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
operating surgeon, 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
pleura took 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 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.
CHAPTER XII
ON SHELL WOUNDS
The title of this work hardly allows of its conclusion without a brief
mention of the shell wounds observed during the campaign.
As already pointed out, these formed but a very small proportion of the
injuries treated in the hospitals, and beyond this they possessed
comparatively small surgical interest, since, as a rule, the features
presented were those of mere lacerated wounds, while the more severe of
the cases which survived only offered scope for operations of the
mutilating class so uncongenial to modern surgical instincts.
The fatal wounds consisted in extensive lacerations resulting in the
destruction of the head or limbs, the laying open of the abdominal or
thoracic cavities, or the production of visceral injuries beyond the
possibility of repair. Of such injuries no further mention will be made.
A very great variety of shells was employed during the campaign,
especially on the part of the Boers, and the frontispiece gives some
idea of these. The photograph was taken by Mr. Kisch after the relief of
Ladysmith. For the want of more extended knowledge I shall confine
myself to the description of a few injuries caused by two classes of
large shell, those of the Vickers-Maxim or 'Pom-pom,' and two varieties
of shrapnel.
The large shells employed may be divided into classes according to the
metal used in their construction, and the nature of the explosive with
which they were filled. These details are of some surgical import,
because they affect the nature of the fragments into which the shells
are broken up.
Fragments of shells constructed with cast iron and burst with powder,
and also of forged steel exploded with lyddite, are depicted in fig. 90.
[Illustration: FIG. 90.--A, B, D. Fragments of 200 lb. forged Steel
Howitzer Shell exploded by lyddite. C. Fragment of Cast-iron Shell
exploded by powder. B exhibits transverse markings which might be
mistaken for the lines seen in the Boer segment shells, but which really
correspond to the area of fixation of the copper driving band]
Examination of fragment C of a cast-iron shell exploded by powder shows
the characteristic granular fracture, and edges, although sharp, yet of
a comparatively rounded nature. The fragment is also heavier for its
surface measurement, as the metal is thicker than that seen in the
remaining fragments, although the cast-iron shell was of a much smaller
calibre than the steel one. The lesser degree of penetrative power, and
increased capacity to contuse, possessed by such fragments are obvious.
A B and D are fragments of a large forged steel howitzer shell exploded
by lyddite, such as were cast by our guns. The photograph well shows the
more tenacious structure of the metal in the incomplete longitudinal
fissuring exhibited, while the margins are of a sharp knifelike
character, well calculated to penetrate or, in the case of superficial
injuries, to produce wounds of a more sharply incised character than the
cast-iron shell. Fragments A and B also show an appearance suggestive of
partial fusion, characteristic of high explosive action, in the turning
of the prominent margins.
The larger fragments of such shells were responsible for the most
serious mutilating injuries, while small fragments sometimes caused
comparatively simple perforating wounds. I remember a fragment of the
fused character not larger than a small nut which had perforated the
front of the thigh of a Boer, and lodged near the inner surface of the
femur. Removal of the fragment was followed by a free gush of
hæmorrhage. When the wound was opened up an opening was found in the
external circumflex artery, hæmorrhage from which had been controlled by
the impaction of the piece of shell. As an example of the cutting power
of sharp fragments of shell I might instance the case of another Boer in
whom light passing contact had been made by the missile. A gaping
incised wound extended from above the angle of the scapula down to the
outer surface of the buttock. The wound involved the latissimus dorsi,
and the external and internal oblique muscles of the abdomen. The
separate muscular layers were sharply defined in the lateral parts of
the floor of the wound, and remained so for some time during the gradual
contraction of the large granulating surface produced. The degree of
contusion was in fact slight, while the incised character was strongly
marked.
In some cases the fragments merely struck the soldiers on the flat
without producing any wound. In one such case a blow upon the
epigastrium was, according to the patient, followed by the vomiting of a
considerable amount of blood. A fluid diet was ordered, and no further
ill effects were noted. The following case illustrates an oblique blow
of a perforating character, which was nevertheless recovered from.
