The cases of injury to the small intestine are perhaps best arranged in three classes.

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 class. 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 class 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.

3. Cases in which the position of the wounds raised the possibility of injury to the intestine, but in which the symptoms were slight or of moderate severity, and which recovered spontaneously.

The whole crux in diagnosis lay in the attempt to separate the two latter classes, and, personally, I must own to having been no nearer a position of being able to form an opinion on this point, in the late than in the early stage of my stay in South Africa. The advent of peritoneal septicaemia was in many instances the only determining moment. On this matter I can only add that, in civil practice, an exploratory abdominal section is often the only means of determination of a rupture of the bowel wall.

With regard to the cases of suspected injury to the bowel which recovered spontaneously, the symptoms were somewhat special in their comparative slightness, and in the limited nature of the local signs. Thus the pulse seldom rose to as much as 100 in rate, 80 was a common average. Respiration was never greatly quickened, 24 was a common rate. The temperature rarely exceeded 100 deg.. Vomiting was occasionally severe, but usually not persistent, ceasing on the second day. A good quantity of urine was passed. As to the local signs, these again were of a limited nature; distension did not occur, or was slight; movement of the abdominal wall was only restricted in the neighbourhood of the wound, the affected area amounted to a quarter, or at most half, the abdominal wall, and rigidity was localised to a similar segment. Local tenderness usually existed; but, as a rule, there was little or no dulness to point to the occurrence either of fluid effusion or a considerable deposition of lymph.

Again many of the patients suffered with very slight symptoms of constitutional shock, although there was considerable variation in this particular.

(165*) Wounded at Graspan, sustaining a compound fracture of the fibula. While being carried off the field, a second bullet (Lee-Metford) entered immediately outside the left posterior superior iliac spine, perforated the pelvis, and emerged 1-1/2 inch within the left anterior superior spine. The patient was then put down and left on the field ten hours; later he was carried to shelter for the night, and arrived at Orange River on the second day. He suffered with some pain in the abdomen, especially during the journey in the train, but was not sick; the bowels were confined.

When seen on the third day at 6 P.M., some pain was complained of in the abdomen, which moved freely in the upper part, but was motionless below the umbilicus. No distension. Tenderness around wound of exit and some rigidity. The bowels had acted four times during the day; motions loose, dark brown, and containing no blood. Face not anxious, eyes bright, temperature 102 deg.. Pulse 96, regular, and of good strength. Tongue moist and little furred.

The abdomen was opened at 5 A.M. on the fourth day, as the local signs had become more pronounced, and the patient had passed a restless night in great abdominal pain. A local incision was chosen, as the wound was presumably in the sigmoid flexure. The sigmoid flexure was adherent to the abdominal wall opposite the wound of exit, and a dark ecchymosed patch was found, but no perforation could be detected. Foul pus and gas escaped freely from the pelvis, but no wound of the large bowel could be discovered here. On enlarging the incision upwards three openings were found in a coil of jejunum, probably that about five feet from the duodenal junction usually provided with the longest mesentery. No fourth opening could be found. The openings were circular, about 1/3 inch in diameter, clean cut, with a ring of everted mucous membrane, and the wall of the bowel in the neighbourhood was thickened. All three openings were included within a length of 2-1/2 inches. There was no surrounding ecchymosis of the bowel wall. Very little escaped intestinal contents were found in the situation of the bowel. The latter had apparently been retracted upwards, and lay to the left of the lumbar spine. The wounds were readily closed by five Lembert's sutures, three crossing the openings, and one at each end. The belly was then washed out with boiled water and closed. The delay in finding the wounds due to the mistaken impression that they would be found in the pelvis materially prolonged the operation, which lasted an hour and a half. The patient never rallied, and died seventeen hours later. It is possible that a wound in the sigmoid flexure was present which had already closed at the time of operation.

(166*) Wounded at Magersfontein. Entry (Mauser), opposite central point of left ilium; exit, 1-1/2 inch above the centre of the right Poupart's ligament. Vomiting commenced soon after the injury, and this was continuous until the patient's arrival in the Stationary hospital on the fourth day, when the condition was as follows:—

Face extremely anxious in expression. Temperature 101 deg., sweating freely. Pulse 110, fair strength. Tongue moist. Abdomen much distended, rigid, motionless, tympanitic throughout. Bowels confined. No urine had been passed for twenty-four hours, [Symbol: ounce]ij in bladder on catheterisation, clear, and containing no blood.

Abdominal section. Median incision. A considerable quantity of bloody effusion was evacuated. Intestine generally congested and distended. No lymph. Two wounds were found in the ileum on the opposite sides of one coil; the openings were circular, with the mucous membrane everted. No escape of faecal matter was visible until the intestine was delivered, when intestinal contents spurted freely across the room. The openings were sutured with five Lembert's stitches. The bowel was punctured in two places to relieve distension, and then returned into the belly, after washing with boiled water.

Four pints of saline solution were infused into the median basilic vein, and 1/30 grain strychnine sulph. was injected hypodermically.

The patient did not rally, and died twelve hours after the operation.

(167*) Wounded at Graspan. Entry (Lee-Metford), midway between the umbilicus and pubes; exit, 1 inch to the left of the fifth lumbar spine. The patient was seen on the third day in the following condition: in great pain, expression extremely anxious, vomiting constantly. Pulse 150 running, respirations 48. Temperature 100 deg., sweating freely. Great distension, rigidity, and general tenderness of immobile abdomen. No improvement followed the administration of brandy and hypodermic injection of strychnine 1/30 grain, and operation was deemed hopeless.

In the evening the patient was apparently dying. Face blue and sunken and covered with sweat, eyes dull, speechless, pulse imperceptible, restlessness extreme, bowels acting involuntarily, no urine in bladder.

The man was placed in a tent by himself, and to my surprise was alive and better the next morning; the expression was still anxious, but the face brighter and not sweating; the pulse only numbered 100, but was very weak, and the hands and feet were cold. The condition of the abdomen was unaltered, but the thoracic respiration had decreased in rapidity from 48 to 28.

His condition still seemed to preclude any chance of successful intervention, but none the less life was retained until the morning of the seventh day, the state alternating between a moribund one and one of slight improvement. He was lucid at times, although for the most part wandering, and was so restless that no covering could be kept upon him. Vomiting was continuous, so that no nourishment could be retained; the bowels acted frequently involuntarily, and little or no urine was passed. Meanwhile, the abdomen became flat, then sunken, an area of induration and tenderness about 6 inches in diameter developing around the wound of entry. Slight variations in the pulse, and from normal to subnormal in the temperature, were noted, and death eventually occurred from septicaemia and inanition.

(168*) Wounded at Driefontein. Entry (Mauser), above the posterior third of the left iliac crest, at the margin of the last lumbar transverse process (probably through ilio-lumbar ligament); exit, 1 inch below and to the left of the umbilicus.

The patient was wounded at 3 P.M., but not brought into the Field hospital until 9 P.M., when the temperature of the tents was below 28 deg.F. He was considerably collapsed, suffering much pain, and vomited freely. The abdomen was flat, but very tender. Bowels confined. The column had to move at 5 A.M. the next morning, when the temperature was still near freezing, and during the day continuous fighting prevented any chance of operation. The man steadily sank during the day, and died thirty-six hours after the reception of the injury.

Post-mortem condition.—Belly not distended, dull anteriorly in patches, and right flank dull throughout. When the belly was opened, extensive adhesion of omentum and intestine enclosing numerous collections of pus were disclosed, and on disturbing the adhesions a large collection of turbid blood-stained fluid was set free from the right loin. The great omentum was much thickened and matted, with deposition of thick patches of lymph; very firm recent adhesions also united numerous coils of small intestine. The pus was foetid, but no appreciable quantity of intestinal contents was detected in it. The lower half or more of the small intestine was injected, reddened, and thickened. The wounds which were situated in the lower part of the jejunum and ileum were multiple, and seven perforations were detected; besides these the intestine was marked by bruises, and some gutter slits affecting the serous and muscular coats only. Considerable ecchymosis surrounded these latter. The clean perforations were circular, less than 1/4 inch in diameter, and for the most part closed by eversion of the mucous membrane. Intestinal contents were not apparent, but escaped freely on manipulation of the bowel.

