At the anterior border of the right lobe of the liver an abscess cavity existed in connection with the wound of the liver, and this was continuous with the aperture of exit, although not discharging. The aperture of exit was plugged by a tag of omentum (see fig. 89). No obvious source of the hæmorrhage was forthcoming, but it probably originated in one of the large branches of the vena cava. The bullet had struck the transverse process of the lumbar vertebra, but had not given rise to any signs of spinal concussion.
(189*) Ascending colon.—Wounded at Modder River. Entry (Mauser), midway between the tip of the tenth right rib and the iliac crest. Bullet retained. A second wound existed over the centre of the left sterno-mastoid, and the bullet here was also retained and never localised. The patient stated that he brought up blood at short intervals for half an hour immediately after he was wounded. This might have been explained by the wound in the neck, but no difficulty in swallowing was noted. The bowels acted the day after he was shot, and, except for some local tenderness and immobility, no abdominal signs were noted. Three weeks later a swelling was obvious to the right side of the umbilicus, and a tympanitic abscess developed; this was opened, and a deformed Mauser bullet extracted. Foul pus, but no fæcal matter, was evacuated, and after discharging for a fortnight the wound closed, and the man was sent home as 'well.' In this case I assumed a wound of the ascending colon had occurred.
(190*) Rectum and bladder.—Wounded at Graspan, while retiring at the double. Entry (Mauser), 1 inch to the right of the coccyx; exit, 1 inch above the junction of the middle and outer thirds of left Poupart's ligament. The man suffered with some pain in the abdomen, and for first two days with retention of urine. The urine was drawn off with the catheter, and contained blood. During the next five days micturition was hourly or more frequent; gas was passed per urethram, and the urine was very foul, containing evident fæcal matter. Micturition continued frequent, with purulent cystitis for one month. Local tenderness, pain, and immobility developed over the lower quarter of the abdomen, extending to the right iliac fossa. A local abscess pointed a little to the right of the mid line, and 2 inches above the symphysis, and from this foul-smelling pus, but no fæces, was discharged for three months, during which period the surrounding dulness and induration gradually decreased and the sinus healed. When the patient left for England there was still occasional slight discharge from the original wound of entry, and there was slight discomfort on micturition, but he was otherwise well.
A year later the man had resumed active duty, and, except for occasional pain on stooping, considered himself well.
The following cases are appended as of some general interest. The first two (191, 192) illustrate extra-peritoneal injuries to the rectum. In neither did positive evidence exist of wound of the bowel, but the symptoms in each rendered this accident probable. Case 193 is an illustration of apparent escape of the anal canal in a wound in which from the position of the external apertures this escape would have appeared impossible.
Wounds of the extra-peritoneal portion of the rectum, as a rule, appeared to have a somewhat better prognosis than would have been expected; in any case, the prognosis was far better than that obtaining in wounds of the base of the urinary bladder. My experience on the subject of these wounds was, however, limited to the two cases quoted.
Case 194 is inserted as an example of the complicated nature of the abdominal injuries not so very unfrequently met with. It illustrates well the difficulty which may arise at any stage in the course of treatment of an injury, in the certain determination or exclusion of wound of a part of the alimentary canal.
(191) Wounded at Magersfontein. Entry (Mauser), in the right loin, immediately below the ribs in the mid-axillary line; exit, about the centre of the left buttock, on a level with the tip of the great trochanter. A second lacerated shell wound of back was present. All the wounds suppurated. For the first sixteen days following the injury all control was lost over the anal sphincter, and bloody fæces, and later slime, constantly escaped, but no fæcal matter ever escaped from the wound in the buttock. There was no history of previous dysentery, and rectal examination afforded no information. The buttock wound had to be opened up, disclosing a tunnel in the ilium.
The wounds granulated slowly with continuous suppuration, but were healed, and the patient returned home at the end of fourteen weeks, the bowels acting normally.
(192) Wounded at Paardeberg. Entry (Mauser), at the junction of the middle and posterior thirds of the left iliac crest; the bullet was retained, and removed (Mr. Pegg) from the back of the right thigh, 3 inches below the back of the great trochanter. After the injury retention of urine followed, with incapacity to control loose motions, though solid ones could be retained. The retention was treated by catheterisation, which was followed by cystitis. The power of micturition was slowly recovered, and three weeks later he could pass water, at times in a dribbling stream only; the cystitis had improved. The man returned to England very much improved, but not quite well, at the end of five weeks.