Fig. 86 exhibits a lateral injury of a more p.r.o.nounced form. The bullet here struck the most prominent portion of the under surface of the bowel, and produced a circular perforation not very unlike one produced by rectangular impact, except in the lesser degree of eversion of the mucous membrane. Here again the appearance is somewhat altered by the presence of a considerable amount of lymph, but this is of less importance in this figure because the lymph is localised to the portion of the bowel in the immediate neighbourhood of the opening which had suffered contusion and erasion.

[Ill.u.s.tration: FIG. 86.--Gutter Wound of Small Intestine caused by lateral impact. Position of shallow portion of gutter indicated by deposition of inflammatory lymph. Circular perforation. (St. Thomas's Hospital Museum)]

Fig. 87, A B, ill.u.s.trates a symmetrical perforation of the small intestine; the aperture of entry (A) is roughly circular, and a ring of mucous membrane protrudes and partially closes the opening. The aperture of exit is a curved slit, again partially occluded by the mucous membrane. The same amount of difference between the two apertures did not always exist; in many cases both were circular, and apparently symmetrical. Beyond this I have seen three apertures in close proximity, two lying on the same aspect of the bowel, and the first of these was no doubt an opening due to lateral impact similar to that seen in fig. 86.

In the recent condition little difference existed between the three apertures.

The localised ecchymosis surrounding the apertures is quite characteristic of this form of injury, and is a valuable aid to finding the openings during an operation.

Fig. 88 shows the interior of the same segment of bowel, as fig. 87. It shows the localised ecchymosis as seen from the inner surface, here rather more extensive from the fact that the blood spreads more readily in the submucous tissue.

[Ill.u.s.tration: FIG. 87.--Perforating Wounds of Small Intestine. A.

Entry; note circular outline and eversion of mucous membrane. B. Wound of exit; curved slit-like character, eversion of mucous membrane. Note the localised ecchymosis, more abundant round exit aperture. (St.

Thomas's Hospital Museum)]

It will be noted that the main feature of the form of injury is the regular outline and the small size of the wounds. Another feature not ill.u.s.trated by the figures should also be mentioned. In the ruptures of intestine with which we are acquainted in civil practice the wound in the gut is almost without exception situated at the free border of the bowel, but in these injuries it was just as frequently at the mesenteric margin. The importance of this factor is considerable, since wounds near the mesenteric edge are much more likely to be accompanied by haemorrhage, and thus the opportunity for diffusion of infection is considerably multiplied, to say nothing of the danger from loss of blood.

Beyond these more or less pure perforations, long slits or gutters were occasionally cut. I saw instances of these in the case of the ascending colon, and in the small curvature of the stomach. The comparative fixity of the portion of bowel struck is a matter of great importance in the production of this form of injury.

[Ill.u.s.tration: FIG. 88.--The same piece of Intestine as that shown in fig. 87, laid open to show the ecchymosis on the inner aspect of the Bowel. The two indicating lines lead to the openings, which appear slit-like, and are sunk at the bottom of folds. (St. Thomas's Hospital Museum)]

It may be well to add that, although the figures inserted are all taken from small-intestine wounds, the nature of the wounds of the peritoneum-clad part of the large intestine in no way differed from them, except in so far as fixity of the bowel exposed it to a more extensive wound when the bullet took a parallel course to its long axis.

A more important point in the injuries to the large intestine was the possibility of an extra-peritoneal wound. I saw several such lesions of the colon, every one of which ended fatally. I became still more fully convinced of the greater seriousness of extra- to intra-peritoneal rupture of this portion of the gut than I was when I expressed a similar opinion in a former paper.[20] It will be seen later that the results of intra- and extra-peritoneal wounds of the bladder fully confirm this view, as all extra-peritoneal injuries died, while many intra-peritoneal perforations recovered spontaneously.

_Wounds of the mesentery._--I had little experience of this injury; in fact, case 169, on which I operated, was my sole observation. It stands to reason, however, that injuries to the mesentery would be much more frequent proportionately to wounds of the gut than is the case in the ruptures seen in civil practice, since the whole area of the mesentery is equally open to injury. Viewing the extreme danger of haemorrhage into the peritoneal cavity in these injuries, I should be inclined to expect that a considerable proportion of those deaths from abdominal wounds which took place on the field of battle were due to this source.

