'The number of the wounded was 154, and in fifteen it was considered that the abdominal cavity had been penetrated. Of these patients, five had already died within twenty-four to twenty-eight hours after the injury, and I saw ten who were still alive. Of these nine were left alone, and four died within the next twenty-four or thirty-six hours; five were still alive when I left Karee on Sunday afternoon, April 1. On one I operated, but he died on April 2.The Karee statistics are really the only complete ones which I have as yet been able to obtain. The following are the notes of the cases above alluded to.Besides the five cases of abdominal wounds which had already died, and of which I could get no complete details, the following ten are cases which I saw from twenty-four to thirty hours after they were shot:—
'The number of the wounded was 154, and in fifteen it was considered that the abdominal cavity had been penetrated. Of these patients, five had already died within twenty-four to twenty-eight hours after the injury, and I saw ten who were still alive. Of these nine were left alone, and four died within the next twenty-four or thirty-six hours; five were still alive when I left Karee on Sunday afternoon, April 1. On one I operated, but he died on April 2.
The Karee statistics are really the only complete ones which I have as yet been able to obtain. The following are the notes of the cases above alluded to.
Besides the five cases of abdominal wounds which had already died, and of which I could get no complete details, the following ten are cases which I saw from twenty-four to thirty hours after they were shot:—
Case I.—The point of entrance was 2 inches to the right of the umbilicus, and the bullet was found lying under the skin far back in the left loin. The patient was pulseless, and there was much rigidity of the abdomen, tenderness, and vomiting. He died a few hours later.Case II.—The bullet, coming from the side, had entered the abdomen 4 inches below and behind the right nipple. There was no exit wound. The patient had been vomiting a good deal, but not any blood; the abdomen was very rigid and tender. He was obviously very ill, and died the next morning. The bullet had probably perforated the liver andstomach.Case III.—There was a large wound above the right anterior iliac spine (probably the point of exit), and a small opening behind and near the spine on the same side. There was great tenderness and rigidity of the abdomen. He died a few hours later.Case IV.—In this case there was a transverse wound of the abdomen, the bullet having entered on the right side in the middle of the lumbar region and passed out on the left side, rather higher up and further back. All the symptoms of acute peritonitis were present. The patient died the next morning.Case V.—The bullet had entered the anterior end of the sixth intercostal space on the left side, and was found lying under the skin over the seventh intercostal space on the right side and about 2 inches further back. He had vomited blood on the previous day. The bullet may have perforated thestomach. The epigastrium was somewhat tender, but there were no marked symptoms. On April 1 he was going on well.Case VI.—The place of entrance of the bullet was 1 inch in front of the right anterior superior spine, and of exit behind the left sacro-iliac synchondrosis. There was much hæmorrhage at the time. His condition when I saw him was fair, and there was no marked abdominal tenderness. On April 1 his morning temperature was 101°. There were no signs of general peritonitis, and his condition was good.Case VII.—The bullet had entered from behind, about the tip of the twelfth rib on the left side, and had left about the middle of the epigastrium, and rather to the left of the middle line.Vomiting was still going on, but not of blood. There was much tenderness and rigidity of the abdomen, and he was almost pulseless. On April 1 his general condition was better, but the abdomen was very rigid and tender. (Subsequently died.)Case VIII.—The point of entrance of the bullet was about 2 inches from the anterior end of the seventh left intercostal space, and of exit rather lower down and further back on the right side. The patient said that he had vomited brown fluid after the injury. There was much abdominal pain, but his general condition was fair. On April 1 there was still much pain, but his general condition was good.Case IX.—The bullet had entered about 1½ inch in front of the anterior inferior spine on the right side, had gone directly backwards, and had come out in the buttock. The patient, however, suffered very little. On March 31 there was slight tympanites and tenderness in the right iliac fossa. The bowels acted well, and no blood was passed. On April 1 he was very well, and it was considered very doubtful if any viscus was wounded.Case X.—The point of entrance was in the middle of the right buttock, a little above the level of the trochanter; the exit was through the anterior abdominal wall in the right semilunar line at the level of the umbilicus. The patient was decidedly ill; the abdomen was a good deal distended, and pressure on it caused an escape of gas through the anterior opening. There was a good deal of abdominal tenderness and rigidity. I opened the abdomen outside the right linea semilunaris, and found a perforation in the anterior wall of theascending colon, without any adhesions around, which was easily stitched up. The posterior opening was found about 2 inches lower down, with a piece of omentum firmly adherent to it and completely closing it. As the patient was in a bad state, I thought it better, instead of excising the piece of intestine beyond the holes or tearing off the omentum, to leave the wounds alone, merely cleaning out the peritoneal cavity as well as I could and arranging for free drainage. He rallied from the operation very well, and for twenty-four hours it looked as if he might get better; but he gradually got worse and died on April 2.'
Case I.—The point of entrance was 2 inches to the right of the umbilicus, and the bullet was found lying under the skin far back in the left loin. The patient was pulseless, and there was much rigidity of the abdomen, tenderness, and vomiting. He died a few hours later.
Case II.—The bullet, coming from the side, had entered the abdomen 4 inches below and behind the right nipple. There was no exit wound. The patient had been vomiting a good deal, but not any blood; the abdomen was very rigid and tender. He was obviously very ill, and died the next morning. The bullet had probably perforated the liver andstomach.
Case III.—There was a large wound above the right anterior iliac spine (probably the point of exit), and a small opening behind and near the spine on the same side. There was great tenderness and rigidity of the abdomen. He died a few hours later.
Case IV.—In this case there was a transverse wound of the abdomen, the bullet having entered on the right side in the middle of the lumbar region and passed out on the left side, rather higher up and further back. All the symptoms of acute peritonitis were present. The patient died the next morning.
Case V.—The bullet had entered the anterior end of the sixth intercostal space on the left side, and was found lying under the skin over the seventh intercostal space on the right side and about 2 inches further back. He had vomited blood on the previous day. The bullet may have perforated thestomach. The epigastrium was somewhat tender, but there were no marked symptoms. On April 1 he was going on well.
Case VI.—The place of entrance of the bullet was 1 inch in front of the right anterior superior spine, and of exit behind the left sacro-iliac synchondrosis. There was much hæmorrhage at the time. His condition when I saw him was fair, and there was no marked abdominal tenderness. On April 1 his morning temperature was 101°. There were no signs of general peritonitis, and his condition was good.
Case VII.—The bullet had entered from behind, about the tip of the twelfth rib on the left side, and had left about the middle of the epigastrium, and rather to the left of the middle line.
Vomiting was still going on, but not of blood. There was much tenderness and rigidity of the abdomen, and he was almost pulseless. On April 1 his general condition was better, but the abdomen was very rigid and tender. (Subsequently died.)
Case VIII.—The point of entrance of the bullet was about 2 inches from the anterior end of the seventh left intercostal space, and of exit rather lower down and further back on the right side. The patient said that he had vomited brown fluid after the injury. There was much abdominal pain, but his general condition was fair. On April 1 there was still much pain, but his general condition was good.
Case IX.—The bullet had entered about 1½ inch in front of the anterior inferior spine on the right side, had gone directly backwards, and had come out in the buttock. The patient, however, suffered very little. On March 31 there was slight tympanites and tenderness in the right iliac fossa. The bowels acted well, and no blood was passed. On April 1 he was very well, and it was considered very doubtful if any viscus was wounded.
