Perhaps no chapter of military surgery was looked forward to with more eager interest than that dealing with wounds of the abdomen. In none was greater expectation indulged in with regard to probable advance in active surgical treatment, and in none did greater disappointment lie in store for us.

Wounds of the solid viscera, it is true, proved to be of minor importance when produced by bullets of small calibre; but wounds of the intestinal tract, although they showed themselves capable of spontaneous recovery in a certain proportion of the cases observed, afforded but slight opportunity for surgical skill, and results generally deviated but slightly from those of past experience. Such success as was met with depended rather on the mechanical genesis and nature of the wounds than upon the efforts of the surgeon, and operative surgery scored but few successes.

It is true that to the Civil Surgeon accustomed to surroundings replete with every modern appliance and convenience, and the possibility of exercising the most stringent precautions against the introduction of sepsis from without, abdominal operations presented difficulties only faintly appreciated in advance; but this alone scarcely accounted for the want of success attending the active treatment of wounds of the intestine when occasion demanded. Failure was rather to be referred to the severity of the local injury to be dealt with, or to the operations being necessarily undertaken at too late a date. Many fatalities, again, were due to the a.s.sociation of other injuries, a large proportion of the wound tracks involving other organs or parts beyond the boundaries of the abdominal cavity.

The frequent a.s.sociation of wounds of the thoracic cavity with those of the abdomen afforded many of the most striking examples of immunity from serious consequences as a result of wound of the pleura. It must be conceded that in a large number of such injuries only the extreme limits of the pleural sac were encroached upon, yet in some the tracks pa.s.sed through the lungs, although without serious consequences. Under the heading of injury to the large intestine a somewhat special form of pleural septicaemia will be referred to.

It may at once be stated that such favourable results as occurred in abdominal injuries were practically limited to wounds caused by bullets of small calibre, and that, although in the short chapter dealing with sh.e.l.l injuries a few recoveries from visceral wounds will be mentioned, I never met with a penetrating visceral injury from a Martini-Henry or large sporting bullet which did not prove fatal.

_Wounds of the abdominal wall._--It is somewhat paradoxical to say that these injuries possessed special interest from their comparative rarity of occurrence, since they were not of intrinsic importance. Their infrequency depended on the difficulty of striking the body in such a plane as to implicate the belly wall alone, and their interest in the diagnostic difficulty which they gave rise to.

In many cases the position of the openings and the strongly oval or gutter character possessed by them were sufficient proof of the superficial pa.s.sage of the bullet; in others we had to bear in mind that the position of the patient when struck was rarely that of rest in the supine position, in which the surgical examination was made, and considerable difficulty arose. Some superficial tracks crossing the belly wall have already been referred to in the chapter on wounds in general and in that dealing with injuries to the chest, in which the above characters sufficed to indicate that penetration of the abdominal cavity had not occurred. In other instances a definite subcutaneous gutter could be traced, and often in these a well-marked cord in the abdominal wall corresponding to the track could be felt at a later date.

Again, limitation to the abdominal wall was sometimes proved by the position of the retained bullet, or sometimes by the presence in the track of foreign bodies carried in with the projectile. See case 160.

Fig. 84 ill.u.s.trates an example where the limitation to the abdominal wall was evident on inspection. Here the division of the thick muscles of the abdominal wall had led to the formation of a swelling exactly similar to that seen after the subcutaneous rupture of a muscle, and two soft fluctuating tumours bounded by contracted muscle existed in the substance of the oblique and rectus muscles.

[Ill.u.s.tration: FIG. 84.--Wound of Abdominal Wall (Lee-Metford). Division of fibres of external oblique and rectus abdominis muscles. Case 159]

The cases which presented the most serious diagnostic difficulty in this relation were those in which the wound was situated in the thicker muscular portions of the lower part of the abdominal and pelvic walls.

Such a case is ill.u.s.trated in the chapter on fractures (see fig. 55, p.

191). I saw one or two such instances, in which only the exploration necessary for treatment of the fracture decided the point. In many of the wounds affecting the lateral portion of the abdominal wall the question of penetration could never be definitely cleared up, as wounds of the colon sometimes gave rise to absolutely no symptoms.

