from whtoh it was borrowed.
 
 WAR SURGERY OF THE 
 ABDOMEN
 
 WAR SURGERY OF 
 THE ABDOMEN 
 
 BY 
 
 G.M.G., F.R.C.S. Eng., M.B., B.S. Lond., 
 
 >URI;KI>\, >i. THOMAS' HOSPITAL; LECTURER ox SI-RUKRY IN THK MEDICAL 
 SCHOOL; CONSULTING SURGEON. BRITISH ARMIES IN FRANCE 
 
 WITH 26 ILLUSTRATIONS 
 
 PHILADELPHIA 
 
 P. BLAKISTON'S SON & CO. 
 
 1012 WALNUT STREET 
 
 1918
 
 TO 
 THE STRETCHER-BEARER 
 
 Printed in Great Britain
 
 PREFACE 
 
 THIS Book contains the experiences in abdominal surgery of 
 a sector of the battle line over a period of thirty months. 
 It is founded on the practice of many surgeons, working 
 under different conditions and in different hospitals. The 
 personal equation and influence of locality have thus been 
 largely eliminated. It is hoped, therefore, that the figures 
 quoted may present a standard with which other surgeons 
 can compare their results. 
 
 My thanks are due to the Medical Research Committee for 
 the great help it has given. It has provided the means of 
 recording and tracing the cases. The illustrations are the 
 work of its artist, A. K. Maxwell, to whom I would also 
 express my indebtedness. Many of the blocks have been 
 kindly lent by the Medical Society of London and by the 
 Kritish Journal of Surgery. 
 
 CUTHBERT WALLACE.
 
 CONTENTS 
 
 CHAPTER I. 
 
 INTRODUCTORY. 
 
 Foreword Utility of Former Experience Exchange of Knowledge 
 Surgical Opinion when the War started Method of Treatment 
 in the Earlier Period of the War Experiences of the Allies 
 Commencement of the Operative Treatment Collection and 
 Evacuation of Wounded Selection of Cases for Rapid Evacuation 
 
 CHAPTER II. 
 
 A GENERAL REVIEW OF ABDOMINAL WOUNDS. 
 
 Relative Frequency of Abdominal Wounds Nature of the Projectiles 
 that cause the Wounds Relative Number of Different Projectiles 
 and the Proportion retained Relative Mortality of the Different 
 Projectiles General Incidence of Wounds Influence of the 
 Position of Wound and Direction of Missile on Prognosis 
 Possibility of Escape of Viscera in Penetrating Wounds The 
 Possibility of Spontaneous Recovery after the Perforation of 
 Hollow Viscera Rupture of Viscera outside the Actual Course 
 of the Projectile Mechanism of Wound Production after 
 Penetration Comparative Frequency of Wounds in the Different 
 Viscera State of the Alimentary Canal in respect of its Contents 
 State of the Alimentary Canal in respect of the Nervo-muscular 
 Mechanism . 14 
 
 CHAPTER III. 
 
 WHERE TO OPERATE. 
 
 The Time Factor Where to operate on Abdominal Cases Arrange- 
 ments at the Present Time in the French and Belgian Armies . 45 
 
 CHAPTER IV. 
 
 DIAGNOSIS AND TREATMENT CONSIDERED GENERALLY. 
 
 Diagnosis of Intraperitoneal Damage- Care of the Patient before 
 Operation Question of Operation Wounds on Back to be 
 first treated -The Incision Treatment of the Peritoneal Cavity 
 Post -operative Treatment ...... 51
 
 viii CONTENTS 
 
 CHAPTER V. 
 WOUNDS OF HOLLOW ALIMENTARY ORGANS AND THEIR TREATMENT. 
 
 PAGE 
 
 Wounds of Particular Organs Stomach Small Intestine Large 
 Intestine Character of the Lesions in Different Parts of the 
 Colon Rectum (the last 12 cm. of the Alimentary Canal) 
 Protrusion of Omentum and Viscera Behaviour of the Omen- 
 turn in Abdominal Wounds . . 65 
 
 CHAPTER VI. 
 
 WOUNDS OF SOLID ALIMENTARY ORGANS AND SPLEEN. 
 Liver Pancreas Spleen ... .100 
 
 CHAPTER VII. 
 
 GENITO-URINARY ORGANS. 
 Kidney Ureter Bladder 109 
 
 CHAPTER VIII. 
 
 ABDOMINO-THORACIC WOUNDS AND DIAPHRAGMATIC HERM K. 
 Abdomino-thoracic Wounds Diaphragmatic Hernise . . .119 
 
 CHAPTER IX. 
 
 CAUSES OF FAILURE. 
 Haemorrhage Sepsis Clinical Shock . . . . . .129 
 
 CHAPTER X. 
 
 STATISTICS, RESULTS, AND THE FUTURE. 
 
 Mortality in the Preoperative Days Methqd of recording Cases 
 Comparative Mortality at Different Hospitals Results of 
 Operative Treatment The Future . . . . .141 
 
 INDEX . 148
 
 WAR SURGERY OF THE 
 ABDOMEN. 
 
 CHAPTER I. 
 
 INTRODUCTORY. 
 
 Foreword. 
 
 IT may be asked if there is really such a thing as war 
 surgery as distinct from civil surgery. Fundamentally there 
 is not so much difference as might be thought. What difference 
 there is lies in the anatomical nature of the injuries, such 
 injuries being influenced in a certain proportion of the cases 
 by the high speed of the projectile and by the carrying into the 
 wound of infective material. 
 
 It is a question as to whether war conditions allow the 
 surgeon to apply the principles that he knows to be right. 
 No man shot in the belly would be left to lie in bed in the civil 
 hospital of a great town. The expectant treatment was only 
 adopted because the surgeon could not operate under favourable 
 conditions. 
 
 War surgery is largely concerned in overcoming adverse 
 circumstances and in striving to make war conditions as much 
 like peace conditions as possible. It is in great measure a 
 matter of when and where to operate and how best to move the 
 wounded man to the place where he will win back to health. 
 
 At first the circumstances of the surgeon are strange. He 
 cannot at first orient himself or get his bearings. Strange 
 problems present themselves, and the surgeon feels lost. As he 
 grows more familiar with his surroundings he recognises that 
 his enemies are the same, but under a new guise. Then his 
 way becomes clearer, and he perceives that the old surgical 
 truths are as true as ever. 
 
 W.S.A. 1
 
 2 War Surgery of the Abdomen 
 
 Take compound fractures. Early on in the war these were 
 practically untreated as regards attention to the interior of the 
 wound until they arrived at the base many hours after their 
 receipt. They did badly, and what surgeon in civil practice 
 would be surprised if fractures left uncleaned for sixteen to 
 twenty-four hours exhibited violent sepsis ? When preparations 
 were made at the Front for mechanical cleaning within a few 
 hours of the wound when the civil practice gained acceptance 
 there was at once a vast improvement. It took nearly three 
 years of war to evolve this method, and yet it is in the books 
 written years ago. 
 
 Again, take the battle of antiseptics as applied to recent 
 wounds. It was a failure of antiseptics, and not of asepsis, 
 if there was a failure. Surgeons, horrified at the bad course 
 of the wounds, tried antiseptic after antiseptic. This trial 
 was bred of despair, and as in the past, so in this war, we 
 have seen the surgeon turn from one chemical to another. 
 It was not until the well-established surgical practice of 
 excision of dead and dirty tissue was again adopted within 
 a reasonable time of wounding that any material progress 
 was made. 
 
 All surgery must be governed by the conditions in which it 
 is practised and must, therefore, be somewhat modified by war, 
 but in no previous war has the medical man had it so much his 
 own way. 
 
 Most of the doctors in this war were till lately civilians, 
 and possibly inclined to be impatient of routine. Without 
 administration or routine the finest hospital would be of but 
 little value, for patients would arrive late and in bad con- 
 dition ; on the other hand, administration largely exists to 
 allow the doctor to practise his art. 
 
 Utility of Former Experience. 
 
 This is somewhat doubtful. In some ways it has been a 
 hindrance. In judging the number of wounded, the proportion 
 of killed to wounded, the accommodation required, it seems 
 to have been a help, for such things alter but little, though
 
 Introductory 3 
 
 they arc altering. As a general guide to surgery it has, if 
 anything, been somewhat of a handicap. 
 
 In South Africa one learnt to treat many wounds with little 
 respect. Wounds were allowed to scab over, and did remarkably 
 well. Many surgeons became convinced that rest, starvation, 
 and morphia were the right treatment of abdominal wounds. 
 This war, fought on an infected soil, has proved that dirty 
 wounds must be cleaned. It has also shown that the penetrating 
 abdominal wound should be explored. 
 
 Exchange of Knowledge. 
 
 The changing conditions of wars seem to show that surgical 
 histories brought out after the war are largely a labour loss, 
 if not a waste of time. A series of well-observed cases and the 
 careful drawing of deductions while the war is in progress are 
 worth pages of statistics when the fight is over. Every effort 
 must be made to summarise and render accessible the experiences 
 of the early months for use in the later. This has been done 
 by both combatant and medical branches by means of pamphlets, 
 instructions, lectures, and demonstrations. 
 
 The Army is full of schools, where officers and men are taught 
 new methods. A short course at a school is more valuable 
 than sheets of printing, and produces greater results. 
 
 The passing of a wounded man from one unit to another is 
 unavoidable in war, but every means must be taken to lessen 
 the disadvantage. This is best done by sending careful notes 
 with the patient as he passes from the Front to the Base and 
 by letting the surgeon, who first had charge of the case, know 
 his after-history. The front line surgeon can thus collect data 
 and modify his treatment accordingly. It should be just as 
 incumbent on the Base to supply information to the Front as 
 for the Front to supply the Base. 
 
 Sympathy between units is very necessary for the smooth 
 and efficient working of the medical service. There is always 
 a tendency to criticise the unit in front of you ; but it is 
 well, if you feel thus inclined, to try and put yourself in the 
 place of the man from whom you received the case. An exchange 
 
 12
 
 4 War Surgery of the Abdomen 
 
 of information leads to good feeling. A friendly criticism is 
 helpful, a captious criticism distinctly harmful. 
 
 Again, one of the most useful functions of a consulting surgeon 
 has been the carrying of facts and opinion from one unit to 
 another. The so-called radial method of surgical control is best, 
 that is, where the surgeon is responsible for the wounded of a 
 certain sector of the line both at the Front and Base. Unfor- 
 tunately, this cannot be always managed, and in heavy fighting 
 the wounded from one portion of the line will flow into many 
 base areas. In quiet times it is possible under certain condi- 
 tions, and much knowledge is thus gained that can be utilised in 
 fighting times. It is the peace-time observation that is so 
 useful, as then there is time for deliberate thought. 
 
 Medical societies have been instituted in different areas, 
 and have done good work. One society where medical officers 
 both from the Front and Base, have met, has been of the greatest 
 value. Men who meet and discuss matters will seldom quarrel, 
 especially if they dine together afterwards. 
 
 Surgical Opinion when the War started. 
 