Case X.—The point of entrance was in the middle of the right buttock, a little above the level of the trochanter; the exit was through the anterior abdominal wall in the right semilunar line at the level of the umbilicus. The patient was decidedly ill; the abdomen was a good deal distended, and pressure on it caused an escape of gas through the anterior opening. There was a good deal of abdominal tenderness and rigidity. I opened the abdomen outside the right linea semilunaris, and found a perforation in the anterior wall of theascending colon, without any adhesions around, which was easily stitched up. The posterior opening was found about 2 inches lower down, with a piece of omentum firmly adherent to it and completely closing it. As the patient was in a bad state, I thought it better, instead of excising the piece of intestine beyond the holes or tearing off the omentum, to leave the wounds alone, merely cleaning out the peritoneal cavity as well as I could and arranging for free drainage. He rallied from the operation very well, and for twenty-four hours it looked as if he might get better; but he gradually got worse and died on April 2.'
The above statistics are particularly valuable, as they give the incidence of abdominal injuries compared with those in general in one definite battle. This amounted to the high number of 15 in 154 or9.74per cent. wounded. I am inclined to think that this is a higher proportion than theaverage of the campaign, and that more of the men must have been exposed in the erect position than was ordinarily the case during the fighting.
The statistics also show that 33.33 per cent. of the patients with abdominal injuries died within from twenty-four to twenty-eight hours, and that the percentage of deaths had risen to 73.33 per cent. at the end of the third day. These numbers again seem high, but in this relation it may be noted that, as a small force only was present, and as all the patients were together, Mr. Cheyne had unusually good opportunities for seeing all the cases.
One other point is doubtful from the report, and that is what percentage of the wounds were caused by bullets of small calibre. In one case it is definitely stated that the wound was large, and in the second that gas escaped from the wound; both of these may have been instances in which a large bullet, or some expanding form, had been employed, and there is no doubt that the use of such projectiles was more common at this stage of the campaign than it was earlier.
Treatment of injuries to the intestine.—Some general rules for the immediate treatment of all cases may be laid down. First, the patients must be removed with as little disturbance as possible, and absolute starvation must be insisted upon. If the patients be suffering from severe shock, hypodermic injections of strychnine should be administered, or possibly some stimulant by the rectum.
After a battle, when these cases may be brought in in considerable number, they should be collected and placed in the same tent. The objection to congregating a number of severely wounded patients together must be disregarded in the face of the manifest advantage of being able to treat all alike in the matter of feeding. After the battles of the Kimberley relief force, Surgeon-General Wilson, at my request, had all the abdominal cases placed in a large marquee, where we were able to carefully watch the whole of the patients from hour to hour, and little chance existed for any indiscretion on the part of the patients in the way of eating or drinking.
If possible, the patients should be kept absolutely quiet until they are evidently out of danger. A week's stay at Orange River sufficed for this object in the cases referred to. The avoidance of transport is manifestly of extreme prognostic importance.
When feeding is commenced at the end of twenty-four or thirty-six hours, it must be in the form at first of warm water, then milk administered in tea-spoonfuls only.
In doubtful cases the use of morphia must be avoided.
Operative treatment is required in a certain number of the cases, but in the majority of instances we are met with the extreme difficulty that in a very large proportion of the occasions upon which these wounds are received an exploratory abdominal section is not warranted in consequence of the conditions under which it has to be performed.
A word must be added as to these difficulties; they are in part purely of an administrative nature, partly surgical. After a great battle the wounded are numerous, and amongst them a very considerable proportion of the wounds and injuries are of such a nature as to do extremely well if promptly dealt with, and each of these makes small demands on the time of the staff. Abdominal operations, on the other hand, are unsatisfactory from a prognostic point of view, and their performance requires much time and the assistance of a considerable number of the men, who are obliged to neglect the treatment of the more promising cases for those of doubtful issue. This difficulty, although not surgical in its nature, is nevertheless a practical one of great importance and appeals strongly to the Principal Medical Officers in charge of the arrangements. It is only to be avoided by an increase of the staff, which is not likely to be made except on very special occasions.
Other difficulties are purely surgical. First, the difficulty of diagnosing with certainty a perforating lesion. In the presence of the fact that many incomplete lesions follow wounds crossing the intestinal area, and that these give rise to modified symptoms, I believe this determination to be impossible without the aid of an exploratory incision. Here we are met with the remaining surgical difficulties—disadvantages such as the absence of sufficient aid to the operatingsurgeon, difficulties connected with the temperature, wind, and dust, and as to the subsequent treatment of the patient. Again difficulty in obtaining the most important adjunct, suitable water, or indeed any water in a sufficient quantity.
It is of course obvious that conditions may exist in which all these troubles may be avoided. Again, the practical difficulty adverted to above does not come in the way when a single man happens to sustain an abdominal wound on the march. Under such circumstances an exploration may be not only justifiable, but obligatory, and the general rules of surgery must be followed rather than such incomplete indications as are suggested below.
My own experience led me to the following conclusions:
1. A wound in the intestinal area should be watched with care. In the face of the numerous recoveries in such cases, habitual abdominal exploration is not justified, under the conditions usually prevailing in the field.
2. The very large class of patients excluded by this rule from operation leads us to a smaller and less satisfactory number to be divided into two categories:
Patients who die during the first twelve hours. The whole of these are naturally unfit for operation, and their general condition when seen often precludes any thought of it.
Patients with very severe injuries, as evidenced by the escape of fæces, or with wounds from flank to flank or taking an antero-posterior course in the small intestinal area. These patients die, and the majority of them will always die whether operated upon or not. The undertaking of operations upon them is unpleasant to the surgeon, as being unlikely to be attended with any great degree of success, whence the impression may gain ground that patients are killed by the operations. None the less, I think these operations ought to be undertaken when the attendant conditions allow, and it is from this class of case that the real successes will be drawn in the future. The history of such injuries, after all, corresponds exactly with what we were long familiar with in traumatic ruptures in civil practice, and now know may be avoided by a sufficiently early interference. The whole question here is one of time, and this will always be the trouble in military work.
3. The expectant attitude which is obligatory under the above rules in doubtful cases, brings us face to face with a large proportion of patients in the early or late stage of peritoneal septicæmia. These cases run on exactly the same lines as those in which the same condition is secondary to spontaneous perforation of the bowel, in which we consider it our duty to operate, and in which a definite percentage of recoveries is obtained. Hence another unpleasant duty is here imposed upon the surgeon. Two such cases on which I operated are recounted above, and although I cannot say they give much encouragement, I should add that in the only one I left untouched, I regretted my want of courage for the five days during which the patient continued to carry on a miserable existence.
4. The treatment of the cases in which an expectant attitude is followed by the advent of localised suppuration presents no difficulty; simple incision alone is needed, and healing follows.
As a rule this is a late condition. In one case of injury to the ascending colon recounted above, however, considerable local escape of fæces had occurred, and a successful result was obtained by a local incision on the third day without suture of the bowel. In this case I believe the wound in the bowel to have been of the nature of a long slit, but the surrounding adhesions were so firm as to render any interference with them a great risk, and a successful result was obtained at the cost of a somewhat prolonged recovery. I am convinced that the best course was followed here. (No. 131.)
When the suppuration was of a less acute character, it was generally advisable to allow the pus to make its way towards the surface before interference.
5. Cases of injury to the colon in which the posterior aspect is involved should be treated by free opening up of the wound, and either by suture of the bowel or else its fixation to the surface. I operated on one such case, and although the patient eventually died on the eighth day, from septicæmia, he certainly had a chance. Two cases where the opening looked so free that one almost thought the wound could be regarded as a lumbar colotomy did badly; in both infection of the pleuratook place, besides extension of suppuration into the retro-peritoneal areolar tissue. In the future I should always feel inclined to enlarge such wounds and bring the bowel to the surface.
