(184) Possible wound of cæcum.—Wounded at Spion Kop. Bullet (Mauser) perforated the right forearm, then entered belly. Entry, 3 inches from the right anterior superior iliac spine, in the line of the supra-pubic fold of the belly wall (a transverse slit); exit, in right buttock, on a level with the tip of the great trochanter and 2 inches within it. The wound was received immediately after breakfast had been eaten. There was retention of urine and constipation for three days, but no sickness. Local pain and tenderness were severe, and at the end of three weeks there was still local tenderness, slight induration, and dragging pain on defæcation. The patient returned to England at the end of a month well, except for slight local tenderness.
(185) Possible wound of colon.—Wounded at Paardeberg; range 200 yards. Walking at time. The bullet (Mauser) perforated the left forearm, just below the elbow-joint. Entry, into belly 1 inch anterior to the tip of the left eleventh costal cartilage; no exit.
The injury was followed by pain in the left half of the abdomen and vomiting, which continued for two days. The bowels acted on the third day; no nourishment was taken for two days, but a small quantity of water was allowed. No further symptoms were noted, and at the end of a fortnight the patient was well, except for slight local tenderness. The bullet could not be detected with the X-rays.
(186) Wound of cæcum.—Wounded at Paardeberg. Entry (Mauser), 2 inches diagonally above and within right anterior superior iliac spine; exit, immediately to the right of the fifth lumbar spinous process; the patient was lying on his left side when struck. A burning pain down the right thigh immediately followed the accident, and lasted some days. There was no sickness, the bowels were confined three days, and there was pain across the back and down the thigh.
On the tenth day he arrived at the Base, when he was lying on his back suffering considerable pain. The temperature ranged to 101°. There was diarrhœa and cystitis, with a considerable amount of pus in the urine, which was very offensive. A small fluctuating spot existed on the back, just to the right of the original exit wound which was firmly healed. The abdomen moved fairly with respiration in its upper part, but was motionless below, especially in the right iliac fossa; some induration was to be felt here. The right thigh was kept flexed.
During the next few days the pus disappeared from the urine, and with this change the induration in the right iliac fossa increased. An incision (Mr. Gairdner) was made into the fluctuating spot behind, and pus evacuated. The patient recovered.
(187) Possible wound of cæcum.—Wounded outside Heilbron. Entry (Mauser), in the right loin, 2½ inches above the iliac crest, at the margin of the erector spinæ; exit, 1½ inch above and within the right anterior superior spine of the ilium. There was little shock. The patient was brought six miles in a wagon into camp, and slept comfortably with a small morphia injection. Prior to the accident the patient was suffering from diarrhœa, but afterwards the bowels were confined. The next morning there had been no sickness and little pain. The tongue was moist and clean, the pulse 80, the respirations 24, the belly moved generally, although inspiration was shallow; the temperature was 99°. Slight tenderness in the belly to the inner side of the exit wound, but no dulness.
The patient was starved for the first thirty-six hours, a little warm water then being allowed. No symptoms developed, and a perfect recovery followed.
(188) Colon, liver.—Wounded outside Heilbron. Entry (Mauser), midway between the last right rib and the crista ilii; exit, below the eighth costal cartilage in nipple line. There were no serious primary symptoms, but ten days after the accident the temperature rose, swelling and pain developed in the right loin, and on the fourteenth day a large tympanitic abscess was opened (Dr. Flockemann, German Ambulance.) Fæcal-smelling gas and pus were evacuated. There was no extension of the abscess forwards. A week later the patient had much improved, although there were evident signs of general absorption, and the discharge from the abscess cavity was abundant and very foul. On the thirteenth day a serious hæmorrhage occurred from the loin wound, which was opened up, but no evident source was discovered; hæmorrhage was repeated the next day, and the man died.
At the post-mortem examination a large quantity of chocolate-coloured fluid was found free in the abdomen and pelvis. A chain of small local abscesses was found surrounding the ascending colon, and a larger one over the front of the cæcum. The wall of the ascending colon was generally thickened, and from this, in three places, openings with rounded margins connected the abscess cavities with the lumen of the bowel. One of the openings, larger than the others, was possibly the aperture of entry of the bullet; the others were apparently spontaneous.