 There is no doubt that for many years it has been held that the 
 operative treatment of abdominal wounds was not to be advised 
 under war conditions. This was partly due to want of success, 
 and partly to the fact that many military surgeons were opposed 
 to extensive operating anywhere near the firing line. As 
 abdominal surgery, to be successful, must be done at once, it 
 is obvious that it could not be undertaken with success where 
 all operations had to be postponed to a late period. Although 
 the expectant treatment was the orthodox one when the South 
 African War broke out, many civil surgeons hoped to prove that 
 it was wrong. Surgeon-General W. F. Stevenson even issued 
 an appeal for the trial of operation. The result was, however, 
 only to confirm former opinion, though this opinion was now 
 held on two somewhat different grounds. One school held that 
 the expectant treatment was in itself the right procedure, the 
 other that it was the best that could be done in war. 
 
 Some people believed that wounded intestine healed suffi-
 
 Introductory 5 
 
 cicntly often to warrant abstention ; others, headed by Makins, 
 believed that small-gut lesions were practically always fatal, 
 and that the success obtained by the " wait and see " policy was 
 due to the escape of the bowel, although the belly had been 
 penetrated. Makins' opinion that the small gut area could be 
 traversed by the small bullet without injury has been proved 
 in this war. If one reads the literature of the South African 
 War, both private and official, the reason for want of success 
 is at once obvious the cases arrived too late. It was not so 
 much a question of the success of the expectant treatment as a 
 failure of the operative. Operations were secondary or late, 
 and two strikingly successful cases of resection of small gut 
 (Messrs. Neale and Tuke) were operated on within six and 
 twelve hours respectively. 
 
 The reason for the late operation was the nature of fighting in 
 an unsettled country of great distances. The wounded could 
 not be quickly brought to a hospital equipped with the necessary 
 appliances. To operate in the veldt with what appliances were 
 at hand was too disheartening. It was impossible to get even 
 moderately decent conditions. There was little or no water, 
 and what there was was often too filthy for words the water 
 of dams. In addition there was the plague of flies and dust 
 that settled on everything. Lastly, the operated man could not 
 be kept quiet ; it was lucky if he could ride in a horse 
 ambulance. 
 
 The conditions were utterly different from what now pertain, 
 and this is the first time since the rise of abdominal surgery that 
 a great campaign has been fought in a settled country, and, 
 what is more important still, with a fixed fighting line. 
 
 The small number of figures dealt with in the South African 
 campaign was also a source of error. In order to form an 
 adequate idea of the efficacy of any treatment it is necessary 
 to strike an average over a large series of cases. Now, in this 
 present war, one of the difficulties of establishing the operative 
 treatment was the runs of bad luck which any operator had to 
 face. Even now, with conditions as near ideal as possible, one 
 may meet a series of nine consecutive fatal cases. This must 
 have a very depressing effect on any young surgeon, or one who
 
 is not convinced that the operative treatment is, in the main, 
 the best of all. Now, nine abdominal cases mean, roughly, 
 about 600 wounded men, taking a moderate estimate of the 
 proportion of abdominal wounds to total wounds. As a matter 
 of fact, in the South African campaign, a casualty list of 600 
 wounded was considered a large one. It can therefore be seen 
 that if an operator happened to encounter such a series it is 
 not a matter for surprise if he had doubts as to the correctness 
 of his procedure. 
 
 The statistics of the South African campaign are very defec- 
 tive. Surgeon-General Stevenson, in the official history of the 
 war, was only able to collect 207 cases of abdominal wounds. 
 Among them it is stated that there were 26 laparotomies with 
 18 deaths, a mortality of 69 '2 per cent., and according to 
 Stevenson the mortality was really even worse. The total 
 death-rate of all abdominal wounds quoted, operated and 
 unoperated, is given as 30-4 per cent. 
 
 In his most recent work (1910), " Wounds in War," the 
 mortality is shown as 51-6 for laparotomies, the total cases 
 remaining the same namely, 207. In any case the numbers 
 are really too small to have any real value. 
 
 Figures show that in the present campaign a mortality 
 of 50 per cent, is a good result, but such a mortality in 
 civil practice would be considered an awful death-rate to face. 
 And yet it means, looking on the bright side, many lives 
 saved. 
 
 There is no doubt that certain people shot through the 
 abdomen in South Africa, and treated expectantly, recovered. 
 As a matter of fact, there were two officers well known in the 
 Royal Army Medical Corps who recovered after such treatment, 
 and I have no doubt that a knowledge of their recovery 
 greatly strengthened the opinion that expectant treatment 
 was, on the whole, the best. 
 
 The South African campaign may then be said to have left 
 surgical opinion opposed to operation. This opinion seems to 
 have been only strengthened by succeeding wars the French 
 War in Morocco, the Balkan War, and the Russo-Japanese 
 War.
 
 Introductory 7 
 
 Method of Treatment in the Earlier Period of the War. 
 
 It is not intended here to say anything about the period of 
 the retreat. Under such conditions adequate provision for 
 operating near the Front was an impossibility, and all that could 
 be done was to get rid of the wounded to the Base with the 
 least possible discomfort to them. When the line became fixed 
 the conditions were very different, and there was. a possibility 
 of operating under good conditions. It was no longer a question 
 of whether a man could be operated upon, but whether he should 
 be operated upon. Still, however, the old belief in the efficacy 
 of the expectant treatment obtained. 
 
 In order to understand what was done during this period it is 
 necessary to say a word or two about the standard system by 
 which the wounded man was evacuated. Shortly, it was as 
 follows : A wounded man was first seen by the regimental 
 medical officer, to whom he was brought in the regimental aid- 
 post situated somewhere in the trench system. He was then 
 transferred by a stretcher to an advanced dressing station, 
 usually situated just behind the trenches, and from there by car 
 to the Field Ambulance, and there he was kept until the time 
 the motor convoy arrived, often only once in the twenty-four 
 hours. By this he was taken to the Casualty Clearing Station, 
 which was the first place adequately equipped for operative treat- 
 ment. In the early days the Clearing Station was a very different 
 hospital from what it is now, but still there was reasonable 
 facility for the performance of any operation if it was thought 
 advisable. With the idea of avoiding the disturbance of move- 
 ment, a man wounded in the abdomen was kept sometimes, 
 though not usually, in the regimental aid-post ; often he was 
 kept at a Field Ambulance, but usually he was transferred to 
 the Casualty Clearing Station and there treated. 
 
 The usual mode of procedure was to put the man in the 
 Fowler position, to improve the general condition by rest and 
 warmth, to withhold food and water for three days, and to 
 administer morphia. The thirst, which was a distressing 
 symptom of this treatment, was combated to a certain degree 
 by rectal salines and mouth-washes.
 
 8 War Surgery of the Abdomen 
 
 I should like here to pay tribute to the great care and atten- 
 tion which the medical officers lavished on the cases. Certain 
 officers were told off day and night to attend to these patients, 
 and everything that could be done to alleviate their suffering 
 and to make them as comfortable as possible and to cheer them 
 up was done. If anything could have got these men well the 
 attention that they received would have done so. The people 
 who conducted the treatment were firmly convinced of its 
 efficacy. 
 
 This belief was strengthened by the behaviour of the patient. 
 Many patients, at first gravely ill, went through a period of 
 improvement which often was very striking. It was in a way 
 unfortunate, but there is no doubt that improvement did take 
 place, and so well were many of them that they were evacuated 
 to the Base, and arrived there sometimes in good condition 
 and sometimes gravely ill. The men who saw the cases leave 
 them apparently on the way to recovery could not bring them- 
 selves to believe that such cases did badly at the Base. It was 
 unfortunate that the means of communication between the 
 Base and the Front was, in those days, inadequate, and this 
 serves to emphasise what has already been stated about the 
 value of free interchange of reports between the Front and 
 the Base. 
 
 If .evacuation of these cases had not been necessary and it 
 had been possible to keep them at the Clearing Stations, the 
 expectant treatment would not have survived as long as it 
 did, for medical officers would have seen such cases become 
 worse and worse, and in the end die. As a matter of fact, during 
 my six months' experience at the Red Cross Hospital at Netley 
 I only saw two cases of wounds of the abdominal viscera ; one 
 was a case of caecostomy and the other a transverse colostomy. 
 
 The expectant treatment was also a very trying time for the 
 wounded man. The knowledge that nothing could be done for 
 him by operation, and that the only thing was to wait events, 
 had a very depressing effect on the soldiers, although the medical 
 officers did everything to cheer them up. 
 
 It is curious, but true, that the wounded soldier welcomes 
 operation. He feels that something is being done for him. I
 
 Introductory 9 
 
 have sometimes been asked the question, " Can't you operate ? " 
 If I have answered in the negative, with an assurance that 
 operation was unnecessary and that he would do well, I have 
 often detected a look of disappointment on the patient's face. 
 Operation has no horror for the soldier. 
 
 Experiences of the Allies. 
 
 The French have gone through the same experience in the 
 treatment of abdominal wounds. 
 
 I cannot do better than quote you a letter which Professor 
 Turner has kindly written me. He says : 
 
 " Abdominal surgery has undergone in France the following 
 revolution. Until the month of February, 1915, installations 
 did not allow one to operate, under good conditions, on wounds 
 of the abdominal cavity, and abstention was necessary in these 
 circumstances. At this period I found in a small ambulance 
 quite near the Front, and very well organised, several cases of 
 cure of wounds of the intestine by laparotomy. I reported them 
 to the Society of Surgery, and a movement commenced in 
 favour of operation for all abdominal wounds. It is because the 
 motor surgical ambulances and the medical arrangements have 
 been better organised, and because the evacuation of the 
 wounded has been done in a relatively short time, that we have 
 been able to arrive at a certain measure of success." 
 
 With the French, as with us, the period of the retreat corre- 
 sponded to the period of expectant treatment, and when the 
 line became fixed the treatment underwent the same change 
 as it did in the British Army. As a matter of fact, after the 
 establishment of the operative treatment some French surgeons 
 have from time to time again championed the expectant treat- 
 ment, but this finds little acceptance with the majority. 
 
 Commencement of the Operative Treatment. 
 
 Although rest treatment was the rule in the first days of 
 the war, some attempts at operation were made. Souttar also 
 commenced early operation with the Belgian Army. Owen 
 Richards was the first, I believe, to publish results of operative
 
 io \Var Surgery of the Abdomen 
 
 treatment in the British Army.* His first operation was per- 
 formed on January 28th, 1915, and the first . successful case, 
 that of a resection of 2i feet of the small intestine, was 
 operated upon on March 18th, 1915, thirty-six hours after receipt 
 of the injury. A few other British surgeons had tried what 
 could be done by operation, but the results were undeniably 
 bad, so bad that most people had abandoned the attempt. 
 The reason for this was, no doubt, the late arrival of the cases 
 at a place where an operation could be performed. 
 
 In June, 1915, a series of operations and post-mortem examina- 
 tions showed that the injuries were of such a nature that 
 recovery was not to be expected without surgical aid except in 
 a few instances. 
 
 It was also found that haemorrhage was a frequent cause of 
 early death, and that bullets produced very extensive injuries. 
 It has always been granted that haemorrhage was the chief cause 
 of early death, but the advocates of expectant treatment seem 
 to have focussed their attention more on the danger of peri- 
 toneal infection and the possibility of its localisation or dis- 
 appearance than on the possibility of spontaneous arrest of 
 haemorrhage. 
 