As regards actual technique the majority of the wounds are particularly well suited to suture; three stitches across the opening and one at either end of the resulting crease sufficed to close the opening effectively. The openings in the small intestine were not as a rule difficult to find, on account of the ecchymosis which surrounded them. From what I have seen stated in the reports given by other surgeons, there seems to have been more difficulty in discovering wounds in the large gut. Under ordinary circumstances the only instruments specially needed are a needle and some silk. At my first two operations, as my instruments had gone astray, the wounds were readily closed by a needle and cotton borrowed from the wife of a railway porter.
If aseptic sponges or pads are not available, boiled squares of ordinary lint may be employed for the belly, and towels wrung out of 1 to 20 carbolic acid solution used to surround the field of operation. Whenever there is any likelihood of the necessity for operations, water boiled and filtered should be kept ready in special bottles.
When septic peritonitis was already present, the ordinary procedure of dry mopping, followed by irrigation, was necessary, before closing the belly.
The after-treatment should be on the usual lines as to feeding, &c.
I am unaware to what degree success followed intestinal operations generally during the campaign. I saw only one case in which the small intestine had been treated by excision and the insertion of a Murphy's button in which a cure followed: this case was in the Scottish Royal Red Cross hospital under the care of Mr. Luke. I heard of two cases in which the large intestine was successfully sutured, and of one other in which recovery followed the removal of a considerable length of the small bowel for multiple wounds.
In concluding these most unsatisfactory remarks, I should add that the impressions are those that were gained as theresult of the conditions by which we were bound in South Africa, and which might recur even in a more civilised region. Under really satisfactory conditions nothing I saw in my South African experience would lead me to recommend any deviation from the ordinary rules of modern surgery, except in so far as I should be more readily inclined to believe that wounds in certain positions already indicated might occur without perforation of the bowel when produced by bullets of small calibre; and further in cases where I believed the fixed portion of the large bowel was the segment of the alimentary canal that had been exposed to risk, I should not be inclined to operate hastily.
A careful consideration of the whole of the cases that I saw leaves me with the firm impression that perforating wounds of the small intestine differ in no way in their results and consequences when produced by small-calibre bullets, from those of every-day experience, although when there is reason merely to suspect their presence an exploration is not indicated under circumstances that may add a fresh danger to the patient.
Wounds of the urinary bladder.—Perforating wounds of the bladder are the injuries nearest akin to those we have just considered, but a great gulf separates them, in so far as the escape of a few drops or even a considerable quantity of normal urine does not necessarily mean peritoneal infection. The difference in this particular was very forcibly demonstrated in my experience, since an uncomplicated perforation of the bladder in the intra-peritoneal portion of the viscus proved to be an injury that not infrequently recovered spontaneously, I believe in a considerable proportion of the cases.
I include only one such case in my list because it was the only example which happened to be under my personal observation during its whole course, but from time to time I was shown several others in which the position of the external apertures and the transient presence of hæmaturia left little doubt as to the nature of the injury. The case recounted above, No. 190, is of especial interest, since the patient recovered from an injury which involved both the bladder and a fixed portion of the large intestine in contact with its posterior surface.
In another, No. 194, a transient inflammatory thickening pointed to a local inflammation of a non-infective character, since no suppuration ensued, and this may have been a case of extra-peritoneal wound; on the other hand, the bladder may have entirely escaped injury. In wounds of the portions of the viscus not clad in peritoneum, as a rule, a very different prognosis obtains. Two typical cases are related, which I believe fairly represent the general results which follow when the bladder is either wounded behind the symphysis or at the base. The first case, No. 195, exemplifies a very characteristic form of wound when small-calibred bullets are concerned. The bullet, taking a course more or less parallel to that of the wall of the viscus, cut a long slit in its anterior wall. This bullet in its onward passage comminuted the horizontal ramus of the pubes, and lodged in the thigh. Into the latter region the greater part of the extravasated urine escaped. I think the history of this case fully shows that I made a blunder in not performing a proper exploration, instead of contenting myself with an incision in the thigh. My only excuse was that the patient at the time I saw him was in a very collapsed state, and a severe grade of abdominal distension suggested that septic peritonitis was already in an advanced stage. In point of fact, the patient at once improved, sufficiently so to be able to undergo a second exploration at a later date by Mr. Hanwell at the Base, only dying of septicæmia at the end of twenty-one days. Even a free supra-pubic vent might, I believe, have given him a chance of life.
When the perforation was at the base of the bladder, however, the prognosis was very bad, and, as far as I know, not a single patient escaped death. The increase of risk in an extra-peritoneal wound of this viscus is indeed very great, while an intra-peritoneal perforation may be considered an injury of lesser severity, provided the urine be of normal character.
(194a)Possible wound of the bladder.—Wounded at Magersfontein.Entry(Mauser), immediately above the symphysis pubis;exit, in the buttock, behind the tip of the left great trochanter. The man was struck while advancing, and fell, thinking at the time 'that he was struck in the foot.' He lay twelve hours onthe field, and passed water for the first time when the bearer removed him. During the next two days he passed urine only twice, and no blood was noticed. The bowels acted on the evening of the third day. When seen on the fourth day he complained of aching pain in the lower part of the belly, and a concentric patch of tender induration extended for about 1½ inch around the wound. The abdominal wall was moving well. The tongue was clean and moist. There was no blood in the urine, and micturition was not frequent. Temperature 99.4°. Pulse 80, good strength. The patient was then sent to the Base. At the end of seventeen days there was still a little tenderness in the left iliac fossa; but the man was otherwise well, and at the end of a month he was sent home.(195)Extra-peritoneal wound of the bladder.—Wounded at Magersfontein.Entry(Mauser), at the fore part of the right buttock. No exit. The patient was seen on the third day. He had an expression of extreme anxiety, and complained of very great pain in the abdomen and thigh. The abdomen was greatly distended and tympanitic, and the left thigh and groin were very much swollen and œdematous, with some redness of surface. Temperature 100°, pulse 120. No sickness, tongue moist, bowels confined. Retention of urine. The condition of the patient was very grave; but he was anæsthetised, clear urine was withdrawn from the bladder by catheter, and an incision was made into the thigh just below the inner third of Poupart's ligament, where fluctuation was evident. Two pints of bloody urine were evacuated, and when a finger was introduced it passed over a fracture of the pubes into the pelvis, but not into the peritoneal cavity. In view of the patient's condition it was not thought wise to proceed further, and he somewhat improved later, and was sent to the Base. Loss of power in the right lower extremity pointed to injury to the anterior crural nerve.On the patient's arrival at Wynberg there were signs of local peritonitis in the lower half of the abdomen, and all his urine was passed from the wound in the left thigh. Some days later this wound was enlarged to allow of the freer exit of pus, and a fragment of bone was removed. The wound granulated healthily, but the man steadily emaciated and lost ground, with signs of chronic septicæmia, and he died on the twenty-first day. At thepost-mortemexamination a transverse wound of the anterior wall of the bladder behind the pubes, below the peritoneal reflexion, was found gaping somewhat widely, and 2 inches inlength. There was little sign of previous peritonitis. The retained bullet was discovered beneath the femoral vessels in the left thigh.(196)Extra-peritoneal perforation of the bladder.—Wounded at Paardeberg.Entry(Mauser), 3 inches above the left tuber ischii;exit, above the symphysis, immediately over the right margin of the penis. The patient was retiring to fetch ammunition when shot. Urine was noted to escape from both apertures the day after, and this continued until he was sent down to the Base on the fourteenth day. The patient was then considerably emaciated, complained of great pain, especially down the left thigh (sciatic nerve), the temperature averaged 100°, the pulse 80, tongue clean and moist, bowels acted regularly, no sign of injury to the rectum. He was taking food fairly, but was very sleepless. Urine was passed per urethram, and also escaped by both wounds. The abdomen was flaccid and sunken, respiratory movements being confined to the upper half.As there was evidence of considerable infiltration in the buttock, the original entry wound was enlarged, and a catheter was tied into the bladder. Little change occurred in the symptoms and the local condition, urine and pus continued to escape freely from the posterior wound, and the patient gradually sank, dying on the thirty-eighth day. At thepost-mortemexamination the peritoneum was found intact and unaltered, but there was extensive pelvic cellulitis around the bladder, a large slough and some pus lying in the cavum Retzii. An aperture of entry still open existed in the centre of the anterior wall of the bladder, and a patent exit opening at the base of the trigone. The bullet had passed out of the pelvis by the great sciatic notch.