[Illustration: FIG. 91.--Various portions of Brass Percussion and Time
Fuses]
(210) _Shell-wound of abdomen. Injury to liver._--Wounded at
Paardeberg by a fragment of shell. Aperture of entry, a ragged
opening in the median line. The fragment of shell was retained
over the ninth costal cartilage in the nipple line. The wound
bled freely, but the man was taken into camp, and then four
miles on to the hospital, where he was anæsthetised and the
fragment extracted. The wound of entry was at the same time
enlarged, cleansed, and partly sutured. The patient vomited
once after the anæsthetic, and the bowels remained confined for
three or four days after the injury. The extraction wound
healed readily, but a considerable amount of slimy,
bile-stained discharge was still escaping from the ragged
entrance wound on the man's arrival at the Base on the
fourteenth day. The abdomen was then normal in appearance, and
as to physical signs, except for a tympanitic note over the
hepatic area to the right of the wound. The temperature was
normal, the pulse 90, the tongue clean, and the bowels were
acting. At the end of four weeks pleurisy, with effusion,
developed on the right side; the chest was aspirated and
[Symbol: ounce]xx of clear serum drawn off. The man then
rapidly improved; the bile-stained discharge ceased at the end
of five weeks, and a small granulating wound eventually closed
at the end of two months, when the man returned to England.
Fig. 91 is inserted to illustrate the multifarious nature of the
fragments into which the component parts of shells may break up. The
pieces are for the most part of brass, and formed parts of either time
or percussion fuses.
Fig. 92 represents the one-pound Vickers-Maxim shell in its actual size.
The wounds produced by this shell are of some interest, since the
Vickers-Maxim may be said to have been on trial during this campaign.
The general opinion seems to have been to the effect that the moral
influence produced by the continuous rapid firing of the gun and the
attendant unpleasant noise were its chief virtues. A considerable number
of wounds must, however, have been produced by it, which, if not of
great magnitude and severity, were, at any rate, calculated to put the
recipients out of action, and these wounds, moreover, were slower in
healing than many of the rifle-bullet injuries.
The shell is so small that it was said to occasionally strike the body
as a whole, and perforate. I was shown a case in which a wounded officer
was confident that an entire shell had perforated his arm. The entry
wound was at the outer part of the front of the forearm, the exit at the
inner aspect of the arm, just above the elbow. Two ragged contused
wounds existed, which healed slowly, but no serious nervous or vascular
injury had been produced. Although it is probable that only a fragment
perforated in this case, it is of interest in connection with the
following.
In a case shown to me by Sir William Thomson in the Irish Hospital at
Bloemfontein, an entire shell had passed between the left arm and body
of a trooper, perforating the haversack, as also a non-commissioned
officer's notebook contained within it, without exploding. The only
injury sustained by the trooper was a contusion on the inner aspect of
the elbow-joint, with slight signs of contusion of the ulnar nerve. The
case is of some importance, as showing that a comparatively resistent
body can be perforated without necessary explosion on the part of the
shell; hence the possibility of a similar perforation of the soft parts
of the body.
[Illustration: FIG. 92.--Unexploded 1-lb. Vickers-Maxim Shell. (Actual
size)]
Fig. 93 is of a number of fragments of Vickers-Maxim shells, and it was
by such that the great majority of the wounds were produced.
Wounds from fragments of these shells were, indeed, not at all rare.
They were met with on any position; but, as far as my experience went,
they were more common on the lower extremities than in other parts of
the body, if the sufferers were in the erect position when wounded. I
saw a good many wounds in the neighbourhood of the knee, some of which
implicated the joint. When the injuries were received by patients in the
lying or crouching positions, any part of the body was equally likely to
be affected, or, again, the presence of large stones or rocks in the
vicinity might determine the scattering of the flying fragments at a
more dangerous height than when the shells burst from contact with the
actual ground.
The relation of one or two examples of wounds from pom-pom fragments may
not be without interest, the more so as they illustrate the favourable
influence of a low degree of velocity on the part of a projectile. I saw
three wounds produced by the percussion fuses of these shells, an
experience which shows that they were not very uncommon.