 The discovery that bullets produced extensive gut injuries 
 was also of great importance, as much stress had been laid on 
 the smallness of the lesions produced by the modern small-bore 
 bullet ; in fact, the hope of spontaneous recovery from gut 
 lesions was based on the assumption that such projectiles were 
 comparatively innocuous. This idea was constantly put forward 
 in the early period of the war. 
 
 The re-establishment of the fact that haemorrhage was the chief 
 cause of early death was of great importance, as it showed that 
 only by rapid evacuation could one hope to combat such a con- 
 dition. In June, 1915, Surgeon-General W. G. Macpherson 
 directed some of the Field Ambulances to send the abdominal 
 wounds with all possible celerity to the nearest Casualty Clearing 
 Station. The results obtained by this small experiment were 
 encouraging, and in the first week in August, 1915, an order 
 was given which made the rapid evacuation of abdominal 
 
 * Brit. Med. Journ., August 7th, 1915.
 
 Introductory 11 
 
 wounds the official method. This was followed by rapid improve- 
 ment in the results obtained. 
 
 Collection and Evacuation of Wounded. 
 
 In forming a judgment on the results obtained by the opera- 
 tive treatment of abdominal injuries and where it is best to 
 operate on them it is necessary to know something about the 
 means by which such cases reach a Casualty Clearing Station. 
 A knowledge of the difficulties is also necessary in order to form 
 an appreciation of the really magnificent work which is being 
 done by the regimental medical officer and his stretcher-bearers, 
 and by the personnel of the Field Ambulances. One can 
 consider this subject under two heads : (1) the collection ; (2) the 
 evacuation of the wounded man. 
 
 (1) By collection is meant the finding and bringing back to the 
 Regimental Aid-Post of the wounded ; and without going into 
 particulars it can be well understood what the difficulties are 
 when an attack has been made and our troops have advanced. 
 If it is difficult to find and collect the wounded after a successful 
 attack, it is still more difficult when the fortunes of battle sway 
 backwards and forwards ; and it is under the latter conditions 
 that the wounded lie out for a considerable period. In quiet 
 times the collection is not difficult, for the men are wounded 
 very often in the trenches themselves. 
 
 (2) The Evacuation. A man has been wounded in the front 
 trench. The first field dressing most probably will be applied 
 by himself or by one of his companions, possibly by the medical 
 officer himself. The patient will then walk, be carried, or be 
 taken on some kind of stretcher to the Regimental Aid- Post. 
 Even this is performed under considerable difficulties, because 
 the nature of the trench system involves getting round many 
 sharp angles. The Regimental Aid-Post is situated somewhere in 
 the trench system or in a communication trench. To reach this, 
 even in quiet times, an hour or more may sometimes be required. 
 It is in a dug-out, a- cellar, or a ground floor room reinforced 
 and sandbagged. There is a dressing-room, fitted up as well as 
 possible with shelves and trestles. Adjoining will be some place
 
 12 \Yar Surgery of the Abdomen 
 
 where the wounded may rest till evacuated. There may be 
 electric light, though usually there is only an acetylene lamp or 
 a humble candle. It is not a place where any one would wish 
 to perform a capital operation. Here the patient will be 
 attended by the regimental medical officer. He will be properly 
 dressed, fed, given hot drinks, warmed up, adequately covered 
 with blankets, and provided with hot bottles. 
 
 Under the present system of evacuation an abdominally 
 wounded man will not wait in this place. Now commences the 
 long journey sometimes as much as two miles down the 
 communication trench. Sometimes the journey is so arduous 
 that one complete tour is all that a stretcher party can manage 
 without a long spell of rest. Underfoot are the duck boards or 
 a rough brick pavement. The provision of these renders walking 
 more easy, but the surface is necessarily uneven, especially 
 where one board joins another. Sometimes a rung is out, and at 
 other times the board is apt to tilt and look you in the face. 
 Then there are the innumerable corners formed by the zigzags 
 of the trench made to stop the enfilade fire and limit the danger 
 of an exploding shell, or to prevent the enemy looking straight 
 down the trench. 
 
 In summer the air is stifling. In winter, or after rain, the 
 surface of the boards is greasy in the extreme, and sometimes 
 they are completely under water. At night-time the difficulties, 
 as may be well imagined, are greatly increased. Sometimes the 
 turns in the trenches are so sharp that the traverses of the 
 stretcher have to be closed in order to allow its passage round 
 the corners, or it has to be lifted high above the angle. 
 
 Much ingenuity has been expended in devising stretchers 
 for the easier transit of the wounded man, for getting round 
 corners easily, and relieving the work of the bearers. In most 
 cases the stretchers are carried on the bearers' shoulders ; the 
 regulation method has been found much too fatiguing. 
 
 Many wheeled stretchers have been tried, but the inequalities 
 of the ground and the sharp corners to be turned are difficulties 
 which have not yet been overcome. Sometimes it is possible 
 to put a man on a trolley-line or light railway and run him 
 down over the open ground. In some cases the trenches have
 
 Introductory 13 
 
 an overhead mono-rail on which a short form of stretcher can 
 be suspended. 
 
 At the end of the communication trench the patient comes to 
 the Advanced Dressing Station. This, as a rule, is more spacious 
 than the Regimental Aid-Post, but similar in construction. 
 Here the patient is again warmed up and given drink. The 
 hot bottles are changed or refilled and the patient despatched, 
 if his condition warrants it, in a motor ambulance to the Casualty 
 Clearing Station or Advanced Operating Centre. Sometimes 
 the ambulance will call at the Field Ambulance if this is not off 
 the route. 
 
 The above description applies to comparatively quiet times. 
 In times of battle there may be no dug-outs, cellars, or 
 overhead shelters. The wounded man must be attended to 
 in the open, in the lee of a wall or " pill-box," and then to reach 
 the Advanced Dressing Station he must be carried 3,000 
 5,000 yards across the open, the bearers on whose shoulders the 
 stretcher rests picking a precarious way along the edge of 
 
 innumerable shell-holes filled with mud and water. 
 
 * 
 
 Selection of Cases for Rapid Evacuation. 
 
 The rapid evacuation of all abdominal cases to the Casualty 
 Clearing Stations puts a great deal of responsibility on the 
 Field Ambulance officers. It is no light task to decide what 
 cases can stand evacuation ; in fact, it is one of the most difficult 
 things that a medical officer is called upon to determine. . Many 
 patients, of course, are better for rest and food and warmth ; but 
 in the case of abdominal wounds it must be remembered that 
 haemorrhage is the chief cause of early death, and that the only 
 hope for their salvation lies in the arrest of the haemorrhage by 
 surgical means. It is therefore obvious that it is worth while 
 taking risks in cases of abdominal wounds which it would not 
 be right to take in other cases. There is also the danger of 
 death from peritoneal infection, but experience has shown that 
 the need for celerity on this account is as nothing compared to 
 that necessary on account of haemorrhage.
 
 CHAPTER II. 
 A GENERAL REVIEW OF ABDOMINAL WOUNDS. 
 
 Relative Frequency of Abdominal Wounds. 
 
 IN the earlier period of the war there was some difficulty in 
 arriving at an accurate figure. There was the difficulty of 
 diagnosis in the first place. In the second place, it was found 
 that the data varied according to the persuasion of the surgeon 
 who made the observations. A medical officer who believed 
 in the expectant treatment gave a higher proportion than one 
 who favoured operation. Again, the Field Ambulances always 
 gave a higher number than the Casualty Clearing Stations. 
 
 The difference between the figures in the Field Ambulances 
 and Casualty Clearing Stations is accounted for in the following 
 manner : (1) the Field Ambulance would naturally and rightly 
 err on the side of making the graver diagnosis ; (2) the mortality 
 was high in the Field Ambulances, so that fewer cases reached 
 the Casualty Clearing Station ; (3) at the Casualty Clearing 
 Station a more careful diagnosis acted in two ways : (a) it 
 included some buttock, chest, back, and thigh wounds as 
 abdominal wounds ; (b) it excluded many cases of wounds of 
 parietes. On the whole the effect was to lessen the proportion 
 of abdominal wounds to total wounds. 
 
 With the establishment of the operative treatment and the 
 keeping of accurate records the errors have diminished. It is 
 now possible to state that the number of abdominal wounds 
 that reach an operating hospital is not likely to exceed 2 per 
 cent, of the total wounded received, provided that no segrega- 
 tion of such cases is practised. 
 
 Nature of the Projectiles that cause the Wounds. 
 
 Bullets. There are very many different kinds of bullets used 
 in this war, and apparently their number goes on increasing.
 
 A General Review of Abdominal Wounds 15 
 
 As is well known, the standard English, French, and German 
 bullet is a pointed one. The English and German is a composite 
 projectile which is liable to break up into mantle and core. 
 The French bullet is much longer than either of the above, 
 and is made of solid copper alloy. Although not liable to 
 break up, it is liable to very great distortion. Naturally we are 
 mostly concerned with the German projectile, which, as a rule, 
 is pointed, but sometimes the old ogival-headed bullet has been 
 extracted from wounds. All the modern pointed bullets are 
 more unstable than the bullets of the Boer War. The instability 
 is said to be most marked at the beginning and the end of the 
 flight. In this war, where the fight takes place amongst houses, 
 there are many opportunities for the bullet to be deformed 
 and deflected. Again, the velocity and stability of a bullet is 
 largely affected by passing through sandbags or a parapet, 
 which, as a matter of fact, has to be something like 4 feet thick 
 to be bullet-proof. There is plenty of evidence that, whether 
 from inherent instability or from hitting some object, the 
 bullet does spin, and in several cases a bruised impress has been 
 seen on the skin which could only have been made by a sidelong 
 impact of the bullet. Again, in those cases where two legs 
 have been wounded by the same bullet the first leg has been 
 perforated by a small standard track, and the opposite leg has 
 suffered a large gaping wound, the obvious explanation being 
 that the bullet in passing through the first limb was made to 
 spin, and so caused a more extensive wound on the opposite 
 member. A good deal has been heard about the explosive effect 
 of the modern pointed bullet ; and although one may say that 
 it does cause worse wounds than the ogival-headed projectile, 
 I am by no means persuaded that its so-called explosive effect 
 is anything but a very rare occurrence. I am strengthened in 
 this opinion by the study of accidental wounds, of which one 
 sees a great number. Men are shot at all sorts of close ranges 
 up to actual contact, and yet, unless a hard bone is touched, it 
 is not usual to get the explosive type of wound. 
 
 Shell Fragments. These are, of course, of all sizes, but the 
 fragments which are the cause of the abdominal wounds that the 
 surgeon is called to treat are generally not more than 1| inch
 
 7 
 
 9 
 
 10 
 
 11. 
 
 FIG. 1. Types of Projectiles that cause Abdominal Wounds. 
 