In a certain proportion of the injuries the peritoneal cavity was no doubt perforated without the infliction of any further visceral injury, and in these also the doubt as to the occurrence of penetration was never solved.

(158) _Wound of belly wall._--Wounded at Modder River. _Entry_ (Mauser), 2 inches below the centre of the left iliac crest; _exit_, 1-1/2 inch above and internal to the left anterior superior iliac spine. The patient was on horseback at the time of the injury and did not fall; he got down, however, and lay on the field an hour, whence he was removed to hospital.

Probably the track pierced the ilium, and remained confined to the abdominal wall. There were no signs of visceral injury.

(159) Cape Boy. Wounded at Modder River. _Entry_ (Lee-Metford), immediately above and outside right anterior superior spine; _exit_, 1-1/2 inch below and to right of umbilicus. A well-marked swelling corresponded with division of the fibres of the oblique muscles and of the rectus, and on palpation a hollow corresponding with the track was felt. The abdominal muscles were exceptionally well developed (fig. 84).

(160) Wounded at Magersfontein while lying p.r.o.ne. _Entry_, irregular, oblique, and somewhat contused, over the eighth left rib, in the anterior axillary line; _exit_, a slit wound immediately above and to the left of the umbilicus. The bullet struck a small circular metal looking-gla.s.s before entering, hence the irregularity of the wound. The patient developed a haemothorax, but no abdominal signs; the former was probably parietal in origin, secondary to the fractured rib, and the whole wound non-penetrating as far as the abdominal cavity was concerned.

(161) Wounded at Magersfontein. _Entry_ (Mauser), 1-1/2 inch external to and 1/2 inch below the left posterior superior iliac spine; _exit_, 1 inch internal horizontally to the left anterior superior spine.

No signs of intra-peritoneal injury were noted, but free suppuration occurred in left loin; the ilium was tunnelled.

The same patient was wounded by a Jeffrey bullet in the hand; the third metacarpal was pulverised, although the bullet, which was longitudinally f.l.a.n.g.ed, was retained.

(162) Wounded outside Heilbron. _Entry_, below the eighth right costal cartilage; _exit_, below the eighth cartilage of the left side. The wound of entry was slightly oval; that of exit continued out as a 'flame'-like groove for 2 inches. A week later the wound track could be palpated as an evident hard continuous cord.

_Penetration of the intestinal area without definite evidence of visceral injury._--This accident occurred with a sufficient degree of frequency to obtain the greatest importance, both from the point of view of diagnosis and prognosis, and as affecting the question of operative interference. Amongst the cases reported below a number occurred in which it was impossible to settle the question whether injury to the bowel had occurred or not, and I will here shortly give what explanation I can for the apparent escape of the intestine from serious injury.

We may first recall the general question of the escape of structures lying to one or other side of the track of the bullet. I believe that there can be no doubt as to the accuracy of the remarks already made as to the escape of such structures as the nerves by means of displacement, and that the occurrence of such escapes is manifestly dependent on the degree of fixity of the nerve or the special segment of it implicated.

The general tendency of the tissues around the tracks to escape extensive destruction from actual contusion has also been referred to, and is, I think, indisputable.

If these observations be accepted, I think there can be no difficulty in allowing that the small intestine is exceptionally well arranged to escape injury. First of all, it is very moveable; secondly, it is so arranged that in certain directions a bullet may pa.s.s almost parallel to the long axis of the coils; thirdly, it is elastic, capable of compression, and light, and hence offers but a small degree of resistance to the pa.s.sage of the bullet across the abdominal cavity.

Certain evidence both clinical and pathological supports the contention that the small intestine may escape injury from the pa.s.sing bullet.

First of all, the fact may be broadly stated that injuries to the small intestine were fatal in the great majority of certainly diagnosed cases, while, on the other hand, many tracks crossed the area occupied by the small intestine without serious symptoms of any kind resulting.