(169*) Wounded at Magersfontein. Entry (Mauser), over the eighth rib in the anterior axillary line; exit, 1 inch to the left of second lumbar spinous process, just below the last rib. Vomiting commenced almost immediately after reception of the injury, and the bowels acted frequently. This condition persisted until the fourth day, when the patient was brought down to Orange River, and the signs were as follows. Considerable pain in left half of abdomen, pulse 110, fair strength, temperature 101 deg.. Some general distension of abdomen with complete disappearance of hepatic dulness. Some movement of right half of abdomen, left half immobile, dulness extending from the flank as far forwards as linea semilunaris. An incision was made in left linea semilunaris, and Oj blood evacuated from the left loin. There was no lymph on the intestines nor sign of inflammation. No perforation was discovered in either stomach or intestine, but on two coils of jejunum there were deep slits 3/4 inch long, extending through both peritoneal and muscular coats. Beyond these wounds, on other coils oval patches of ecchymosis, due to direct bruising, were present. The peritoneal cavity was sponged free of all blood and irrigated with boiled water; no bleeding point was discovered, and the abdomen was closed.

The next morning the patient was comfortable; temperature 100.2 deg., pulse 100. Tongue clean and moist; he vomited once during the night.

Some bloody discharge had collected in the dressing, and at the lower angle of wound there was a local swelling, apparently in the abdominal wall. The flank was resonant.

During the afternoon the patient became faint, and when seen at 6 P.M. was in a state of collapse, in which he shortly died.

Death was apparently due to renewal of the previous haemorrhage. No post-mortem examination was made.

(170*) Wounded at Magersfontein. Entry (Mauser), 1/2 inch to the left of the second sacral spine; exit, immediately below the left anterior superior iliac spine; the patient was kneeling at the time, and the same bullet traversed his left thigh in the lower third. When seen on the third day, the lower part of the abdomen was motionless, tumid, and tender. The bowels had been confined for three days; there had been no sickness, and the tongue was moist and clean. Temperature 100 deg., pulse 90, fair strength, respirations 38. The patient had once had an attack of acute appendicitis, and he himself said he was sure he now had 'peritonitis,' as he had pain exactly similar in the belly to that he had suffered in his previous illness.

No further signs, however, developed under an expectant treatment, and he remained some two months in hospital, while the wound in the thigh and a third injury to the elbow-joint were healing.

(171) Entry (Mauser), at the highest point of the left crista ilii; exit, through the right ilium, 2 inches horizontally anterior to the posterior superior spine. Absolutely no abdominal symptoms followed. The bowels were confined five days, and then opened by enema. The patient complained of some stiffness in the lumbo-sacral region, but the right synchondrosis was no doubt implicated in the track.

(172) Wounded at Paardeberg (range 800 yards). Entry (Mauser), 2 inches diagonally below and to the right of the umbilicus; exit, not discoverable. For the first two days the patient had to lie out with the regiment; on the fourth he was removed to the Field hospital. During the first three days the patient vomited (green matter) frequently, and the belly was hard and painful; as biscuit was the only available food, no nourishment was taken. The bowels acted on the second night. At the end of a week the patient was sent by bullock wagon (three days and nights) to Modder River, and then down to Capetown, where he walked into the hospital on the thirteenth day, apparently well.

Two days later the temperature rose to 104 deg., and enteric fever was diagnosed, no local signs pointing to the injury existing. The patient made a good recovery.

(173) Wounded at Colenso. Entry (Mauser), at junction of outer 2/5 with inner 3/5 of line from right anterior superior iliac spine to umbilicus; exit, at upper part of right great sacro-sciatic foramen, in line of posterior superior iliac spine. Advancing on foot when struck; he then fell and crept fifty yards to behind a rock, where he remained seven and a half hours. For two days subsequently he vomited freely; the bowels acted nine hours after the injury, and then became constipated. No further symptoms were noted, and at the end of three weeks the abdomen was absolutely normal. The man is now again on active service.

(174*) Wounded at Modder River while retiring on foot. Entry (Mauser), at highest point of right iliac crest; exit, 2-1/2 inches to right of and 1/2 inch above level of umbilicus. The injury was not followed by sickness, and the bowels remained confined. During the first two days 'pain struck across the abdomen' when micturition was performed.

When the patient came under observation on the third day the condition was as follows:—Complains of little pain, temperature normal, pulse 72, respirations 24, tongue moist, bowels confined. Rigidity of abdominal wall and deficient mobility of nearly whole right half of belly, the whole lower half of which moves little with respiration. No track palpable in abdominal parietes. No dulness, no distension. The temperature rose to 99.5 deg. at night. On the fourth day the bowels acted freely, the pulse fell to 60, the respirations were 24, and the temperature normal.

Tenderness and rigidity persisted in the right flank to the end of a week, after which time no further signs persisted.

(175*) Wounded at Modder River while lying on right side. Range 500 yards. Walked 400 yards after injury. Entry (Mauser), at the junction of the posterior and middle thirds of the right iliac crest; exit, 3 inches to right of and 1/2 inch below the level of the umbilicus. The injury was followed by no signs of intra-abdominal lesion; on the third day the temperature was normal, pulse 80, and the tongue clean and moist. Some soreness at times and tenderness on pressure were complained of, but the man was discharged well at the end of one month.

(176*) Wounded while doubling in retirement at Modder River. Entry (Mauser), immediately above the junction of the posterior and middle thirds of the left iliac crest; exit, 1 inch below costal margin (eighth rib), 3 inches to the right of the median line. The bullet was lying in the anterior wound, whence it was removed by the orderly who applied the first dressing on the field. The patient remained on the field seven and a half hours, and when brought into hospital at once commenced to vomit. The ejected matter, at first green in colour, during the next forty-eight hours changed to a dirty brown. Meanwhile, the abdomen was somewhat painful. When seen on the third day he had ceased to vomit for three hours. The face was slightly anxious, and the patient lay on the ground with the lower extremities extended. Temperature 99 deg., pulse 72, fair strength. Respirations 32, shallow. Tongue moist, lightly furred, bowels not open for four days. He slept fairly last night. Abdomen soft, moving well with respiration, no distension, slight tenderness below and to the right of the umbilicus, and local dulness in right flank.

The next day the pulse fell to 60 and the bowels acted, but there was no change in the local condition. The man looked somewhat ill until the end of a week, but was then sent to the Base, and at the expiration of a month was sent home well.

(177*) Wounded at Modder River. Two apertures of entry (Mauser); (a) below cartilage of eighth rib in left nipple line; (b) 2 inches below and 4-1/2 inches to the left of the median line. No exit wound discovered, and no track could be palpated between the two openings, which were both circular and depressed. When seen on fourth day there was tenderness in the lower half of the abdomen, and the left thigh was held in a flexed position. Respirations 20, respiratory movement confined to upper half of abdominal wall. Pulse 70, temperature 99 deg.. Tongue moist, covered with white fur; bowels confined since the accident; no sickness. The patient remained under observation thirteen days, during which time pain and difficulty in movement of the left thigh persisted, also slight tenderness in the lower part of the abdomen; but at the end of a month he was sent to England well, but unfit to take further part in the campaign. I thought the bullet might be in the left psoas, but it was not localised.