[Illustration: FIG. 93.--Fragments of Vickers-Maxim 1-lb. Shells. The
centre fragment of the lower row is the point of a steel armour-piercing
shell; although unsuitable for the purpose, they were occasionally
employed in the field by the Boers]
(211) _Perforating shell-wound of abdomen._--Wounded at
Magersfontein by the fuse screw of a small shell
(Vickers-Maxim). Aperture of entry ragged, roughly circular,
and 2 inches in diameter, with much-contused margins situated
in the median line, nearly midway between the ensiform
cartilage and umbilicus. The screw was lodged in the abdominal
wall at the margin of the thorax, just outside the left nipple
line. The aperture of entry was cleansed by Major Harris,
R.A.M.C., who determined the fact that penetration of the
peritoneal cavity had occurred, and removed the fuse (see fig.
94) by a separate incision. The patient made an uneventful and
uninterrupted recovery, the wound healing by granulation and
leaving little weakness of the abdominal wall. He returned to
England at the end of five weeks.
In a second case the fuse, together with a fragment of the iron case,
entered the buttock by a ragged opening. The fragment of iron escaped by
an exit aperture of about the same size. When the patient arrived at the
Base some days after the injury, a hard body was felt in the wound, and
on exploration the fuse was found and removed.
In a third case the fuse struck the side of the foot below the outer
malleolus and comminuted the astragalus, and then passing forwards
lodged beneath the extensor tendons of the toes. The wound was explored
at the time of the injury and some fragments of bone removed;
considerable cellulitis supervened, and the fuse was only discovered
some days later when the patient came under the care of Sir W. Thomson
in the Irish Hospital in Pretoria. It was there removed, together with
some more fragments of bone, and the wound slowly granulated. The
patient then returned to England, when the wound rapidly healed after
the removal of some further necrosed fragments of cancellous tissue. The
astragalus had been reduced to a mere shell of compact tissue, and the
convexity of the articular surface was altogether lost. The deformity,
together with the formation of adhesions in the ankle-joint, led to the
development of a firm anchylosis.
[Illustration: FIG. 94.--Pom-pom Percussion Fuse, exact size]
My friend Mr. Abbott removed a similar fuse from the substance of the
lung after the lapse of nine months, the patient having developed an
empyema, and a chronic fistula, which rapidly closed after the removal
of the foreign body.
[Illustration: PLATE XXV
OBLIQUE FRACTURE OF THE HUMERUS CAUSED BY A FRAGMENT OF A VICKERS-MAXIM
OR POM-POM SHELL
The entire absence of comminution is very striking]
I will add one further case, that illustrated by plate XXV. In this a
fragment of a pom-pom shell entered the outer aspect of the right
shoulder to escape on the inner aspect of the arm, just below the
confines of the axilla. An oblique, non-comminuted fracture of the
humerus resulted, which in spite of moderate suppuration united well in
the course of six weeks. The case is of particular interest as
illustrating the nature of the fracture to be expected when the velocity
retained by the missile is low.
The above instances show that such peculiarities as belong to wounds
produced by pom-pom shells depend on the comparatively small size and
weight of the fragments, and on the small degree of impetus with which
they are propelled.
[Illustration: FIG. 95.--Boer Segment Shell, or Shrapnel. The large
fragment is a piece of the case, the smaller are two of the pieces of
iron packed within]
Fig. 95 illustrates a form of shrapnel employed by the Boers, the case
of which is of cast metal arranged in definite segments, while the
interior is filled with small fragments of iron so shaped as to pack in
concentric layers. As to the wounds produced by the contained fragments
I have no experience, since I never saw one of the pieces of iron
removed. This no doubt depended in part on the very unsatisfactory
practice made by the Boers with shrapnel generally. Even when they fired
English shrapnel, the shells were, as a rule, exploded far too high to
cause any serious danger to the men beneath. I saw on one occasion a
large number of shrapnel shells exploded over a body of Imperial
Yeomanry, but as a result of the great height at which all the shells
were exploded, not a single casualty resulted.
