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

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, 1½ 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, 2½ 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, 1½ inch from the lumbar spines, at the level of the last right rib.