(178*) Wounded at Modder River. Entry (Mauser), 3-1/2 inches above and 1-1/2 inch within the left anterior superior iliac spine; exit, 1-1/2 inch to the right of the tenth dorsal spinous process. The same bullet had perforated the forearm just above the wrist prior to entering the abdomen. No local or constitutional signs indicated either bowel injury or perforation of liver. The man, however, was suffering from a slight attack of dysentery, passing blood and mucus per rectum with great tenesmus. He was sent to the Base at the end of a week, and returned to England well three weeks later. He attributed his dysentery to the wound, as the symptoms did not exist prior to its reception; but as the disease coincided exactly with what was very prevalent amongst the troops at the time, I do not think there was any connection between it and the injury.

(179) Wounded near Thaba-nchu. Entry, over the centre of the sacrum at the upper border of fourth segment; exit, 1-1/2 inch above left Poupart's ligament, 2 inches from the median line. Aperture of entry oval, with long vertical axis. Exit wound a transverse slit, with slight tendency to starring (see fig. 19, p. 58). One hour after being shot the patient vomited once. There was some evidence of shock and considerable pain. The bowels acted involuntarily simultaneously with the vomiting, and incontinence of faeces and retention of urine persisted for four days. The vomit was bilious in appearance; no blood was seen either in it or the motions.

Forty-six hours after the injury the condition was as follows: Face slightly anxious and pale; skin moist, temperature 100.4 deg.; pulse 116, regular and of fair strength; respirations 24; abdomen slightly tumid; tenderness over lower half, especially on left side; the lower half moves little with respiration.

Twenty-four hours later the patient had improved. He was comfortable and hopeful; slept well with morphia 1/3 grain hypodermically. Tongue moist, covered with white fur; has been taking milk only, [Symbol: ounce]ij every half-hour. No sickness. Temperature

99 deg.. Pulse 104. Respirations 24. Abdomen flatter; general respiratory movement; tenderness now mainly localised to an area 2-1/2 inches in diameter, to the left of the umbilicus, above exit wound.

The patient continued to improve, and on the fifth day travelled six hours in a bullock wagon to Bloemfontein. Soon after arrival his temperature was normal: pulse 80, respirations 16, with good abdominal movement. Local tenderness persisted in the same area, but was less in degree. Tongue rather dry, bowels confined. Micturition normal. Two drachms of castor oil and an enema were given.

On the ninth day patient was practically well, except for slight deep tenderness. He remained in bed on ordinary light diet, but at the end of the third week he was seized by a sudden attack of pain, the temperature rising to 103 deg. and the pulse to 140, the abdomen becoming swollen and tender. He was then under the charge of Mr. Bowlby, who ordered some opium, and the symptoms rapidly subsided. Although this wound crossed the small intestine area, it is probable that the symptoms may have been due to an injury of the rectum or sigmoid flexure.

3. Wounds of the large intestine.—Injuries to every part of the large bowel were observed, and spontaneous recoveries were seen in all parts except the transverse colon, which, as already remarked, is near akin to the small intestine with regard to its position and anatomical arrangement.

The only case of perforation of the vermiform appendix that I heard of, one under the care of Mr. Stonham, died of peritoneal septicaemia. Several cases of recovery from wounds of the caecum and ascending colon are recounted below. The only points of importance in the nature of the signs of these injuries were their primary insignificance, and the comparative frequency with which local peritoneal suppuration followed them. The absence of a similar sequence in some of the cases in which wounds of the small intestine were assumed, was, in my opinion, one of the strongest reasons for doubting the correctness of the diagnosis. It is also a significant fact that injuries of the ascending colon—that is to say, of the portion of the large bowel which perhaps lies most free from the area occupied by the small intestine—were those which most frequently recovered.

The following cases afford examples of the course followed in a number of injuries to the large intestine, and illustrate both the uncomplicated and the complicated modes of spontaneous recovery.

No. 180 affords a good example of an extra-peritoneal injury, and of the especially fatal character of such lesions. This case was also one of my surgical disappointments.

Nos. 182, 183 are of great interest in several particulars. First, the aperture of exit was large and allowed the escape of faeces, not a very common feature in wounds not proving immediately fatal. Secondly, in neither were any peritoneal signs observed. Thirdly, in each the exit wound communicated with the pleura, and the patients died from septicaemia mainly due to absorption from the surface of that membrane (Pleural septicaemia).

No. 190 is a most striking instance of spontaneous cure, since no doubt can exist that both rectum and bladder were perforated.

(180*) Injury to the caecum and ascending colon.—Boer, wounded at Graspan while sheltering behind a rock, lying on his back.

Entry (Lee-Metford), in right thigh, 3 inches below and 1 inch within anterior superior spine of ilium; exit, in back, on a level with the fourth lumbar spinous process and 3 inches from that point.

Half an hour after the wound the patient commenced to suffer severe stabbing pain; he lay on the field one hour; later he was taken to a Field hospital, and on the second day was sent by train a distance of twenty-five miles.

When seen at the end of fifty hours the condition was as follows. Face anxious, complexion dusky. Great abdominal pain, especially about the umbilicus. Vomiting frequent and distressing; bowels confined since the accident; tongue dry and furred. Urine scanty. Pulse full and strong, 125; respirations, entirely thoracic, 30.

Abdomen generally distended and tympanitic, wall rigid and motionless. Dulness in right flank, together with superficial oedema and emphysema.

Abdominal section fifty-three and a half hours after accident. Incision in right linea semilunaris. Great omentum adherent to ascending colon, which was covered with plastic lymph. Gas and intestinal contents escaped from an opening at the line of reflexion of the peritoneum from the ascending colon; retro-peritoneal extravasation and emphysema extended the whole length of the ascending colon and around duodenum, the wall of the colon itself exhibiting subperitoneal emphysema. The colon was freed and the rent sewn up with interrupted sutures. About [Symbol: ounce] iv of foul faecal fluid were evacuated from loin, and a free counter-opening made. The opening in the ilium by which the bullet had entered the abdomen was found at the brim of the pelvis; the loin and peritoneal cavity were sponged dry and flushed with boiled water; no lymph was seen on the small intestine. A large gauze plug was inserted into the posterior wound, one end of the plug being brought out of the operation incision.

During the succeeding six days progress was not unsatisfactory: the abdomen became soft, moved with respiration, there was no sickness, and the bowels acted. The pulse fell to 90, respirations to 20, and the temperature did not exceed 102 deg. F. The wound suppurated freely, however, and although there were no further signs of peritoneal septicaemia, it was evident that general infection had taken place, and on the sixth day a parotid bubo developed on the right side, which was opened.

On the seventh day the patient suddenly commenced to fail rapidly; vomiting was almost continuous—at first curdled milk, later frothy watery fluid—and on the eighth day he died. The abdomen remained soft, sunken, and flaccid, and death no doubt resulted from general septicaemia rather than from peritoneal infection, absorption taking place from the large foul cavity behind the colon. As the cavity in part surrounded the descending duodenum, this possibly accounted for the attack of vomiting which preceded death.

(181*) Ascending colon.—Wounded at Graspan while lying in prone position. Entry (Mauser), over ninth rib in line of right linea semilunaris; exit, in right buttock, just below and behind the top of the great trochanter.

The injury was followed by little abdominal pain, but a strange sensation of local gurgling was noted. The bowels acted as soon as the patient reached camp, some hours after being wounded. There was no sickness and nothing abnormal was noted in the motions, except that they were loose and light-coloured.

On the evening of the third day the patient came under observation in the ambulance train for Capetown. He looked somewhat anxious and ill, but he complained of little pain; the temperature was 102 deg., pulse 88, fair strength, soft and regular. There was local dulness, tenderness, and deficiency of movement in the right iliac region. As it was night, he was removed from the train and an operation was performed the next morning.

