Surgical Experiences in South Africa, 1899-1900 Part 45

(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 s.p.a.ce 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 haematuria, and very severe cyst.i.tis developed, while the patient suffered with severe abdominal pain. The cyst.i.tis persisted, also retention, which gradually gave way to dribbling, while irregular rise of temperature and tenderness in the loins pointed to ascending inflammation in 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 the _post-mortem_ examination the following condition was found:--On the right side general pleural adhesions, recent lymph over ascending colon and caec.u.m, [Symbol: ounce]vj of b.l.o.o.d.y 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 s.p.a.ce in the posterior axillary line; _exit_, in the tenth right inters.p.a.ce, in mid axillary line. The patient was in the p.r.o.ne position when struck, and lay on the field from 5 A.M. until 6 P.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 s.h.i.+ft on movement; the abdomen was elsewhere tympanitic. Tongue furred, bowels confined; there has been no sickness, and no haematemesis. Urine normal, and in good quant.i.ty. 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 [Symbol: ounce]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 faecal 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 haematoma (similar to that described in case 194), but it became quite soft and fluctuating, and was then tapped, and [Symbol: ounce]50 of blood-stained fluid, which proved to be urine, were removed. The urine rapidly reacc.u.mulated, and the cavity was then laid freely open. Urine continued to discharge in large quant.i.ty for two months, the man meanwhile remaining well, and pa.s.sing a somewhat variable daily quant.i.ty of urine ([Symbol: ounce]xxiv-[Symbol: ounce]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 haematemesis. Later there was some haemoptysis. Pulse 120, respirations 48.

Twenty-four hours later the vomiting had ceased; the patient had pa.s.sed 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 pa.s.sed twice, and was chiefly blood. The patient died shortly afterwards, apparently mainly from internal haemorrhage, 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 haematuria 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 haemorrhage 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 haemorrhage 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 ill.u.s.trating the result of an injury to one of the large bile ducts. Putting the deaths from primary haemorrhage 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 fistulae 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 coa.r.s.ely granular margins extended the whole antero-posterior length of the under surface of the left lobe, and the escape of bile was free.

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 sh.e.l.l 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 haemorrhage 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 haemorrhage, 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 the field, 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; [Symbol: ounce]ii-iij of bile escaped daily, and there was occasional diarrhoea. 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 s.p.a.ce, just behind the posterior axillary line. The trooper was sitting bolt upright on his horse at the time; both were shot and fell together. 'St.i.tch' 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 s.p.a.ce in right mid axillary line; _exit_, 1-1/2 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 st.i.tch 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 inters.p.a.ce 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 st.i.tch 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 haemorrhage, 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 haemorrhage.

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 a.s.sertion 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 haemorrhage, 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 haemorrhage 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 a _post-mortem_ examination, 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_, 2-1/2 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_, 1-1/2 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 cla.s.s 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 range of 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 ca.n.a.l, or in wounds of the solid viscera in which haemorrhage 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 haemorrhages, 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.