Chapter XI: Injuries to the Abdomen (2)

(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.

A word must be added as to these difficulties; they are in part purely of an administrative nature, partly surgical. After a great battle the wounded are numerous, and amongst them a very considerable proportion of the wounds and injuries are of such a nature as to do extremely well if promptly dealt with, and each of these makes small demands on the time of the staff. Abdominal operations, on the other hand, are unsatisfactory from a prognostic point of view, and their performance requires much time and the assistance of a considerable number of the men, who are obliged to neglect the treatment of the more promising cases for those of doubtful issue. This difficulty, although not surgical in its nature, is nevertheless a practical one of great importance and appeals strongly to the Principal Medical Officers in charge of the arrangements. It is only to be avoided by an increase of the staff, which is not likely to be made except on very special occasions.

Other difficulties are purely surgical. First, the difficulty of diagnosing with certainty a perforating lesion. In the presence of the fact that many incomplete lesions follow wounds crossing the intestinal area, and that these give rise to modified symptoms, I believe this determination to be impossible without the aid of an exploratory incision. Here we are met with the remaining surgical difficulties--disadvantages such as the absence of sufficient aid to the operating surgeon, difficulties connected with the temperature, wind, and dust, and as to the subsequent treatment of the patient. Again difficulty in obtaining the most important adjunct, suitable water, or indeed any water in a sufficient quantity.

It is of course obvious that conditions may exist in which all these troubles may be avoided. Again, the practical difficulty adverted to above does not come in the way when a single man happens to sustain an abdominal wound on the march. Under such circumstances an exploration may be not only justifiable, but obligatory, and the general rules of surgery must be followed rather than such incomplete indications as are suggested below.

My own experience led me to the following conclusions:

1. A wound in the intestinal area should be watched with care. In the face of the numerous recoveries in such cases, habitual abdominal exploration is not justified, under the conditions usually prevailing in the field.

2. The very large class of patients excluded by this rule from operation leads us to a smaller and less satisfactory number to be divided into two categories:

Patients who die during the first twelve hours. The whole of these are naturally unfit for operation, and their general condition when seen often precludes any thought of it.

Patients with very severe injuries, as evidenced by the escape of fæces, or with wounds from flank to flank or taking an antero-posterior course in the small intestinal area. These patients die, and the majority of them will always die whether operated upon or not. The undertaking of operations upon them is unpleasant to the surgeon, as being unlikely to be attended with any great degree of success, whence the impression may gain ground that patients are killed by the operations. None the less, I think these operations ought to be undertaken when the attendant conditions allow, and it is from this class of case that the real successes will be drawn in the future. The history of such injuries, after all, corresponds exactly with what we were long familiar with in traumatic ruptures in civil practice, and now know may be avoided by a sufficiently early interference. The whole question here is one of time, and this will always be the trouble in military work.

3. The expectant attitude which is obligatory under the above rules in doubtful cases, brings us face to face with a large proportion of patients in the early or late stage of peritoneal septicæmia. These cases run on exactly the same lines as those in which the same condition is secondary to spontaneous perforation of the bowel, in which we consider it our duty to operate, and in which a definite percentage of recoveries is obtained. Hence another unpleasant duty is here imposed upon the surgeon. Two such cases on which I operated are recounted above, and although I cannot say they give much encouragement, I should add that in the only one I left untouched, I regretted my want of courage for the five days during which the patient continued to carry on a miserable existence.

4. The treatment of the cases in which an expectant attitude is followed by the advent of localised suppuration presents no difficulty; simple incision alone is needed, and healing follows.

As a rule this is a late condition. In one case of injury to the ascending colon recounted above, however, considerable local escape of fæces had occurred, and a successful result was obtained by a local incision on the third day without suture of the bowel. In this case I believe the wound in the bowel to have been of the nature of a long slit, but the surrounding adhesions were so firm as to render any interference with them a great risk, and a successful result was obtained at the cost of a somewhat prolonged recovery. I am convinced that the best course was followed here. (No. 131.)

When the suppuration was of a less acute character, it was generally advisable to allow the pus to make its way towards the surface before interference.

5. Cases of injury to the colon in which the posterior aspect is involved should be treated by free opening up of the wound, and either by suture of the bowel or else its fixation to the surface. I operated on one such case, and although the patient eventually died on the eighth day, from septicæmia, he certainly had a chance. Two cases where the opening looked so free that one almost thought the wound could be regarded as a lumbar colotomy did badly; in both infection of the pleura took place, besides extension of suppuration into the retro-peritoneal areolar tissue. In the future I should always feel inclined to enlarge such wounds and bring the bowel to the surface.