The segment casing of the shell, however, I several times saw removed
from the body. The fragment shown in fig. 95 was removed from the
buttock of a man after one of Lord Methuen's early battles. It may be
remarked that the buttock is rather a common, and also a favourable,
seat for shell wounds with retention of the fragment. This no doubt
depends on the fact that the buttock is one of the few superficial
regions in which sufficient depth of tissue exists for the retention or
the passage of so large an object as a fragment of shell.
Fig. 96 is of a number of leaden shrapnel bullets from our own shells. A
normal undeformed bullet, such as was the usual cause of wounds, is
shown at the left-hand upper corner. The remainder show common forms of
deformity caused by striking on the ground or against rocks. I attribute
small importance to the deformed bullets, as I never saw one removed,
and it is probable that a ricochet shrapnel bullet would rarely retain
sufficient force to penetrate. The lower fragments are inserted to
illustrate a fact that would scarcely have been assumed, that these
bullets on impact occasionally suffer a fracture of a somewhat
crystalline nature. The occurrence of this gross form of fracture is of
some interest in relation to the extreme fragmentation sometimes
undergone by the hardened leaden cores of the small-calibre bullets.
A considerable number of wounds from leaden shrapnel bullets were met
with among our own men, as well as among the Boers. The wounds possessed
little special interest, except from the fact that the bullets were
often retained. I saw bullets in the chest on several occasions, also in
the abdomen, pelvis, the neighbourhood of joints, and in the limbs.
I saw one patient who had suffered no less than six perforating wounds
as the result of the bursting of one shrapnel shell.
I will here quote one case of interest as completing the various forms
of perforating wound of the abdomen met with during the campaign.
[Illustration: FIG. 96.--Normal, Deformed, and Fractured Leaden Shrapnel
Bullets]
(212) _Perforating shrapnel-wound of abdomen._--Boer wounded at
Graspan. Aperture of _entry_ (shrapnel), opposite eighth left
costal cartilage, 1 inch external to nipple line. The opening
was circular, and surrounded by an area of ecchymosis 4 inches
in diameter; _exit_, 4-1/2 inches above and to the right of the
umbilicus. Patient was at first in a Boer ambulance, and only
seen by me on the ninth day. At that date he was dressed and
walking with a gauze pad and bandage over the wounds. From the
exit wound, which was 1 inch in diameter, protruded a piece of
sloughing omentum, the margin of the wound being everted and
raised over a circular indurated area.
It was thought best to allow the sloughing omentum, which was
very foul, to separate spontaneously, and then to return the
stump. At the end of three weeks, however, the slough had not
only separated, but the stump had retracted, and only a small
granulating surface was left, which healed spontaneously.
I have little to say regarding the treatment of shell wounds. The
mutilating injuries, if not of a fatal character, necessitated treatment
of a corresponding nature to the damage. In all such cases the general
rules of surgery indicate the lines to be followed.
In the case of shrapnel wounds the bullets were often better removed;
but when in dangerous positions, as sunk deeply in the chest, abdomen,
or pelvis, they were best left, unless some very special indication for
removal existed. Large fragments of shell always demanded removal.
In conclusion I will only make the further remark, that shell wounds,
with the exception of clean leaden shrapnel tracks, always suppurated.
I make this closing statement with the view of emphasising the influence
exerted on the aseptic course of modern rifle wounds by the small
calibre of the bullet, since both bullet and shell wounds were exposed
to the same surrounding conditions.
