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, ℥ij every half-hour. No sickness. Temperature
99°. Pulse 104. Respirations 24. Abdomen flatter; general respiratory movement; tenderness now mainly localised to an area 2½ 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).