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 cla.s.ses, 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 septicaemia 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 quant.i.ty of urine was pa.s.sed. 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 const.i.tutional 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 p.r.o.nounced, and the patient had pa.s.sed 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 pa.s.sed for twenty-four hours, [Symbol: ounce]ij in bladder on catheterisation, clear, and containing no blood.

Abdominal section. Median incision. A considerable quant.i.ty of b.l.o.o.d.y 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 faecal matter was visible until the intestine was delivered, when intestinal contents spurted freely across the room. The openings were sutured with five Lembert's st.i.tches. 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 p.u.b.es; _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 pa.s.sed. 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 septicaemia 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 28F. 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 quant.i.ty 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 b.l.o.o.d.y 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 haemorrhage.

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 const.i.tutional signs indicated either bowel injury or perforation of liver. The man, however, was suffering from a slight attack of dysentery, pa.s.sing blood and mucus per r.e.c.t.u.m 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 faeces 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 r.e.c.t.u.m or sigmoid flexure.