(164*) Wounded at Enslin. Entry (Mauser), 3/4 of an inch from the spine, opposite the eighth intercostal space; exit, through the seventh left costal cartilage, 1 inch from the median line. The patient was lying in the prone position when shot: he vomited blood freely, and the bowels acted three times before he was seen forty hours after the accident, each motion containing dark blood.
On the commencement of the third day the patient's expression was extremely anxious, and he was suffering great pain. Pulse 96, temperature 100°. Tongue moist, occasional vomiting, bowels open yesterday. Has taken fluid nourishment since injury. The abdomen moved with respiration, but was moderately distended, especially in the line of the transverse colon; it was tympanitic on percussion, there was no dulness in the flanks, and only moderate rigidity of the wall on palpation. Frothy fluid stained with bile and fæcal in odour was escaping from the wound of exit, and the everted margins of the latter were bile-stained.
A vertical incision was carried downwards from the wound for 4 inches. A rugged furrow was found on the under surface of the left lobe of the liver; the stomach was contracted and firmly adherent by recent lymph to the under surface of the liver and the diaphragm. The transverse colon was much distended. On separating the stomach a slit wound was found at the lesser curvature, immediately to the right of the œsophagus. This wound was closed with some difficulty with two tiers of sutures; the cavity was mopped out, and then irrigated with boiled water; a plug was introduced along the line of the furrow in the liver, and the lower part of the abdominal incision closed.
The patient stood the operation well, and was removed to his tent; during the day, however, two thunder showers occurred during each of which water, several inches if not a foot deep, rushed through the camp. After the second flood he was removed to the operating room, the only house we had, and slept there. The pulse rose to 120, and respiration to 26, and there was pain, which was subdued by 1/3 grain of morphia, administered subcutaneously. A fair amount of urine was passed, and the bowels acted once, the motion containing blood.
On the second day after operation there was some improvement; the pulse still numbered 116, and the temperature was raised to 100°, but the belly moved fairly, and pain was moderate. Abundant foul-smelling, bile-stained discharge came from the wound when the plug was removed. Rectal feeding was supplemented by small quantities of milk and soda by the mouth.
The condition did not materially change, but on the fourth day it was evident that the suturing of the stomach wound had given way, and liquid food escaped readily when taken. The discharge remained bile-stained and very foul. No extension of inflammation to the general peritoneal cavity occurred, but it was evident that the patient was suffering from constitutional infection from the foul wound, the lower part of which opened up somewhat after the removal of the stitches on the seventh day. The wound was irrigated three times daily with 1-300 creolin lotion, but remained very foul. The man slowly lost strength, although escape from the stomach considerably decreased. On the tenth day a sudden severe hæmorrhage occurred, presumably from a large branch of the cœliac axis. The bleeding was readily controlled by a plug, and did not recur; but the patient rapidly sank, and died on the twelfth day after the operation, and fourteen days after reception of the injury. No post-mortem examination was made.
2. Wounds of the small intestine.—These were comparatively common, but offered little that was special either in their symptoms or the results attending them. Wounds were met with in every part of the small gut; but I saw no case in which an injury to the duodenum could be specially diagnosed.
As to the symptoms which attended these injuries, it is somewhat difficult to speak with precision, and it must be left to my readers to form an opinion as to how many of the cases recounted below were really instances of perforating wounds. My own view is that in the majority of the cases that got well spontaneously, the injury was not of a perforating nature, and that for reasons which have been already set forth. It will, however, be at once noted that in all the five cases in which the injury was certainly diagnosed in hospital death occurred.
The cases of injury to the small intestine are perhaps best arranged in three classes.
1. Those who died upon the field, or shortly after removal from it. In these the external wounds were often large, the omentum was not rarely prolapsed, and escape of fæces sometimes occurred early. Shock from the severity of the lesion, and hæmorrhage, were no doubt important factors in the early lethal issue in this class. Many of the injuries were no doubt produced by bullets striking irregularly, by ricochets, by bullets of the expanding forms, or by bullets of large calibre. As being beyond the bounds of surgical aid, this class possessed the least interest.