(194a)Possible wound of the bladder.—Wounded at Magersfontein.Entry(Mauser), immediately above the symphysis pubis;exit, in the buttock, behind the tip of the left great trochanter. The man was struck while advancing, and fell, thinking at the time 'that he was struck in the foot.' He lay twelve hours onthe field, and passed water for the first time when the bearer removed him. During the next two days he passed urine only twice, and no blood was noticed. The bowels acted on the evening of the third day. When seen on the fourth day he complained of aching pain in the lower part of the belly, and a concentric patch of tender induration extended for about 1½ inch around the wound. The abdominal wall was moving well. The tongue was clean and moist. There was no blood in the urine, and micturition was not frequent. Temperature 99.4°. Pulse 80, good strength. The patient was then sent to the Base. At the end of seventeen days there was still a little tenderness in the left iliac fossa; but the man was otherwise well, and at the end of a month he was sent home.
(195)Extra-peritoneal wound of the bladder.—Wounded at Magersfontein.Entry(Mauser), at the fore part of the right buttock. No exit. The patient was seen on the third day. He had an expression of extreme anxiety, and complained of very great pain in the abdomen and thigh. The abdomen was greatly distended and tympanitic, and the left thigh and groin were very much swollen and œdematous, with some redness of surface. Temperature 100°, pulse 120. No sickness, tongue moist, bowels confined. Retention of urine. The condition of the patient was very grave; but he was anæsthetised, clear urine was withdrawn from the bladder by catheter, and an incision was made into the thigh just below the inner third of Poupart's ligament, where fluctuation was evident. Two pints of bloody urine were evacuated, and when a finger was introduced it passed over a fracture of the pubes into the pelvis, but not into the peritoneal cavity. In view of the patient's condition it was not thought wise to proceed further, and he somewhat improved later, and was sent to the Base. Loss of power in the right lower extremity pointed to injury to the anterior crural nerve.
On the patient's arrival at Wynberg there were signs of local peritonitis in the lower half of the abdomen, and all his urine was passed from the wound in the left thigh. Some days later this wound was enlarged to allow of the freer exit of pus, and a fragment of bone was removed. The wound granulated healthily, but the man steadily emaciated and lost ground, with signs of chronic septicæmia, and he died on the twenty-first day. At thepost-mortemexamination a transverse wound of the anterior wall of the bladder behind the pubes, below the peritoneal reflexion, was found gaping somewhat widely, and 2 inches inlength. There was little sign of previous peritonitis. The retained bullet was discovered beneath the femoral vessels in the left thigh.
(196)Extra-peritoneal perforation of the bladder.—Wounded at Paardeberg.Entry(Mauser), 3 inches above the left tuber ischii;exit, above the symphysis, immediately over the right margin of the penis. The patient was retiring to fetch ammunition when shot. Urine was noted to escape from both apertures the day after, and this continued until he was sent down to the Base on the fourteenth day. The patient was then considerably emaciated, complained of great pain, especially down the left thigh (sciatic nerve), the temperature averaged 100°, the pulse 80, tongue clean and moist, bowels acted regularly, no sign of injury to the rectum. He was taking food fairly, but was very sleepless. Urine was passed per urethram, and also escaped by both wounds. The abdomen was flaccid and sunken, respiratory movements being confined to the upper half.
As there was evidence of considerable infiltration in the buttock, the original entry wound was enlarged, and a catheter was tied into the bladder. Little change occurred in the symptoms and the local condition, urine and pus continued to escape freely from the posterior wound, and the patient gradually sank, dying on the thirty-eighth day. At thepost-mortemexamination the peritoneum was found intact and unaltered, but there was extensive pelvic cellulitis around the bladder, a large slough and some pus lying in the cavum Retzii. An aperture of entry still open existed in the centre of the anterior wall of the bladder, and a patent exit opening at the base of the trigone. The bullet had passed out of the pelvis by the great sciatic notch.
The above remarks and cases sufficiently set forth the prognosis in these injuries. For the intra-peritoneal lesions an expectant plan of treatment may be followed by uncomplicated recovery. Mention has already been made of a case in which a Mauser bullet was retained in the bladder and was subsequently passed per urethram. In such a case a cystotomy would be indicated were the bullet discovered in the viscus.
As to extra-peritoneal injuries it is difficult to lay down guiding lines. I believe the ideal treatment would be a supra-pubic cystotomy and drainage of the bladder by a Sprengel's pump apparatus, such as we employ at home. Under these circumstances, with the possibility of keeping the bladder actuallyempty, I believe good results might be obtained. Certainly drainage of the bladder by a catheter tied in proved worse than useless, and I very much doubt whether a simple supra-pubic opening would give any better results under the circumstances under which a patient has to be treated in a Field hospital.
Cases might, however, occur in which oblique passage of the bullet cuts a groove and makes a large opening in the peritoneum-clad portion of the viscus. Under satisfactory conditions a laparotomy would be here indicated. I take it that this condition would most probably be accompanied by retention of bloody urine, which fact would arouse suspicion.
Wounds of the kidney.—Tracks implicating the kidneys were of comparatively common occurrence. As uncomplicated injuries they healed rapidly, and without producing any serious symptoms beyond transient hæmaturia.
The nature of the lesion appeared to vary with the direction of the wound. In many cases a simple puncture no doubt alone existed, an injury no more to be feared than the exploratory punctures often made for surgical purposes. In other cases the wounds may have been of the nature of notches and grooves.
Two of the cases recounted below were of a more severe variety; in one (No. 201) both kidneys were implicated by symmetrical wounds of the loin, and in the case of the right organ a transverse rupture was produced, which was followed by the development of a hydro-nephrosis, and later by suppuration. This injury was probably the result of a wound from a short range, as the patient was one of those wounded in the early part of the day at the battle of Magersfontein. It was complicated by a wound of the spleen and an injury to the spinal cord producing incomplete paraplegia accompanied by retention of urine. The last complication was responsible for the death of the patient, since ascending infection from the bladder led to the development of pyo-nephrosis and death from secondary peritonitis.
Case 202 is an instance of a transverse wound of the upper part of the abdominal cavity; it is impossible to say what further complications were present. The early development of a tympanitic abscess suggested an injury to the colon, but this was not by any means certain. The condition of the kidney was very likely similar to that in the last case, but the ultimate recovery of the patient left this a matter of doubt. The case was also one dependent on a short-range wound, since the patient, one of the Scandinavian contingent, was wounded at Magersfontein during close fighting.