 (1) Piece of H.E. shell. Wounded small gut and lodged in mesentery. (2) Rifle grenade 
 fragment. Penetrated through the gantro-hepatic omentum and divided all the 
 tissues of the left kidney. (3) German bullet. (4) British bullet. (5) Shoe nails 
 from an early German bomb. (6) Fragment of grenade. Wounded small gut. 
 (7) Lead fragment. Penetrated the back and wounded jejunum. (8) Fragment of 
 H.E. shell. Penetrated buttock and wounded bladder. (9) Frajfment of bomb. 
 Penetrated the back and wounded jejunum. (10) Bomb fragment. Penetrated 
 under ribs and wounded kidney. (11) Shell fragment. Wounded jejunum in three 
 places. (12) Fragment of H.E. shell. Penetrated belly wall, carried in portions of 
 clothes, but wounded no viscus. (13) Fragment .f H.E. chell. Wounded liver. 
 small gut, and pelvic colon. Drawn natural size. (Medicul Society and lirit. Journ. 
 of Surgery.)
 
 A General Review of Abdominal Wounds 17 
 
 in the greatest diameter, usually a good deal smaller. There 
 are different kinds of shells used, and some importance may 
 be attached to the nature of the shell by which the man is 
 wounded. 
 
 High-Explosive Shells. These shells may burst in the air, on 
 contact with the ground, or after they have impacted themselves 
 deeply in the earth. The velocity of the fragments into which 
 the shell is blown depends both on the " remaining velocity " and 
 on the disruptive charge, and the fragments fly out mostly in a 
 forward and lateral direction. The shape of the fragments 
 depends largely on the type of shell if the shell is segmented, 
 the pieces are more or less quadrilateral ; if not segmented, 
 the fragments are still more or less quadrilateral in shape, and 
 have extremely sharp and ragged edges. Such shells, bursting 
 on the ground, naturally become Covered with dirt. 
 
 The knowledge of where a shell bursts in relation to the 
 patient is sometimes of importance as telling whether the 
 abdomen is involved. If a shell bursts above a man who is 
 wounded in the lower thorax it is likely that the fragment has 
 entered the peritoneum. Again, if a man is hit in the buttock 
 and the shell explodes on the ground the possibility of the 
 pelvis being involved should at once be borne in mind. An 
 officer was riding along a road, and a shell burst on percussion 
 quite close to him. He had a buttock wound. A fragment 
 was found to have entered the pelvis and torn the small gut 
 and a large pelvic vein. 
 
 Shrapnel. These shells usually burst in the air with a time 
 fuse. They are of all sizes, and the metal balls with which they 
 are filled also vary somewhat in size. The penetrating power 
 of such balls is due to the remaining velocity of the shell. The 
 direction of the shrapnel balls will, as a rule, be downwards. 
 In some cases a shell is of a combined high-explosive and 
 shrapnel type. 
 
 Shell Caps. These come from both types of shell and form 
 some of the largest fragments that the surgeon meets with. 
 They often cause contusions without perforation. 
 
 Bombs and Grenades. In the early part of the war these 
 bombs were often extemporised, and consisted of tin boxes 
 
 W.S.A. 2
 
 1 8 War Surgery of the Abdomen 
 
 filled with an explosive, scrap iron, cobblers' nails, and screws, 
 etc. Nowadays they are made of iron, the surface of which is 
 marked with grooves, so that on explosion they break up into 
 quadrilateral fragments. Sometimes the force of the explosive 
 will cause a bomb to burst into smaller fragments, often no 
 bigger than a big match-head. Although small, these fragments 
 have apparently from their high velocity a very great 
 penetrating power in the immediate neighbourhood of the 
 explosion, though this is rapidly lost as the distance increases. 
 
 Trench Mortars. Bombs from these are of various shapes, but 
 consist essentially of a very large high-explosive charge with a 
 comparatively thin containing envelope ; they therefore very 
 often burst into large ragged fragments as well as minute ones. 
 They are generally timed to burst either on the ground or in the 
 ground. 
 
 Bayonet Wounds. These are very seldom met with, being 
 usually fatal on the field. Mention may be made of two cases. 
 In the first the bayonet penetrated the man's back and came 
 out by his umbilicus ; no viscus was injured, and the man 
 succumbed to haemorrhage. The second was the case of a man 
 who was late in answering a challenge, and was bayoneted by 
 the sentry ; the bayonet entered the left hypochondrium, 
 wounded the greater curvature of the stomach, and entered the 
 back wall of the abdomen ; though promptly operated on, he 
 died, not of his stomach wound, but of retroperitoneal sepsis. 
 
 Relative Number of Different Projectiles and the Proportion retained. 
 
 Table I. has been drawn up with the intention of giving 
 some idea of the relative frequency of the different projectiles 
 met with in abdominal wounds ; it also shows the number 
 retained in the body. This table must be taken as only approxi- 
 mately correct, for several reasons. In the first place, it is often 
 impossible for a man to tell what hit him ; in the second place, 
 one cannot always be sure, from' a study of the entrance and 
 exit wounds, what was the nature of the projectile ; and, again, 
 many do not differentiate between high-explosive shell and 
 shrapnel, the soldier generally including most shells which are
 
 A General Review of Abdominal Wounds 19 
 
 not of a large calibre under the name of shrapnel. As a matter 
 of fact, there is very little difference in the nature of the frag- 
 ments in high-explosive shells, bombs, rifle grenades, or trench 
 mortars, if one excludes the larger fragments, with which we 
 are very little concerned. 
 
 TABLE I. Relative Frequency of Different Projectiles met with 
 and of those retained. Total Number of Cases, 834. 
 
 
 
 Bullet. 
 
 Shell 
 Fragment. 
 
 Shrapnel. 
 
 Bomb or 
 Grenade. 
 
 Out 
 Retained 
 
 203 
 131 
 
 30 
 254 
 
 15 
 
 67 
 
 6 
 128 
 
 Total 
 
 334 
 
 284 
 
 82 
 
 134 
 
 Bullets. Bullets and high-explosive shell furnish the larger 
 proportion of abdominal wounds. More bullets pass through 
 the body than other projectiles ; the reason for this is obvious. 
 The causes for retention are not so obvious, and I have known 
 bullets, fired at a comparatively short distance, remain within 
 the body. In other cases the bullet may have passed through 
 the earth, and so have had its velocity diminished. Ricochets 
 account for a certain number. 
 
 Shells. These show a high proportion of retention, which is 
 obviously due to the shape of the fragments. 
 
 Bombs and Grenades. The retained fragments are strikingly 
 in excess of those passed out. 
 
 The large proportion of retained fragments at once suggests 
 the possibility of armour ; and no doubt armour could be 
 devised which would keep out many fragments. It really is 
 more or less a question of what the soldier is able to carry. One 
 cannot help being struck with the resistive power of an ordinary 
 book, as one has often seen projectiles arrested by such articles 
 when carried by the soldier. The great saving of life effected 
 by the steel helmet makes one hope that something may be 
 produced equally efficacious in protecting the body. Although 
 
 22
 
 20 
 
 War Surgery of the Abdomen 
 
 we could not expect such shields to be supportable and at the 
 same time bullet-proof, yet many bullets have lost so much 
 velocity that they are retained, and the number of bullets is 
 greatly outnumbered by shell and bomb fragments, which possess 
 far less penetrative power. 
 
 Relative Mortality of the Different Projectiles. 
 
 The following table shows that bullets are but little less 
 dangerous than shells, and that bombs and grenades are the 
 least noxious : 
 
 TABLE !!. Relative Mortality in 629 Cases. 
 
 
 
 Bullet. 
 
 Shell 
 Fragment. 
 
 Shrapnel. 
 
 Bomb or 
 Grenade. 
 
 To Base 
 
 91 
 
 105 
 
 15 
 
 60 
 
 Died 
 
 106 
 
 154 
 
 40 
 
 58 
 
 Total . . 197 
 
 259 
 
 55 
 
 118 
 
 General Incidence of Wounds. 
 
 The charts (Figs. 2 and 3) were made by plotting the entrance 
 wounds on the front and back of the body respectively. The 
 wounds of the back form a substantial proportion of the whole. 
 There is a tendency for the wounds to collect towards the sides, 
 especially on the back of the body. 
 
 The comparative absence of mid-line wounds is also seen in 
 Fig. 3, which represents the wounds in cases too bad for operation 
 when they reach a Casualty Clearing Station. This distribution 
 is brought about by the presence in the mid-line of the spine 
 and the great vessels. Men shot in these situations die on the 
 field of battle. The collection of wounds towards the sides of 
 the body may possibly also be caused by the fact that a man's 
 front and back are more or less protected in the trench, while 
 the sides of the body are open to enfilade fire. Many of the 
 wounds on the back, especially those of the buttock and thigh,
 
 \ General Review of Abdominal Wounds 21 
 
 are due to bombs and rifle grenades. The posterior wounds show 
 a larger proportion of deaths than the anterior. 
 
 Influence of the Position of Wound and Direction of Missile on Prognosis. 
 
 CASES TOO SERIOUS FOR OPERATION. The chart (Fig. 4 was 
 obtained by plotting the entrance wounds and the track of the 
 
 FIG 2. Regional incidence of wounds. Front view. 429 wounds. Mortality 
 
 53 per cent. 
 
 bullet, when known, in those cases which arrived at the Casualty 
 Clearing Station in such a condition as to preclude any operative 
 procedure ; they all died. It is rather striking to notice how the 
 chart becomes blackened in a fan-shaped area, the apex of which 
 is the left hypochondrium. There is a comparative absence of 
 mid-line wounds and of hypogastric wounds. This must not be 
 taken as meaning that hypogastric wounds are not dangerous, 
 but only that they do not cause such injuries as to render 
 operation useless. The side-to-side wound would appear to be
 
 22 
 
 War Surgery of the Abdomen 
 
 the most dangerous among wounds that reach an operating unit. 
 This seriousness was noticed in the South African campaign. 
 
 In the chart (Fig. 3) are a good many buttock wounds. From 
 experience gained in operating on such cases, we must regard 
 lesions of the pelvic vessels as a fairly frequent cause of death. 
 
 The mortality that accompanies abdomino-thoracic injuries 
 
 FIG. 3. Regional incidence of wounds. Back view. '222 wounds. Mortality 
 
 60 per cent. 
 
 is possibly explained in part by the fact that such wounds 
 involve this dangerous hypochondriac area. 
 
 Some curious instances of side-to-side wounds may be of 
 interest : (1) A wound of the upper pole of the left kidney and 
 lower pole of the right, wound of ascending colon ; paraplegia ; 
 fatal. (2) Wound of the right kidney and spleen, vertebra 
 penetrated ; no paraplegia ; fatal from splenic haemorrhage. 
 (3) Spleen torn on its anterior edge, left kidney perforated 
 through its centre, upper pole of right kidney destroyed ; fatal 
 (bullet). (4) Wound of the left kidney and the posterior surface
 
 A General Review of. Abdominal Wounds 23 
 
 of the ascending colon ; fatal. (5) Hepatic and splenic flexures 
 alone wounded ; fatal. 
 
 In sixty-eight cases a post-mortem was performed ; Table III. 
 shows the injuries, and Table IV. the number of times individual 
 organs were hit. 
 
 In nearly every case there was much blood in the abdomen, 
 and in thirteen cases the note is made that death was due to 
 
 Transpyloric 
 plane 
 
 Orijice of 
 vermiform process 
 
 Trans tubercular 
 jo lane 
 
 FIG. 4. Chart of cases too seriously wounded to be submitted to operation, all being 
 fatal. A black dot represents an anterior wound, a circle a posterior wound ; 
 the track of the projectile is shown by a line. 
 
 haemorrhage. In only five cases is shock noted as the cause of 
 death, viz. : (1) One perforation of ileum with a shattered 
 os ilium. (2) Multiple wounds of small gut ; no blood in 
 belly. (3) Shock ; no other details. (4) Wound of ileum and 
 sigmoid ; peritonitis and shock. (5) Wound of rectum and small 
 gut. 
 
