This track in all probability involved the diaphragm twice, both lungs and pleurae, and passed immediately beneath the heart. The liver was also perforated, but the spleen and stomach probably escaped as far as could be judged from the symptoms. The patient afterwards developed a pneumo-haemo-thorax on the right side. The immediate symptoms were great distress in breathing and rapid irregular pulse. The difficulty in respiration was probably in part accounted for by the injuries to the lung and diaphragm. The pulse remained from 112 to 120 for three days, at first soft and hardly perceptible, later very irregular, and dropping one every fifth or sixth beat; and it seemed fair to attribute this to the shock to the nervous mechanism of the heart. The patient recovered from the chest injury.

In some other patients in whom the track passed close below the heart a disturbance of the pulse rate was noted, but this was in some cases a slowing, not below 48, in others quickening to 100, with irregularity both in force and beat.

(146) Entry, in the fourth right interspace, 3 inches from the middle line; exit, in the seventh left interspace, in the mid-axillary line. This wound was received at a distance of 500-600 yards, but the bullet penetrated both sides of a stout silver cigarette case and some cigarettes before entering the body. There were minor signs of pulmonary injury, 'coughing day and night,' and slight discoloration of the sputum on three or four occasions. The respirations were quickened to 32, and as much as ten days after the injury the pulse only beat 48 to the minute; it then rose to 56, but beat in a very deliberate manner.

In other cases the signs were almost nil.

(147) Entry, in the fourth right intercostal space 3/4 of an inch from the sternum; exit, in the sixth left interspace in the posterior axillary line. This patient had no symptoms, beyond quickening of the pulse to 100, and a 'feeling of tightness at the heart.' He shortly returned to active duty.

(148) Entry, situated in the third right interspace 3 inches from the sternal margin; exit, in the fourth left space 2-3/4 inches from the sternal margin. In this case the bullet without doubt passed through the anterior mediastinum, and slight injury to the lung was evidenced by transient haemoptysis.

Some remarks regarding wounds of the thoracic vessels have already been made in Chapter IV., where instances of injury to the innominate and left subclavian arteries are recounted. The escape of the large trunks was generally quite as astonishing as in other parts of the body, especially in the superior mediastinum.

(149) Entry, over the first right intercostal space beneath the centre of the clavicle; exit, at left anterior axillary fold. The great vessels must have been crossed here in immediate contact, and considerable haemorrhage from the wound of entry caused great anxiety; this ceased spontaneously, however, and, beyond transient haemoptysis and a right pneumo-thorax, no further trouble occurred.

(150) Entry, in the ninth interspace, just anterior to the anterior axillary line; exit, through the right half of the sternum, 1/2 an inch below the upper border. No primary haemorrhage of importance followed, but I believe this patient subsequently died. The wound was received at a range of within fifty yards.

Wounds of the lungs.—Numerically, pulmonary wounds formed the most important series of visceral injuries met with in the thorax, the frequency of incidence corresponding with the proportionate sectional area occupied by the organs. Although these injuries did well, and needed little interference on the part of the surgeon, many points of interest were raised by them.

Thus the comparative importance of the wound in the chest-wall to that in the lung itself, was scarcely what, without actual experience, would have been expected, the former proving so very much the more important element of the two.

The question of velocity on the part of the bullet took a very secondary position in these injuries. I saw a number of cases in which the patients estimated the range at which they received their wounds as from 30 to 50 yards, and although some of the wounds were of a severe type, the increased gravity depended rather on the injury to the chest-wall than to that of the lung. If the bullet passed by the intercostal space, avoiding the rib, I very much doubt if the relative velocity was of any importance, further than from the fact that a sufficiently low degree to allow of lodgment of the bullet was distinctly unfavourable.

In view of the general lack of significance in these injuries it was interesting to note how very definite was the ill effect of early transport on the after course. This depended on the frequent development of parietal haemothorax in patients who were not kept absolutely at rest.

The tracks produced in the lungs by the bullets were very minute, and in the few cases in which opportunity arose for their examination post mortem some little time after the infliction of the wound, there was great difficulty in localising them. The slight damage incurred by the pulmonary tissue is due to its elasticity and non-resistent character.

Pulmonary haemothorax was distinctly rare. Reasoning from the analogous wounds of the liver, tracks scoring the surface of these organs might be much more to be feared than clean perforations. The elasticity of the lung tissue, however, must make such lesions rare. In point of fact, there is no reason why a perforation by a bullet of small calibre should be much more feared than a puncture from an exploring trocar, and the danger of the two wounds is probably very nearly the same.

The only points of importance as to the particular region of the lung traversed were the distance from the periphery as affecting the probable size of the vessels injured, and perhaps the implication of the base or apex of the organ respectively. I am under the impression that wounds in the apical region were somewhat more liable to be followed by the development of pneumothorax, and possibly haemothorax, while wounds at the base gained their chief importance from the frequency of concurrent injury to the abdominal viscera. I had no experience of the immediate results of wound of the great vessels at the root of the lung, but assume that they led to speedy death.