INDEX
Abdomen, injuries to, 407
General prognosis in, 470
Abdominal wounds:
Explosive, 414
Non-perforating, 409
Perforating, 411
Abscess of the brain, 287
Acetabulum, fracture of, 193
Acetylene light, 30
Ambulance:
Foreign, 30
Trolly (McCormack-Brook), 18
Wagons, 19
Amputations:
Effect of transport on, 110
for fracture, 177
Aneurisms:
Effect of rest on, 127
Gangrene after, 152
Traumatic, 122
False, 123
True, 126
Treatment of, 127
Aneurismal varix:
Arm and forearm, 147
Effect on circulation, 134
Carotid, 146
Femoral, 147
Mode of development, 130
Popliteal, 147
Prognosis in, 144
Signs of, 131
Treatment of, 144
Anosmia, 348
Antrum, wounds of, 306
Aphasia:
Amnesic, 276
Ataxic, 273
Functional, 351
Arterial hæmatoma, 123
Prognosis in, 126
Treatment of, 126
Arteries:
Compression by cicatrices, 113
Contusion of, 112
Division of, 114
Perforation of, 114
Arterio-venous aneurism:
Arm and forearm, 150
Cervical, 149
Femoral, 150
Leg, 150
Popliteal, 151
Treatment of, 148
Biliary fistula, 467
Bladder:
Wounds of, 443, 457
Extra-peritoneal, 458
Intra-peritoneal, 457
Retained bullet in, 110, 460
Bones. See Fractures
Bowlby, Mr.:
Retained bullets in joints, 229, 230
Wound of pharynx, 311
Brain:
Abscess of, 287
Cerebral irritation, 269
Compression of, 267
Concussion of, 266
Effect of ricochet on, 249
Explosive injury of, 247, 248
Frontal injuries, 247, 249, 266
Fronto-parietal injuries, 273
Occipital injuries, 276
Parietal injuries, 273
Prognosis in cerebral injuries, 289
Treatment, 289
Bread, 7
Buck wagon, 21
Bullets:
Characters directly affecting wounds:
Aseptic nature, 70
Calibre, 41
Composition of, 51
Deformities of, 81
Fragmentation, 88
Length, 41
Mantles of, 52, 82, 83
Penetration, 49
Revolution, 45
Ricochet, 82
Shape, 42
Stability, 51
Striking force, 50
Velocity of flight, 42
Weight, 42
Effect of resistance of bones on, 86, 87, 88, 93
Retention of, 71, 79
Indications for removal of, 110
in bladder, 110, 460
in chest, 381, 401
in nasal fossa, 244
in or near joints, 229, 230
in skull, 244, 249, 260, 266, 284, 298
in spinal canal, 337
Reversal of, 81
Varieties of:
Determination of, 105
Expanding, 91
Explosive, 95
Guedes, 48, 51
Krag-Jörgensen, 48, 51
Jeffreys, 94
Large leaden, 95
Lee-Metford, 52, 89
Mark IV., 94
Mauser, 52, 83
Soft-nosed, 93
Tampered, 95
Tweedie, 94
Waxed, 52
Cauda equina, injury to, 325, 330
Cellulitis, 34
Cervical nerve roots, injury to, 107
Plexus, 357
Cheatle, Mr. G. L.:
Entry and exit wounds, 72
First field dressing, 107
Wound of heart, 383
" " intestine, 413
Cheek, wounds of, 309
Chest, injuries to, 374
Character of wounds, 377
Influence of small calibre of bullet on, 374
Martini wounds, 374, 388
Non-penetrating wounds, 375
Penetrating wounds, 376
Cheyne, Mr. W. W., F.R.S.:
Abdominal wounds, 449
Spent bullets, 243, 449
Civil surgeons, 38
Climate, 8, 36, 71
Comparison of South African with other campaigns, 14
Compression of brain, 267
Spinal cord, 319
Concussion of brain, 266
Eye, 300
Joints, 226
Nerves, 341, 343
Spinal cord, 315
Contour wounds, 65
Contusion:
Nerves, 343
Spinal cord, 316
Costal cartilages, fractures of, 379
Cox, Dep. Insp.-Gen.:
Case of varix, 148
Day, Mr. J. J.:
Fractures of the skull, 251
Deadliness of modern weapons, 16
Diaphragm, wounds of, 381
