in
every case in which the bowel was perforated, but it was sometimes so
slight as to be scarcely noticeable. This may be said to have been most
common in injuries to the large intestine. Wounds of the cæcum,
ascending and descending colon, the sigmoid flexure, or the rectum, were
sometimes followed by no serious symptoms, either local or general.
Again in these portions of the bowel the development of local signs, and
the later formation of an abscess, were by no means uncommon.
In the case of the small intestine I never observed this sequence, and
the same may be said of the transverse colon, which in its anatomical
arrangement and position so nearly approximates to the small bowel. In
suspected wounds of these portions of the bowel either the symptoms were
so slight as to render it doubtful whether a perforation had occurred,
or marked signs of general peritoneal septicæmia developed, and death
resulted.
The condition of the peritoneum in fatal cases varied much. In some a
dry peritonitis, or one in which a considerable quantity of slightly
turbid fluid was effused, was found. In others a rapid suppurative
process, accompanied by the effusion of large quantities of plastic
lymph, was met with. My experience suggested that the latter condition
was the result of free infection from multiple wounds of the gut, the
former the accompaniment of single wounds. Hence I should ascribe the
difference mainly to the extent of the primary infection.
This is perhaps a suitable place to further discuss the explanation of
the escape of a considerable number of the patients who received wounds
of the abdomen, possibly implicating the bowel. Although this was not, I
think, so common an occurrence as has been sometimes assumed, yet many
examples were met with. Several reasons have been advanced.
(1) Great importance has been given to the fact that many of the men
were wounded while in a state of hunger, no food having been taken for
twelve or more hours before the reception of the injury. In view of the
well-proved fact in these, as in other intestinal injuries, that free
intestinal escape does not occur, and that it is usually a mere question
of infection, this explanation, in my opinion, is of small importance.
It might with far more justice be pointed out that many of these wounded
men were for them in the happy position of not having friends freely
dosing them with brandy and water after the reception of the injury, and
this was possibly an element of some importance.
Some of the men did, however, drink freely, and in one case which
terminated fatally a comrade gave a man wounded through the belly an
immediate dose of Beecham's pills.
(2) Mr. Treves has suggested that the effect of the severe trauma on the
muscular coat of the bowel is to cause a cessation of peristaltic
movement. This, as in the case of 'local shock' elsewhere, may no doubt
be of importance, and to it should be added the simultaneous cessation
of abdominal respiratory movements in the segment of the belly wall
covering the injured part. The occurrence of general cessation of
peristaltic movement is, however, to some extent opposed by the fact
that in a certain number of the cases early passage of motions was seen
just as happens in the intestinal ruptures seen in civil practice.
I should be inclined to ascribe the escape from serious infection in
these injuries to the same cause which accounts for their comparative
insignificance in other regions--namely, the small calibre of the bullet
and consequent small size of the lesion: in point of fact to the minimal
nature of the primary infection. I very much doubt if any patient who
had more than one complete perforation of the small intestine got well
during the whole campaign. This opinion is, moreover, supported by the
fact that the prognosis was so far better in cases of injury to the
large than to the small intestine, in which former segment of the bowel
we have the advantages of a position beyond the region in which
intestinal movement is most free, the unlikelihood of multiple injury,
and a drier and more solid type of fæcal contents.
In the instances in which recovery followed perforating injuries without
any bad signs we can only assume a minimal infection, and sufficient
irritation and reaction on the part of the bowel to produce rapid
adhesion between contiguous coils, and thus provisional closure.
The other mode of spontaneous recovery which I saw several times take
place in the injuries to the large bowel consisted in the limitation of
the spread of infection by early adhesions and the development of a
local abscess. The non-observance of this process in any case of injury
to the small intestine raises very great doubts in my mind as to the
frequent recovery of patients in whom the small intestine was
perforated.
INJURIES TO THE INTESTINAL TRACT
1. _Wounds of the stomach._--A considerable number of wounds in such a
situation as to have possibly implicated the stomach were observed, and
of these a certain number recovered spontaneously. The only two
instances that came under my own observation are recorded below. It will
be noted that in each the special symptoms were the classic ones of
vomiting and hæmatemesis. In the first case blood was also passed per
anum, and in the second the diagnosis was reinforced by the escape of
stomach contents from the external wound.