_Wounds of the omentum._--Here, again, I am unable to express any opinion, although the supposition that haemorrhage from this source took place is natural.

Prolapse of omentum was comparatively rare, except in cases with large wounds; it was apparently seen with some frequency among patients who died rapidly on the field of battle. I only saw it twice, and on each occasion in sh.e.l.l wounds. The wounds from small-calibre bullets were as a rule too small to allow of external prolapse.

Fig. 89, however, ill.u.s.trates a very interesting observation. A patient in the German Ambulance in Heilbron, under Dr. Flockemann, died as a result of suppuration and haemorrhage secondary to an injury to the colon. At the autopsy a portion of the omentum was found adherent in the wound of exit, but it had not reached the external surface. The chief interest of the observation lies in the light it throws on the mechanism of these injuries. It is impossible to conceive that a small-calibre bullet coming into direct contact with the omentum could do anything but perforate it. It, therefore, appears clear that in a displacement like that figured, only lateral impact occurred with the omentum, which was carried along by the spin and rush of the bullet into the ca.n.a.l of exit, where it lodged.

[Ill.u.s.tration: FIG. 89.--Great Omentum carried by the bullet into an exit track leading from the abdominal cavity. A. Outline of opening in the peritoneum]

_Results of injury to the intestine._ 1. _Escape of contents and infection of the peritoneal cavity._--I think there is little special to be said on this subject. The escape of contents into the peritoneal cavity was by no means free, unless the injury was multiple. Thus in one case of injury to the small intestine, No. 166, on which I operated, there was absolutely no gross escape until the bowel was removed from the abdominal cavity, when the contents spurted out freely. In one case of very oblique injury to the colon there was a considerable quant.i.ty of faecal matter in a localised s.p.a.ce, but as a rule the ordinary condition best described as 'peritoneal infection' from the wound was found. The bad effect of anything like free escape was well shown in multiple perforations; in these suppurative peritonitis rapidly developed and the patients died at the end of thirty-six hours or less. A typical case is quoted in No. 168.

2. _Peritoneal infection, and general septicaemia._--As is evident from the results quoted among the cases, the degree which this reached varied greatly. It may of course be a.s.sumed that in some measure it occurred in every case in which the bowel was perforated, but it was sometimes so slight as to be scarcely noticeable. This may be said to have been most common in injuries to the large intestine. Wounds of the caec.u.m, ascending and descending colon, the sigmoid flexure, or the r.e.c.t.u.m, were sometimes followed by no serious symptoms, either local or general.

Again in these portions of the bowel the development of local signs, and the later formation of an abscess, were by no means uncommon.

In the case of the small intestine I never observed this sequence, and the same may be said of the transverse colon, which in its anatomical arrangement and position so nearly approximates to the small bowel. In suspected wounds of these portions of the bowel either the symptoms were so slight as to render it doubtful whether a perforation had occurred, or marked signs of general peritoneal septicaemia developed, and death resulted.

The condition of the peritoneum in fatal cases varied much. In some a dry peritonitis, or one in which a considerable quant.i.ty of slightly turbid fluid was effused, was found. In others a rapid suppurative process, accompanied by the effusion of large quant.i.ties of plastic lymph, was met with. My experience suggested that the latter condition was the result of free infection from multiple wounds of the gut, the former the accompaniment of single wounds. Hence I should ascribe the difference mainly to the extent of the primary infection.

This is perhaps a suitable place to further discuss the explanation of the escape of a considerable number of the patients who received wounds of the abdomen, possibly implicating the bowel. Although this was not, I think, so common an occurrence as has been sometimes a.s.sumed, yet many examples were met with. Several reasons have been advanced.

(1) Great importance has been given to the fact that many of the men were wounded while in a state of hunger, no food having been taken for twelve or more hours before the reception of the injury. In view of the well-proved fact in these, as in other intestinal injuries, that free intestinal escape does not occur, and that it is usually a mere question of infection, this explanation, in my opinion, is of small importance.

It might with far more justice be pointed out that many of these wounded men were for them in the happy position of not having friends freely dosing them with brandy and water after the reception of the injury, and this was possibly an element of some importance.

Some of the men did, however, drink freely, and in one case which terminated fatally a comrade gave a man wounded through the belly an immediate dose of Beecham's pills.

