The injury was followed by little abdominal pain, but a strange sensation of local gurgling was noted. The bowels acted as soon as the patient reached camp, some hours after being wounded. There was no sickness and nothing abnormal was noted in the motions, except that they were loose and light-coloured.
On the evening of the third day the patient came under observation in the ambulance train for Capetown. He looked somewhat anxious and ill, but he complained of little pain; the temperature was 102°, pulse 88, fair strength, soft and regular. There was local dulness, tenderness, and deficiency of movement in the right iliac region. As it was night, he was removed from the train and an operation was performed the next morning.
Prior to operation the condition was as follows: Pulse 84, temperature 100°; respiration easy, 20. Tongue moist, but thickly coated in centre. Abdomen moves fairly, and is resonant, except in right lower quadrant. No distension. Dulness, tenderness, and rigidity in right iliac region, marked to outer side of cæcum. Entry wound nearly and exit quite healed. Cannot flex right thigh. The following operation was performed. Appendix incision, about ℥j of fæcal fluid and fæces in a localised cavity on outer and anterior aspect of cæcum evacuated; adhesions very firm. Cavity sloughy throughout and cæcum covered with dull grey lymph. The opening in the bowel was not localised, and it was considered wiser to treat the case like one of perforation from appendicitis than to run the risk of breaking down adhesions. A small awl-like opening was found in the ilium with powdered bone at its entrance leading to the wound of exit.
The after-treatment of the case gave rise to no anxiety, but healing of the resulting sinus was slow; fæcal-smelling pus escaped for some days, and a number of small sloughs came away. On the twelfth day the patient was sent down to Wynberg, where he remained twelve weeks. A counter-incision was needed in the loin to drain the suppurating cavity three weeks after the primary operation, and five weeks after the operation an escape of gas and fæces took place from the anterior wound, while the bowels were acting, as a result of a dose of castor oil. No further escape of fæces occurred, and he left for England with a small sinus only. No extension of inflammation into the original wound track ever occurred, both openings and the canal healing by primary union.
The sinus remained open, and occasionally discharged for a further period of six months, and then healed firmly; since when the patient has been in perfect health.
(182*) Splenic flexure, descending colon.—Wounded at Magersfontein. Entry (Mauser), in sixth left intercostal space in mid-axillary line; exit, in left loin, below last rib, at outer margin of erector spinæ. The patient remained in the Field hospital three days, during which time he exhibited no serious abdominal symptoms, but during the journey to Orange River (53½ miles) he was sick. He remained at Orange River two days, and while there an enema was administered, producing a normal motion. The abdomen was slightly distended; it moved fairly, there was slight rigidity, but little tenderness. Temperature 100.8°, pulse 120. No appearance of fæces in wound.
When seen on the sixth day the condition was as follows:—Patient cheerful and not in great pain. Temperature 99.2°; pulse 120; respirations 48, very shallow. Abdomen soft, moving freely, no distension or general tenderness. Fluid fæces escaping in abundance from the wound in loin. Redness of skin and swelling below level of wound, and cellular emphysema above. Fæcal-smelling fluid was also escaping from the thoracic wound.
The wound was enlarged, but the patient rapidly sank, and died of septicæmia on the seventh day.
(183*) An exactly similar case came under observation from the battle of Modder River, except that the opening in the loin was somewhat larger, and earlier and freer escape of fæces took place from it. In this also fæcal matter passed freely into the left pleural cavity, and fæcal matter was expectorated, while there was an almost complete absence of abdominal symptoms. Death occurred on the fourth day.
No post-mortem examination was made in either case, but I believe in both the extra-peritoneal aspect of the colon was implicated and that the septicæmia was in great part due to absorption from the pleural rather than the peritoneal cavity, since in neither case were the abdominal symptoms a prominent feature.