(192) Wounded at Paardeberg. _Entry_ (Mauser), at the junction of the middle and posterior thirds of the left iliac crest; the bullet was retained, and removed (Mr. Pegg) from the back of the right thigh, 3 inches below the back of the great trochanter. After the injury retention of urine followed, with incapacity to control loose motions, though solid ones could be retained. The retention was treated by catheterisation, which was followed by cyst.i.tis. The power of micturition was slowly recovered, and three weeks later he could pa.s.s water, at times in a dribbling stream only; the cyst.i.tis had improved. The man returned to England very much improved, but not quite well, at the end of five weeks.

(193) Wounded at Modder River. _Entry_, in the right b.u.t.tock, near the outer border at the upper part; _exit_, at the lower part of outer border of left b.u.t.tock. The line of the wound exactly crossed the position of the a.n.u.s, but no sign of injury to the r.e.c.t.u.m could be discovered.

(194) Wounded at Magersfontein. _Entry_ (Mauser), 1/2 inch below the margin of the iliac crest, at the junction of its middle and posterior thirds, and on a level with the fifth lumbar spinous process; _exit_, below the cartilage of the eighth rib, just within the left nipple line. Struck while retiring; fell at once, and remained thirty hours on the field.

Patient stated that he vomited 'blood like coffee grounds' six times while lying on the field, and twice after being brought in. His bowels were confined for three days. His right lower extremity was paralysed.

On the fifth day there was considerable induration around the wound of exit, and the upper half of the abdomen was immobile and tender. The temperature rose to 100, and the pulse was 96.

Shortly afterwards a similar condition was noted in the lower half of the abdomen; the temperature continued to be raised and the pulse quickened, when on the thirteenth day a considerable quant.i.ty of pus was pa.s.sed per r.e.c.t.u.m, and diarrhoea set in; this continued for three days, with marked improvement in the general symptoms. Micturition, which had been painful, became normal; the pulse and temperature fell, and the expression became less anxious. The patient continued to sleep badly, however, and complained of pain.

At the end of the third week he still looked ill, but was easier. Temperature normal in the morning, 100 in evening, pulse 80. Tongue thickly furred, but moist. Still on milk diet; appet.i.te bad; bowels irregular.

The abdomen moved little in the lower half, induration persisted in the left iliac fossa, the left thigh continued flexed, and resonance was impaired to the left of the umbilicus.

At the end of six weeks a distinct hard swelling in two parts, separated by a resonant area, was noted to the left of the umbilicus and in the left iliac fossa. The abdomen moved fairly, and there was little tenderness over the swelling.

During the next week the swelling appeared to increase and to fluctuate; at the same time the temperature again began to rise to 100 and 101 at eve. The swelling was taken to be a localised peritoneal suppuration, and an incision was made over it; but this led down to a free peritoneal cavity, with a tumour pressing up from the posterior abdominal wall. The wound was therefore closed, and a fresh extra-peritoneal incision made, immediately above Poupart's ligament, when the swelling proved to be a large retro-peritoneal haematoma. As the cavity extended into the pelvis and up to the level of the costal margin, it was deemed wise only to evacuate a part of the blood-clot. The origin of the bleeding was not determined, and the wound was closed and healed by first intention. The man continued to improve, and left for home five weeks later.

This patient has continued to improve since his return, but the left thigh is still somewhat flexed.

_Prognosis in intestinal injuries._--This was of a most discouraging character compared with the prognosis in abdominal injuries as a whole.

The cases were of two cla.s.ses, however: those that died within twenty-four hours, and those that died at the end of from three days to a week.

Cases falling into the first category are obviously of little importance from the point of view of surgical treatment. Many of them died from the widespread nature of the injury, and the shock produced by it; others from haemorrhage from the large abdominal vessels. It is unlikely that any could have been saved, even under the most satisfactory conditions.

In the following small table, therefore, I have included only the cases which have been already quoted, which survived long enough to be amenable to surgical treatment, and which were for some days under my own observation. Some of them, in fact almost all, I watched until they were either convalescent, or died, and in six I performed operations.

I am aware, and have short details of the histories of eight patients wounded in the same battles who died prior to the termination of the first thirty-six hours; but these are not included, for the reason stated above, and also because I am uncertain whether all the injuries were produced by bullets of small calibre.