The second case was a surgical disappointment. No doubt the fatal issue
was mainly dependent on the fact that the external wound had to be kept
open to allow of the escape of the abundant discharge from the wounded
liver. In the absence of the hepatic wound, however, I believe it would
have been possible for this patient to have got well spontaneously, in
view of the firm adhesions which had formed around the opening in the
stomach, and the consequent localisation which had been effected.
Another unfortunate element in this case was the comminuted fracture of
the seventh costal cartilage, which maintained the patency of the
aperture of exit. The latter point, however, was of doubtful importance
from this aspect, as the vent provided for the gastric and biliary
secretions may have been the safety-valve that had allowed localisation
to develop.
I believe that the secondary hæmorrhage was the main element in robbing
us of a success in this case, and that this depended on the digestion of
the wound by the gastric secretion. The early troubles which arose in
the treatment of this patient well illustrate the difficulties by which
the military surgeon is at times met; but the patient was admirably
attended to and nursed by my friend Mr. Pershouse, and an orderly who
was specially put on duty for the purpose.
(163) Wounded at Rensburg. _Entry_ (Mauser), in ninth left
intercostal space in posterior axillary line; _exit_, a
transverse slit 1/2 an inch in length to left of xiphoid
appendage. Patient was retiring when struck; he did not fall,
but ran for about 1,000 yards, whence he was conveyed to
hospital. He vomited half an hour after the injury (last meal
bread and 'bully beef,' taken two hours previously), and during
the evening three times again, the vomit consisting mainly 'of
dark thick blood.' He was put on milk diet, and not completely
starved; on the third day a large quantity of dark clotted
blood was passed per rectum with the stool, and this continued
for two days.
Ten days after the injury the temperature was still rising to
100°, and did not become normal till the fourteenth day. The
pulse averaged 80. The abdomen, meanwhile, moved fairly well,
respirations 18 to 20. Some tenderness was present in the
epigastrium and towards the spleen. Resonance throughout.
Ordinary diet was now resumed, and beyond slight epigastric
pain on deep inspiration, no further symptoms were observed,
and the patient left for England at the end of the month. The
spleen may have been traversed in this patient, as well as the
lower margin of the right lung.
(164*) Wounded at Enslin. _Entry_ (Mauser), 3/4 of an inch from
the spine, opposite the eighth intercostal space; _exit_,
through the seventh left costal cartilage, 1 inch from the
median line. The patient was lying in the prone position when
shot: he vomited blood freely, and the bowels acted three times
before he was seen forty hours after the accident, each motion
containing dark blood.
On the commencement of the third day the patient's expression
was extremely anxious, and he was suffering great pain. Pulse
96, temperature 100°. Tongue moist, occasional vomiting, bowels
open yesterday. Has taken fluid nourishment since injury. The
abdomen moved with respiration, but was moderately distended,
especially in the line of the transverse colon; it was
tympanitic on percussion, there was no dulness in the flanks,
and only moderate rigidity of the wall on palpation. Frothy
fluid stained with bile and fæcal in odour was escaping from
the wound of exit, and the everted margins of the latter were
bile-stained.
A vertical incision was carried downwards from the wound for 4
inches. A rugged furrow was found on the under surface of the
left lobe of the liver; the stomach was contracted and firmly
adherent by recent lymph to the under surface of the liver and
the diaphragm. The transverse colon was much distended. On
separating the stomach a slit wound was found at the lesser
curvature, immediately to the right of the oesophagus. This
wound was closed with some difficulty with two tiers of
sutures; the cavity was mopped out, and then irrigated with
boiled water; a plug was introduced along the line of the
furrow in the liver, and the lower part of the abdominal
incision closed.
The patient stood the operation well, and was removed to his
tent; during the day, however, two thunder showers occurred
during each of which water, several inches if not a foot deep,
rushed through the camp. After the second flood he was removed
to the operating room, the only house we had, and slept there.
The pulse rose to 120, and respiration to 26, and there was
pain, which was subdued by 1/3 grain of morphia, administered
subcutaneously. A fair amount of urine was passed, and the
bowels acted once, the motion containing blood.
On the second day after operation there was some improvement;
the pulse still numbered 116, and the temperature was raised to
100°, but the belly moved fairly, and pain was moderate.
Abundant foul-smelling, bile-stained discharge came from the
wound when the plug was removed. Rectal feeding was
supplemented by small quantities of milk and soda by the mouth.
