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 œdema 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 ℥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.