Symptoms of wound of the lung.—I shall describe the whole complex usually observed, although it is obvious that the wound of the chest-wall is responsible for a large proportion of the signs.

The majority of these injuries were accompanied by a certain degree of systemic shock, and this was more marked in wounds received at a short range. The shock was, however, rather to be attributed to the injury to the chest-wall and thoracic concussion than to that to the lung itself. I think it may also be stated that few patients were inclined to walk or remain in the erect position after receiving these wounds; this feature was also noted in horses in whom a bullet passed through the lungs.

The remarks made as to the pain accompanying fractures of the ribs apply equally here. Pain was not a prominent symptom, except in so far as the actual impact caused temporary suffering. It was striking how often patients who received wounds through the arm prior to the same bullet traversing the chest appreciated the chest wound only, yet the chest might pass unnoticed when a still more sensitive part was struck later, as has been already mentioned in the section on wounds in general.

Dyspnoea was not a prominent primary symptom. The patients sometimes had 'all the wind knocked out of them' at the moment of impact, but when seen at the Field hospitals a short time later, the respirations were shallow, but easy and regular, and only moderately quickened; thus 24 was a not uncommon rate. Naturally if accumulation of blood in the pleura began early and continued, these remarks do not hold good; and again in some older men of full-blooded type and the subjects of recurrent attacks of bronchitis, a considerable degree of pain, dyspnoea, and even cyanosis was sometimes present soon after the injury. The complication of wound of the diaphragm has already been referred to in this relation.

Local respiratory immobility of the thoracic parietes and consequent asymmetry of movement were constant. This was especially a marked feature when the upper part of the chest was implicated on one side only. It rather corresponded, however, to the local shock observed in wounds of the limbs than to the instinctive immobility accompanying fractures of the ribs; since, as already explained, small-calibre bullet wounds of the ribs are not necessarily painful on movement, and the sign existed even when the bullet had passed by an intercostal space. This sign was naturally a transitory one.

Haemoptysis was a fairly constant sign, but sometimes quite absent when no doubt could exist as to the perforation of the lung. As a rule, a considerable quantity of blood might be coughed up shortly after the injury; but I never knew this to be sufficient in amount to give rise to any misgivings as to danger from the haemorrhage. After the first evacuation of blood from the wounded lung, the sign varied much; in the majority of instances the patients continued to expectorate small quantities of blood mixed with mucus, for some three or four days, the blood gradually assuming a coagulated condition. Sometimes only the primary haemoptysis was noted, and still more rarely the expectoration of clots was continued for a week, or even longer. This probably depended partly on personal idiosyncrasy, partly on the size of the vessels which had been implicated in the track.

Cough was not commonly the troublesome symptom noted in the contused wounds of the lung seen in civil practice accompanying fracture of the ribs. Moist sounds were usually audible on auscultation, but in many cases over a very limited area and only on the first few days.

Cellular emphysema was distinctly rare, and usually limited in extent: thus I saw it in the posterior triangle of the neck alone in an apical wound; over about a third of the upper part of the thorax in another wound through the second intercostal space, and in this case oddly enough the emphysema was the only sign of injury to the lung; and very occasionally widely distributed—in the latter case there were also usually multiple fractures of the ribs. Neither issue of air from the external wound nor frothy blood was ever seen with small-calibre wounds, but I saw one instance in a case of Martini-Henry wound.

Pneumothorax was also rare. I saw pneumothorax three times out of about half a dozen Martini-Henry wounds, but I do not think it occurred as often in 100 small-calibre wounds. The Martini-Henry wounds all recovered; but convalescence was very prolonged, and the same remark to a less degree holds good in the small-calibre cases.

That the slow recovery in cases of pneumothorax in the Martini-Henry wounds was due mainly to the size of the opening in the thoracic parietes was, I think, proved by the fact that in the small-calibre bullet wounds, followed by the development of pneumothorax, the external wounds were usually large and irregular in type; also, that in the only pneumothorax which I saw produced during an extraction operation, the air was very rapidly absorbed. In the latter case, however, there was little reason to conclude that wound of the lung had occurred primarily, and certainly no opening existed at the time the thorax was incised.

Haemothorax.—This was the most frequent and also the most interesting of the complications of wound of the chest. In 90 per cent. or more of the cases, the haemorrhage was of parietal source, and due either to direct injury to the intercostal vessels by the bullet or to laceration by spicules of comminuted ribs. For this reason, the passage of the bullet whether by an intercostal space, or through a rib, provided the wound was not at the posterior part of the space where the artery crosses, was a point of considerable prognostic importance. Exclusion of the lung as the source of haemorrhage was, I think, amply justified by the absence of continuous recurrent or progressive haemoptysis in the majority of the cases, and by the very small trace of injury found in the lungs of patients who died some weeks after the injury. In such it was difficult to discriminate the tracks at all. I only happened to see one case where free haemoptysis, during the course of development of a haemothorax, pointed to the lung as the source of the blood.