Displacement of structures by the bullet, 68
Abdomen, 411
Nerves, 342
Vessels, 382, 384
Viscera, 310, 382, 411
Drink, 8
Dust, 8, 35
Bacteriology of, 36
Empyema, 394, 396
Enteric fever, 9
Epilepsy, traumatic, 291
Equipment of foreign ambulances, 31
Surgical, 4
Erysipelas, 34
Expanding bullets, 91
Explosive bullets, 95
Explosive wounds:
of abdomen, 414
of fractures, 155
of head, 245
of leg, 221
of soft parts, 97
of thigh, 197
Eye, injuries to, 299
Facial paralysis:
Cortical, 273-277
Peripheral, 355
First field dressings, 107
Flies, 36
Flockemann, Dr.:
Hæmothorax, 393
Injury to abdomen, 420
Fractures:
Course of healing of, 172
Explosive wounds in, 155
into joints, 163, 228
Limb bones, 154
Local shock in, 172
Long bones, types of, 161
Longitudinal, 163
Notch, 165
Oblique, 165
Perforating, 166
Stellate, 161
Transverse, 166
Wedge, 165
Osteomyelitis in, 174
Pom-pom fractures, 483
Prognosis, general, in, 174
Special features of, 155
Special bones:
Acetabulum, 193
Carpus, 183
Clavicle, 178
Femur, 193
Fibula, 219
Humerus, 178
Jaws, 306
Malar, 305
Mastoid process, 299
Metacarpus, 185
Metatarsus, 224
Orbital walls, 300
Patella, 215
Pelvis, 189
Radius, 183
Ribs, 377
Scapula, 177, 379
Skull:
Base, 262
Glancing, 254
Gutter, 255
Perforating, deep, 245
Superficial, 259
Treatment of, 293
Spine, 314
Sternum, 379
Tarsus, 223
Tibia, 217
Short and flat bones, 168
Suppuration of soft parts in, 173
Symptoms of, 171
Treatment of:
General, 175
Femur, 205
Leg, 221
Upper Extremity, 135
Variation in character during the campaign, 154
Fractures in Franco-German war (Sir W. MacCormac), 167
Fragmentation of bullets, 88
Fuses of shells, wounds by, 481
Gangrene:
Acute traumatic, 34
After ligature of main vessels, 152
Genital organs, wounds of, 472
Guedes rifle, 65
Gutter wounds:
of bladder, 458
of bones, 231
of intestine, 417
of joints, 231
of liver, 466
of pelvis, 189
of scalp, 242
of skull, 255
of soft parts, 157
Hæmarthrosis, 232
Hæmorrhage, 104, 114
Control by bullets, 116
by loop of nerve, 116
Deaths from, 116
Fever dependent upon, 118
Internal, 116
Interstitial, 118
Primary, 114
Recurrent, 117
Secondary, 117
Treatment of, 120
Hæmorrhoids, 10
Hæmothorax, 386, 389
Behaviour of blood in, 390
Course of, 390, 394
Diagnosis of, 398
Effect of transport on, 389
Empyema after, 394
Pleuritic effusion in, 390
Prognosis in, 399
Recurrent bleeding in, 393
Parietal, 389, 398
Pulmonary, 386, 389
Symptoms of, 391
Temperature in, 391, 393
Treatment of, 400
Head, injuries to, 241
Health of the troops, 7
Heart, wounds of, 382
in neighbourhood of, 384
Hemianopsia, 276
Altitudinal, 277
Lateral, 276
Hospitals:
Field, 29, 37
Foreign, 30
General, 31, 38
Improvised, 28, 39
Indian Field, 29
Stationary, 27, 31, 33, 37
Varieties of, 28
Hospital ships, 24
Tents, 32
Trains, 23
Hydronephrosis, 464
Impact, irregular, 80, 82
Instruments, 4
Intestine, injuries to:
Diagnosis of, 428
Difficulties of operation, 453
Indications for operation, 454
Lateral contusion, 416
Prognosis, 446
Treatment, 452
Wounds of, 415
Extra-peritoneal, 419
Large intestine, 436, 444
Results of, 421
Small intestine, 427
Irregular wounds, 97
Itinerary, 2
Jam, 7
Jaws, fractures of:
Lower, 306
Upper, 306
Treatment of, 308
Jenner, L. L., bacteriology of dust, 36