Prior to operation the condition was as follows: Pulse 84, temperature 100 deg.; respiration easy, 20. Tongue moist, but thickly coated in centre. Abdomen moves fairly, and is resonant, except in right lower quadrant. No distension. Dulness, tenderness, and rigidity in right iliac region, marked to outer side of caecum. Entry wound nearly and exit quite healed. Cannot flex right thigh. The following operation was performed. Appendix incision, about [Symbol: ounce]j of faecal fluid and faeces in a localised cavity on outer and anterior aspect of caecum evacuated; adhesions very firm. Cavity sloughy throughout and caecum covered with dull grey lymph. The opening in the bowel was not localised, and it was considered wiser to treat the case like one of perforation from appendicitis than to run the risk of breaking down adhesions. A small awl-like opening was found in the ilium with powdered bone at its entrance leading to the wound of exit.

The after-treatment of the case gave rise to no anxiety, but healing of the resulting sinus was slow; faecal-smelling pus escaped for some days, and a number of small sloughs came away. On the twelfth day the patient was sent down to Wynberg, where he remained twelve weeks. A counter-incision was needed in the loin to drain the suppurating cavity three weeks after the primary operation, and five weeks after the operation an escape of gas and faeces took place from the anterior wound, while the bowels were acting, as a result of a dose of castor oil. No further escape of faeces occurred, and he left for England with a small sinus only. No extension of inflammation into the original wound track ever occurred, both openings and the canal healing by primary union.

The sinus remained open, and occasionally discharged for a further period of six months, and then healed firmly; since when the patient has been in perfect health.

(182*) Splenic flexure, descending colon.—Wounded at Magersfontein. Entry (Mauser), in sixth left intercostal space in mid-axillary line; exit, in left loin, below last rib, at outer margin of erector spinae. The patient remained in the Field hospital three days, during which time he exhibited no serious abdominal symptoms, but during the journey to Orange River (53-1/2 miles) he was sick. He remained at Orange River two days, and while there an enema was administered, producing a normal motion. The abdomen was slightly distended; it moved fairly, there was slight rigidity, but little tenderness. Temperature 100.8 deg., pulse 120. No appearance of faeces in wound.

When seen on the sixth day the condition was as follows:—Patient cheerful and not in great pain. Temperature 99.2 deg.; pulse 120; respirations 48, very shallow. Abdomen soft, moving freely, no distension or general tenderness. Fluid faeces escaping in abundance from the wound in loin. Redness of skin and swelling below level of wound, and cellular emphysema above. Faecal-smelling fluid was also escaping from the thoracic wound.

The wound was enlarged, but the patient rapidly sank, and died of septicaemia on the seventh day.

(183*) An exactly similar case came under observation from the battle of Modder River, except that the opening in the loin was somewhat larger, and earlier and freer escape of faeces took place from it. In this also faecal matter passed freely into the left pleural cavity, and faecal matter was expectorated, while there was an almost complete absence of abdominal symptoms. Death occurred on the fourth day.

No post-mortem examination was made in either case, but I believe in both the extra-peritoneal aspect of the colon was implicated and that the septicaemia was in great part due to absorption from the pleural rather than the peritoneal cavity, since in neither case were the abdominal symptoms a prominent feature.

(184) Possible wound of caecum.—Wounded at Spion Kop. Bullet (Mauser) perforated the right forearm, then entered belly. Entry, 3 inches from the right anterior superior iliac spine, in the line of the supra-pubic fold of the belly wall (a transverse slit); exit, in right buttock, on a level with the tip of the great trochanter and 2 inches within it. The wound was received immediately after breakfast had been eaten. There was retention of urine and constipation for three days, but no sickness. Local pain and tenderness were severe, and at the end of three weeks there was still local tenderness, slight induration, and dragging pain on defaecation. The patient returned to England at the end of a month well, except for slight local tenderness.

(185) Possible wound of colon.—Wounded at Paardeberg; range 200 yards. Walking at time. The bullet (Mauser) perforated the left forearm, just below the elbow-joint. Entry, into belly 1 inch anterior to the tip of the left eleventh costal cartilage; no exit.

The injury was followed by pain in the left half of the abdomen and vomiting, which continued for two days. The bowels acted on the third day; no nourishment was taken for two days, but a small quantity of water was allowed. No further symptoms were noted, and at the end of a fortnight the patient was well, except for slight local tenderness. The bullet could not be detected with the X-rays.

(186) Wound of caecum.—Wounded at Paardeberg. Entry (Mauser), 2 inches diagonally above and within right anterior superior iliac spine; exit, immediately to the right of the fifth lumbar spinous process; the patient was lying on his left side when struck. A burning pain down the right thigh immediately followed the accident, and lasted some days. There was no sickness, the bowels were confined three days, and there was pain across the back and down the thigh.

On the tenth day he arrived at the Base, when he was lying on his back suffering considerable pain. The temperature ranged to 101 deg.. There was diarrhoea and cystitis, with a considerable amount of pus in the urine, which was very offensive. A small fluctuating spot existed on the back, just to the right of the original exit wound which was firmly healed. The abdomen moved fairly with respiration in its upper part, but was motionless below, especially in the right iliac fossa; some induration was to be felt here. The right thigh was kept flexed.

During the next few days the pus disappeared from the urine, and with this change the induration in the right iliac fossa increased. An incision (Mr. Gairdner) was made into the fluctuating spot behind, and pus evacuated. The patient recovered.

(187) Possible wound of caecum.—Wounded outside Heilbron. Entry (Mauser), in the right loin, 2-1/2 inches above the iliac crest, at the margin of the erector spinae; exit, 1-1/2 inch above and within the right anterior superior spine of the ilium. There was little shock. The patient was brought six miles in a wagon into camp, and slept comfortably with a small morphia injection. Prior to the accident the patient was suffering from diarrhoea, but afterwards the bowels were confined. The next morning there had been no sickness and little pain. The tongue was moist and clean, the pulse 80, the respirations 24, the belly moved generally, although inspiration was shallow; the temperature was 99 deg.. Slight tenderness in the belly to the inner side of the exit wound, but no dulness.

The patient was starved for the first thirty-six hours, a little warm water then being allowed. No symptoms developed, and a perfect recovery followed.

(188) Colon, liver.—Wounded outside Heilbron. Entry (Mauser), midway between the last right rib and the crista ilii; exit, below the eighth costal cartilage in nipple line. There were no serious primary symptoms, but ten days after the accident the temperature rose, swelling and pain developed in the right loin, and on the fourteenth day a large tympanitic abscess was opened (Dr. Flockemann, German Ambulance.) Faecal-smelling gas and pus were evacuated. There was no extension of the abscess forwards. A week later the patient had much improved, although there were evident signs of general absorption, and the discharge from the abscess cavity was abundant and very foul. On the thirteenth day a serious haemorrhage occurred from the loin wound, which was opened up, but no evident source was discovered; haemorrhage was repeated the next day, and the man died.

At the post-mortem examination a large quantity of chocolate-coloured fluid was found free in the abdomen and pelvis. A chain of small local abscesses was found surrounding the ascending colon, and a larger one over the front of the caecum. The wall of the ascending colon was generally thickened, and from this, in three places, openings with rounded margins connected the abscess cavities with the lumen of the bowel. One of the openings, larger than the others, was possibly the aperture of entry of the bullet; the others were apparently spontaneous.

At the anterior border of the right lobe of the liver an abscess cavity existed in connection with the wound of the liver, and this was continuous with the aperture of exit, although not discharging. The aperture of exit was plugged by a tag of omentum (see fig. 89). No obvious source of the haemorrhage was forthcoming, but it probably originated in one of the large branches of the vena cava. The bullet had struck the transverse process of the lumbar vertebra, but had not given rise to any signs of spinal concussion.