 In one case retroperitoneal sepsis was noted as the cause of 
 death. In only three instances was peritonitis deemed the cause
 
 24 War Surgery of the Abdomen 
 
 of death. The number of times the small gut was injured is the 
 salient feature in the series, and perhaps another interesting 
 point is that the stomach figures five times. Wounds of the 
 solid organs were responsible for death in twelve instances. 
 
 TABLE III. Showing Injuries in Moribund Cases. 
 
 Stomach and kidney . . . . . . . . . . 2 
 
 ,, ,, colon . . . . . . . . . . 1 
 
 liver . . . . . . . . . 1 
 
 ,, ,, ,. spleen, and pancreas . . . . 1 
 
 Small gut 27 
 
 ,, and colon . . . . . . . . . . 4 
 
 ., ,, rectum . . . . . . . . . . 2 
 
 ,, ,, embolism from wounded carotid . . 1 
 
 Colon . . . . . . . . . . . . . . 5 
 
 ,, and kidney . . . . . . . . . . . . 1 
 
 Rectum . . . . . . . . . . . . . . 2 
 
 Liver . . . . 8 
 
 ,, and spleen . . . . . . . . . . 2 
 
 kidney . . 1 
 
 Spleen and kidney . . . . . . . . . . 1 
 
 Bladder 3 
 
 Paraplegia and acute dilatation of stomach . . . . 1 
 
 Prolapse of stomach, small gut, and colon . . . . 1 
 
 ,, ,, colon, and spleen .. .. .. 1 
 
 ,, small gut . . . . . . . . . . 1 
 
 ,, spleen and splenic flexure . . , . . . 1 
 
 Wound of internal iliac vein . . . . . . . . 1 
 
 Total cases . . 68 
 
 TABLE IV. Showing the Number of Times Individual Organs 
 
 were wounded. 
 
 Stomach . . . . . . . . . . 5 
 
 Small gut . . . . . . . . 34 
 
 Colon 10 
 
 Spleen . . . . . . . . . . 4 
 
 Liver . . . . . . . . 13 
 
 Kidney . . . . . . . . . . 5 
 
 Rectum . . . . . . . . . . 4 
 
 Bladder 3 
 
 Pancreas 1
 
 A General Review of Abdominal Wounds 25 
 
 CASES RECOVERING WITHOUT OPERATION.' Fig. 5 was 
 obtained by plotting the entrance wound and the track of the 
 missile, when known, in cases that recovered without operation. 
 Most of these wounds lie within the liver area. The chart also 
 shows wounds in various other parts of the abdomen ; and 
 their recovery, as will be seen later, is most probably due to 
 
 Orifice of 
 vermiform process 
 
 FIG. 5. Chart of cases that recovered without operation. Dots, circles, and lines 
 have the same significance as in Fig. 4. 
 
 the fact that the hollow viscera had escaped although the 
 abdomen had been penetrated. 
 
 AYOUNDS ABOVE THE TRANSPYLORIC PLANE. AllterO-pOS- 
 
 terior wounds in this region are among the least serious of all 
 abdominal penetrations. Side-to-side wounds are, as has been 
 seen, serious, especially if they are far back. Wounds which 
 enter the abdomen from above downwards, and which may bo 
 described as vertical, are also serious. Sometimes one has great 
 surprises, and one case may be mentioned in which a soldier
 
 26 War Surgery of the Abdomen 
 
 was shot accidentally by a revolver bullet which entered above 
 the blade-bone and was taken out of the gastro-colic omentum ; 
 no hollow viscus was injured, and the man made a complete 
 recovery. 
 
 Epigastric Wounds. In the mid-line true antero -posterior 
 wounds are seldom seen in hospital. The lesser curvature, the 
 oesophagus, and a large portion of the stomach lie within this 
 area. Wounds in this region were usually accounted as stomach 
 wounds, and recovery often reckoned as an instance of spon- 
 taneous healing. Operation has proved that in some cases the 
 projectile misses the stomach and perforates the gastro-hepatic 
 omentum. Naturally, wounds in this region will often involve 
 both surfaces of the stomach. Epigastric wounds have not 
 maintained their reputation as favourable lesions. 
 
 Antero -posterior Hypochondriac Wounds. On the right the 
 liver will be perforated, on the left the cardiac area of the 
 stomach as well as the greater curvature. Towards the lateral 
 line of the body the kidneys, spleen, and splenic flexure will be 
 involved in addition to the liver and stomach. 
 
 Oblique Epigastric and Hypochondriac Wounds. When the 
 wounds are oblique from side to side, no distinction can be drawn 
 between the two regions, as projectiles traverse both. These 
 wounds are decidedly more dangerous than antero-posterior 
 wounds. Indeed, they become more fatal as they get more 
 oblique. On the right side a greater length of liver is traversed, 
 and the dangers of haemorrhage and sepsis are increased. On 
 the left the stomach is perforated more and more obliquely, 
 until a point is reached where the axis or flight of the bullet 
 becomes parallel to the anterior wall or greater curvature. The 
 result is either a long slit or a double hole through which the 
 contents leak freely. The spleen, kidney, and splenic flexures 
 will also at times be involved with the stomach. Wounds of the 
 kidney and spleen are a fairly common combination, those of the 
 stomach and spleen a rare one. 
 
 Vertical Epigastric and Hypochondriac Wounds. These are 
 nearly always more or less inclined downwards and inwards, 
 but cases occur of almost vertical wounds in which both the 
 entrance and exit wounds are on the anterior surface of the body
 
 A General Review of Abdominal Wounds 27 
 
 and almost vertically above one another. When a projectile 
 passes in these directions, the injury of the liver or stomach is 
 complicated by one of the colon or small intestine, for the missile 
 often passes below the transpyloric plane. In one such case 
 both the antrum of the stomach and the transverse colon were 
 almost completely cut in two. Vertical wounds on the lateral 
 surface of the body appear at first as thoracic. On the right side 
 they are not so dangerous, since they may only traverse the 
 liver ; but on the left they may wound the stomach, spleen, and 
 liver. 
 
 Posterior and Lateral Wounds of Hypochondriac Regions. As 
 usually met with, these are single entry wounds. Such wounds 
 between the left axillary lines often exhibit the omentum 
 protruded through the ribs. On the left the spleen, kidney, 
 and the splenic flexure may be wounded, and therefore such 
 wounds are more dangerous than those occurring on the right. 
 They are difficult to treat, as access to this region is not easy, 
 and the infiltration of the retroperitoneal tissue renders detection 
 of the colon perforation difficult even if the spleen and kidney 
 are successfully dealt with. Posterior wounds in the costo- 
 vertebral angle, or through the lower ribs, cause similar injuries 
 to those on the lateral body surface. 
 
 WOUNDS BETWEEN THE TRANSPYLORIC AND INTERTUBER- 
 
 CULAR PLANES. This region is a very fatal one (see Fig. 4). 
 Above the umbilicus the injuries resemble to a considerable 
 degree those met with above the transpyloric plane, but below the 
 umbilicus we have largely to deal with small intestine injuries. 
 
 Antero posterior Wounds. Again, these are seldom met with in 
 the mid-line. On either side of the spine, in the upper part of 
 the region, perforations through the transverse colon are met 
 with, and are usually easily dealt with. Lower down, but still 
 near the middle line, the small intestine is wounded, and the 
 gravity of the cases at once rises. In the lumbar region, wounds 
 of the ascending or descending colon are encountered. If the 
 peritoneal surface alone is involved, the danger is not so great, 
 provided no large destruction of the wall has taken place. 
 Wounds of the left lumbar region are more dangerous than those 
 on the right, for here the coils of the jejunum overlie the great
 
 28 War Surgery of the Abdomen 
 
 bowel. There is another point of interest about flank wounds, 
 and that is the possibility of the escape of the colon or perito- 
 neum from injury owing to the thickness of the muscles of the 
 abdominal wall at this point. As a matter of fact, the colon, 
 especially the descending, when seen from the front lies farther 
 from the lateral line of the body than might be supposed. 
 Wounds entering the back in this region are more fatal on the 
 whole than those that enter the front : not only do they wound 
 the viscera, but they plough up the retroperitoneal tissue, or 
 cause it to be stripped by blood infiltration. When such a course 
 is taken by a bullet or small shell-fragment, the external wound 
 may be insignificant, but a hidden leak into the retrocolic tissue 
 may cause death before sufficient relief has been given by a free 
 incision or a colostomy. 
 
 WOUNDS BELOW THE INTERTUBERCULAR PLANE. These 
 include wounds through the hips, buttocks, and thighs. All are 
 very serious. 
 
 Antero-posterior Wounds. In the hypogastric region these 
 are dangerous on account of small-gut lesions. Mid-line 
 wounds frequently come to operation, as there are no great 
 vessels to cause death before hospital is reached. If the 
 bladder is full it will be involved, but it is a somewhat 
 remarkable fact that such injuries are not very common. The 
 pelvic colon and the rectum may be injured. Towards the side 
 of the body, in the iliac regions, wounds of the caecum and iliac 
 colon are encountered. 
 
 Side-to-side Wounds. These may involve the caecum, small 
 gut, and pelvic and iliac colons. Such injuries are very danger- 
 ous, the small-gut wounds being nearly always multiple. The 
 pelvic vessels may also be injured, and cause death from direct 
 haemorrhage. 
 
 Semi-vertical Wounds. In the Lancet of December 18th, 
 1915, 1 called attention to the dangerous nature of these injuries, 
 and many have since confirmed this opinion. They are caused 
 by missiles which enter the buttock, perineum, or thighs. In 
 the early days of the war a wound in the buttock or thigh was 
 often unconnected in the surgeon's mind with the possibility 
 of an intestinal lesion. These wounds nearly always cause
 
 A General Review of Abdominal Wounds 29 
 
 multiple injuries of the small intestine ; the bladder and rectum 
 are also involved. Such wounds are nearly always accom- 
 panied by pain in the abdomen soon after their receipt. The 
 soldier often thought that he had been hit in the abdomen, 
 while the surgeon was not inclined to accept this diagnosis ; 
 the fatality of such cases was partly due to the abdominal injury 
 being overlooked, and time lost. 
 
 Possibility of Escape of Viscera in Penetrating Wounds. 
 
 It has always been a much debated point as to whether a 
 projectile could traverse the peritoneal cavity without wounding 
 the hollow viscera. Makins held that it was possible from his 
 experience in South Africa. Others denied the possibility. There 
 has never been any doubt that the liver and kidneys could be 
 damaged without involving other organs. The point that 
 required settling was the escape of the stomach in the upper 
 part and the small intestine and colon in the lower. Those who 
 believed in treating abdominal wounds by rest and starvation 
 pointed to cures, by this means, of patients in whose cases it 
 appeared, by a study of the track of the bullet, that a hollow 
 viscus must have been perforated. Makins held that there was 
 a possibility of recovery in cases of colon injury, but that small- 
 intestine lesions were always fatal. 
 