Haemorrhage into the pleural cavity occurred in some degree in a very large proportion of the chest wounds, but it was especially interesting to note how greatly its extent was influenced by the amount of transport to which the patients were subjected in the early stages after the injury. During the early part of the campaign, on the western side, I saw a large number of chest wounds, and had I been asked my opinion as to the relative frequency of occurrence of haemothorax I should have placed it at about 30 per cent. The patients in these early battles needed little wagon transport, and when sent down to the Base travelled in comfortable ambulance trains. After the commencement of the march from Modder River to Bloemfontein, however, these conditions were changed, and all the chest as other cases were exposed to the necessity of three days and nights' journey to the Stationary hospitals and afterwards to the long journey to Cape Town. Of these patients, at least 90 per cent. suffered with haemothorax of varying degrees of severity.

In some cases, the least common, signs of considerable intra-pleural haemorrhage immediately followed the wound; in others, the accumulation of blood was gradual, and only manifest in any degree at the end of three or four days, when it became stationary if the patient was kept at rest. In a second series the haemorrhage was of the recurrent variety; these cases differing little in character from those of slight continuous haemorrhage. In a third, the bleeding was definitely of a secondary character, corresponding with one of the classes of secondary haemorrhage described in Chapter IV., and occurring on the eighth or tenth day from giving way of an imperfectly closed wounded vessel. In either of the two latter classes the development of the haemothorax often corresponded with a journey, or with allowing the patient to get up.

The general course of these effusions was towards spontaneous absorption and recovery. Coagulation of the blood took place early, the fluid serum separated, and tended to undergo absorption with some rapidity, leaving a small amount of coagulum at the base, which evidenced its presence for many weeks by a persistence of a certain degree of dulness on percussion. Early coagulation, I think, accounted for the usual absence of gravitation ecchymosis as a sign.

The course to recovery was sometimes broken by signs of slight pleuritic inflammation, which, as affecting the amount of effusion, will be spoken of under the heading of symptoms. In some cases the amount of blood was so great as to necessitate means being taken for its removal; in these a reaccumulation often took place. Occasionally an empyema followed in cases thus treated.

The nature of the blood evacuated on tapping varied much. In very early aspirations unchanged blood was often met with, but clot sometimes made evacuation difficult and necessitated a second puncture. In the tappings done at the end of a week or more a dark porter-like fluid was common, while when suppuration was imminent a brick-red-coloured grumous fluid replaced normal blood. In the cases where early incision was resorted to, blood both fluid and in clots was often mixed with a certain proportion of lymph flakes, perhaps indicating the part taken by inflammatory reaction to the irritation of the clot in producing the rise of temperature.

Symptoms of haemothorax.—In the more severe cases of primary bleeding the symptoms did not, as a rule, reach their full height until the third or fourth day after the injury. The patients then often suffered severely. The pulse and temperature rose, and to general symptoms of loss of blood were added: occasional lividity of countenance; severe dyspnoea, accompanied by inability to lie on the sound side or to assume the supine position; absence of respiratory movement on the injured side; pain, restlessness, cough, and sometimes continuance of haemoptysis, small clots usually being expectorated.

Accompanying these symptoms were the usual physical signs of fluid in the pleura in differing degrees and combination. Dulness of varying extent up to complete absence of resonance on one side, often accompanied in the incomplete cases by well-marked skodaic resonance anteriorly. Loss of vocal resonance, and fremitus; oegophony, tubular respiration over the root of the lung or at the upper limit of the dulness, and more or less extensive displacement of the heart. Obvious increase in girth, fulness of the intercostal spaces, or gravitation ecchymosis was rare. The latter was most common in instances in which multiple fracture of the ribs existed (see fig. 83). I think the rarity of the last sign must have been due to the early coagulation of the blood, and its retention by the pleura, as I saw well-marked gravitation ecchymosis in one or two cases of mediastinal haemorrhage.

The above complex of symptoms was common to all the cases, but in the slighter ones they gave rise to little trouble, and cleared up with great rapidity.



The most interesting feature was offered by the temperature, as this was very liable to lead one astray. A primary rise always occurred with the collection of blood in the pleura, this reaching its height on the third or fourth day, usually about 102 deg. F. in well-marked cases; it then fell, and in favourable instances remained normal. In a large number of cases, however, where the amount of blood was considerable, this was not the case, the primary fall not reaching the normal, and a second rise occurred which reached the same height as before or higher. The second rise was accompanied by sweating, quickened pulse, and the probability of the development of an empyema had always to be considered. I believe in most cases this secondary rise was an indication of a further increase in the haemorrhage, for the dulness usually increased in extent, and such rises were often seen when the patient had been moved or taken a journey. Again, the temperature often fell to normal after paracentesis and removal of the blood, to rise again with a fresh accumulation, which was not uncommon. I have already mentioned the large proportional incidence of haemothorax observed in the patients who had to travel down from Paardeberg, and I might instance another case related to me by Dr. Flockemann of the German ambulance, which was very striking. A Boer, wounded at Colesberg, developed a haemothorax which quieted down, and he was removed to Bloemfontein; on arrival at the latter place the temperature rose, and other signs of fever suggested the development of an empyema; an exploring needle, however, only brought blood to light. After a short stay at Bloemfontein the symptoms entirely subsided, and the man was sent to Kroonstadt, when an exactly similar attack resulted, again quieting down with rest.