(189*) Ascending colon.—Wounded at Modder River. Entry (Mauser), midway between the tip of the tenth right rib and the iliac crest. Bullet retained. A second wound existed over the centre of the left sterno-mastoid, and the bullet here was also retained and never localised. The patient stated that he brought up blood at short intervals for half an hour immediately after he was wounded. This might have been explained by the wound in the neck, but no difficulty in swallowing was noted. The bowels acted the day after he was shot, and, except for some local tenderness and immobility, no abdominal signs were noted. Three weeks later a swelling was obvious to the right side of the umbilicus, and a tympanitic abscess developed; this was opened, and a deformed Mauser bullet extracted. Foul pus, but no faecal matter, was evacuated, and after discharging for a fortnight the wound closed, and the man was sent home as 'well.' In this case I assumed a wound of the ascending colon had occurred.

(190*) Rectum and bladder.—Wounded at Graspan, while retiring at the double. Entry (Mauser), 1 inch to the right of the coccyx; exit, 1 inch above the junction of the middle and outer thirds of left Poupart's ligament. The man suffered with some pain in the abdomen, and for first two days with retention of urine. The urine was drawn off with the catheter, and contained blood. During the next five days micturition was hourly or more frequent; gas was passed per urethram, and the urine was very foul, containing evident faecal matter. Micturition continued frequent, with purulent cystitis for one month. Local tenderness, pain, and immobility developed over the lower quarter of the abdomen, extending to the right iliac fossa. A local abscess pointed a little to the right of the mid line, and 2 inches above the symphysis, and from this foul-smelling pus, but no faeces, was discharged for three months, during which period the surrounding dulness and induration gradually decreased and the sinus healed. When the patient left for England there was still occasional slight discharge from the original wound of entry, and there was slight discomfort on micturition, but he was otherwise well.

A year later the man had resumed active duty, and, except for occasional pain on stooping, considered himself well.

The following cases are appended as of some general interest. The first two (191, 192) illustrate extra-peritoneal injuries to the rectum. In neither did positive evidence exist of wound of the bowel, but the symptoms in each rendered this accident probable. Case 193 is an illustration of apparent escape of the anal canal in a wound in which from the position of the external apertures this escape would have appeared impossible.

Wounds of the extra-peritoneal portion of the rectum, as a rule, appeared to have a somewhat better prognosis than would have been expected; in any case, the prognosis was far better than that obtaining in wounds of the base of the urinary bladder. My experience on the subject of these wounds was, however, limited to the two cases quoted.

Case 194 is inserted as an example of the complicated nature of the abdominal injuries not so very unfrequently met with. It illustrates well the difficulty which may arise at any stage in the course of treatment of an injury, in the certain determination or exclusion of wound of a part of the alimentary canal.

(191) Wounded at Magersfontein. Entry (Mauser), in the right loin, immediately below the ribs in the mid-axillary line; exit, about the centre of the left buttock, on a level with the tip of the great trochanter. A second lacerated shell wound of back was present. All the wounds suppurated. For the first sixteen days following the injury all control was lost over the anal sphincter, and bloody faeces, and later slime, constantly escaped, but no faecal matter ever escaped from the wound in the buttock. There was no history of previous dysentery, and rectal examination afforded no information. The buttock wound had to be opened up, disclosing a tunnel in the ilium.

The wounds granulated slowly with continuous suppuration, but were healed, and the patient returned home at the end of fourteen weeks, the bowels acting normally.

(192) Wounded at Paardeberg. Entry (Mauser), at the junction of the middle and posterior thirds of the left iliac crest; the bullet was retained, and removed (Mr. Pegg) from the back of the right thigh, 3 inches below the back of the great trochanter. After the injury retention of urine followed, with incapacity to control loose motions, though solid ones could be retained. The retention was treated by catheterisation, which was followed by cystitis. The power of micturition was slowly recovered, and three weeks later he could pass water, at times in a dribbling stream only; the cystitis had improved. The man returned to England very much improved, but not quite well, at the end of five weeks.

(193) Wounded at Modder River. Entry, in the right buttock, near the outer border at the upper part; exit, at the lower part of outer border of left buttock. The line of the wound exactly crossed the position of the anus, but no sign of injury to the rectum could be discovered.

(194) Wounded at Magersfontein. Entry (Mauser), 1/2 inch below the margin of the iliac crest, at the junction of its middle and posterior thirds, and on a level with the fifth lumbar spinous process; exit, below the cartilage of the eighth rib, just within the left nipple line. Struck while retiring; fell at once, and remained thirty hours on the field. Patient stated that he vomited 'blood like coffee grounds' six times while lying on the field, and twice after being brought in. His bowels were confined for three days. His right lower extremity was paralysed.

On the fifth day there was considerable induration around the wound of exit, and the upper half of the abdomen was immobile and tender. The temperature rose to 100 deg., and the pulse was 96. Shortly afterwards a similar condition was noted in the lower half of the abdomen; the temperature continued to be raised and the pulse quickened, when on the thirteenth day a considerable quantity of pus was passed per rectum, and diarrhoea set in; this continued for three days, with marked improvement in the general symptoms. Micturition, which had been painful, became normal; the pulse and temperature fell, and the expression became less anxious. The patient continued to sleep badly, however, and complained of pain.

At the end of the third week he still looked ill, but was easier. Temperature normal in the morning, 100 deg. in evening, pulse 80. Tongue thickly furred, but moist. Still on milk diet; appetite bad; bowels irregular.

The abdomen moved little in the lower half, induration persisted in the left iliac fossa, the left thigh continued flexed, and resonance was impaired to the left of the umbilicus.

At the end of six weeks a distinct hard swelling in two parts, separated by a resonant area, was noted to the left of the umbilicus and in the left iliac fossa. The abdomen moved fairly, and there was little tenderness over the swelling. During the next week the swelling appeared to increase and to fluctuate; at the same time the temperature again began to rise to 100 deg. and 101 deg. at eve. The swelling was taken to be a localised peritoneal suppuration, and an incision was made over it; but this led down to a free peritoneal cavity, with a tumour pressing up from the posterior abdominal wall. The wound was therefore closed, and a fresh extra-peritoneal incision made, immediately above Poupart's ligament, when the swelling proved to be a large retro-peritoneal haematoma. As the cavity extended into the pelvis and up to the level of the costal margin, it was deemed wise only to evacuate a part of the blood-clot. The origin of the bleeding was not determined, and the wound was closed and healed by first intention. The man continued to improve, and left for home five weeks later.

This patient has continued to improve since his return, but the left thigh is still somewhat flexed.

Prognosis in intestinal injuries.—This was of a most discouraging character compared with the prognosis in abdominal injuries as a whole. The cases were of two classes, however: those that died within twenty-four hours, and those that died at the end of from three days to a week.

Cases falling into the first category are obviously of little importance from the point of view of surgical treatment. Many of them died from the widespread nature of the injury, and the shock produced by it; others from haemorrhage from the large abdominal vessels. It is unlikely that any could have been saved, even under the most satisfactory conditions.

In the following small table, therefore, I have included only the cases which have been already quoted, which survived long enough to be amenable to surgical treatment, and which were for some days under my own observation. Some of them, in fact almost all, I watched until they were either convalescent, or died, and in six I performed operations.

I am aware, and have short details of the histories of eight patients wounded in the same battles who died prior to the termination of the first thirty-six hours; but these are not included, for the reason stated above, and also because I am uncertain whether all the injuries were produced by bullets of small calibre.

-+ -+ -+ -+ + Localised Viscous wounded Number of Secondary Recovered Died cases suppuration occurred -+ -+ -+ -+ + Stomach certain 2 1 1 Stomach possible 1 1 Small intestine certain 5 0 5 Small intestine possible 10 0 10 Large intestine certain 8 4[21] 4 4 Large intestine possible 4 4 -+ -+ -+ -+ + Bladder certain 3 3 1 2 Bladder possible 1 1 Liver 6 6 Kidneys 6 4 2 Spleen 3 2 1 -+ -+ -+ -+ + Total 49[22] 34 15 -+ -+ -+ -+ +

Included in the above table are thirty instances of intestinal injury, and these are divided up according to the segment of the intestinal canal implicated, and also as to whether the perforation was certain, or only assumed from the position of the external apertures and the presence of abdominal symptoms of a noticeable grade.

