Chapter XI: Injuries to the Abdomen (3)

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 the result 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.

(194_a_) _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 on the 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 1-1/2 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 oedematous, 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 the
_post-mortem_ examination 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 in
length. 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 the
_post-mortem_ examination 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 actually empty, 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.

INJURIES TO THE SOLID ABDOMINAL VISCERA

_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 1-1/2 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
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 cæcum, [Symbol: ounce]vj 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 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
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
[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 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 [Symbol:
ounce]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 ([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 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 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 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 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 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_,
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 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 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 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 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 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 transverse colon 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 THE EXTERNAL GENITAL ORGANS

Wounds of the _scrotum_ were 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 the _testicles_ I 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 the _penis_ also occurred, but as a rule were unimportant. I append a case, however; in which the penile urethra was wounded, which is of some interest.

(209) Wounded at Heilbron. Range 1,500 yards. _Entry_, 2-1/2
inches below the right anterior superior iliac spine; the
bullet traversed the groin superficially in the line of
Poupart's ligament, emerged, and crossed both penis and
scrotum. The trooper was in the saddle when struck, and the
penis probably somewhat coiled up. Three wounds were found, one
at the junction of the penis and scrotum which opened the
urethra, a second one about 3/4 of an inch along the under
surface of the penis, and a third on the left side of the base
of the prepuce. A considerable amount of oedema and
ecchymosis of the scrotum developed, but no extravasation of
urine. A catheter was kept in the urethra for some days, and
the opening eventually closed by granulation.

I only once saw a patient with an injury to the deep urethra; in this case concurrent injury to other pelvic organs led to death on the third day. As a good many of the patients with pelvic wounds died rapidly, the accident may have been more common than my experience would suggest.

FOOTNOTES:

[19] _British Med. Journal_, May 12, 1900, i. 1195.

[20] 'On Traumatic Rupture of the Colon.' _Annals of Surgery_, vol. xxx. 1899, p. 137.

[21] Two of these died.

[22] The cases of injury to the solid viscera are those only which happen to be quoted in the text, and give no idea of relative mortality.

[23] _British Medical Journal_, May 12, 1900, vol. i. p. 1194.