The condition did not materially change, but on the fourth day
it was evident that the suturing of the stomach wound had given
way, and liquid food escaped readily when taken. The discharge
remained bile-stained and very foul. No extension of
inflammation to the general peritoneal cavity occurred, but it
was evident that the patient was suffering from constitutional
infection from the foul wound, the lower part of which opened
up somewhat after the removal of the stitches on the seventh
day. The wound was irrigated three times daily with 1-300
creolin lotion, but remained very foul. The man slowly lost
strength, although escape from the stomach considerably
decreased. On the tenth day a sudden severe hæmorrhage
occurred, presumably from a large branch of the coeliac axis.
The bleeding was readily controlled by a plug, and did not
recur; but the patient rapidly sank, and died on the twelfth
day after the operation, and fourteen days after reception of
the injury. No _post-mortem_ examination was made.
2. _Wounds of the small intestine._--These were comparatively common,
but offered little that was special either in their symptoms or the
results attending them. Wounds were met with in every part of the small
gut; but I saw no case in which an injury to the duodenum could be
specially diagnosed.
As to the symptoms which attended these injuries, it is somewhat
difficult to speak with precision, and it must be left to my readers to
form an opinion as to how many of the cases recounted below were really
instances of perforating wounds. My own view is that in the majority of
the cases that got well spontaneously, the injury was not of a
perforating nature, and that for reasons which have been already set
forth. It will, however, be at once noted that in all the five cases in
which the injury was certainly diagnosed in hospital death occurred.
The cases of injury to the small intestine are perhaps best arranged in
three classes.
1. Those who died upon the field, or shortly after removal from it. In
these the external wounds were often large, the omentum was not rarely
prolapsed, and escape of fæces sometimes occurred early. Shock from the
severity of the lesion, and hæmorrhage, were no doubt important factors
in the early lethal issue in this class. Many of the injuries were no
doubt produced by bullets striking irregularly, by ricochets, by bullets
of the expanding forms, or by bullets of large calibre. As being beyond
the bounds of surgical aid, this class possessed the least interest.
2. Cases brought into the Field, or even the Stationary hospitals, with
symptoms of moderate severity, or even of an insignificant character,
in which evidence of septic peritonitis suddenly developed and death
ensued.
3. Cases in which the position of the wounds raised the possibility of
injury to the intestine, but in which the symptoms were slight or of
moderate severity, and which recovered spontaneously.
The whole crux in diagnosis lay in the attempt to separate the two
latter classes, and, personally, I must own to having been no nearer a
position of being able to form an opinion on this point, in the late
than in the early stage of my stay in South Africa. The advent of
peritoneal septicæmia was in many instances the only determining moment.
On this matter I can only add that, in civil practice, an exploratory
abdominal section is often the only means of determination of a rupture
of the bowel wall.
With regard to the cases of suspected injury to the bowel which
recovered spontaneously, the symptoms were somewhat special in their
comparative slightness, and in the limited nature of the local signs.
Thus the pulse seldom rose to as much as 100 in rate, 80 was a common
average. Respiration was never greatly quickened, 24 was a common rate.
The temperature rarely exceeded 100°. Vomiting was occasionally severe,
but usually not persistent, ceasing on the second day. A good quantity
of urine was passed. As to the local signs, these again were of a
limited nature; distension did not occur, or was slight; movement of the
abdominal wall was only restricted in the neighbourhood of the wound,
the affected area amounted to a quarter, or at most half, the abdominal
wall, and rigidity was localised to a similar segment. Local tenderness
usually existed; but, as a rule, there was little or no dulness to point
to the occurrence either of fluid effusion or a considerable deposition
of lymph.
Again many of the patients suffered with very slight symptoms of
constitutional shock, although there was considerable variation in this
particular.
(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
superior iliac spine, perforated the pelvis, and emerged 1-1/2
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 6 P.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 5 A.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 2-1/2 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), opposite
central point of left ilium; _exit_, 1-1/2 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, [Symbol: ounce]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
only numbered 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 3 P.M., but not brought into the
Field hospital until 9 P.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 5 A.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 foetid, 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
6 P.M. was in a state of collapse, in which he shortly died.
Death was apparently due to renewal of the previous hæmorrhage.
No _post-mortem_ examination 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 lower third. 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 symptoms were 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_, 2-1/2
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 the patient 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 of _entry_
(Mauser); (_a_) below cartilage of eighth rib in left nipple
line; (_b_) 2 inches below and 4-1/2 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), 3-1/2 inches
above and 1-1/2 inch within the left anterior superior iliac
spine; _exit_, 1-1/2 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_, 1-1/2
inch above 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, [Symbol: ounce]ij every half-hour. No
sickness. Temperature
99°. Pulse 104. Respirations 24. Abdomen flatter; general
respiratory movement; tenderness now mainly localised to an
area 2-1/2 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 which _local_ peritoneal 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
inch within 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
oedema 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
[Symbol: ounce] 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. The
abdomen 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 [Symbol: ounce]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 the
loin 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 (53-1/2 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.
