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 septicaemia.

Several cases of recovery from wounds of the caec.u.m 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 a.s.sumed, 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 ill.u.s.trate 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 faeces, 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 septicaemia mainly due to absorption from the surface of that membrane (_Pleural septicaemia_).

No. 190 is a most striking instance of spontaneous cure, since no doubt can exist that both r.e.c.t.u.m and bladder were perforated.

(180*) _Injury to the caec.u.m 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 faecal 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 septicaemia, 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 septicaemia 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 p.r.o.ne position. _Entry_ (Mauser), over ninth rib in line of right linea semilunaris; _exit_, in right b.u.t.tock, 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 caec.u.m. Entry wound nearly and exit quite healed. Cannot flex right thigh. The following operation was performed. Appendix incision, about [Symbol: ounce]j of faecal fluid and faeces in a localised cavity on outer and anterior aspect of caec.u.m evacuated; adhesions very firm. Cavity sloughy throughout and caec.u.m 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; faecal-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 faeces took place from the anterior wound, while the bowels were acting, as a result of a dose of castor oil. No further escape of faeces 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 ca.n.a.l 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 s.p.a.ce in mid-axillary line; _exit_, in left loin, below last rib, at outer margin of erector spinae. 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 faeces 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 faeces escaping in abundance from the wound in loin. Redness of skin and swelling below level of wound, and cellular emphysema above. Faecal-smelling fluid was also escaping from the thoracic wound.

The wound was enlarged, but the patient rapidly sank, and died of septicaemia 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 faeces took place from it. In this also faecal matter pa.s.sed freely into the left pleural cavity, and faecal 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 septicaemia 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 caec.u.m._--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 b.u.t.tock, 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 defaecation. 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 quant.i.ty 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 caec.u.m_.--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 cyst.i.tis, 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 caec.u.m._--Wounded outside Heilbron.

_Entry_ (Mauser), in the right loin, 2-1/2 inches above the iliac crest, at the margin of the erector spinae; _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.) Faecal-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 haemorrhage occurred from the loin wound, which was opened up, but no evident source was discovered; haemorrhage was repeated the next day, and the man died.

At the _post-mortem_ examination a large quant.i.ty 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 caec.u.m. 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 haemorrhage 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 faecal matter, was evacuated, and after discharging for a fortnight the wound closed, and the man was sent home as 'well.' In this case I a.s.sumed a wound of the ascending colon had occurred.

(190*) _r.e.c.t.u.m 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 pa.s.sed _per urethram_, and the urine was very foul, containing evident faecal matter.

Micturition continued frequent, with purulent cyst.i.tis 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 faeces, 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) ill.u.s.trate extra-peritoneal injuries to the r.e.c.t.u.m. In neither did positive evidence exist of wound of the bowel, but the symptoms in each rendered this accident probable. Case 193 is an ill.u.s.tration of apparent escape of the a.n.a.l ca.n.a.l 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 r.e.c.t.u.m, 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 ill.u.s.trates 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 ca.n.a.l.

(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 b.u.t.tock, on a level with the tip of the great trochanter. A second lacerated sh.e.l.l wound of back was present. All the wounds suppurated. For the first sixteen days following the injury all control was lost over the a.n.a.l sphincter, and b.l.o.o.d.y faeces, and later slime, constantly escaped, but no faecal matter ever escaped from the wound in the b.u.t.tock. There was no history of previous dysentery, and rectal examination afforded no information. The b.u.t.tock 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.