Similar recurrent attacks of haemorrhage and fever occurred, however, in patients confined to their beds without moving after the first journey. Some temperature charts, in illustration of this point, are added to the cases quoted later. The explanation of the recurrent haemorrhages is, I think, to be found in the reduction of the intra-thoracic pressure with coagulation and shrinkage of the clot in the pleura in the patients kept quiet in bed, while in the patients who had to travel it was probably the result of direct mechanical disturbance.

In many of these cases a pleural rub was audible at the upper margin of the dulness with the development of the fresh symptoms. Whether this was due to actual pleurisy or to the rubbing of surfaces rough from the breaking down of slight recent adhesions which had formed a barrier to the effusion, I am unable to say, but the signs were fairly constant. In some instances the increase in the amount of fluid was, no doubt, due to pleural effusion resulting from irritation from the presence of blood-clot, or perhaps the shifting of the latter; in these the secondary rise of temperature may well be ascribed to the development of pleurisy.

I am inclined to believe, however, that the primary rise of temperature was similar to that seen when blood accumulates in the peritoneal cavity as the result of trauma, and the secondary rises in most cases to those which we saw so frequently accompanying the interstitial secondary haemorrhages spoken of in Chapter IV., and are to be explained on the theory of absorption of a blood ferment. The secondary rises always occurred with a fresh effusion, often of blood, occasioning an extension, which broke down probable light adhesions and exposed a fresh area of normal pleural membrane to act as a surface for absorption.

It is, of course, manifest that the fever might also be ascribed to the infection of the clot or serum from without, and in the first cases I saw I was inclined to take this view, since we had in every case the primary wounds of chest-wall, and possibly of lung, and in some the addition of a puncture by an exploring needle between the first and second rise. After a wider experience, however, I abandoned the infection theory, as it seemed opposed by the very infrequent sequence of suppuration. The effect of simple removal of the blood or serum was also often so striking as to strongly suggest that it alone was responsible for the fever. Exactly the same result, moreover, followed evacuation of the interstitial blood effusions already mentioned elsewhere.

The common course of all the cases of haemothorax was to spontaneous recovery, the rapidity of the subsidence of the signs depending mainly on the quantity of the primary haemorrhage, and the occurrence of further increases. The blood serum tended to collect at the upper limit of the original blood effusion (as was often proved on tapping), and this was first absorbed; the clot deposited on the pleural surface and at the basal part of the cavity was, however, not absorbed with the same rapidity. In the majority of the patients when they left the hospitals, at the end of six weeks on an average, some dulness and deficiency of vesicular murmur always remained, and the clot and the surrounding surface, irritated by its presence, will, no doubt, be responsible for permanent adhesions in many cases. That such adhesions do form in the majority of cases I feel certain, as, although these patients when they left the hospital were to all intents and purposes apparently well, few of them could undertake sustained exertion without getting short of breath, and sometimes suffering from transitory pain, and for this reason it became customary to invalid them home.

In a small proportion of the cases empyema followed; but I never saw this in any case that had neither been tapped nor opened, and I saw only one patient die from a chest wound uncomplicated by other injuries. This case was an interesting one of recurrent haemorrhage followed by inflammatory troubles:—



(151) The wound was received at short range, probably at from 100 to 200 yards. Entry, 1 inch from the left axillary margin in the first intercostal space; exit, at the back of the right arm 1-1/2 inch below the acromial angle; both pleurae were therefore crossed. The patient expectorated at first fluid, then clotted, blood in considerable quantity. When brought into the advanced Base hospital on the third day, there were signs of blood in the left pleura, cellular emphysema over the right side of the chest, and signs of collapse of the right lung. The temperature chart gives shortly the course of the case: the right pneumo-thorax cleared up spontaneously, also the emphysema; but the left pleura needed tapping to relieve symptoms of pressure on four occasions, the 13th, 15th, 19th, and 25th days respectively. On the first two occasions blood was removed, on the third blood serum only, and on the last pus. The patient was relieved after each aspiration; after the third, the temperature fell to normal, the general condition also improved, and he promised to do well. None the less, reaccumulation took place, the evacuated fluid assumed an inflammatory character, and an incision to evacuate pus was eventually followed by death on the twenty-seventh day. The amount of haemoptysis throughout was considerable, and the case was possibly one of pulmonary haemothorax, as after death no source of haemorrhage could be localised in the intercostal space. The track in the lung was almost healed, and although a part of it allowed the introduction of a probe for about an inch, it could be traced no further even on section of the organ, and no special vessel could be located as the original bleeding spot.

Empyema.—I may here add the little that I have to say on this subject. During the whole campaign the single case of primary empyema that I saw was the one recorded below, which deserves special mention as illustrating the disadvantage of extracting bullets on the field. Under the conditions which necessarily accompanied this operation the ensurance of asepsis was impossible, and the additional wound no doubt proved the source of infection.

