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 ℥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 (℥xxiv-℥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.