Secondly, experience showed that when the bullet crossed the line of the fixed portions of the large intestine the gut rarely escaped, and that, although a considerable proportion of these cases recovered spontaneously, in a large number of them immediate symptoms, or secondary complications, clearly substantiated the nature of the original injury. As far as my experience went, however, I never saw any instance in which an undoubted injury of the small intestine was followed by the development of a local peritoneal suppuration and recovery, a sequence by no means uncommon in the case of wounds of the large intestine. Although, therefore, I am not prepared to deny the possibility of spontaneous recovery from an injury to the small intestine, under certain conditions which will be stated later, I believe that in the immense majority of cases in which a bullet crossed the small intestine area without the supervention of serious symptoms, the small intestine escaped perforating injury.

Beyond the clinical evidence offered above, certain pathological observations support the view that the intestine escapes perforation by displacement. Most of my knowledge on this subject was derived from the limited number of abdominal sections I performed on cases of injury to the small intestine, and may be summed up as follows.

The small intestine may present evidence of lateral contusion in the shape of elongated ecchymoses, either parallel, oblique, or transverse to its long axis. These ecchymoses resemble in extent and outline those which ordinarily surround a wound of the intestinal wall produced by a bullet (see fig. 87, p. 418).

The wall of the small intestine may be wounded to an extent short of perforation, either the peritoneal coat alone being split, or the wound implicating the muscular coat and producing an appearance similar to that seen when the intestine is dragged upon during an operation, but without so much gaping of the edges (see fig. 85, p. 416).

I met with these conditions in a.s.sociation with co-existing complete perforations of the small intestine, and in one case of intra-peritoneal haemorrhage in which no complete perforation was discoverable (No. 169, p. 432).

The implication and perforation of the small intestine are to some extent influenced by the direction of the wound. A striking case is included below, No. 201, in which a bullet pa.s.sed from the loin to the iliac fossa on each side of the body, approximately parallel to the course of the inner margin of the colon, and I also saw some other wounds in this direction in which no evidence of injury to the small intestine was detected, and which got well. Again wounds from flank to flank were, as a rule, very fatal; but I saw more than one instance where these wounds were situated immediately below the crest of the ilium, in which the intestine escaped injury (see case 171). A very striking observation was made by Mr. Cheatle in such a wound. The patient died as a result of a double perforation of both caec.u.m and sigmoid flexure; none the less the bullet had crossed the small intestine area without inflicting any injury.

The sum of my experience, in fact, was to encourage the belief that, unless the intestine was struck in such a direction as to render lateral displacement an impossibility, the gut often escaped perforation.

As a rule, the wounds of the abdomen which from their position proved the most dangerous to the intestine were--

1. Wounds pa.s.sing from one flank to the other were very dangerous, as crossing complicated coils of the small intestine, and two fixed portions of the colon. This danger was most marked when the wounds were situated between the eighth rib in the mid axillary line and the crest of the ilium; above this level the liver, or possibly liver and stomach, were sometimes alone implicated, and the cases did well. Again, when the wounds crossed the false pelvis the patients sometimes escaped all injury to viscera.

2. Antero-posterior wounds in the small intestine area were very fatal if the course was direct; in such the small intestine seldom escaped injury.

3. Wounds with a certain degree of obliquity from anterior wall to flank, or from flank to loin, were on the other hand comparatively favourable, as the small intestine often escaped, and if any gut was wounded, it was often the colon.

4. Vertical wounds implicating the chest and abdomen, or the abdomen and pelvis, were on the whole not very unfavourable. For instance, when the bullet entered by the b.u.t.tock and emerged below the umbilicus, a number of patients escaped fatal injury; this depended on the comparatively good prognosis in wounds of the r.e.c.t.u.m and bladder. A good many patients in whom the bullet entered by the upper part of the loin, and escaped 1-1/2 inch within the anterior superior spine of the ilium, also did well. The same holds good when the wounds either entered or emerged under the anterior costal margin of the thorax, either prior to or after traversing the thorax.

Wounds pa.s.sing directly backward from the iliac regions were in my experience very unfavourable; but I believe mainly as a result of haemorrhage from the iliac arteries.