(152) Entry, at the posterior margin of the sterno-mastoid muscle, 2 inches above the clavicle; the bullet came to the surface beneath the skin over the fifth rib, in the nipple line of the right side. There was never any haemoptysis, but the patient suffered with some dyspnoea throughout. After a three days' stay in the Field hospital, where the subcutaneous bullet was removed, the patient was transported by wagon and train to the Base, a journey of about 600 miles.

On the fifth day pus escaped from the extraction wound, and when the case was examined at the Base, the temperature was 101 deg., the pulse over 100, the respirations 30, and the whole side of the chest was dull, with the exception of a patch of boxy resonance over the apex anteriorly. On the following day the chest was drained, and a considerable amount of pus evacuated, which was mixed with breaking-down blood-clot. A fortnight later a second operation had to be performed to improve the drainage, and the patient made a tedious recovery.

The following case well illustrates the symptoms in a severe case of haemothorax, and empyema following aspiration:—

(153) The patient was wounded at Paardeberg at a range of from 500 to 700 yards. Entry, just to the left of the episternal notch; exit, in the fifth left interspace posteriorly, midway between the spine and vertebral margin of the scapula. A quantity of bright blood was brought up at once, and later blood was coughed up in clots.

There was no great pain at the moment of the injury; the man again got up to the firing line, and later walked two miles to the Field hospital without aid. He remained here a week, when he was sent down to the Base, and during the first three days' journey in the wagon he began to get worse. On the fourth day cough began to be very troublesome.

When he arrived at the Base, fifteen days after the original injury, there was much dyspnoea; the temperature was 102 deg., and the pulse 110. The left side of the chest was dull throughout; an aspirating needle was introduced, and a pint of very dark liquid blood drawn off. The whole of the blood was not removed on account of the very severe cough and pain which the evacuation occasioned. The man appeared to steadily improve until three weeks later, when the temperature, which throughout had been uneven, became consistently high, and signs of fluid at the base increased. An aspirating needle was introduced, and 16 ounces of pus were drawn off. Two days later a piece of rib was resected (Mr. Pegg) and another pint of pus evacuated. After this, rapid improvement took place, and in ten days the man was able to be up and dressed, although a small amount of discharge still persisted. He eventually made an excellent recovery.

Secondary empyemata not uncommonly followed incision of the chest, or excision of a rib for draining a haemothorax. These operations in the early part of the campaign were more freely undertaken on the supposition that rise of temperature and other symptoms of fever pointed to incipient breaking down of the clot. Subsequent experience showed this not to be the case, and early operations for drainage ceased to be undertaken. In these operations a primary difficulty was met with in effectively clearing out the clot, a drain had to be left, and suppuration occurred later in a considerable proportion. The suppurations were most troublesome; local adhesions formed, and the pus collected in small pockets, which were difficult to find and to drain, and even when the collections seemed to have been successfully dealt with at the time, residual abscesses often followed at a very late date. Thus, I saw a case with a contracted chest and a fresh abscess the day before I left Cape Town, in whom I had advised and witnessed an operation for the evacuation of clot in the presence of signs of fever a week after my arrival in the country, nine months previously. I saw another case where general infection followed incision of a haemothorax, but the patient fortunately recovered.

The question of pleurisy has already been mentioned in connection with haemothorax; it no doubt accounted for secondary effusion in some cases, and beyond this I have nothing to add to what has been there said.

Pneumonia was rare; there were occasionally signs of consolidation, but, I think, quite as often in the opposite lung as in the one injured. I never saw a fatal case, and I am inclined to think that when it occurred it was as often the result of cold and exposure as of the injury to the lung. Abscess of the lung I only saw once, and that in a case in which the injury to the chest was complicated by paraplegia from spinal injury and septicaemia, and it was possibly pyaemic.

Diagnosis.—No difficulties special to small-calibre wounds were experienced, except such as have been already dealt with. The only class of case which frequently gave rise to difficulty was haemothorax. Here two points especially needed consideration. (1) The source of the haemorrhage as parietal or visceral. As has been already foreshadowed, this was mainly to be decided by the amount and persistence of the haemoptysis, but naturally free haemoptysis did not negative concurrent parietal bleeding. Then the actual source of the bleeding other than from the lung had to be considered; in the great majority of cases the intercostal vessels were responsible, and attention to the course of the tracks often allowed this to be definitely decided upon.

A case included in the chapter on Injuries to the Blood Vessels (No. 5, p. 127) is of great interest in this particular; in that instance feebleness of the radial pulse, together with the position of the wound, was a valuable indication of injury to the subclavian artery, but weakened somewhat by the fact of retention of the bullet, and hence uncertainty as to the exact course that it had taken, and as to whether the bullet itself was not responsible for pressure on the vessel. Such indications, however, should make one very chary of interference with a haemothorax, even with extremely urgent symptoms, in the light of our present knowledge of the nature of the lesions to the great vessels produced by small-calibre bullets, and their tendency to be incomplete.

(2) The imminence of suppuration or its actual occurrence.—In most cases it sufficed to preserve an expectant attitude, and in the persistence or increase of symptoms, to have recourse to an exploratory puncture as the best means of solution of the difficulty.