Joints, injuries to, 225
Arterial wounds in, 121, 233
Classification of, 229
Course after, 232
Fractures into, 228
Signs and symptoms, 232
Suppuration of, 233
Treatment, general, 235
Joints, retained bullets in or near, 229, 230
Joints, special:
Ankle, 239
Elbow, 236
Hand, 237
Hip, 238
Knee, 238
Shoulders, 236
Tarsus, 240
Ker, J. E., cases of aneurism, 152
Kidney, wounds of, 461
Krag-Jörgensen rifle, 65
Laminectomy, 335, 340
Larynx, wounds of, 312
Leaden bullets, 95
Lee-Metford rifle, 53, 64
Lewtas, Col. I. M. S., cases of aneurism, 144
Lightning stroke, 10
Liver, wounds of, 466
Local shock, 103
in fractures, 172
Lower jaw, fractures of, 306
Lungs, wounds of, 385
Diagnosis, 398
Effect of velocity on, 385
Prognosis, 399
Retained bullets in, 401
Symptoms of, 386
Treatment of, 400
Lyddite shells, 475
MacCormac, Sir W.:
Aneurism, 150
Fractures, 167
Malar bone, fractures, 305
Mandible, fractures, 306
Mantles, stability of, 51, 83
Martini-Henry rifle, 48
Wounds by, 96
Mastoid process, 299
Mauser rifle, 64
Meat, 7
Mediastinal wounds, 382, 384
Mesentery, wounds of, 420
Mills-Roberts, Mr. H. R.:
Spinal hæmorrhage, 321
'Modders, the,' 9
Mortality, general, 11
amongst officers, 14
in battles of Kimberley Relief Force, 12
Nasal _fossæ_, bullet in, 244
Neck, wounds of, 309
Nerves, injuries to, 341
Concussion, 341, 343, 346
Contusion, 343, 347
Displacement of, 342
Laceration, 344, 348
Perforation, 345
Prognosis in, 370
Scar, implication of, 345, 350
Section, 344
Symptoms of, 346
Treatment of, 371
Velocity in relation to, 341
Nerves, special:
Cranial:
Fifth, 353
Fourth, 353
Eighth, 353, 354
Eleventh, 356
Olfactory, 352
Optic, 352
Seventh, 354, 372
Sixth, 353
Tenth, 356
Third, 353
Twelfth, 357
Spinal:
Brachial, 357
Cervical, 347, 357
Lumbar, 359
Sacral, 359
Sacro-coccygeal, 360
Thoracic, 358
Neuritis:
Ascending, 350
Peripheral, 355
Traumatic, 349
Neurosis, traumatic 351
Nose, wounds of, 305, 348
Nurses, 38
Officers, mortality among, 14
Olecranon, fracture of, 183, 237
Omentum, wounds of, 420
Prolapse of, 420
Operations:
Difficulties of, 35
in field, 296
in Field hospitals, 109
Orbit, wounds of, 299
Prognosis and treatment of, 304
Osteomyelitis in fractures, 174
Outfit, surgical, 3
Pain in wounds, 103
Paraplegia, functional, 337
Penetration of bullets, 49
Penis, wounds of, 472
Peritoneal infection, 412
Pharynx, wounds of, 311
Pleural septicæmia, 437
Pleurisy, 390, 398
Pneumonia, 9, 398
Pneumo-thorax, 388
Pom-pom shells, 478
Portland Hospital, 34
Psychical disturbance, 101
Rain, 9, 36
Range of fire:
Difficulty of judging influence on mortality, 17
Rectum, wounds of, 443, 444
Removal of wounded from the field, 18
Respiration in spinal injuries, 329
Retained bullets. See Bullets
Reversed bullets, 81
Revolution of bullet, 45, 46
Ribs, fractures of, 377
Signs of, 379
Ricochet, 82
Effect on wound type, 249
Lee-Metford, 89
Mauser, 84
Within body,
Abdomen, 415
Skull, 249
Rifles:
Bore, 41
Guedes, 47, 54
Krag-Jörgensen, 47, 54
Lee-Metford, 47, 64
Martini-Henry, 47, 97
Mauser, 47, 64
Modern principles of, 40
Trajectory, 44
Varieties employed, 47, 48
Scalp wounds, 242, 264
Scapula, fractures of, 177, 379
Scrotum, wounds of, 472
Septic disease, 34
Septicæmia:
General, 34
in enteric fever, 9
