Surgical Experiences in South Africa, 1899-1900 / Being Mainly a Clinical Study of the Nature and Effects of Injuries Produced by Bullets of Small Calibre

by George Henry Makins

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 1½ mile. There was very slight bleeding. Entry (Mauser), in the tenth right intercostal space in the mid-axillary line; exit, in eleventh interspace, 2 inches from the spinous processes. Cylindrical blood-clots, 3 inches in length, were passed on the first two occasions of micturition after the accident, and the urine contained blood. For four days he could only lie on the wounded side. When seen on the third day the urine was normal, and there were no signs of injury to either thoracic or abdominal viscera. He returned to England well at the end of a month.