Prognosis.—The prognosis both as to life and as to subsequent ill-effects was remarkably good; in many cases of uncomplicated injury to the lung the patients rejoined their regiments at the end of a month or six weeks. In the more serious cases complicated by the collection of blood in the pleura, convalescence was more prolonged, and an average time of six to eight weeks often elapsed before the patients could be safely discharged from hospital. In the more serious a certain amount of dulness always persisted at this time over the base of the lung, and the chest was usually somewhat contracted on the injured side, with evidence in the way of decreased vesicular murmur that the lung was still not free from compression. With regard to the persistence of dulness on percussion, it is well to bear in mind that a thin layer of blood apparently produces as serious impairment of resonance as a much larger quantity of serum. The signs appeared to favour the view that the space necessary for the location of the haemorrhage had been obtained at the expense of the lung rather than by distension of the thoracic parietes, and also, I think, denoted the presence of adhesions. Possibly they will entirely disappear with the return of full excursion movements of respiration, the latter being often still somewhat restricted when the patients left hospital. All the patients with such signs were liable to attacks of pain and shortness of breath on actual bodily exertion. I happened to meet with an officer, the subject of a Lee-Metford wound of the thorax, sustained five years previously, and he told me that he was nine months before he could take active exercise without feeling short of breath.

As to the cases of haemothorax and empyema which needed drainage, all did well; but expansion of the lung was much less satisfactory than would have been expected, probably on account of especially firm adhesions. The importance of concurrent injury I need hardly dwell on; but I might add that perforation of one or both arms, the most common one, did not materially affect the general statements above made.

Treatment.—In the early stages of the pulmonary wounds rest was the all-important indication, and when this was assured few serious cases of haemothorax occurred. Beyond simple rest, the administration of opium with a view to checking internal haemorrhage was used with good effect. The wounds needed simple dressing only.

The treatment of haemothorax at a later date, however, was of much interest and difficulty. I think the following lines may be laid down for guidance in such cases:—

(i) Haemothorax, even of considerable severity, will undergo spontaneous cure. An early rise of temperature may be disregarded.

(ii) Tapping the chest is indicated when pressure signs on the lung are sufficiently severe to cause serious symptoms, and the removal of the blood undoubtedly shortens the period of recovery, as well as relieves symptoms.

In such cases the collection of blood has usually been rapid and continuous; hence a fresh haemorrhage is always probable when the local pressure has been removed. Tapping therefore should not necessarily mean complete evacuation, and should be followed by careful firm binding up of the chest, the administration of opium, and the most stringent precautions for rest.

(iii) Tapping may be needed as a diagnostic aid, and in such circumstances as much fluid as can be removed should be evacuated with the same precautions as mentioned in the last paragraph.

(iv) Tapping may be indicated for the evacuation of serum expressed from the blood-clot, or due to pleural effusion, on the same lines as in any other collection of fluid in the pleural cavity.

(v) Early free incision is, as a rule, to be steadfastly avoided. Some cases already quoted fully illustrate its disadvantages.

(vi) Cases in which an incision and the ligature of a parietal artery are indicated are very rare. I never saw such a one myself.

(vii) If a haemothorax suppurates, it must be treated on the ordinary lines of an empyema. In view of the constant formation of adhesions and difficulty in drainage, a portion of a rib should always be resected in order to ensure sufficient space for after-treatment. The cavities, as a rule, are better irrigated, the usual precautions being taken where there is any reason to fear that the lung is still in communication with the cavity.

Care in carrying out asepsis in tapping, which should be performed with an aspirator, need hardly be more than mentioned. It will be noted that in some of the cases quoted suppuration followed tapping, but it must be remembered that in these the two primary wounds already existed as possible channels of infection.

Retained bullets of small calibre in the thoracic cavity were not common, unless the lodgment had occurred in the bodies of the vertebrae. I saw very few. Shrapnel bullets and fragments of shells, however, were, in proportion to the frequency of wounds from such projectiles, more commonly retained. The rules to be followed in such cases do not materially deviate from those to be observed in the body generally.

When the bullet is causing no trouble, and is lodged in either the bone of the spine or the lung substance, no interference is advisable. When, on the other hand, the bullet as viewed by the X-rays is seen to be in the pleural cavity, and any symptoms of its presence exist, it may be justifiable to remove it. I saw this done in one case for the removal of a shrapnel bullet from the lower reflexion of the pleura on account of fixed pain and tenderness complained of by the patient. The bullet, a shrapnel, had perforated the arm, which the patient was sure was by his side at the moment of injury, and the X-rays showed it to lie at the bottom of the pleural cavity, where we assumed it had fallen. When, however, the bullet was removed by Mr. Watson, he found that the fixed pain and tenderness had been the result of a fracture of a rib from the inner side, not involving loss of continuity; hence the actual indication for the operation had been a delusive one, since the bullet had not fallen, but expended its last force in injuring the rib. The patient made an excellent recovery, and rejoined his regiment at the end of six weeks. I saw several cases in which the bullet was lodged in either the lung or bones of the spine do well with no interference. The great disadvantage of primary removal in inducing an artificial pneumo-thorax and in laying open a haemothorax is obvious.