No _post-mortem_ examination 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 diarrhoea 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, 2-1/2 inches above the
iliac crest, at the margin of the erector spinæ; _exit_, 1-1/2
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 diarrhoea, 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 the _post-mortem_ examination 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 the
aperture 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 passed _per 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 and
induration 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 diarrhoea 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.
-------------------------+-----------+-------------+-----------+------+
| | Localised | | |
Viscous wounded | Number of | Secondary | Recovered | Died |
| cases | suppuration | | |
| | occurred | | |
-------------------------+-----------+-------------+-----------+------+
Stomach certain | 2 | -- | 1 | 1 |
Stomach possible | 1 | -- | 1 | -- |
Small intestine certain | 5 | 0 | -- | 5 |
Small intestine possible | 10 | 0 | 10 | -- |
Large intestine certain | 8 | 4[21] | 4 | 4 |
Large intestine possible | 4 | -- | 4 | -- |
-------------------------+-----------+-------------+-----------+------+
Bladder certain | 3 | 3 | 1 | 2 |
Bladder possible | 1 | -- | 1 | -- |
Liver | 6 | -- | 6 | -- |
Kidneys | 6 | -- | 4 | 2 |
Spleen | 3 | -- | 2 | 1 |
-------------------------+-----------+-------------+-----------+------+
Total | 49[22] | -- | 34 | 15 |
-------------------------+-----------+-------------+-----------+------+
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 favourable seat 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 was _certainly_ diagnosed
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 doubt some 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 or 44.4 per 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:--
'The number of the wounded was 154, and in fifteen it was
considered that the abdominal cavity had been penetrated. Of
these patients, five had already died within twenty-four to
twenty-eight hours after the injury, and I saw ten who were
still alive. Of these nine were left alone, and four died
within the next twenty-four or thirty-six hours; five were
still alive when I left Karee on Sunday afternoon, April 1. On
one I operated, but he died on April 2.
The Karee statistics are really the only complete ones which I
have as yet been able to obtain. The following are the notes of
the cases above alluded to.
Besides the five cases of abdominal wounds which had already
died, and of which I could get no complete details, the
following ten are cases which I saw from twenty-four to thirty
hours after they were shot:--
CASES FROM THE ACTION AT KAREE
CASE I.--The point of entrance was 2 inches to the right of the
umbilicus, and the bullet was found lying under the skin far
back in the left loin. The patient was pulseless, and there was
much rigidity of the abdomen, tenderness, and vomiting. He died
a few hours later.
CASE II.--The bullet, coming from the side, had entered the
abdomen 4 inches below and behind the right nipple. There was
no exit wound. The patient had been vomiting a good deal, but
not any blood; the abdomen was very rigid and tender. He was
obviously very ill, and died the next morning. The bullet had
probably perforated the liver and _stomach_.
CASE III.--There was a large wound above the right anterior
iliac spine (probably the point of exit), and a small opening
behind and near the spine on the same side. There was great
tenderness and rigidity of the abdomen. He died a few hours
later.
CASE IV.--In this case there was a transverse wound of the
abdomen, the bullet having entered on the right side in the
middle of the lumbar region and passed out on the left side,
rather higher up and further back. All the symptoms of acute
peritonitis were present. The patient died the next morning.
CASE V.--The bullet had entered the anterior end of the sixth
intercostal space on the left side, and was found lying under
the skin over the seventh intercostal space on the right side
and about 2 inches further back. He had vomited blood on the
previous day. The bullet may have perforated the _stomach_. The
epigastrium was somewhat tender, but there were no marked
symptoms. On April 1 he was going on well.
CASE VI.--The place of entrance of the bullet was 1 inch in
front of the right anterior superior spine, and of exit behind
the left sacro-iliac synchondrosis. There was much hæmorrhage
at the time. His condition when I saw him was fair, and there
was no marked abdominal tenderness. On April 1 his morning
temperature was 101°. There were no signs of general
peritonitis, and his condition was good.
CASE VII.--The bullet had entered from behind, about the tip of
the twelfth rib on the left side, and had left about the middle
of the epigastrium, and rather to the left of the middle line.