 Until quite recently, when coeliotomy became the routine 
 treatment of abdominal wounds, a proof that such escape was 
 possible was almost wanting. The classical case of Cheatle's 
 was often quoted as a proof, but there were people who were not 
 convinced by it. 
 
 Fig. 6 shows a chart of cases in which the abdomen was 
 opened and explored, and no hollow viscus found injured. The 
 abdominal cavity was usually full of blood. This blood came 
 from two sources : (1) the vessels of the omentum, mesentery, 
 or abdominal wall (deep epigastric usually) ; in these cases the 
 haemorrhage was arrested by ligature of the vessel : (2) from 
 cracks in the peritoneum raised 'by a retroperitoneal effusion of 
 blood ; here little beyond clearing the abdomen could be done, 
 for experience has shown that such collections of blood are best 
 left alone.
 
 30 \Yar Surgery of the Abdomen 
 
 In many cases there were bruising and tears of the peritoneal 
 and muscular walls of the stomach or intestine. These tears 
 and bruises explain the cases where a faecal fistula or an intra- 
 peritoneal abscess has appeared some time after the receipt of 
 the wound. 
 
 Orifice of 
 vermiform process 
 
 Transjtyloric 
 plane. 
 
 Trans tubercular 
 ft lane 
 
 FIG. 6. rChart of cases in which coeliotomy was performed and no hollow viscus 
 found injured. Dots., circles, and lines as in Fig. 4. 
 
 The Possibility of Spontaneous Recovery after the Perforation of 
 
 Hollow Viscera. 
 
 It is quite true that people do recover spontaneously after 
 wounds of the hollow viscera, but the number is very small. 
 Those that recover may be said to be the exceptions that prove 
 the rule. The following are instances : 
 
 (1) Healing of Stomach. Makins * describes a case in which 
 
 * Journ. of the Royal Army Medical Corps, January, 1916.
 
 A General Review of Abdominal Wounds 31 
 
 a wound of the posterior surface of the stomach was firmly sealed 
 to the pancreas and spleen ; death resulted from secondary 
 haemorrhage. Lieutenant-Colonel T. R. Elliott and Captain 
 Herbert Henry have also described cases of spontaneous 
 healing. I myself have seen a healed wound of the stomach 
 in a patient who succumbed to other injuries. Lastly, 
 Captain Green-Armytage actually closed the abdomen in a 
 case where a hole in the stomach was impossible of suture, 
 and a cure resulted. Although such healing does result, it must 
 be looked upon as more of academic than of practical interest. 
 No surgeon would nowadays use such cases as an argument in 
 favour of abstention. 
 
 (2) Healing of Colon. There have been frequent instances of 
 recovery after wounds of the vertical colons, as has been insisted 
 on by Makins, who attributes such a favourable result to the 
 intense local reaction produced by the contents of this portion 
 of the bowel. 
 
 (3) Healing of Small Intestine. For the history of the follow- 
 ing remarkable case I am indebted to Surgeon-General Bowlby 
 and Captain Bell : A soldier was shot from side to side through 
 the body at the battle of Loos. He was not operated on, and 
 recovered. There was nothing special about his convalescence. 
 He was again shot in the abdomen in the battle of the Somme 
 and was operated upon. When the abdomen was opened, 
 several perforations of the small intestine were found in the 
 neighbourhood of a mass of adhesions. The wounded and 
 adherent segments were excised, and the man made a good 
 recovery. On slitting up the adherent coils an entero-entero- 
 stomy was found between two adjacent loops ; in addition, 
 there were several small herniated diverticula of the mucous 
 membrane, obviously pointing to closure of the previous penetra- 
 tions. This case is of interest because the process of healing 
 corresponds to that which Captain H. Drummond has shown to 
 be the case when the intestines of rabbits are perforated, and 
 put back without suture. The herniated mucous membrane 
 remains herniated, and gradually becomes covered with a layer 
 of lymph, which slowly organises and seals the hole, the 
 herniated mucous membrane still forming a diverticulum.
 
 32 \Yar Surgery of the Abdomen 
 
 Rupture of Viscera outside the Actual Course of the Projectile. 
 
 (1) Rupture of Viscera by Contusion of the Abdomen. As in 
 civil life, one meets with a fair number of abdominal injuries 
 caused by horse kicks. Others are caused by falling in of 
 dug-outs, by burial of men by shell explosions, and by blows of 
 fragments of wood which are hurled about. They present 
 nothing out ofHhe common, and the injuries seen are the same as 
 some in civil life. Captain J. B. Hay craft had one case, which 
 may be mentioned, in which the post-mortem examination on a 
 man who died after such burial showed numerous contusions of 
 the small intestine, without rupture. 
 
 (2) Similar injuries are caused by large shell fragments, 
 usually shell caps, and several cases of the latter injury have 
 been seen in which rupture of the intestine was accompanied 
 by extensive contusions. Some years ago Makins wrote a 
 paper on this subject, and he came to the conclusion that such 
 injuries are caused by the bowel being caught between the 
 unyielding posterior abdominal wall and the oncoming object. 
 This supposition is strengthened by the association of bruises 
 with perforations in the case above quoted. 
 
 (3) Cases in which the Viscera are damaged by Indriven Bone 
 Fragments. (a) There are many cases of injury to the liver and 
 spleen by the driving in of fractured ribs, (b) The caecum, the 
 ascending and descending colon, and also the small gut in the 
 pelvis, are all apt to be injured by small bony spicules driven in 
 through the peritoneum. Although the projectile itself does not 
 penetrate this membrane, it is important to remember this 
 possibility, because when such wounds are explored it is most 
 probable that the small holes caused by the bony fragments will 
 be overlooked, and the peritoneum assumed to be inviolate. 
 
 (4) Rupture of Solid Organs by Indirect Violence of a Passing 
 Projectile. Such injuries are not uncommon. Fig. 7 shows a 
 picture of a kidney in which many cracks in the capsule were 
 produced by a missile which did not touch the organ. The 
 spleen is often ruptured in this manner, and sometimes the 
 liver. In one case the diaphragm was intact, but on opening 
 the peritoneum much blood escaped, and there was an extensive
 
 A General Review of Abdominal Wounds 
 
 33 
 
 tear in the spleen. In another case the diaphragm was ruptured 
 over a small area, the blow being a glancing one. There was a 
 corresponding wound on the outer surface of the spleen, and from 
 this wound there ran in all directions radiating fissures in the 
 capsule, showing that the spleen had been burst by the indirect 
 force exerted upon it. 
 
 IMC. 1. Kidney : indirect effects of gunshot organ fissured, concentric fissures 
 run across the intima of the renal artery. Bullet entered left buttock, 
 traversed sacrum and fifth lumbar vertebra, and passed out through right 
 psoas, keeping behind the colon ; the track was quite clear of the colon and 
 kidney. (Specimen prepared by Captain J. S. Dunn.) 
 
 (.')) Rupture of .Hollow ()>\<I<IHX />// Indirect 1'iolcnce. Cases of 
 this class have been reported by Owen Richards, John Fraser, 
 J. W. Dew. and others. 
 
 (a) Rupture of the intestine by a bullet without penetration. 
 The first case was that of a man whose recti were divided 
 almost completely by a bullet. The wound was explored, anil 
 
 W.S.A. 3
 
 34 War Surgery of the Abdomen 
 
 the posterior rectus sheath found intact. As there were no 
 symptoms, the abdomen was not opened ; the man died. At 
 the post-mortem a careful search failed to show any rupture of 
 the peritoneum. There were three holes in the small intestine 
 which lay immediately under the wound in the abdominal wall, 
 showing the gut had not moved, although more than twenty- 
 four hours had elapsed since the receipt of the injury. Eraser's 
 case was that of a man wounded by a piece of shell in the right 
 iliac fossa, the caecum being found bruised, and a small hole in 
 the mesenteric border of the ileum. In Dew's case the projectile 
 had cut through all the abdominal wall except the peritoneum, 
 through which the caecum could be seen. As there were no 
 symptoms, the abdomen was not opened, but the man died from 
 a ruptured ileum. Stevenson, Shaw, and Mackenzie have 
 described a rupture of liver and jejunum by a missile that did 
 not open the abdomen. 
 
 It would seem that these ruptures may be caused in two 
 possible ways : (1) When an object such as the abdomen and its 
 contents, made up of layers of varying toughness, is sharply 
 hit, more friable layers underneath may give way, while the 
 more resisting overlying layers remain intact. (2) This may 
 be termed the " paper-bag " theory, the viscus being ruptured 
 by a smart blow in a similar way to that in which an inflated 
 paper bag is burst on being hit. There is no proof that this 
 happens, but it is rather a seductive theory. The following 
 case of .1. Fraser's is interesting in this connection : A bullet 
 penetrated the abdomen just below the umbilicus ; there were 
 no symptoms at first, but when they arose later on, coeliotomy 
 showed a ruptured bladder. The bladder was apparently out 
 of the direct line of the projectile. 
 
 There is another possibility which must not be lost sight of: a 
 man may fall to the ground, or against some object, when he is hit, 
 and the ruptured intestine be due to the blow thus produced, and 
 not to the actual missile which was the indirect cause of the fall. 
 
 Mechanism of Wound Production after Penetration. 
 
 The multiplicity of the wounds of the small intestine has 
 raised some doubt as to their method of production, especially
 
 A General Review of Abdominal Wounds 35 
 
 in the case of bullets, where widely different types of wound are 
 seen. The question arises whether a bullet pursuing a straight 
 course can cause these injuries, or whether we must invoke a rota- 
 tion of the bullet, or a bursting effect. If a bullet is rotating 
 quickly on a transverse axis, it could easily produce complete 
 division of the gut, but if it is rotating quickly enough to pro- 
 duce such injuries, it is hard to see how it could at the same 
 time produce small perforations. Some support is given to the 
 rotation theory by the retention of many bullets ; one knows 
 that their flight is unstable at the end. If the rotation theory 
 is correct, one ought to have some evidence of this rotation at 
 the entrance and exit holes. As a fact, it is impossible to 
 establish any relations between the size of the entrance and 
 exit wounds in the skin and the amount of damage done to the 
 intestine. As to the possibility of a bursting effect (paper-bag 
 theory) it is impossible to make any definite statement. In a 
 case operated on by Captain Hamilton Drummond there was 
 a rupture of the small intestine between the leaves of the 
 mesentery which was not found until the intestine was laid 
 open. The position of the rupture was outside the track of 
 the bullet (see also Fraser's case of ruptured bladder). One 
 must remember, however, that the intestine is not greatly 
 distended by either gaseous or fluid contents. It seems almost 
 impossible to believe that anything of the nature of a hydraulic 
 or pneumatic effect could be produced. In this connection the 
 following case is pertinent : A soldier was shot through the 
 abdomen, the muzzle of the rifle being in contact with the body. 
 The entrance wound was close beside the umbilicus, and the 
 exit wound at a corresponding point behind. The bullet passed 
 by the side of the vertebral column and made three type lesions 
 in the jejunum. He was promptly operated on, and made a 
 perfect recovery. If any pneumatic or hydraulic effect is to be 
 expected, it should have been found in this case. I am rather 
 inclined to think that these different types of wound are caused 
 by the varying state of distension of the small gut. As is well 
 known, one meets with lengths of the small intestine alter- 
 nately distended with air and collapsed. If the bullet strikes 
 a distended portion, it will perforate it or cut a hole in it. If it 
 
 32
 
 36 War Surgery of the Abdomen 
 
 strikes a portion which is collapsed, the intestine is so small 
 that the bullet is large enough in diameter to divide both 
 coats the whole breadth of the bowel. 
 