The common history of the symptoms after a wound of the kidney was moderate hæmorrhage from the organ, persisting for two to four days. In one of the cases recounted below the hæmaturia was accompanied by the passage of ureteral clots, but this was not a common occurrence.
For the sake of comparison I have included one case of wound of the kidney from a large bullet, in which death was due to internal hæmorrhage. In this instance the injury was a complex one, the lung certainly, and the back of the liver probably, being concurrently injured. None the less if the same track had been produced by a bullet of small calibre I believe the injury would not have proved a fatal one. I never saw such free renal hæmorrhage in any of the Mauser or Lee-Metford wounds.
(197)Wound of right kidney.—Wounded at Modder River while lying in the prone position; retired 100 yards at the double with his company, and walked a further 1½ mile. There was very slight bleeding.Entry(Mauser), in the tenth right intercostal space in the mid-axillary line;exit, in eleventh interspace, 2 inches from the spinous processes. Cylindrical blood-clots, 3 inches in length, were passed on the first two occasions of micturition after the accident, and the urine contained blood. For four days he could only lie on the wounded side. When seen on the third day the urine was normal, and there were no signs of injury to either thoracic or abdominal viscera. He returned to England well at the end of a month.(198)Wound of right kidney.—Wounded at Modder River while kneeling to dress another man's wound.Entry(Mauser), in the seventh right intercostal space in the nipple line;exit,1 inch to the right of the twelfth dorsal spine. The man was carried off the field, and during the first day vomited frequently. For two days there was blood in his urine, and he passed water four to five times daily. He returned to duty at the end of three weeks.(199)Wound of the left kidney.—Wounded at Magersfontein.Entry(Mauser), 2 inches to the left and 1 inch below the left nipple. No exit. Lying in prone position when struck. Bloody urine was passed at normal intervals for four days, when the hæmaturia ceased. No thoracic signs, and no other sign of abdominal injury. There was tenderness in the left loin below the twelfth rib for some days, possibly over the position of the bullet, but the latter was neither localised nor removed.(200)Wound of the right kidney.—Wounded at Magersfontein while retiring on his feet.Entry(Mauser), immediately to the right of the second lumbar spinous process; bullet retained and lay beneath margin of ninth right costal cartilage. The man passed urine containing blood twelve times during the first day, and hæmaturia continued until the evening of the third day. On the third day the belly was tumid and did not move well; there was no dulness in the right flank. Pulse 120, fair strength. Temperature 99°. Respirations 20. Tongue moist, bowels confined for four days. The fifth day the pulse fell to 76, and the bowels were moved by an enema. Great tenderness over bullet. The tenderness persisted over the bullet and also in the right flank until the tenth day, when the bullet was removed. At the end of a month the patient returned to England well but during the third week there was occasionally blood in the urine.(201)Wound of both kidneys (rupture of right) and spleen.—Wounded at Magersfontein.Entry(Mauser), (a) 1 inch to right of second lumbar spinous process; (b) above angle of left ninth rib:exits, (a) 1 inch internal to right anterior superior iliac spine; (b) in seventh intercostal space in mid-axillary line. The wound on the right side gave rise to a lesion of the lumbar bulb (see p. 315), and the patient suffered throughout with retention. There was complete paralysis of the right lower extremity, both motor and sensory. For ten days there was hæmaturia, and very severe cystitis developed, while the patient suffered with severe abdominal pain. The cystitis persisted, also retention, which gradually gave way to dribbling, while irregular rise of temperature and tenderness in the loins pointed to ascending inflammationin the ureters. The patient gradually lost ground, and a month later suddenly developed signs of peritonitis, severe vomiting, distension, and dulness in the right flank; and in two days he died.At thepost-mortemexamination the following condition was found:—On the right side general pleural adhesions, recent lymph over ascending colon and cæcum, ࡍvj of bloody fluid in a localised cavity between colon, kidney, stomach, and liver. Lower quarter of right kidney in half its width separated from main part of organ, yellow in colour, and enveloped in disintegrating clot. Blood-staining of psoas sheath; no injury to vertebral column or to bowel detected.On the left side recent pleural adhesions and consolidation of base of lung, rent of diaphragm; spleen soft and disorganised and presenting a yellow cicatrix at its upper end, and at antero-external aspect of left kidney was a soft yellow puckered spot about the size of a florin, dipping 3/4 of an inch into the organ, which was otherwise healthy, beyond congestion. The capsules of both kidneys were adherent, but there was no sign of suppuration.(202)Wound of right kidney. Traumatic hydronephrosis.—Wounded at Magersfontein.Entry(Lee-Metford), in the eleventh intercostal space in the posterior axillary line;exit, in the tenth right interspace, in mid axillary line. The patient was in the prone position when struck, and lay on the field from 5a.m.until 6p.m.There was no sickness, and the bowels did not act. When seen on the fourth day he was cheerful, but in some pain. The abdominal wall moved well, but was rigid; there was some general distension, and very marked local distension of the gastric area extending across to the right, so that a depressed band extended between the upper and lower parts of the belly. There was marked local dulness in the right flank, which did not shift on movement; the abdomen was elsewhere tympanitic. Tongue furred, bowels confined; there has been no sickness, and no hæmatemesis. Urine normal, and in good quantity. Temperature 100°. Pulse 84, good strength. There was impairment of sensation in the area of distribution of the external cutaneous and crural branch of the genito-crural nerves.On the sixth day the bowels acted, after the administration of ℥j of sulphate of magnesia, and the distension was much lessened, although the belly retained its unusual appearance. The dulness in the flank was unaltered. Temperature 100.8°, pulse 92.A week later the man was much improved, suffering no pain. Temperature ranged from 99 to 100°, and the pulse about 80. The abdomen was normal in appearance, except for general prominence of the right thorax in the hepatic area.During the third week a large tympanitic abscess developed at the aperture of exit, and this was opened (Mr. S. W. F. Richardson) through the chest, and a large collection of foul-smelling pus, but no fæcal matter, evacuated. The patient again improved, but a fortnight later a swelling and apparent signs of local peritonitis developed in the right inguinal and lower umbilical and lumbar regions. An incision made over this, however, disclosed a normal peritoneal cavity and was closed.At the end of ten weeks the patient was sent to the Base hospital; a large firm swelling was then evident, extending from the liver to the inguinal region, and nearly to the median line. This gradually increased until it filled half the belly; it was at first thought to be a retro-peritoneal hæmatoma (similar to that described in case 194), but it became quite soft and fluctuating, and was then tapped, and ℥50 of blood-stained fluid, which proved to be urine, were removed. The urine rapidly reaccumulated, and the cavity was then laid freely open. Urine continued to discharge in large quantity for two months, the man meanwhile remaining well, and passing a somewhat variable daily quantity of urine (℥xxiv-℥lx).At the end of six months the wound had healed, and the man was serving as an orderly in the hospital.(203)Wound of right kidney and lung.—Wounded near Paardekraal, while crawling on hands and knees.Entry(Martini-Henry, or small bullet making lateral impact), just above the right nipple, opening ragged and large, bullet retained. There was very severe shock, accompanied by vomiting, but no hæmatemesis. Later there was some hæmoptysis. Pulse 120, respirations 48.Twenty-four hours later the vomiting had ceased; the patient had passed a restless night, in spite of an injection of morphia. He lay on his right side, pale and collapsed, but answered questions and was quite collected. Pulse imperceptible, respirations 56; the abdomen moved freely. The urine had been passed twice, and was chiefly blood. The patient died shortly afterwards, apparently mainly from internal hæmorrhage, although restlessness was not a prominent feature. As the Column was on the march no autopsy was possible.
