Surgical Experiences in South Africa, 1899-1900 / Being Mainly a Clinical Study of the Nature and Effects of Injuries Produced by Bullets of Small Calibre

by George Henry Makins

(2) Mr. Treves has suggested that the effect of the severe trauma on the muscular coat of the bowel is to cause a cessation of peristaltic movement. This, as in the case of 'local shock' elsewhere, may no doubt be of importance, and to it should be added the simultaneous cessation of abdominal respiratory movements in the segment of the belly wall covering the injured part. The occurrence of general cessation of peristaltic movement is, however, to some extent opposed by the fact that in a certain number of the cases early passage of motions was seen just as happens in the intestinal ruptures seen in civil practice.

I should be inclined to ascribe the escape from serious infection in these injuries to the same cause which accounts for their comparative insignificance in other regions—namely, the small calibre of the bullet and consequent small size of the lesion: in point of fact to the minimal nature of the primary infection. I very much doubt if any patient who had more than one complete perforation of the small intestine got well during the whole campaign. This opinion is, moreover, supported by the fact that the prognosis was so far better in cases of injury to the large than to the small intestine, in which former segment of the bowel we have the advantages of a position beyond the region in which intestinal movement is most free, the unlikelihood of multiple injury, and a drier and more solid type of fæcal contents.

In the instances in which recovery followed perforating injuries without any bad signs we can only assume a minimal infection, and sufficient irritation and reaction on the part of the bowel to produce rapid adhesion between contiguous coils, and thus provisional closure.

The other mode of spontaneous recovery which I saw several times take place in the injuries to the large bowel consisted in the limitation of the spread of infection by early adhesions and the development of a local abscess. The non-observance of this process in any case of injury to the small intestine raises very great doubts in my mind as to the frequent recovery of patients in whom the small intestine was perforated.

Injuries To the Intestinal Tract

1. Wounds of the stomach.—A considerable number of wounds in such a situation as to have possibly implicated the stomach were observed, and of these a certain number recovered spontaneously. The only two instances that came under my own observation are recorded below. It will be noted that in each the special symptoms were the classic ones of vomiting and hæmatemesis. In the first case blood was also passed per anum, and in the second the diagnosis was reinforced by the escape of stomach contents from the external wound.

The second case was a surgical disappointment. No doubt the fatal issue was mainly dependent on the fact that the external wound had to be kept open to allow of the escape of the abundant discharge from the wounded liver. In the absence of the hepatic wound, however, I believe it would have been possible for this patient to have got well spontaneously, in view of the firm adhesions which had formed around the opening in the stomach, and the consequent localisation which had been effected. Another unfortunate element in this case was the comminuted fracture of the seventh costal cartilage, which maintained the patency of the aperture of exit. The latter point, however, was of doubtful importance from this aspect, as the vent provided for the gastric and biliary secretions may have been the safety-valve that had allowed localisation to develop.

I believe that the secondary hæmorrhage was the main element in robbing us of a success in this case, and that this depended on the digestion of the wound by the gastric secretion. The early troubles which arose in the treatment of this patient well illustrate the difficulties by which the military surgeon is at times met; but the patient was admirably attended to and nursed by my friend Mr. Pershouse, and an orderly who was specially put on duty for the purpose.

(163) Wounded at Rensburg. Entry (Mauser), in ninth left intercostal space in posterior axillary line; exit, a transverse slit 1/2 an inch in length to left of xiphoid appendage. Patient was retiring when struck; he did not fall, but ran for about 1,000 yards, whence he was conveyed to hospital. He vomited half an hour after the injury (last meal bread and 'bully beef,' taken two hours previously), and during the evening three times again, the vomit consisting mainly 'of dark thick blood.' He was put on milk diet, and not completely starved; on the third day a large quantity of dark clotted blood was passed per rectum with the stool, and this continued for two days.

Ten days after the injury the temperature was still rising to 100°, and did not become normal till the fourteenth day. The pulse averaged 80. The abdomen, meanwhile, moved fairly well, respirations 18 to 20. Some tenderness was present in the epigastrium and towards the spleen. Resonance throughout. Ordinary diet was now resumed, and beyond slight epigastric pain on deep inspiration, no further symptoms were observed, and the patient left for England at the end of the month. The spleen may have been traversed in this patient, as well as the lower margin of the right lung.