In case of lodgment of the bullet in the lung, bearing in mind the infrequency of untoward symptoms, the latter should be watched for prior to interference.

The following cases illustrate some typical instances of wound of chest accompanied by the development of haemothorax:—



(154) Severe haemothorax. Spontaneous recovery.—Wounded at Modder River at a distance of 30 yards. Entry, at the junction of the left anterior axillary fold with the chest-wall; exit, immediately to the left of the seventh dorsal spinous process. The patient arrived at the Base with signs of an extensive haemothorax, accompanied by a temperature which reached 102 deg. on the fourth day, and on the evening of the tenth 103 deg.. The man was very ill, and an exploring needle was inserted, by which about an ounce of blood was evacuated. The signs of fluid in the left pleura were accompanied by those of consolidation over the lower fourth of the right lung, and the sputa were rusty. Evidence of perforation of the left axillary artery existed in feebleness of the radial pulse; and there was musculo-spiral paralysis.

After the preliminary puncture, the man refused any further operative treatment, although a second rise of temperature commenced on the fifteenth day, culminating in a temperature of 103.2 deg. on the eighteenth. The further treatment of the patient consisted in the ensurance of rest and the alleviation of pain. A steady fall in the temperature extended over another three weeks, together with diminution in the signs of fluid in the pleura. At the end of seventy-four days the man was sent home, some slight dulness at the left base, and contraction of the chest sufficient to influence the spine in the way of lateral curvature, being the only remaining signs.



(155) Severe haemothorax. Secondary effusion. Spontaneous recovery.—Wounded at Koodoosberg Drift, at a distance of 200 yards. Entry, at angle of the right scapula; exit, at the junction of the left anterior axillary fold with the chest-wall. No signs of spinal cord injury. The patient was brought in from the field twelve miles by an ambulance wagon on the second day, and in crossing the Modder River he was accidentally upset into the stream. For the first four days there was no haemoptysis, but for the succeeding nine days small brightish red clots were expectorated. There was some tenderness over the ribs from the fifth to the ninth in the axillary line, and on the ninth day some gravitation ecchymosis appeared over the same region. Cough was an early troublesome symptom in this case, and when admitted to the Base hospital, about the seventh day, there was evidence of fluid extending about a third of the way up the back.

On the tenth day after admission a pleural rub was detected at the upper margin of the dulness, and the latter shortly extended upwards over a little more than half the back. Meanwhile, there was no further haemoptysis, respiration was fairly easy, 24 per minute, but accompanied by slight dilatation of the alae nasi, and the temperature, which had been ranging from 99 deg. to 100 deg., began to rise steadily, on the fifteenth day reaching 102.5 deg.. The patient refused even an exploratory puncture, and was treated on the expectant plan. The temperature slowly subsided, with a steady improvement in the physical signs, and at the end of about ten weeks he left for home with only slight dulness and incapacity for active exertion remaining. (Now again on active service.)



(156) Severe haemothorax. Recurrent secondary effusion. Tapping on two occasions. Cure.—The patient was wounded at Paardeberg, and arrived at the Base on the eighteenth day. Entry, below the first rib, just external to its junction with the costal cartilage; exit, through the ninth rib, just within the posterior axillary line. The whole right side of the chest was dull, with signs of the presence of fluid, the heart being displaced to the left. There was considerable distress; the respirations averaged 40, the pulse 100, and the temperature reached 101.5 deg. the first evening after arrival.

On the nineteenth day the thorax was aspirated (Mr. Hanwell) and 50 ounces of dirty red-coloured fluid, half clot, half serum, were evacuated. Considerable relief was afforded; the respirations became slightly less frequent; the heart returned to a normal position, and distant tubular respiration was audible. The temperature dropped to normal the third day after evacuation of the fluid, but on the sixth day it again commenced to rise, and meanwhile fluid again began to collect.

On the twenty-sixth day a second aspiration resulted in the evacuation of 35 ounces of bloody fluid in which flakes of lymph were found. Three days later the temperature became normal. The respirations fell to 22, and the patient made an uninterrupted recovery.



(157) Moderate haemothorax. Secondary effusion at the end of twenty days. Spontaneous recovery.—Wounded at Paardeberg; range from 700 to 1,000 yards. Entry, in the centre of the second right intercostal space, anteriorly; exit, at the level of the sixth rib posteriorly, through the scapula, close to its vertebral margin.

The patient arrived at the Base on the sixth day; he said he expectorated some blood at the end of about ten minutes after being shot, and experienced a 'half-choking sensation.' A small quantity of phlegm and occasional clots had been expectorated since. He had walked about a good deal; movement occasioned cough, and he became 'blown' very rapidly.