(197)Wound of right kidney.—Wounded at Modder River while lying in the prone position; retired 100 yards at the double with his company, and walked a further 1½ mile. There was very slight bleeding.Entry(Mauser), in the tenth right intercostal space in the mid-axillary line;exit, in eleventh interspace, 2 inches from the spinous processes. Cylindrical blood-clots, 3 inches in length, were passed on the first two occasions of micturition after the accident, and the urine contained blood. For four days he could only lie on the wounded side. When seen on the third day the urine was normal, and there were no signs of injury to either thoracic or abdominal viscera. He returned to England well at the end of a month.
(198)Wound of right kidney.—Wounded at Modder River while kneeling to dress another man's wound.Entry(Mauser), in the seventh right intercostal space in the nipple line;exit,1 inch to the right of the twelfth dorsal spine. The man was carried off the field, and during the first day vomited frequently. For two days there was blood in his urine, and he passed water four to five times daily. He returned to duty at the end of three weeks.
(199)Wound of the left kidney.—Wounded at Magersfontein.Entry(Mauser), 2 inches to the left and 1 inch below the left nipple. No exit. Lying in prone position when struck. Bloody urine was passed at normal intervals for four days, when the hæmaturia ceased. No thoracic signs, and no other sign of abdominal injury. There was tenderness in the left loin below the twelfth rib for some days, possibly over the position of the bullet, but the latter was neither localised nor removed.
(200)Wound of the right kidney.—Wounded at Magersfontein while retiring on his feet.Entry(Mauser), immediately to the right of the second lumbar spinous process; bullet retained and lay beneath margin of ninth right costal cartilage. The man passed urine containing blood twelve times during the first day, and hæmaturia continued until the evening of the third day. On the third day the belly was tumid and did not move well; there was no dulness in the right flank. Pulse 120, fair strength. Temperature 99°. Respirations 20. Tongue moist, bowels confined for four days. The fifth day the pulse fell to 76, and the bowels were moved by an enema. Great tenderness over bullet. The tenderness persisted over the bullet and also in the right flank until the tenth day, when the bullet was removed. At the end of a month the patient returned to England well but during the third week there was occasionally blood in the urine.
(201)Wound of both kidneys (rupture of right) and spleen.—Wounded at Magersfontein.Entry(Mauser), (a) 1 inch to right of second lumbar spinous process; (b) above angle of left ninth rib:exits, (a) 1 inch internal to right anterior superior iliac spine; (b) in seventh intercostal space in mid-axillary line. The wound on the right side gave rise to a lesion of the lumbar bulb (see p. 315), and the patient suffered throughout with retention. There was complete paralysis of the right lower extremity, both motor and sensory. For ten days there was hæmaturia, and very severe cystitis developed, while the patient suffered with severe abdominal pain. The cystitis persisted, also retention, which gradually gave way to dribbling, while irregular rise of temperature and tenderness in the loins pointed to ascending inflammationin the ureters. The patient gradually lost ground, and a month later suddenly developed signs of peritonitis, severe vomiting, distension, and dulness in the right flank; and in two days he died.
At thepost-mortemexamination the following condition was found:—On the right side general pleural adhesions, recent lymph over ascending colon and cæcum, ࡍvj of bloody fluid in a localised cavity between colon, kidney, stomach, and liver. Lower quarter of right kidney in half its width separated from main part of organ, yellow in colour, and enveloped in disintegrating clot. Blood-staining of psoas sheath; no injury to vertebral column or to bowel detected.
On the left side recent pleural adhesions and consolidation of base of lung, rent of diaphragm; spleen soft and disorganised and presenting a yellow cicatrix at its upper end, and at antero-external aspect of left kidney was a soft yellow puckered spot about the size of a florin, dipping 3/4 of an inch into the organ, which was otherwise healthy, beyond congestion. The capsules of both kidneys were adherent, but there was no sign of suppuration.
(202)Wound of right kidney. Traumatic hydronephrosis.—Wounded at Magersfontein.Entry(Lee-Metford), in the eleventh intercostal space in the posterior axillary line;exit, in the tenth right interspace, in mid axillary line. The patient was in the prone position when struck, and lay on the field from 5a.m.until 6p.m.There was no sickness, and the bowels did not act. When seen on the fourth day he was cheerful, but in some pain. The abdominal wall moved well, but was rigid; there was some general distension, and very marked local distension of the gastric area extending across to the right, so that a depressed band extended between the upper and lower parts of the belly. There was marked local dulness in the right flank, which did not shift on movement; the abdomen was elsewhere tympanitic. Tongue furred, bowels confined; there has been no sickness, and no hæmatemesis. Urine normal, and in good quantity. Temperature 100°. Pulse 84, good strength. There was impairment of sensation in the area of distribution of the external cutaneous and crural branch of the genito-crural nerves.
On the sixth day the bowels acted, after the administration of ℥j of sulphate of magnesia, and the distension was much lessened, although the belly retained its unusual appearance. The dulness in the flank was unaltered. Temperature 100.8°, pulse 92.
A week later the man was much improved, suffering no pain. Temperature ranged from 99 to 100°, and the pulse about 80. The abdomen was normal in appearance, except for general prominence of the right thorax in the hepatic area.
During the third week a large tympanitic abscess developed at the aperture of exit, and this was opened (Mr. S. W. F. Richardson) through the chest, and a large collection of foul-smelling pus, but no fæcal matter, evacuated. The patient again improved, but a fortnight later a swelling and apparent signs of local peritonitis developed in the right inguinal and lower umbilical and lumbar regions. An incision made over this, however, disclosed a normal peritoneal cavity and was closed.
At the end of ten weeks the patient was sent to the Base hospital; a large firm swelling was then evident, extending from the liver to the inguinal region, and nearly to the median line. This gradually increased until it filled half the belly; it was at first thought to be a retro-peritoneal hæmatoma (similar to that described in case 194), but it became quite soft and fluctuating, and was then tapped, and ℥50 of blood-stained fluid, which proved to be urine, were removed. The urine rapidly reaccumulated, and the cavity was then laid freely open. Urine continued to discharge in large quantity for two months, the man meanwhile remaining well, and passing a somewhat variable daily quantity of urine (℥xxiv-℥lx).
At the end of six months the wound had healed, and the man was serving as an orderly in the hospital.
(203)Wound of right kidney and lung.—Wounded near Paardekraal, while crawling on hands and knees.Entry(Martini-Henry, or small bullet making lateral impact), just above the right nipple, opening ragged and large, bullet retained. There was very severe shock, accompanied by vomiting, but no hæmatemesis. Later there was some hæmoptysis. Pulse 120, respirations 48.
Twenty-four hours later the vomiting had ceased; the patient had passed a restless night, in spite of an injection of morphia. He lay on his right side, pale and collapsed, but answered questions and was quite collected. Pulse imperceptible, respirations 56; the abdomen moved freely. The urine had been passed twice, and was chiefly blood. The patient died shortly afterwards, apparently mainly from internal hæmorrhage, although restlessness was not a prominent feature. As the Column was on the march no autopsy was possible.
The treatment of uncomplicated wounds of the kidney consisted in the ensurance of rest, either alone, or with the administration of opium if the hæmaturia was severe. The after-treatment in the event of the development of hydronephrosis is on ordinary lines. Tapping, or incision followed by extirpation of the injured viscus, if the less severe procedures failed. I never saw a case where renal hæmorrhage suggested the removal of the kidney as a primary step, and much doubt whether such a case is likely to be met with, as the result of a wound from a bullet of small calibre.