(2) Mr. Treves has suggested that the effect of the severe trauma on the muscular coat of the bowel is to cause a cessation of peristaltic movement. This, as in the case of 'local shock' elsewhere, may no doubt be of importance, and to it should be added the simultaneous cessation of abdominal respiratory movements in the segment of the belly wall covering the injured part. The occurrence of general cessation of peristaltic movement is, however, to some extent opposed by the fact that in a certain number of the cases early pa.s.sage of motions was seen just as happens in the intestinal ruptures seen in civil practice.

I should be inclined to ascribe the escape from serious infection in these injuries to the same cause which accounts for their comparative insignificance in other regions--namely, the small calibre of the bullet and consequent small size of the lesion: in point of fact to the minimal nature of the primary infection. I very much doubt if any patient who had more than one complete perforation of the small intestine got well during the whole campaign. This opinion is, moreover, supported by the fact that the prognosis was so far better in cases of injury to the large than to the small intestine, in which former segment of the bowel we have the advantages of a position beyond the region in which intestinal movement is most free, the unlikelihood of multiple injury, and a drier and more solid type of faecal contents.

In the instances in which recovery followed perforating injuries without any bad signs we can only a.s.sume a minimal infection, and sufficient irritation and reaction on the part of the bowel to produce rapid adhesion between contiguous coils, and thus provisional closure.

The other mode of spontaneous recovery which I saw several times take place in the injuries to the large bowel consisted in the limitation of the spread of infection by early adhesions and the development of a local abscess. The non-observance of this process in any case of injury to the small intestine raises very great doubts in my mind as to the frequent recovery of patients in whom the small intestine was perforated.

INJURIES TO THE INTESTINAL TRACT

1. _Wounds of the stomach._--A considerable number of wounds in such a situation as to have possibly implicated the stomach were observed, and of these a certain number recovered spontaneously. The only two instances that came under my own observation are recorded below. It will be noted that in each the special symptoms were the cla.s.sic ones of vomiting and haematemesis. In the first case blood was also pa.s.sed per anum, and in the second the diagnosis was reinforced by the escape of stomach contents from the external wound.

The second case was a surgical disappointment. No doubt the fatal issue was mainly dependent on the fact that the external wound had to be kept open to allow of the escape of the abundant discharge from the wounded liver. In the absence of the hepatic wound, however, I believe it would have been possible for this patient to have got well spontaneously, in view of the firm adhesions which had formed around the opening in the stomach, and the consequent localisation which had been effected.

Another unfortunate element in this case was the comminuted fracture of the seventh costal cartilage, which maintained the patency of the aperture of exit. The latter point, however, was of doubtful importance from this aspect, as the vent provided for the gastric and biliary secretions may have been the safety-valve that had allowed localisation to develop.

I believe that the secondary haemorrhage was the main element in robbing us of a success in this case, and that this depended on the digestion of the wound by the gastric secretion. The early troubles which arose in the treatment of this patient well ill.u.s.trate the difficulties by which the military surgeon is at times met; but the patient was admirably attended to and nursed by my friend Mr. Pershouse, and an orderly who was specially put on duty for the purpose.

(163) Wounded at Rensburg. _Entry_ (Mauser), in ninth left intercostal s.p.a.ce in posterior axillary line; _exit_, a transverse slit 1/2 an inch in length to left of xiphoid appendage. Patient was retiring when struck; he did not fall, but ran for about 1,000 yards, whence he was conveyed to hospital. He vomited half an hour after the injury (last meal bread and 'bully beef,' taken two hours previously), and during the evening three times again, the vomit consisting mainly 'of dark thick blood.' He was put on milk diet, and not completely starved; on the third day a large quant.i.ty of dark clotted blood was pa.s.sed per r.e.c.t.u.m with the stool, and this continued for two days.

Ten days after the injury the temperature was still rising to 100, and did not become normal till the fourteenth day. The pulse averaged 80. The abdomen, meanwhile, moved fairly well, respirations 18 to 20. Some tenderness was present in the epigastrium and towards the spleen. Resonance throughout.

Ordinary diet was now resumed, and beyond slight epigastric pain on deep inspiration, no further symptoms were observed, and the patient left for England at the end of the month. The spleen may have been traversed in this patient, as well as the lower margin of the right lung.