-------------------------+-----------+-------------+-----------+------+ | | Localised | | | Viscous wounded | Number of | Secondary | Recovered | Died | | cases | suppuration | | | | | occurred | | | -------------------------+-----------+-------------+-----------+------+ Stomach certain | 2 | -- | 1 | 1 | Stomach possible | 1 | -- | 1 | -- | Small intestine certain | 5 | 0 | -- | 5 | Small intestine possible | 10 | 0 | 10 | -- | Large intestine certain | 8 | 4[21] | 4 | 4 | Large intestine possible | 4 | -- | 4 | -- | -------------------------+-----------+-------------+-----------+------+ Bladder certain | 3 | 3 | 1 | 2 | Bladder possible | 1 | -- | 1 | -- | Liver | 6 | -- | 6 | -- | Kidneys | 6 | -- | 4 | 2 | Spleen | 3 | -- | 2 | 1 | -------------------------+-----------+-------------+-----------+------+ Total | 49[22] | -- | 34 | 15 | -------------------------+-----------+-------------+-----------+------+

Included in the above table are thirty instances of intestinal injury, and these are divided up according to the segment of the intestinal ca.n.a.l implicated, and also as to whether the perforation was certain, or only a.s.sumed from the position of the external apertures and the presence of abdominal symptoms of a noticeable grade.

From this a.n.a.lysis it appears clear--

1. That wounds of the stomach have a comparatively good prognosis, and that they may recover spontaneously. It is true that only two examples are included in my table; but I was at various times shown patients with similar injuries and histories, and a number of cases which have been published appear to substantiate the opinion. From our experience of the occasional spontaneous recovery of gastric perforations from disease, I think we might be prepared to expect that the stomach would offer a comparatively favourable seat for these wounds. It may be pointed out, however, that haematemesis, the main feature in the symptoms pointing to wound, is by no means direct proof of more than contusion.

2. That perforating wounds of the small intestine are very fatal injuries; every patient in whom the condition was _certainly_ diagnosed died.

3. That in the cases in which a perforation was inferred from the position of the external apertures and the symptoms, not one patient suffered from the secondary complications--_e.g._ local peritonitis and suppuration, which were common in the case of the large intestine, and which we are accustomed to see after perforation from disease. This renders the occurrence of actual perforation in the majority of the cases a matter of very grave doubt.

If spontaneous recovery does take place after this injury, it is only in cases in which the wounds are single, and slight in character.

4. That in eight cases in which perforation of the large intestine was certain, four recoveries took place; but in each instance suppuration occurred. I am, however, quite prepared to believe that perforation may have occurred in some or all of the other four cases included as 'possible,' provided the wounds were intra-peritoneal.

Wounds of the caec.u.m and ascending colon are those which have the best prognosis, and after these of the r.e.c.t.u.m. The comparatively good prognosis in these parts is what would be expected, on account of their greater fixity, and lesser tendency to be covered by the small intestine.

An extra-peritoneal wound of any of these portions of the bowel is more dangerous than an intra-peritoneal, and more likely to give rise to septicaemia.

Of the cases included in my table eighteen of the possible intestinal injuries were observed among the wounded of the four battles of the Kimberley relief force. These cases I saw early and followed to their termination, and I believe the list contains the great majority of all the patients who received intestinal wounds in those battles. On inquiry I could not learn of others from the officers of the Field hospitals; but no doubt some patients died before their reception into hospital, and some may have been overlooked; again, I know of two cases in which death took place within the first week, but which went direct to the Base and did not come under my observation. These exceptions being made, we have a fairly complete series, from which some deductions may be drawn. The cases included are marked with an asterisk.

Of the eighteen cases, eight or 44.4 per cent. died. These were made up as follows:--Stomach, one case; this patient died at the end of fourteen days, as a result of secondary haemorrhage and septicaemia. It was complicated by a severe wound of the liver and also one of the lung.

Small intestine, four certain cases; all died, two after operation in the stage of septicaemia, and one after operation from recurrent haemorrhage, possibly from the mesentery. Of the other six cases one can only say that the position of the wounds was such as to render wound of the intestine possible, and that all suffered with abdominal symptoms of some severity.

Large intestine. Of six cases in which wound was certain, three died, one after operation. One recovered after operation, two recovered with local peritoneal suppuration. In one case the injury could only be returned as possible.

In connection with this subject I have received permission from Mr.

Watson Cheyne to quote the statistics published by him[23] concerning the abdominal wounds observed after the fighting at Karree Siding, on March 29, which are as follows:--

'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:--

CASES FROM THE ACTION AT KAREE

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 and _stomach_.

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 pa.s.sed 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 s.p.a.ce on the left side, and was found lying under the skin over the seventh intercostal s.p.a.ce on the right side and about 2 inches further back. He had vomited blood on the previous day. The bullet may have perforated the _stomach_. 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 haemorrhage 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 s.p.a.ce, 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 1-1/2 inch in front of the anterior inferior spine on the right side, had gone directly backwards, and had come out in the b.u.t.tock. 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 pa.s.sed. 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 b.u.t.tock, 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 the _ascending colon_, without any adhesions around, which was easily st.i.tched 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 or 9.74 per cent. wounded. I am inclined to think that this is a higher proportion than the average 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 r.e.c.t.u.m.

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.