 Some support is given to this assumption by the behaviour 
 of the large gut. Perforations are here much more common 
 than large tears or complete division. When complete division 
 does occur it is in the portions of the gut that are often found 
 
 FIG. 8. Small intestine divided in seven places by a rifle bullet. Small wound of 
 entrance in epigastric region. Bullet lay free within abdominal cavity. Parts 
 resected. Patient died a few hours after operation. (Brit. Journ. of Surgery.) 
 
 small and collapsed, namely the transverse and descending and 
 pelvic colons. The ascending colon and hepatic flexure nearly 
 always show perforations. 
 
 In considering this subject great interest attaches to a 
 lecture by Professor S. G. Shattock, an abstract of which, as it 
 appeared in the British Medical Journal, December 15th, 1017, 
 is appended below.* 
 
 * For the complete lecture ><< I'roceedings of Royal Snciilij of Medicine, 1917.
 
 A General Review of Abdominal Wounds 37 
 
 Professor S. G. Shattock, F.H.S., observed that, from the 
 strictly pathological standpoint, the new factor introduced 
 into gunshot injuries, as injuries, was the velocity of the 
 penetrating body ; they were otherwise contused and infected 
 wounds like those produced by other foreign bodies, although 
 their number and variety gave them special surgical features. 
 Under the term " explosive effect " more than one thing was 
 included : it was applied (1) to the increase of damage due to 
 shattering of the bullet, (2) to the additional injury resulting 
 from the comminution of a bone and the dispersal of its frag- 
 ments, and (3) to the damage resulting from the high velocity 
 of the missile. The last alone possessed any special patho- 
 logical interest. It had been asserted (Professor Dr. K. 
 Stargardt) that the British bullet was an expanding one, in 
 consequence of the core being composed of aluminium at the 
 point, and elsewhere of lead ; that on striking (bone at least) 
 the momentum of the lead carried this forwards over the harder 
 aluminium, and so split the mantle. In order to test this the 
 author had had recourse to the following experiment : The 
 bullet was fired at a distance of 20 feet through a sternum 
 into cotton waste, from which it was recovered without having 
 struck any second object. The sternum was selected in order 
 to obtain a direct hit. The bullet was found to have undergone 
 no distortion whatever. Two sterna were then spliced together 
 and shot through in the same way ; the bullet on recovery 
 was found quite undamaged. In solid organs the results of 
 high velocity were best seen in the liver when perforated by 
 rifle bullets at close range. The typical injury was a perforation 
 accompanied with radial fissuring of wide extent. Even here 
 the elimination of extraneous factors, such as obliquity of 
 impact, or turning of the missile in transit, damage due to the 
 introduction of clothing, could only be effected by experiment. 
 In firing through suspended sheep livers at 20 feet with a service 
 rifle and pointed bullet, this was the form the injury took ; the 
 mechanical action of gas produced by explosion was eliminated 
 by the distance. In analysing the physics of this result the 
 wave of compressed air produced by the bullet (demonstrated 
 by Professor Vernon Boys in instantaneous photographs) was
 
 38 \Y;ir Surgery of the Abdomen 
 
 wholly negligible. The speaker had found that if tense screens 
 of tissue paper were shot through at 20 feet with a service rifle, 
 the hole was but little larger than the bullet ; were the air wave 
 of any moment, the paper would obviously have been widely 
 rent. Sir Victor Horsley, in commenting upon the cavitation 
 produced in his experiments of firing into clay, attributed 
 more importance to the spin of the bullet (centrifugal action) 
 
 Fin. 9. Rupture and laceration of the right lobe of the liver by bullet discharged 
 at short range. It perforated the right hypogastric region from before backwards.. 
 Soldier died of haemorrhage. (Brit. Journ. of Surgery.) 
 
 than to its forward movement. The speaker had carefully 
 inspected all the plaster casts made from the clay in these 
 experiments, and was unable to find the evidence of such rota- 
 tion ; the coarser ridges (representing shallow fissures in the 
 clay) as well as the finer markings were longitudinal. The turn of 
 the present British bullet was only one in 10 inches, yet explosive 
 effects were observable in, for example, the sheep livers before 
 referred to, where the thickness was only 1| inch, which would
 
 A General Review of Abdominal Wounds 39 
 
 reduce the rotation to less than a fifth. In only one specimen 
 in the collection on view in the Royal College of Surgeons 
 were the divergent fissures curved ; here the bullet had tra- 
 versed the body of the third lumbar vertebra first, and must 
 have had some altogether exceptional twist imparted to it. The 
 question was thus reduced to one of forward velocity. This was 
 well shown in the liver by the fact that in perforations caused 
 by shell fragments at low velocity a patulous tunnel alone 
 resulted. The same difference was beautifully demonstrated 
 in Horsley's casts, where the distal half was only of the calibre 
 of the bullet, the explosive or dilating effect being limited to the 
 proximal. In the case of the clay, the ready entrance of air 
 from behind allowed of its cavitation ; in the liver, where this 
 was out of the question, the cavitation was represented by radial 
 fissuring produced by the passage of the wave through an in- 
 compressible semi-solid medium. In hollow organs the produc- 
 tion of explosive effects depended upon their contents, other 
 things being equal. Such effects from rifle bullets were not 
 observed in the stomach or intestines by reason of the com- 
 pressible air and gas which they contained, nor in the lung, 
 for the same reason. The contusion, unattended with breach 
 of surface, found not rarely in such organs, was possible from 
 their extreme mobility and compressibility. The longitudinal 
 wounds produced at times in the intestine by intact bullets 
 were explained by the wall having been struck axially. In the 
 case of the bladder, the contents of which were incompressible, 
 explosive results were now and then encountered. In the 
 collection there was a bladder perforated by a rifle bullet which 
 entered through the buttock without fracturing bone, and 
 eventually escaped above the pubes ; in the posterior wall of 
 the bladder was an entry admitting the finger ; the anterior 
 wall (exit) was rent from top to bottom. The speaker had 
 obtained similar explosive results by firing through ox bladders 
 distended with water, a service rifle being used at 20 feet. 
 The result was a simple hydrodynamic one, and due to the wave 
 imparted to a mobile and incompressible fluid in a confined 
 space. If the bladder was empty, or only lightly filled, the 
 rending on the far side did not take place. In arteries and veins
 
 40 War Surgery of the Abdomen 
 
 no hydrodynamic effect was observable, whether in unilateral 
 or bilateral perforation. Its absence was possibly due to the 
 indefinite continuity of fluid above and below the stricken spot 
 and to the remarkable strength of both kinds of vessels. The 
 speaker had been unable to produce either macroscopic or micro- 
 scopic damage of the inner or middle coats of the human 
 common iliac artery under the highest pressure that could be 
 exerted with a dissecting-room syringe. In regard to the skeleton, 
 the rigidity of the structure concerned was a complicating factor. 
 If the upper part of the shaft of the tibia was compressed over 
 a small area in a vice, however slowly the compression was made, 
 extensive comminution and fissuring ensued far beyond the spot 
 compressed. Nevertheless the same rule held : the greater the 
 velocity of the missile the greater the damage. 
 
 The classical example of explosive effect was the well-known 
 widespread comminution of the skull when bilaterally perforated 
 by a rifle bullet at close range. The effects due to the gas of 
 explosion had, of course, to be excluded. The results of suicidal 
 shooting were thus liable to lead to false conclusions : a rifle 
 fired into the mouth with blank cartridge would produce 
 extensive comminution. This factor was, however, easily 
 eliminated ; the speaker had found, too, that sheep skulls with 
 the brain in situ underwent extensive comminution when shot 
 through at 20 feet with a service rifle, the foramen magnum 
 being freely open. The result was not, properly speaking, 
 hydraulic, but hydrodynamie that is, it was not due to a 
 generalised and equable internal pressure, but to the sudden 
 impact of the incompressible cerebral substance against the 
 interior of the cranium. A simple experiment, devised by the 
 speaker, would emphasise this. A large, flat-sided " cocoa tin " 
 was shot through in the empty state at 20 feet with a service 
 rifle ; a circular entry and exit of about the diameter of the 
 bullet resulted. A second tin was filled with water and shot 
 through, the lid being removed ; the entry was small and 
 circular, the exit widely split, with large triangular flaps of the 
 metal completely everted. The speaker had obtained pro- 
 nounced explosive effects also in sheep skulls inverted and filled 
 with water, the foramen magnum being freely open ; if the
 
 A General Review of Abdominal Wounds 41 
 
 skull was shot through in the empty condition, a circular entry 
 and exit alone resulted. 
 
 Comparative Frequency of Wounds in the Different Viscera. 
 The following table gives some idea of the relative frequency 
 with which different organs in the abdomen are wounded : 
 
 TABLE V. Relative Frequency with which Different Abdominal 
 Organs are wounded. From a Total of 965 Cases. 
 
 Viscus. 
 
 No. of Times 
 wounded. 
 
 Viscus. 
 
 No. of Times 
 wounded. 
 
 Small gut 
 Colon 
 
 363 
 252 
 
 Spleen 
 Bladder .. 
 
 54 
 45 
 
 Liver 
 
 163 
 
 Rectum 
 
 21 
 
 Stomach 
 
 82 
 
 Pancreas 
 
 5 
 
 Kidney 
 
 74 
 
 Ureter 
 
 3 
 
 State of the Alimentary Canal in respect of its Contents. 
 
 (1) Stomach. The amount of food in the stomach is dependent 
 on the time that has passed between the last meal and the time 
 of wounding. The escape of contents depends on this, and on 
 the size and situation of the wound. If the wound is a small 
 one, and near the lesser curvature or the cardiac end, there will 
 be little found in the abdomen ; if, on the other hand, the wound 
 is large, and near the greater curvature, extravasation may be 
 very considerable. It is only in connection with the stomach 
 that free gas has been seen to escape from the wound or to be 
 present in the abdomen. 
 
 (2) The Small Intestine. The small intestine is usually empty, 
 and it is hard to fix any definite relation between the amount of 
 its contents and the time of the last meal. It is in a very 
 favourable condition from a surgical point of view, even more so 
 perhaps than after the elaborate preparation which has been till 
 recently the rule in civil operative practice. The collapse of 
 the gut is not due to escape of gas, for free gas is not found in 
 the abdomen. 
 
 The usual absence of any large amount of intestinal contents 
 s to be due to a more rapid passage of food along the
 
 42 War Surgery of the Abdomen 
 
 tube than is usually considered normal, or else to a very 
 complete digestion. Otherwise, considering the number of cases 
 treated at various intervals after meals, the presence of contents 
 should be more frequent. It is the absence of contents, more 
 than anything else, that accounts for the little extravasation. 
 Should the intestine be loaded, there is a large escape. 
 