(164*) Wounded at Enslin. _Entry_ (Mauser), 3/4 of an inch from the spine, opposite the eighth intercostal s.p.a.ce; _exit_, through the seventh left costal cartilage, 1 inch from the median line. The patient was lying in the p.r.o.ne position when shot: he vomited blood freely, and the bowels acted three times before he was seen forty hours after the accident, each motion containing dark blood.

On the commencement of the third day the patient's expression was extremely anxious, and he was suffering great pain. Pulse 96, temperature 100. Tongue moist, occasional vomiting, bowels open yesterday. Has taken fluid nourishment since injury. The abdomen moved with respiration, but was moderately distended, especially in the line of the transverse colon; it was tympanitic on percussion, there was no dulness in the flanks, and only moderate rigidity of the wall on palpation. Frothy fluid stained with bile and faecal in odour was escaping from the wound of exit, and the everted margins of the latter were bile-stained.

A vertical incision was carried downwards from the wound for 4 inches. A rugged furrow was found on the under surface of the left lobe of the liver; the stomach was contracted and firmly adherent by recent lymph to the under surface of the liver and the diaphragm. The transverse colon was much distended. On separating the stomach a slit wound was found at the lesser curvature, immediately to the right of the oesophagus. This wound was closed with some difficulty with two tiers of sutures; the cavity was mopped out, and then irrigated with boiled water; a plug was introduced along the line of the furrow in the liver, and the lower part of the abdominal incision closed.

The patient stood the operation well, and was removed to his tent; during the day, however, two thunder showers occurred during each of which water, several inches if not a foot deep, rushed through the camp. After the second flood he was removed to the operating room, the only house we had, and slept there.

The pulse rose to 120, and respiration to 26, and there was pain, which was subdued by 1/3 grain of morphia, administered subcutaneously. A fair amount of urine was pa.s.sed, and the bowels acted once, the motion containing blood.

On the second day after operation there was some improvement; the pulse still numbered 116, and the temperature was raised to 100, but the belly moved fairly, and pain was moderate.

Abundant foul-smelling, bile-stained discharge came from the wound when the plug was removed. Rectal feeding was supplemented by small quant.i.ties of milk and soda by the mouth.

The condition did not materially change, but on the fourth day it was evident that the suturing of the stomach wound had given way, and liquid food escaped readily when taken. The discharge remained bile-stained and very foul. No extension of inflammation to the general peritoneal cavity occurred, but it was evident that the patient was suffering from const.i.tutional infection from the foul wound, the lower part of which opened up somewhat after the removal of the st.i.tches on the seventh day. The wound was irrigated three times daily with 1-300 creolin lotion, but remained very foul. The man slowly lost strength, although escape from the stomach considerably decreased. On the tenth day a sudden severe haemorrhage occurred, presumably from a large branch of the coeliac axis.

The bleeding was readily controlled by a plug, and did not recur; but the patient rapidly sank, and died on the twelfth day after the operation, and fourteen days after reception of the injury. No _post-mortem_ examination was made.

2. _Wounds of the small intestine._--These were comparatively common, but offered little that was special either in their symptoms or the results attending them. Wounds were met with in every part of the small gut; but I saw no case in which an injury to the duodenum could be specially diagnosed.

As to the symptoms which attended these injuries, it is somewhat difficult to speak with precision, and it must be left to my readers to form an opinion as to how many of the cases recounted below were really instances of perforating wounds. My own view is that in the majority of the cases that got well spontaneously, the injury was not of a perforating nature, and that for reasons which have been already set forth. It will, however, be at once noted that in all the five cases in which the injury was certainly diagnosed in hospital death occurred.

The cases of injury to the small intestine are perhaps best arranged in three cla.s.ses.

1. Those who died upon the field, or shortly after removal from it. In these the external wounds were often large, the omentum was not rarely prolapsed, and escape of faeces sometimes occurred early. Shock from the severity of the lesion, and haemorrhage, were no doubt important factors in the early lethal issue in this cla.s.s. Many of the injuries were no doubt produced by bullets striking irregularly, by ricochets, by bullets of the expanding forms, or by bullets of large calibre. As being beyond the bounds of surgical aid, this cla.s.s possessed the least interest.

2. Cases brought into the Field, or even the Stationary hospitals, with symptoms of moderate severity, or even of an insignificant character, in which evidence of septic peritonitis suddenly developed and death ensued.