Wounds of the liver.—Wounds of the liver were, I believe, responsible for more cases of death from primary hæmorrhage than those of the kidney. I heard of a few cases in which this occurred, although I never saw one. Case 204 is of considerable interest as illustrating the result of an injury to one of the large bile ducts. Putting the deaths from primary hæmorrhage on one side, the prognosis in hepatic wounds was as good as in those of the kidneys. A few fairly uncomplicated cases are quoted below, but wounds of the liver occurred in connection with a large number of other injuries both of the chest and abdomen, and except in the case of wound of the stomach, recorded on page 425, No. 164, and in case 188, I never saw any troublesome consequences ensue.
Nature of the lesions.—I never saw any case of so-called explosive lesion of the liver, such as have been described from experimental results; this may have been due to the fact that such patients rapidly expired, but such were never admitted into the hospitals.
The most favourable cases were those in which a simple perforation was effected; such were usually attended by a practical absence of symptoms, unless a large bile duct had been implicated, when a temporary biliary fistula resulted.
Biliary fistulæ were, however, much more common when the bullet scored the surface of the organ. One such case is recounted under the heading of injuries to the stomach, No. 164. Here a deep gaping cleft with coarsely granular margins extended the whole antero-posterior length of the under surface of the left lobe, and the escape of bile wasfree. This was the nearest approach to one of the so-called explosive injuries I met with.
Case 207 is an example of a superficial injury from a bullet possibly of small calibre in which a superficial groove was followed by temporary escape of bile, and it is of interest to note a very similar condition in a shell injury (No. 210) recorded on p. 477.
Although both these cases recovered, I think notching and superficial grooving must be considered much more serious injuries than pure perforation. (See case 188, p. 442.)
The symptoms observed in these injuries have been already indicated in the above description of the nature of the lesions. They consisted in the pure perforations of practically nothing, in the grooves or the perforations implicating a large duct in the escape of bile. In two of the cases in which a biliary fistula was present transient jaundice was noticed.
In many cases the accompanying wound of the diaphragm gave rise to much discomfort; again, in the transverse wounds the action of the heart was often affected by the local cardiac shock accompanying the injury. In one case in which the colon was at the same time wounded (No. 188), an abscess formed at the site of the hepatic wound, as might have been expected.
As uncomplicated injuries, these wounds were little to be feared. Except as a source of hæmorrhage in rapidly dying patients, I never heard of a fatality. As a complication of other injuries, however, the wound of the liver, as has been shown, was sometimes of importance. It was remarkable in case 204 how little trouble the biliary fistula gave rise to, although the bile was discharged across the pleural cavity.
The treatment consisted in rest, and morphia in the cases of suspected progressive hæmorrhage, or in the presence of great pain. In cases where bile was escaping, it was important to ensure a free vent for the secretion.
(204)Wound of liver. Biliary fistula.—Wounded at Magersfontein.Entry(Lee-Metford), below the seventh rib, in the left nipple line;exit, through the eighth rib, in the mid axillary line on the right side. The patient lay for seventeen hours on thefield, during which time the bowels acted once, but there was no sickness. The bowels then remained confined. When seen on the third day the abdomen was normal and the chest resonant throughout on both sides; bile to the amount of some ounces escaped from the wound on the right side. Suffering no pain; temperature 99°, pulse 100. The bowels acted freely the following day.During the next fortnight there was little change; ℥ii-iij of bile escaped daily, and there was occasional diarrhœa. At the end of that time, however, the temperature rose; there was local redness and evidence of retention of pus. The wound was therefore enlarged, some fragments of rib removed, and a drainage tube inserted. After this the temperature fell, and for the next two months the patient suffered little except from the discharge from the sinus; this persisted for three months, becoming less in amount and less bile-stained, the fistula eventually closing in the fourteenth week, when the patient was sent home on parole.(205)Wound of liver.—Entry(Mauser), 1 inch below and to the left of the ensiform cartilage;exit, in the sixth right intercostal space, just behind the posterior axillary line. The trooper was sitting bolt upright on his horse at the time; both were shot and fell together. 'Stitch' on coughing or laughing was the only sign noted after the accident; this rapidly subsided.(206)Wound of the liver.—Wounded at Magersfontein.Entry(Mauser), through the seventh left costal cartilage, 1 inch from the base of the ensiform cartilage;exit, below the twelfth rib 2 inches to the right of the lumbar spines. The patient lay on the field some hours and was brought in at night very cold, and suffering with much shock. No signs of abdominal injury developed, but the pulse remained as slow as 66 for some days, and there was some pain and stiffness about back and sides, or on taking a deep breath. These signs persisted some days, but no others developed, and in six weeks the patient returned to duty.Some three months later this patient suffered from a short severe attack suggesting local peritonitis, but he again returned to duty.(207)Wound of the liver.—Wounded at Tweefontein.Entry, in eighth intercostal space in right mid axillary line;exit, 1½ inch below the point of the ensiform cartilage, 1/2 an inch to the right of the mid line. The wounds were large, and although the impact had been oblique, they were possibly produced by a Martini-Henry or Guedes bullet.On the second day bile began to escape from the exit aperture, and this together with a little pus continued to be discharged for a week, when the wound rapidly healed up. The only symptom which occasioned any trouble was a stitch on inspiration, probably attributable to the wound of the diaphragm. There was no fracture of the rib.(208)Wound of the liver.—Wounded outside Heilbron at a range of fifty yards.Entry(Mauser), in the tenth right interspace 2 inches to the right of the dorsal spines;exit, through the gladiolus, immediately to the right of the median line, and just above the junction with the ensiform cartilage. There was considerable shock on reception of the injury, and a great feeling of dizziness. Continuous vomiting set in and persisted for the first two days, then became occasional, and ceased only at the end of a week. There was also occasional hiccough, and stitch on drawing a long breath. The respiration was shallow and rapid. The bowels acted twice shortly after the injury.The pulse was rapid and small, and a week after the injury was still above 100. The abdomen was then normal and moving symmetrically, and the respiration fairly easy. There were no signs of chest trouble, but some mucous expectoration. A slight icteric tinge existed. The patient made a good recovery.
(204)Wound of liver. Biliary fistula.—Wounded at Magersfontein.Entry(Lee-Metford), below the seventh rib, in the left nipple line;exit, through the eighth rib, in the mid axillary line on the right side. The patient lay for seventeen hours on thefield, during which time the bowels acted once, but there was no sickness. The bowels then remained confined. When seen on the third day the abdomen was normal and the chest resonant throughout on both sides; bile to the amount of some ounces escaped from the wound on the right side. Suffering no pain; temperature 99°, pulse 100. The bowels acted freely the following day.
During the next fortnight there was little change; ℥ii-iij of bile escaped daily, and there was occasional diarrhœa. At the end of that time, however, the temperature rose; there was local redness and evidence of retention of pus. The wound was therefore enlarged, some fragments of rib removed, and a drainage tube inserted. After this the temperature fell, and for the next two months the patient suffered little except from the discharge from the sinus; this persisted for three months, becoming less in amount and less bile-stained, the fistula eventually closing in the fourteenth week, when the patient was sent home on parole.
(205)Wound of liver.—Entry(Mauser), 1 inch below and to the left of the ensiform cartilage;exit, in the sixth right intercostal space, just behind the posterior axillary line. The trooper was sitting bolt upright on his horse at the time; both were shot and fell together. 'Stitch' on coughing or laughing was the only sign noted after the accident; this rapidly subsided.