From this analysis it appears clear—

1. That wounds of the stomach have a comparatively good prognosis, and that they may recover spontaneously. It is true that only two examples are included in my table; but I was at various times shown patients with similar injuries and histories, and a number of cases which have been published appear to substantiate the opinion. From our experience of the occasional spontaneous recovery of gastric perforations from disease, I think we might be prepared to expect that the stomach would offer a comparatively favourable seat for these wounds. It may be pointed out, however, that haematemesis, the main feature in the symptoms pointing to wound, is by no means direct proof of more than contusion.

2. That perforating wounds of the small intestine are very fatal injuries; every patient in whom the condition was certainly diagnosed died.

3. That in the cases in which a perforation was inferred from the position of the external apertures and the symptoms, not one patient suffered from the secondary complications—e.g. local peritonitis and suppuration, which were common in the case of the large intestine, and which we are accustomed to see after perforation from disease. This renders the occurrence of actual perforation in the majority of the cases a matter of very grave doubt.

If spontaneous recovery does take place after this injury, it is only in cases in which the wounds are single, and slight in character.

4. That in eight cases in which perforation of the large intestine was certain, four recoveries took place; but in each instance suppuration occurred. I am, however, quite prepared to believe that perforation may have occurred in some or all of the other four cases included as 'possible,' provided the wounds were intra-peritoneal.

Wounds of the caecum and ascending colon are those which have the best prognosis, and after these of the rectum. The comparatively good prognosis in these parts is what would be expected, on account of their greater fixity, and lesser tendency to be covered by the small intestine.

An extra-peritoneal wound of any of these portions of the bowel is more dangerous than an intra-peritoneal, and more likely to give rise to septicaemia.

Of the cases included in my table eighteen of the possible intestinal injuries were observed among the wounded of the four battles of the Kimberley relief force. These cases I saw early and followed to their termination, and I believe the list contains the great majority of all the patients who received intestinal wounds in those battles. On inquiry I could not learn of others from the officers of the Field hospitals; but no doubt some patients died before their reception into hospital, and some may have been overlooked; again, I know of two cases in which death took place within the first week, but which went direct to the Base and did not come under my observation. These exceptions being made, we have a fairly complete series, from which some deductions may be drawn. The cases included are marked with an asterisk.

Of the eighteen cases, eight or 44.4 per cent. died. These were made up as follows:—Stomach, one case; this patient died at the end of fourteen days, as a result of secondary haemorrhage and septicaemia. It was complicated by a severe wound of the liver and also one of the lung.

Small intestine, four certain cases; all died, two after operation in the stage of septicaemia, and one after operation from recurrent haemorrhage, possibly from the mesentery. Of the other six cases one can only say that the position of the wounds was such as to render wound of the intestine possible, and that all suffered with abdominal symptoms of some severity.

Large intestine. Of six cases in which wound was certain, three died, one after operation. One recovered after operation, two recovered with local peritoneal suppuration. In one case the injury could only be returned as possible.

In connection with this subject I have received permission from Mr. Watson Cheyne to quote the statistics published by him[23] concerning the abdominal wounds observed after the fighting at Karree Siding, on March 29, which are as follows:—

'The number of the wounded was 154, and in fifteen it was considered that the abdominal cavity had been penetrated. Of these patients, five had already died within twenty-four to twenty-eight hours after the injury, and I saw ten who were still alive. Of these nine were left alone, and four died within the next twenty-four or thirty-six hours; five were still alive when I left Karee on Sunday afternoon, April 1. On one I operated, but he died on April 2.

The Karee statistics are really the only complete ones which I have as yet been able to obtain. The following are the notes of the cases above alluded to.

Besides the five cases of abdominal wounds which had already died, and of which I could get no complete details, the following ten are cases which I saw from twenty-four to thirty hours after they were shot:—

CASES FROM THE ACTION AT KAREE

CASE I.—The point of entrance was 2 inches to the right of the umbilicus, and the bullet was found lying under the skin far back in the left loin. The patient was pulseless, and there was much rigidity of the abdomen, tenderness, and vomiting. He died a few hours later.

CASE II.—The bullet, coming from the side, had entered the abdomen 4 inches below and behind the right nipple. There was no exit wound. The patient had been vomiting a good deal, but not any blood; the abdomen was very rigid and tender. He was obviously very ill, and died the next morning. The bullet had probably perforated the liver and stomach.

CASE III.—There was a large wound above the right anterior iliac spine (probably the point of exit), and a small opening behind and near the spine on the same side. There was great tenderness and rigidity of the abdomen. He died a few hours later.

CASE IV.—In this case there was a transverse wound of the abdomen, the bullet having entered on the right side in the middle of the lumbar region and passed out on the left side, rather higher up and further back. All the symptoms of acute peritonitis were present. The patient died the next morning.

CASE V.—The bullet had entered the anterior end of the sixth intercostal space on the left side, and was found lying under the skin over the seventh intercostal space on the right side and about 2 inches further back. He had vomited blood on the previous day. The bullet may have perforated the stomach. The epigastrium was somewhat tender, but there were no marked symptoms. On April 1 he was going on well.

CASE VI.—The place of entrance of the bullet was 1 inch in front of the right anterior superior spine, and of exit behind the left sacro-iliac synchondrosis. There was much haemorrhage at the time. His condition when I saw him was fair, and there was no marked abdominal tenderness. On April 1 his morning temperature was 101 deg.. There were no signs of general peritonitis, and his condition was good.

CASE VII.—The bullet had entered from behind, about the tip of the twelfth rib on the left side, and had left about the middle of the epigastrium, and rather to the left of the middle line.

Vomiting was still going on, but not of blood. There was much tenderness and rigidity of the abdomen, and he was almost pulseless. On April 1 his general condition was better, but the abdomen was very rigid and tender. (Subsequently died.)

CASE VIII.—The point of entrance of the bullet was about 2 inches from the anterior end of the seventh left intercostal space, and of exit rather lower down and further back on the right side. The patient said that he had vomited brown fluid after the injury. There was much abdominal pain, but his general condition was fair. On April 1 there was still much pain, but his general condition was good.

CASE IX.—The bullet had entered about 1-1/2 inch in front of the anterior inferior spine on the right side, had gone directly backwards, and had come out in the buttock. The patient, however, suffered very little. On March 31 there was slight tympanites and tenderness in the right iliac fossa. The bowels acted well, and no blood was passed. On April 1 he was very well, and it was considered very doubtful if any viscus was wounded.

CASE X.—The point of entrance was in the middle of the right buttock, a little above the level of the trochanter; the exit was through the anterior abdominal wall in the right semilunar line at the level of the umbilicus. The patient was decidedly ill; the abdomen was a good deal distended, and pressure on it caused an escape of gas through the anterior opening. There was a good deal of abdominal tenderness and rigidity. I opened the abdomen outside the right linea semilunaris, and found a perforation in the anterior wall of the ascending colon, without any adhesions around, which was easily stitched up. The posterior opening was found about 2 inches lower down, with a piece of omentum firmly adherent to it and completely closing it. As the patient was in a bad state, I thought it better, instead of excising the piece of intestine beyond the holes or tearing off the omentum, to leave the wounds alone, merely cleaning out the peritoneal cavity as well as I could and arranging for free drainage. He rallied from the operation very well, and for twenty-four hours it looked as if he might get better; but he gradually got worse and died on April 2.'

The above statistics are particularly valuable, as they give the incidence of abdominal injuries compared with those in general in one definite battle. This amounted to the high number of 15 in 154 or 9.74 per cent. wounded. I am inclined to think that this is a higher proportion than the average of the campaign, and that more of the men must have been exposed in the erect position than was ordinarily the case during the fighting.