Vomiting was still going on, but not of blood. There was much
tenderness and rigidity of the abdomen, and he was almost
pulseless. On April 1 his general condition was better, but the
abdomen was very rigid and tender. (Subsequently died.)
CASE VIII.--The point of entrance of the bullet was about 2
inches from the anterior end of the seventh left intercostal
space, and of exit rather lower down and further back on the
right side. The patient said that he had vomited brown fluid
after the injury. There was much abdominal pain, but his
general condition was fair. On April 1 there was still much
pain, but his general condition was good.
CASE IX.--The bullet had entered about 1-1/2 inch in front of
the anterior inferior spine on the right side, had gone
directly backwards, and had come out in the buttock. The
patient, however, suffered very little. On March 31 there was
slight tympanites and tenderness in the right iliac fossa. The
bowels acted well, and no blood was passed. On April 1 he was
very well, and it was considered very doubtful if any viscus
was wounded.
CASE X.--The point of entrance was in the middle of the right
buttock, a little above the level of the trochanter; the exit
was through the anterior abdominal wall in the right semilunar
line at the level of the umbilicus. The patient was decidedly
ill; the abdomen was a good deal distended, and pressure on it
caused an escape of gas through the anterior opening. There was
a good deal of abdominal tenderness and rigidity. I opened the
abdomen outside the right linea semilunaris, and found a
perforation in the anterior wall of the _ascending colon_,
without any adhesions around, which was easily stitched up. The
posterior opening was found about 2 inches lower down, with a
piece of omentum firmly adherent to it and completely closing
it. As the patient was in a bad state, I thought it better,
instead of excising the piece of intestine beyond the holes or
tearing off the omentum, to leave the wounds alone, merely
cleaning out the peritoneal cavity as well as I could and
arranging for free drainage. He rallied from the operation very
well, and for twenty-four hours it looked as if he might get
better; but he gradually got worse and died on April 2.'
The above statistics are particularly valuable, as they give the
incidence of abdominal injuries compared with those in general in one
definite battle. This amounted to the high number of 15 in 154 or 9.74
per cent. wounded. I am inclined to think that this is a higher
proportion than the average of the campaign, and that more of the men
must have been exposed in the erect position than was ordinarily the
case during the fighting.
The statistics also show that 33.33 per cent. of the patients with
abdominal injuries died within from twenty-four to twenty-eight hours,
and that the percentage of deaths had risen to 73.33 per cent. at the
end of the third day. These numbers again seem high, but in this
relation it may be noted that, as a small force only was present, and as
all the patients were together, Mr. Cheyne had unusually good
opportunities for seeing all the cases.
One other point is doubtful from the report, and that is what percentage
of the wounds were caused by bullets of small calibre. In one case it is
definitely stated that the wound was large, and in the second that gas
escaped from the wound; both of these may have been instances in which a
large bullet, or some expanding form, had been employed, and there is no
doubt that the use of such projectiles was more common at this stage of
the campaign than it was earlier.
_Treatment of injuries to the intestine._--Some general rules for the
immediate treatment of all cases may be laid down. First, the patients
must be removed with as little disturbance as possible, and absolute
starvation must be insisted upon. If the patients be suffering from
severe shock, hypodermic injections of strychnine should be
administered, or possibly some stimulant by the rectum.
After a battle, when these cases may be brought in in considerable
number, they should be collected and placed in the same tent. The
objection to congregating a number of severely wounded patients together
must be disregarded in the face of the manifest advantage of being able
to treat all alike in the matter of feeding. After the battles of the
Kimberley relief force, Surgeon-General Wilson, at my request, had all
the abdominal cases placed in a large marquee, where we were able to
carefully watch the whole of the patients from hour to hour, and little
chance existed for any indiscretion on the part of the patients in the
way of eating or drinking.
If possible, the patients should be kept absolutely quiet until they are
evidently out of danger. A week's stay at Orange River sufficed for this
object in the cases referred to. The avoidance of transport is
manifestly of extreme prognostic importance.
When feeding is commenced at the end of twenty-four or thirty-six hours,
it must be in the form at first of warm water, then milk administered in
tea-spoonfuls only.
In doubtful cases the use of morphia must be avoided.
Operative treatment is required in a certain number of the cases, but in
the majority of instances we are met with the extreme difficulty that in
a very large proportion of the occasions upon which these wounds are
received an exploratory abdominal section is not warranted in
consequence of the conditions under which it has to be performed.