Fig. 89.
Great Omentum carried by the bullet into an exit track leading from the abdominal cavity. A. Outline of opening in the peritoneum
Results of injury to the intestine. 1. Escape of contents and infection of the peritoneal cavity.—I think there is little special to be said on this subject. The escape of contents into the peritoneal cavity was by no means free, unless the injury was multiple. Thus in one case of injury to the small intestine, No. 166, on which I operated, there was absolutely no gross escape until the bowel was removed from the abdominal cavity, when the contents spurted out freely. In one case of very oblique injury to the colon there was a considerable quantity of fæcal matter in a localised space, but as a rule the ordinary condition best described as 'peritoneal infection' from the wound was found. The bad effect of anything like free escape was well shown in multiple perforations; in these suppurative peritonitis rapidly developed and the patients died at the end of thirty-six hours or less. A typical case is quoted in No. 168.
2. Peritoneal infection, and general septicæmia.—As is evident from the results quoted among the cases, the degree which this reached varied greatly. It may of course be assumed that in some measure it occurred in every case in which the bowel was perforated, but it was sometimes so slight as to be scarcely noticeable. This may be said to have been most common in injuries to the large intestine. Wounds of the cæcum, ascending and descending colon, the sigmoid flexure, or the rectum, were sometimes followed by no serious symptoms, either local or general. Again in these portions of the bowel the development of local signs, and the later formation of an abscess, were by no means uncommon.
In the case of the small intestine I never observed this sequence, and the same may be said of the transverse colon, which in its anatomical arrangement and position so nearly approximates to the small bowel. In suspected wounds of these portions of the bowel either the symptoms were so slight as to render it doubtful whether a perforation had occurred, or marked signs of general peritoneal septicæmia developed, and death resulted.
The condition of the peritoneum in fatal cases varied much. In some a dry peritonitis, or one in which a considerable quantity of slightly turbid fluid was effused, was found. In others a rapid suppurative process, accompanied by the effusion of large quantities of plastic lymph, was met with. My experience suggested that the latter condition was the result of free infection from multiple wounds of the gut, the former the accompaniment of single wounds. Hence I should ascribe the difference mainly to the extent of the primary infection.
This is perhaps a suitable place to further discuss the explanation of the escape of a considerable number of the patients who received wounds of the abdomen, possibly implicating the bowel. Although this was not, I think, so common an occurrence as has been sometimes assumed, yet many examples were met with. Several reasons have been advanced.
(1) Great importance has been given to the fact that many of the men were wounded while in a state of hunger, no food having been taken for twelve or more hours before the reception of the injury. In view of the well-proved fact in these, as in other intestinal injuries, that free intestinal escape does not occur, and that it is usually a mere question of infection, this explanation, in my opinion, is of small importance. It might with far more justice be pointed out that many of these wounded men were for them in the happy position of not having friends freely dosing them with brandy and water after the reception of the injury, and this was possibly an element of some importance.
Some of the men did, however, drink freely, and in one case which terminated fatally a comrade gave a man wounded through the belly an immediate dose of Beecham's pills.