The statistics also show that 33.33 per cent. of the patients with abdominal injuries died within from twenty-four to twenty-eight hours, and that the percentage of deaths had risen to 73.33 per cent. at the end of the third day. These numbers again seem high, but in this relation it may be noted that, as a small force only was present, and as all the patients were together, Mr. Cheyne had unusually good opportunities for seeing all the cases.

One other point is doubtful from the report, and that is what percentage of the wounds were caused by bullets of small calibre. In one case it is definitely stated that the wound was large, and in the second that gas escaped from the wound; both of these may have been instances in which a large bullet, or some expanding form, had been employed, and there is no doubt that the use of such projectiles was more common at this stage of the campaign than it was earlier.

Treatment of injuries to the intestine.—Some general rules for the immediate treatment of all cases may be laid down. First, the patients must be removed with as little disturbance as possible, and absolute starvation must be insisted upon. If the patients be suffering from severe shock, hypodermic injections of strychnine should be administered, or possibly some stimulant by the rectum.

After a battle, when these cases may be brought in in considerable number, they should be collected and placed in the same tent. The objection to congregating a number of severely wounded patients together must be disregarded in the face of the manifest advantage of being able to treat all alike in the matter of feeding. After the battles of the Kimberley relief force, Surgeon-General Wilson, at my request, had all the abdominal cases placed in a large marquee, where we were able to carefully watch the whole of the patients from hour to hour, and little chance existed for any indiscretion on the part of the patients in the way of eating or drinking.

If possible, the patients should be kept absolutely quiet until they are evidently out of danger. A week's stay at Orange River sufficed for this object in the cases referred to. The avoidance of transport is manifestly of extreme prognostic importance.

When feeding is commenced at the end of twenty-four or thirty-six hours, it must be in the form at first of warm water, then milk administered in tea-spoonfuls only.

In doubtful cases the use of morphia must be avoided.

Operative treatment is required in a certain number of the cases, but in the majority of instances we are met with the extreme difficulty that in a very large proportion of the occasions upon which these wounds are received an exploratory abdominal section is not warranted in consequence of the conditions under which it has to be performed.

A word must be added as to these difficulties; they are in part purely of an administrative nature, partly surgical. After a great battle the wounded are numerous, and amongst them a very considerable proportion of the wounds and injuries are of such a nature as to do extremely well if promptly dealt with, and each of these makes small demands on the time of the staff. Abdominal operations, on the other hand, are unsatisfactory from a prognostic point of view, and their performance requires much time and the assistance of a considerable number of the men, who are obliged to neglect the treatment of the more promising cases for those of doubtful issue. This difficulty, although not surgical in its nature, is nevertheless a practical one of great importance and appeals strongly to the Principal Medical Officers in charge of the arrangements. It is only to be avoided by an increase of the staff, which is not likely to be made except on very special occasions.

Other difficulties are purely surgical. First, the difficulty of diagnosing with certainty a perforating lesion. In the presence of the fact that many incomplete lesions follow wounds crossing the intestinal area, and that these give rise to modified symptoms, I believe this determination to be impossible without the aid of an exploratory incision. Here we are met with the remaining surgical difficulties—disadvantages such as the absence of sufficient aid to the operating surgeon, difficulties connected with the temperature, wind, and dust, and as to the subsequent treatment of the patient. Again difficulty in obtaining the most important adjunct, suitable water, or indeed any water in a sufficient quantity.

It is of course obvious that conditions may exist in which all these troubles may be avoided. Again, the practical difficulty adverted to above does not come in the way when a single man happens to sustain an abdominal wound on the march. Under such circumstances an exploration may be not only justifiable, but obligatory, and the general rules of surgery must be followed rather than such incomplete indications as are suggested below.

My own experience led me to the following conclusions:

1. A wound in the intestinal area should be watched with care. In the face of the numerous recoveries in such cases, habitual abdominal exploration is not justified, under the conditions usually prevailing in the field.

2. The very large class of patients excluded by this rule from operation leads us to a smaller and less satisfactory number to be divided into two categories:

Patients who die during the first twelve hours. The whole of these are naturally unfit for operation, and their general condition when seen often precludes any thought of it.

Patients with very severe injuries, as evidenced by the escape of faeces, or with wounds from flank to flank or taking an antero-posterior course in the small intestinal area. These patients die, and the majority of them will always die whether operated upon or not. The undertaking of operations upon them is unpleasant to the surgeon, as being unlikely to be attended with any great degree of success, whence the impression may gain ground that patients are killed by the operations. None the less, I think these operations ought to be undertaken when the attendant conditions allow, and it is from this class of case that the real successes will be drawn in the future. The history of such injuries, after all, corresponds exactly with what we were long familiar with in traumatic ruptures in civil practice, and now know may be avoided by a sufficiently early interference. The whole question here is one of time, and this will always be the trouble in military work.

3. The expectant attitude which is obligatory under the above rules in doubtful cases, brings us face to face with a large proportion of patients in the early or late stage of peritoneal septicaemia. These cases run on exactly the same lines as those in which the same condition is secondary to spontaneous perforation of the bowel, in which we consider it our duty to operate, and in which a definite percentage of recoveries is obtained. Hence another unpleasant duty is here imposed upon the surgeon. Two such cases on which I operated are recounted above, and although I cannot say they give much encouragement, I should add that in the only one I left untouched, I regretted my want of courage for the five days during which the patient continued to carry on a miserable existence.

4. The treatment of the cases in which an expectant attitude is followed by the advent of localised suppuration presents no difficulty; simple incision alone is needed, and healing follows.

As a rule this is a late condition. In one case of injury to the ascending colon recounted above, however, considerable local escape of faeces had occurred, and a successful result was obtained by a local incision on the third day without suture of the bowel. In this case I believe the wound in the bowel to have been of the nature of a long slit, but the surrounding adhesions were so firm as to render any interference with them a great risk, and a successful result was obtained at the cost of a somewhat prolonged recovery. I am convinced that the best course was followed here. (No. 131.)

When the suppuration was of a less acute character, it was generally advisable to allow the pus to make its way towards the surface before interference.

5. Cases of injury to the colon in which the posterior aspect is involved should be treated by free opening up of the wound, and either by suture of the bowel or else its fixation to the surface. I operated on one such case, and although the patient eventually died on the eighth day, from septicaemia, he certainly had a chance. Two cases where the opening looked so free that one almost thought the wound could be regarded as a lumbar colotomy did badly; in both infection of the pleura took place, besides extension of suppuration into the retro-peritoneal areolar tissue. In the future I should always feel inclined to enlarge such wounds and bring the bowel to the surface.

As regards actual technique the majority of the wounds are particularly well suited to suture; three stitches across the opening and one at either end of the resulting crease sufficed to close the opening effectively. The openings in the small intestine were not as a rule difficult to find, on account of the ecchymosis which surrounded them. From what I have seen stated in the reports given by other surgeons, there seems to have been more difficulty in discovering wounds in the large gut. Under ordinary circumstances the only instruments specially needed are a needle and some silk. At my first two operations, as my instruments had gone astray, the wounds were readily closed by a needle and cotton borrowed from the wife of a railway porter.

If aseptic sponges or pads are not available, boiled squares of ordinary lint may be employed for the belly, and towels wrung out of 1 to 20 carbolic acid solution used to surround the field of operation. Whenever there is any likelihood of the necessity for operations, water boiled and filtered should be kept ready in special bottles.

When septic peritonitis was already present, the ordinary procedure of dry mopping, followed by irrigation, was necessary, before closing the belly.

The after-treatment should be on the usual lines as to feeding, &c.