_The occurrence of wounds of the abdomen of an 'explosive'

character._--The vast majority of the abdominal wounds observed in the Stationary or Base hospitals were of the type dimensions. A certain number of the abdominal injuries which proved fatal on the field or shortly afterwards were described as explosive in character, and were referred by the observers to the employment of expanding bullets.

A few words on this subject seem necessary, because it seems doubtful whether such injuries could be produced by any of the forms of expanding bullet of small calibre in use, unless the track crossed one of the bones in the abdominal or pelvic wall. That this was sometimes the case there is no doubt: thus I saw two cases in which the splenic flexure of the colon was wounded, in which the external opening was large, and a comminuted fracture of the ribs of the left side existed. One can well believe that bullets pa.s.sing through the pelvic bones might 'set up' to a considerable extent, and although I never happened to see such a case, an explanation of some of the wounds described by others might be found in this occurrence.

In instances in which the soft parts alone were perforated, I am disinclined to believe that bullets of small calibre, either regulation or soft-nosed, were responsible for the injuries. I had the opportunity of examining two Mauser bullets of the Jeffreys variety which crossed the abdomen and caused death. In the first (figured on page 94, fig. 40) very little alteration beyond slight shortening had occurred. In the second the deformity was almost the same, except that the side of the bullet was indented, probably from impact with some object prior to its entry into the body. In each case the bullet was of course travelling at a low rate of velocity; hence no very strong inference can be drawn from either. In the case of the second specimen, which was removed by Mr. Cheatle, a remarkable observation was made, which tends to throw some light on one possible mode of production of large exit apertures.

This bullet crossed the caec.u.m, making two small type openings; but later, when it crossed the sigmoid flexure, it tore two large irregular openings in the gut. This might be explained on the ground that the velocity was so small as only just to allow of perforation, which therefore took the nature of a tear. I am inclined to suggest, as a more likely explanation, that the spent bullet turned head over heels in its course across the abdomen, and made lateral or irregular impact with the last piece of bowel it touched. A slightly greater degree of force would have allowed a similar large and irregular opening to be made in the abdominal wall also.

In this relation the question will naturally be raised as to how far the explosive appearances may have been due to high velocity alone on the part of the bullet. I am disinclined from my general experience to believe that explosive injuries of the soft parts were to be thus explained. On the other hand, I believe that the possession of a low degree of velocity very greatly increased the danger in abdominal wounds. I believe that the bowel was, under these circ.u.mstances, less likely to escape by displacement, and was more widely torn when wounded; again, that inexact impact led to increase of size in the external apertures, and the bullet was of course more often retained.

Mr. Watson Cheyne[19] published a very remarkable instance of one of the dangers of an injury from a spent bullet, in which, in spite of non-penetration of the abdominal cavity, the small intestine was ruptured in two places.

I believe the majority of the wounds designated as explosive were the result of the pa.s.sage of large leaden bullets, either of the Martini-Henry or Express type. The small opportunity of observing such injuries in the hospitals of course depended on the fact that the majority were rapidly fatal.

_Nature of the anatomical lesion in wounds of the intestine._--The openings in the parietal peritoneum tended to a.s.sume the slit or star forms, probably on account of the elasticity of the membrane. A diagram of one of these forms is appended to fig. 89. In this instance the opening in the peritoneum was made from the abdominal aspect, prior to the escape of the bullet from the cavity, and on the impact of the tip, the long axis of the bullet was oblique to the surface of the abdominal wall.

In the intestinal wall the openings varied in character according to the mode of impact.

In some cases the gut was merely contused by lateral contact of the pa.s.sing bullet. The result of this was evidenced later by the presence of localised oval patches of ecchymosis. These were identical in appearance with the patches shown surrounding the wounds in fig. 87.

[Ill.u.s.tration: FIG. 85.--Lateral Slit in Small Intestine produced by pa.s.sage of bullet. Slit somewhat obscured by deposition of inflammatory lymph. (St. Thomas's Hospital Museum)]

More forcible lateral impact produced a split of the peritoneum, or of this together with the muscular coat. Such a lateral slit is shown in fig. 85, although the clearness of outline is somewhat impaired by the presence of a considerable amount of inflammatory lymph.