Peritoneal, 421
Pleural, 437
Shells, 474
Varieties of, 475
Vickers-Maxim, 478
Lyddite, 476
Shrapnel, 483
Shell wounds:
of abdomen, 480, 485
Proportionate occurrence of, 11
Shell fuse wounds, 481
Ships, hospital, 24
Shock:
General, 101
Local, 103
Treatment of, 110
Shrapnel, 483
Simla, 25
Skull. See Fractures
Fractures independent of gross brain lesion, 242
with brain lesion, 248
Spinal column:
Injuries to, 314
Fractures of centra, 317
Spinous processes, 315
Transverse processes, 314
Spinal cord, injuries to, 315
Compression by bullets, 319
Concussion, 319
Contusion, 320
Diagnosis, 335
Hæmato-myelia, 322
Section of, 323
Shock accompanying, 328
Signs of, 323
Transport of, 339
Treatment of, 339
Spinal hæmorrhage:
Epidural, 321
Hæmato-myelia, 322
Peri-pial, 321
Spleen, wounds of, 469
Splints:
Aluminium, 177
Field cane, 209, 221
Hodgen's, 211
Wire gauze, 187
Sternum, fractures of, 379
Stevenson, Col. W. F.:
Local shock, 106
Explosive wounds, 159
Stokes, Sir W.:
Treatment of aneurism, 151
Stomach, wounds of, 424
Stonham, Mr. C.:
Wound of vermiform appendix, 437
Sunstroke, 10
Suppuration of wounds, 78
in fracture, 173
Synovitis, vibration, 226
Temperature of air, 8, 36
in blood effusions, 118, 391, 393
Tents, 32
Testicle, wounds of, 472
Tetanus, 34
Thirst, 8
Thomson, Sir W.:
Pom-pom wounds, 479
Wound of nose, 305
Thoracic vessels, wounds of, 384
Tonga, the, 19
Tongue, wounds of, 309
Trachea, wounds of, 312
Traction engines, 23
Trains, hospital, 23
Trajectory, 44
Transport:
after battles, 26
of wounded men from field, 18
of wounded of the Kimberley Relief Force, 25
of chest injuries, 386
of fractures, 176
of spinal injuries, 339
Traumatic aneurism. See Aneurism
Traumatic epilepsy, 291
Traumatic gangrene, 34
Traumatic neurosis, 107, 351
Treves, Mr. F.: on cessation of intestinal peristalsis, 423
Trolly (McCormack-Brook), 19
Upper jaws, 306
Urethra, wounds of, 472
Urinary Bladder. See Bladder
Varix. See Aneurismal varix
Vegetables, 7
Veldt sores, 10
Velocity of bullet:
Circumstances influencing, 43
Initial, 42, 49
Remaining of various rifles, 49
Velocity, influence of:
on fractures of long bones, 163
on fractures of short and flat bones, 168
on wounds of abdomen, 414
of chest, 385
of joints, 226, 230
of lungs, 385
of nerves, 341
of skull, 251
of spine, 319
Vermiform appendix, wounds of, 437
Vibration synovitis, 226
Vickers-Maxim shell, 478
Vomiting in spinal injuries, 329
Wagons:
Ambulance, 20
Buck, 22
Ox, 20
Warfare, deadliness of, 40
Water in South Africa:
Character of, 8, 36
Transport of, 5
Waxed bullets, 52
Wobble, 80, 81, 251
Wounded men, removal from the field, 18
Wounds, general:
Aperture of entry, 55, 72
Aperture of exit, 58, 74
Climate, influence on, 71
Clinical, course of, 69
Contour tracks, 65
Direct nature of tracks, 63
Directions of tracks, 66
Displacement of structures, 68
Explosive exit wounds, 97
Foreign bodies in, 71
First field dressing, 107
Hæmorrhage, 104
Irregular types of, 80, 97
Mode of healing, 72
Multiple character, 67
Nature of tracts, 68
Pain, 103
Prognosis, 106
Psychical disturbance, 101
Shock, 101
Small bore, 67
Superficial tracts, 65
Suppuration, 69, 78
Symptoms, 100
Tracks, nature of, 68
Treatment, 107
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