(206)Wound of the liver.—Wounded at Magersfontein.Entry(Mauser), through the seventh left costal cartilage, 1 inch from the base of the ensiform cartilage;exit, below the twelfth rib 2 inches to the right of the lumbar spines. The patient lay on the field some hours and was brought in at night very cold, and suffering with much shock. No signs of abdominal injury developed, but the pulse remained as slow as 66 for some days, and there was some pain and stiffness about back and sides, or on taking a deep breath. These signs persisted some days, but no others developed, and in six weeks the patient returned to duty.
Some three months later this patient suffered from a short severe attack suggesting local peritonitis, but he again returned to duty.
(207)Wound of the liver.—Wounded at Tweefontein.Entry, in eighth intercostal space in right mid axillary line;exit, 1½ inch below the point of the ensiform cartilage, 1/2 an inch to the right of the mid line. The wounds were large, and although the impact had been oblique, they were possibly produced by a Martini-Henry or Guedes bullet.
On the second day bile began to escape from the exit aperture, and this together with a little pus continued to be discharged for a week, when the wound rapidly healed up. The only symptom which occasioned any trouble was a stitch on inspiration, probably attributable to the wound of the diaphragm. There was no fracture of the rib.
(208)Wound of the liver.—Wounded outside Heilbron at a range of fifty yards.Entry(Mauser), in the tenth right interspace 2 inches to the right of the dorsal spines;exit, through the gladiolus, immediately to the right of the median line, and just above the junction with the ensiform cartilage. There was considerable shock on reception of the injury, and a great feeling of dizziness. Continuous vomiting set in and persisted for the first two days, then became occasional, and ceased only at the end of a week. There was also occasional hiccough, and stitch on drawing a long breath. The respiration was shallow and rapid. The bowels acted twice shortly after the injury.
The pulse was rapid and small, and a week after the injury was still above 100. The abdomen was then normal and moving symmetrically, and the respiration fairly easy. There were no signs of chest trouble, but some mucous expectoration. A slight icteric tinge existed. The patient made a good recovery.
Wounds of the spleen.—Uncomplicated wounds of the spleen were necessarily rare, and beyond this the strict localisation of a track to the spleen is not a matter of great ease. None the less the spleen must have been implicated in a considerable number of the wounds crossing the chest and abdomen. I know of only one case in which a wound which crossed the splenic area caused death from hæmorrhage, and of this I can give no details, as I never saw the patient. In this instance, however, a wound of the spleen was diagnosed after death from the position of the wounds. The patient continued to perform his duty as an officer in the fighting line for at least an hour after being struck, and then died rapidly apparently from an internal hæmorrhage.
In case No. 201, included amongst the renal injuries, a wound of the spleen existed, but had given rise to no symptoms, and at the time of death, some three weeks later, was cicatrised. The only other assertion of importance that I can make is,that, as far as I could judge, wounds of the spleen from bullets of small calibre were not, as a rule, accompanied by hæmorrhage, since I never saw a case in which dulness in the left flank suggested the presence of extravasated blood, and in no case that I saw was there any history of general symptoms pointing to the loss of blood.
This is only to be explained by our similar experience with regard to wounds of the liver unaccompanied by puncture of main vessels, and perhaps hæmorrhage is still less to be expected in the case of the spleen, in consequence of the contractile muscular tunic with which the organ is provided.
I can quote no case of certain injury to the spleen, except that already referred to discovered at apost-mortemexamination, but many wounds were observed in positions of which the following may be taken as a type.Entry, through the seventh left costal cartilage, 3/4 of an inch from the sternal margin;exit, 2½ inches from the left lumbar spines at the level of the last rib.
As an instance of the doctrine of chances I might quote the position of the wound in the patient who lay in the next bed. Both patients were wounded while fighting at Almonds Nek.Entry, through right seventh costal cartilage, 3/4 of an inch from the sternal margin;exit, 1½ inch from the lumbar spines, at the level of the last right rib.
In neither of these cases did anything except the position of the external apertures point to the infliction of visceral injury.
General remarks as to the prognosis in abdominal injuries.The prognosis in each form of individual visceral injury has been already considered, but a few points affecting these injuries as a class should perhaps be further considered.
First, as to the influence of range on the severity of the injuries inflicted; I am not able to confirm the greater danger of short range, except in so far as there is no doubt that more shock attends such injuries, and possibly some of the most severely wounded were killed outright as a direct consequence of the greater striking force of the bullet.
Among the cases in which but slight effects were noted, however, many were said to have been hit within a rangeof 200 yards, as for instance the two injuries quoted under the heading of wounds of the spleen.
I personally saw no cases in which explosive injuries of the solid viscera were to be ascribed to this cause.
Secondly, as to the immediate prognosis in all abdominal injuries, the ensurance of rest and limitation as far as possible of transport were of the highest importance, either in the case of wound of the alimentary canal, or in wounds of the solid viscera in which hæmorrhage was a possible result.
Thirdly, as to the later prognosis in these injuries; very few men are fit to resume active service without a prolonged period of rest. In spite of the insignificance of the primary symptoms, or of the favourable course taken by the injuries, active exertion was almost always followed for some months by the appearance of vague pains and occasionally by indications of recurrent peritoneal symptoms, pointing to the disturbance of quiescent hæmorrhages, or of adhesions. Wounds of the kidney are apparently those least liable to be followed by trouble.
Lastly, the prognosis was influenced in the case of many of the viscera by coexisting injury to other organs or parts.
For instance, at least thirty per cent. of the abdominal wounds were complicated by wound of the thorax; and in the lower segment of the abdomen injury to the extra-peritoneal portions of the pelvic organs was common.
Both the immediate and ultimate prognosis were influenced greatly by this fact.
As to the individual injuries:
1. Wounds in the intestinal area, except in certain directions, often traverse the abdomen without inflicting a perforating injury on the bowel.
2. If the alimentary canal is perforated, injuries in certain segments, even if perforating, may be followed by spontaneous recovery. I should say the prognosis from this point of view is best in the ascending colon, then in the rectum; after these most favourable segments, I should place the others in the following order: stomach, sigmoid flexure, descending colon. As to perforating wounds of the transversecolon and small intestine, I believe spontaneous recovery to be very rare.
3. Wounds of the solid viscera generally, usually heal spontaneously, and give no trouble unless one of the great vessels has been injured. I include in this category all organs except the pancreas, of wounds of which I had no experience.
4. Wounds of the bladder, if of the nature of pure perforations in the intra-peritoneal segment, often heal spontaneously.
5. As a rule, injuries to the organs in their intra-peritoneal course have a far better prognosis than those which implicate the organs in their uncovered portions.
6. The small calibre of the bullet is alone responsible for the favourable results observed.
7. The danger or otherwise of an intestinal injury depends mainly on mechanical conditions; for instance, the fixity of the ascending colon, and its comparative freedom from a covering of small intestine capable by movement of diffusing any infective material, account chiefly for such favourable results as are seen when that segment of the bowel is implicated.
Wounds of thescrotumwere not uncommon, especially in connection with perforations of the upper part of the thigh. They offered no special feature, beyond the common tendency of every-day experience to the development of extensive ecchymosis.
Wounds of thetesticlesI saw on several occasions. I remember only one out of some half-dozen in which castration became necessary. I was told of one case, for the accuracy of which I cannot vouch, in which destruction of one testicle was followed by an attack of melancholia, culminating in the suicide of the patient.
Wounds of thepenisalso occurred, but as a rule were unimportant. I append a case, however; in which the penile urethra was wounded, which is of some interest.