I am unaware to what degree success followed intestinal operations generally during the campaign. I saw only one case in which the small intestine had been treated by excision and the insertion of a Murphy's button in which a cure followed: this case was in the Scottish Royal Red Cross hospital under the care of Mr. Luke. I heard of two cases in which the large intestine was successfully sutured, and of one other in which recovery followed the removal of a considerable length of the small bowel for multiple wounds.

In concluding these most unsatisfactory remarks, I should add that the impressions are those that were gained as the result of the conditions by which we were bound in South Africa, and which might recur even in a more civilised region. Under really satisfactory conditions nothing I saw in my South African experience would lead me to recommend any deviation from the ordinary rules of modern surgery, except in so far as I should be more readily inclined to believe that wounds in certain positions already indicated might occur without perforation of the bowel when produced by bullets of small calibre; and further in cases where I believed the fixed portion of the large bowel was the segment of the alimentary canal that had been exposed to risk, I should not be inclined to operate hastily.

A careful consideration of the whole of the cases that I saw leaves me with the firm impression that perforating wounds of the small intestine differ in no way in their results and consequences when produced by small-calibre bullets, from those of every-day experience, although when there is reason merely to suspect their presence an exploration is not indicated under circumstances that may add a fresh danger to the patient.

Wounds of the urinary bladder.—Perforating wounds of the bladder are the injuries nearest akin to those we have just considered, but a great gulf separates them, in so far as the escape of a few drops or even a considerable quantity of normal urine does not necessarily mean peritoneal infection. The difference in this particular was very forcibly demonstrated in my experience, since an uncomplicated perforation of the bladder in the intra-peritoneal portion of the viscus proved to be an injury that not infrequently recovered spontaneously, I believe in a considerable proportion of the cases.

I include only one such case in my list because it was the only example which happened to be under my personal observation during its whole course, but from time to time I was shown several others in which the position of the external apertures and the transient presence of haematuria left little doubt as to the nature of the injury. The case recounted above, No. 190, is of especial interest, since the patient recovered from an injury which involved both the bladder and a fixed portion of the large intestine in contact with its posterior surface.

In another, No. 194, a transient inflammatory thickening pointed to a local inflammation of a non-infective character, since no suppuration ensued, and this may have been a case of extra-peritoneal wound; on the other hand, the bladder may have entirely escaped injury. In wounds of the portions of the viscus not clad in peritoneum, as a rule, a very different prognosis obtains. Two typical cases are related, which I believe fairly represent the general results which follow when the bladder is either wounded behind the symphysis or at the base. The first case, No. 195, exemplifies a very characteristic form of wound when small-calibred bullets are concerned. The bullet, taking a course more or less parallel to that of the wall of the viscus, cut a long slit in its anterior wall. This bullet in its onward passage comminuted the horizontal ramus of the pubes, and lodged in the thigh. Into the latter region the greater part of the extravasated urine escaped. I think the history of this case fully shows that I made a blunder in not performing a proper exploration, instead of contenting myself with an incision in the thigh. My only excuse was that the patient at the time I saw him was in a very collapsed state, and a severe grade of abdominal distension suggested that septic peritonitis was already in an advanced stage. In point of fact, the patient at once improved, sufficiently so to be able to undergo a second exploration at a later date by Mr. Hanwell at the Base, only dying of septicaemia at the end of twenty-one days. Even a free supra-pubic vent might, I believe, have given him a chance of life.

When the perforation was at the base of the bladder, however, the prognosis was very bad, and, as far as I know, not a single patient escaped death. The increase of risk in an extra-peritoneal wound of this viscus is indeed very great, while an intra-peritoneal perforation may be considered an injury of lesser severity, provided the urine be of normal character.

(194a) Possible wound of the bladder.—Wounded at Magersfontein. Entry (Mauser), immediately above the symphysis pubis; exit, in the buttock, behind the tip of the left great trochanter. The man was struck while advancing, and fell, thinking at the time 'that he was struck in the foot.' He lay twelve hours on the field, and passed water for the first time when the bearer removed him. During the next two days he passed urine only twice, and no blood was noticed. The bowels acted on the evening of the third day. When seen on the fourth day he complained of aching pain in the lower part of the belly, and a concentric patch of tender induration extended for about 1-1/2 inch around the wound. The abdominal wall was moving well. The tongue was clean and moist. There was no blood in the urine, and micturition was not frequent. Temperature 99.4 deg.. Pulse 80, good strength. The patient was then sent to the Base. At the end of seventeen days there was still a little tenderness in the left iliac fossa; but the man was otherwise well, and at the end of a month he was sent home.

(195) Extra-peritoneal wound of the bladder.—Wounded at Magersfontein. Entry (Mauser), at the fore part of the right buttock. No exit. The patient was seen on the third day. He had an expression of extreme anxiety, and complained of very great pain in the abdomen and thigh. The abdomen was greatly distended and tympanitic, and the left thigh and groin were very much swollen and oedematous, with some redness of surface. Temperature 100 deg., pulse 120. No sickness, tongue moist, bowels confined. Retention of urine. The condition of the patient was very grave; but he was anaesthetised, clear urine was withdrawn from the bladder by catheter, and an incision was made into the thigh just below the inner third of Poupart's ligament, where fluctuation was evident. Two pints of bloody urine were evacuated, and when a finger was introduced it passed over a fracture of the pubes into the pelvis, but not into the peritoneal cavity. In view of the patient's condition it was not thought wise to proceed further, and he somewhat improved later, and was sent to the Base. Loss of power in the right lower extremity pointed to injury to the anterior crural nerve.

On the patient's arrival at Wynberg there were signs of local peritonitis in the lower half of the abdomen, and all his urine was passed from the wound in the left thigh. Some days later this wound was enlarged to allow of the freer exit of pus, and a fragment of bone was removed. The wound granulated healthily, but the man steadily emaciated and lost ground, with signs of chronic septicaemia, and he died on the twenty-first day. At the post-mortem examination a transverse wound of the anterior wall of the bladder behind the pubes, below the peritoneal reflexion, was found gaping somewhat widely, and 2 inches in length. There was little sign of previous peritonitis. The retained bullet was discovered beneath the femoral vessels in the left thigh.

(196) Extra-peritoneal perforation of the bladder.—Wounded at Paardeberg. Entry (Mauser), 3 inches above the left tuber ischii; exit, above the symphysis, immediately over the right margin of the penis. The patient was retiring to fetch ammunition when shot. Urine was noted to escape from both apertures the day after, and this continued until he was sent down to the Base on the fourteenth day. The patient was then considerably emaciated, complained of great pain, especially down the left thigh (sciatic nerve), the temperature averaged 100 deg., the pulse 80, tongue clean and moist, bowels acted regularly, no sign of injury to the rectum. He was taking food fairly, but was very sleepless. Urine was passed per urethram, and also escaped by both wounds. The abdomen was flaccid and sunken, respiratory movements being confined to the upper half.

As there was evidence of considerable infiltration in the buttock, the original entry wound was enlarged, and a catheter was tied into the bladder. Little change occurred in the symptoms and the local condition, urine and pus continued to escape freely from the posterior wound, and the patient gradually sank, dying on the thirty-eighth day. At the post-mortem examination the peritoneum was found intact and unaltered, but there was extensive pelvic cellulitis around the bladder, a large slough and some pus lying in the cavum Retzii. An aperture of entry still open existed in the centre of the anterior wall of the bladder, and a patent exit opening at the base of the trigone. The bullet had passed out of the pelvis by the great sciatic notch.

The above remarks and cases sufficiently set forth the prognosis in these injuries. For the intra-peritoneal lesions an expectant plan of treatment may be followed by uncomplicated recovery. Mention has already been made of a case in which a Mauser bullet was retained in the bladder and was subsequently passed per urethram. In such a case a cystotomy would be indicated were the bullet discovered in the viscus.

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 haematuria.

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.