On admission there were signs of fluid in the lower third of the pleural cavity, but no general symptoms beyond an evening rise of temperature to an average of 99 deg.. About the twentieth day the temperature commenced to rise, and on the twenty-third and four following evenings reached 102 deg.. The fever was accompanied by some distress, and a well-marked increase in the physical signs of the presence of fluid in the chest. The pulse rose to 96, and the respirations considerably above the average of 24, which was at first noted. A strictly expectant attitude was maintained, and the temperature steadily fell in a curve corresponding to the rise, gradually reaching the normal at the end of a week. The physical signs at the base steadily cleared up, and at the end of six weeks the patient returned to England convalescent.



CHAPTER XI

INJURIES TO THE ABDOMEN

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

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

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

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

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

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

In many cases the position of the openings and the strongly oval or gutter character possessed by them were sufficient proof of the superficial passage of the bullet; in others we had to bear in mind that the position of the patient when struck was rarely that of rest in the supine position, in which the surgical examination was made, and considerable difficulty arose. Some superficial tracks crossing the belly wall have already been referred to in the chapter on wounds in general and in that dealing with injuries to the chest, in which the above characters sufficed to indicate that penetration of the abdominal cavity had not occurred. In other instances a definite subcutaneous gutter could be traced, and often in these a well-marked cord in the abdominal wall corresponding to the track could be felt at a later date. Again, limitation to the abdominal wall was sometimes proved by the position of the retained bullet, or sometimes by the presence in the track of foreign bodies carried in with the projectile. See case 160.

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



The cases which presented the most serious diagnostic difficulty in this relation were those in which the wound was situated in the thicker muscular portions of the lower part of the abdominal and pelvic walls. Such a case is illustrated in the chapter on fractures (see fig. 55, p. 191). I saw one or two such instances, in which only the exploration necessary for treatment of the fracture decided the point. In many of the wounds affecting the lateral portion of the abdominal wall the question of penetration could never be definitely cleared up, as wounds of the colon sometimes gave rise to absolutely no symptoms.

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

(158) Wound of belly wall.—Wounded at Modder River. Entry (Mauser), 2 inches below the centre of the left iliac crest; exit, 1-1/2 inch above and internal to the left anterior superior iliac spine. The patient was on horseback at the time of the injury and did not fall; he got down, however, and lay on the field an hour, whence he was removed to hospital. Probably the track pierced the ilium, and remained confined to the abdominal wall. There were no signs of visceral injury.

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

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

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

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

The same patient was wounded by a Jeffrey bullet in the hand; the third metacarpal was pulverised, although the bullet, which was longitudinally flanged, was retained.

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

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

We may first recall the general question of the escape of structures lying to one or other side of the track of the bullet. I believe that there can be no doubt as to the accuracy of the remarks already made as to the escape of such structures as the nerves by means of displacement, and that the occurrence of such escapes is manifestly dependent on the degree of fixity of the nerve or the special segment of it implicated. The general tendency of the tissues around the tracks to escape extensive destruction from actual contusion has also been referred to, and is, I think, indisputable.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In instances in which the soft parts alone were perforated, I am disinclined to believe that bullets of small calibre, either regulation or soft-nosed, were responsible for the injuries. I had the opportunity of examining two Mauser bullets of the Jeffreys variety which crossed the abdomen and caused death. In the first (figured on page 94, fig. 40) very little alteration beyond slight shortening had occurred. In the second the deformity was almost the same, except that the side of the bullet was indented, probably from impact with some object prior to its entry into the body. In each case the bullet was of course travelling at a low rate of velocity; hence no very strong inference can be drawn from either. In the case of the second specimen, which was removed by Mr. Cheatle, a remarkable observation was made, which tends to throw some light on one possible mode of production of large exit apertures. This bullet crossed the caecum, making two small type openings; but later, when it crossed the sigmoid flexure, it tore two large irregular openings in the gut. This might be explained on the ground that the velocity was so small as only just to allow of perforation, which therefore took the nature of a tear. I am inclined to suggest, as a more likely explanation, that the spent bullet turned head over heels in its course across the abdomen, and made lateral or irregular impact with the last piece of bowel it touched. A slightly greater degree of force would have allowed a similar large and irregular opening to be made in the abdominal wall also.

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

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

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

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

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

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



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

Fig. 86 exhibits a lateral injury of a more pronounced 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.



Fig. 87, A B, illustrates 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.



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 illustrated 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.



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 shell wounds. The wounds from small-calibre bullets were as a rule too small to allow of external prolapse.

Fig. 89, however, illustrates 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 canal of exit, where it lodged.



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 quantity of faecal matter in a localised space, 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 assumed 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 caecum, ascending and descending colon, the sigmoid flexure, or the rectum, 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 quantity of slightly turbid fluid was effused, was found. In others a rapid suppurative process, accompanied by the effusion of large quantities 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 assumed, 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 passage 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 assume 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 classic ones of vomiting and haematemesis. In the first case blood was also passed 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 illustrate 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 space 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 quantity of dark clotted blood was passed per rectum with the stool, and this continued for two days.

Ten days after the injury the temperature was still rising to 100 deg., 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 space; exit, through the seventh left costal cartilage, 1 inch from the median line. The patient was lying in the prone 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 deg.. 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 passed, 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 deg., 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 quantities 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 constitutional infection from the foul wound, the lower part of which opened up somewhat after the removal of the stitches 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.