 In one case it was possible to get the exact time of the last 
 meal. A man had a dinner of bully-beef and Clarke's beans at 
 1 p.m. ; he was hit at 6 p.m., and operated on at 10 p.m. All 
 evidence goes to show that after a wound, digestion and vermi- 
 cular movements cease, so that one can assume the state of the 
 intestine at 10 p.m. was the same as that at 6 p.m. The operation 
 showed that the man was wounded 3| feet from the caecum, and 
 here the bowel contained much fluid and solid matter, including 
 Clarke's beans, which were extravasated to a large extent. This 
 case was under the care of Captain H. Drummond. 
 
 Another interesting observation was made by Captain John 
 Fraser. A party of soldiers was shelled in billets just after the 
 midday meal, which consisted of large quantities of tea. There 
 were several cases of abdominal wounds. The amount of fluid 
 in the abdomen in some cases of wounded small gut was remark- 
 able, and in contrast to the usual condition. It looked as if the 
 fluid contents had passed rapidly into the small intestine. The 
 stomachs themselves to judge by one case, at all events were 
 still full of food. It is interesting to note that extravasation is 
 apparently more common in vegetarians than in meat eaters. 
 (Major C. H. Barber, I. M.S., Gunshot Wounds of the Abdomen 
 during the Siege of Kut : Lancet, Jan. 20, 1917.) 
 
 (3) The Large Intestine. This is often loaded, and presents a 
 great contrast to the small intestine in this respect. This fact, 
 no doubt, is due to the sedentary life in the trenches. The 
 loaded state of the bowel may have some relation to the infec- 
 tivity of the contents. On the other hand, a constipated condi- 
 tion tends to limit the escape of the contents. 
 
 State of the Alimentary Canal in respect of the Nervo-Muscular 
 
 Mechanism. 
 
 When considering this subject a sharp distinction must be 
 drawn between the appearances seen before, and after sepsis
 
 A General Review of Abdominal Wounds 43 
 
 has produced its effects on the intestine. It is with the former 
 that we are at present concerned. 
 
 The Stomach. This is often normal both as regards its size and 
 the thickness of its walls. On the other hand, it is by no means 
 rare to find it dilated. This dilatation is, as a rule, of moderate 
 dimensions, but may be of considerable extent, and occasionally 
 a condition of acute dilatation is present. This last condition 
 is seen both in peritoneal and retroperitoneal wounds, and with 
 and without spinal injury. Apart from actual dilatation seen in 
 the course of operation, many cases after operation present 
 the clinical symptoms of the condition, which is relieved, as a 
 rule, by stomach lavage, but sometimes ends fatally. 
 
 An experiment performed by Captain H. Drummond and 
 myself may be of interest in this connection. A dog was given a 
 weighed meal containing bismuth. A skiagram showed that the 
 organ emptied itself in six hours. The experiment was repeated, 
 with the addition that the animal was anaesthetised for half 
 an hour. There was no delay in the emptying of the organ. 
 Another experiment was performed similar to the last, but in 
 this instance a resection and suture of intestine was performed. 
 The stomach had not begun to empty itself in six hours. 
 
 The following case shows that the loss of motile power is not 
 altogether dependent on a penetrating wound : An officer had 
 his dinner at 7 p.m. Immediately afterwards he took his platoon 
 into the trenches. On the way up some obstruction occurred in 
 the communication trench, and the officer got out of the trenc'.i 
 to put matters right. His femur was shattered by a bullet at 
 10 p.m. The next morning at 11 a.m., having had no food in 
 the interval, he was given an anaesthetic that the wound might 
 be treated in the ordinary way. He vomited his dinner prac- 
 tically unaffected by digestion. 
 
 The Small Intestine. This presents alternate lengths of 
 moderate distension and collapse, and on the whole the calibre 
 of the tube is on the small side of that usually seen in civil 
 practice. Sometimes this condition is exaggerated, and the 
 appearance of the abdominal contents when first seen on opening 
 the belly is comparable, as Fraser has said, to that of a formal in 
 body. Very occasionally a wounded segment of the gut presents
 
 44 War Surgery of the Abdomen 
 
 a local dilatation at the lesion (sec Fig. 11). Sometimes the 
 upper jejunum shares in the dilatation of the stomach. 
 
 The intestines remain motionless a considerable time after 
 injury. This is shown by the fact that when the missile has 
 taken a comparatively superficial course, and wounded the gut 
 as it lies against the anterior belly wall, the injured part is still 
 found in the same place after a considerable interval. The 
 same thing has been noted in those cases where the gut has 
 been ruptured without abdominal penetration, and death has 
 ensued (see page 33). I have seen the wounded gut still in 
 the place in which it was hit after thirty-six hours. The 
 adhesions that quickly form after wounding no doubt anchor it 
 in place after motility has reappeared. Sir William Watson 
 Cheyne described a similar case in the South African War, 
 where the gut remained in position after three days. 
 
 Drummond and Fraser have raised the interesting point as 
 to whether an extensive injury of the small intestine may not, 
 to a certain degree, assist in its own cure by causing a more 
 profound paralysis than does a more trivial injury. 
 
 It is at present impossible to say definitely how long on the 
 average the gut remains paralysed ; the only other observation 
 bearing on this subject is that peristalsis has been seen in the 
 jejunum eleven hours after injury. 
 
 It is possible that a persistence of the traumatic paralysis of 
 the gut is the source of trouble after a resection, and two cases 
 apparently of this nature have been reported by Richards anil 
 Fraser. 
 
 Some experiments seem to show that in animals, after a 
 resection, the upper segment of the intestine remains paretic 
 after the lower one has regained its power, and that the last 
 part of all to become normal is that in the immediate neigh- 
 bourhood of the resection. It is possible to start a peristaltic 
 wave in the lower segment some time before it can be originated 
 in the upper, and even when a contraction can be brought about 
 in the upper segment, it fails to move, remaining as a stationary 
 constriction of the gut.
 
 CHAPTER III. 
 
 WHERE TO OPERATE. 
 
 The Time Factor. 
 
 TABLE VI. was compiled by dividing the time between the 
 receipt of the wound and the performance of the operation into 
 two-hourly periods, and noting whether cases were sent to the 
 Base or succumbed to their injuries. It mainly shows two 
 things : (1) it gives some idea of the time in which cases are got 
 out of the trenches and submitted to operation ; and (2) it 
 shows the effect on the mortality of the time which has elapsed 
 between the receipt of the injury and the performance of the 
 operation. It will be seen that most cases arrive some time 
 between six and ten hours after the receipt of the injury. Up 
 to six hours the chances are in favour of the patient ; after this 
 period they are always against him. 
 
 To the table have been added a few cases in which patients 
 have died after an unexpectedly short period, and also a few of 
 those in which recovery has followed the lapse of a long period 
 between the receipt of the wound and the operation. So far 
 the limit in successful cases has been forty-eight hours for a 
 resection of the small intestine, and thirty-six hours for a suture 
 of the colon, and for a suture of the stomach. 
 
 TABLE VI.- 591 Cases showing the Effect of Time on Mortality. 
 
 
 Hours. 
 
 2. 
 
 4. 
 
 6. 
 
 8. 
 
 10. 
 
 12. 
 
 14. 
 
 16. 
 
 18. 
 
 20. 
 
 22. 
 
 
 4 
 
 24 and over. 
 
 To Base . . 
 Died 
 
 3 
 
 _' 
 
 30 
 30 
 
 75 
 53 
 
 55 
 
 59 
 
 34 
 41 
 
 19 
 23 
 
 7 
 10 
 
 4 
 12 
 
 11 
 15 
 
 4 
 11 
 
 27 
 52 
 
 Total . . 
 
 5 
 
 60 
 
 128 
 
 114 
 
 75 
 
 42 
 
 17 
 
 16 
 
 26 
 
 15 
 
 4 
 
 79
 
 War Surgery of the Abdomen 
 
 
 To Base. 
 
 
 Died. 
 
 Hours. 
 
 Injury. 
 
 Hours. 
 
 Injury or Cause of Death. 
 
 24 
 
 Colon 
 
 6 
 
 Small gut and haemorrhage. 
 
 57 
 
 Bladder 
 
 6 
 
 
 24 
 
 Sigmoid 
 
 5 
 
 Gas gangrene of abdominal 
 
 30 
 48 
 26 
 
 No visceral injury . . . 
 
 9 < 
 
 Jejunum 
 
 3 
 4 
 4 
 
 wall. 
 Small gut and peritonitis. 
 Stomach and duodenum. 
 Small gut and haemorrhage. 
 
 15 
 
 Stomach 
 
 4 
 
 Stomach. 
 
 65 
 
 72 
 
 Rectum, extrapcritoneal . 
 Colon fistula 
 
 3 
 
 Multiple wounds of small 
 gut. 
 Colon. 
 
 
 
 4 
 
 Spleen, excision of. for 
 haemorrhage. 
 
 Where to operate on Abdominal Cases. 
 
 The time factor table shows that the sooner a man is operated 
 on the better. But there is another important factor. The 
 wounded man must be kept quiet and well nursed. 
 
 In certain sectors of the line it would be physically possible 
 to operate on hifti at the Regimental Aid -Post or Advanced 
 Dressing Station, but it would be under the most disadvan- 
 tageous circumstances. After operation nursing, as usually 
 understood, would be impossible. In addition the man would 
 be under constant shell-fire or close to our own guns, both of 
 which would have a very bad effect on him. Again, there are 
 not enough surgeons to staff such places. 
 
 It is therefore necessary to operate on him at a special 
 operating centre placed between the Advanced Dressing Station 
 and Casualty Clearing Station or to take him back to a Casualty 
 Clearing Station. 
 
 In deciding this it must be remembered that the time occupied 
 in passing from the Advanced Dressing Station to the Casualty 
 Clearing Station is usually a very small part of the time that 
 elapses between the receipt of the wound and the time of 
 arrival at the Casualty Clearing Station. 
 
 If therefore the Casualty Clearing Station is reasonably far
 
 Where to Operate 47 
 
 forward (10,000 15,000 yards from the line), it is, except in 
 some special cases, the best place for the operation. 
 
 It may be well to say here something about the mobile operat- 
 ing vans. They have loomed somewhat largely in the public 
 mind and have been a good deal discussed. The idea is that 
 you can have the motor van fitted out as an operating-room, 
 and that such a van should seek the patient rather than that 
 the patient should be brought to the theatre. It may be stated 
 at once that this idea is impracticable, and much more time 
 would be spent in getting to the patient than is now spent in 
 getting the patient to an ordinary Clearing Station. When 
 speaking of a mobile hospital van it must be understood that 
 one does not include in this category a theatre which can be 
 rapidly erected, adequately warmed and lighted, such as the 
 French and Italians use on many occasions ; such units are 
 only meant to be mobile in much the same degree as the Casualty 
 Clearing Station was intended to be mobile. 
 
 On the other hand, special hospitals are very good when 
 Casualty Clearing Stations cannot be got near the line. I will 
 briefly describe some. 
 
 The first one was situated in a bleaching mill ; it was about 
 5,000 yards behind the firing line, and took all the abdominal 
 wounded of a certain corps. It was formed by sending an 
 operating surgeon and an anaesthetist and four nursing sisters 
 to supplement the personnel of a Field Ambulance which was 
 situated in this building. It had a very good theatre and a 
 large ward, which in cold weather was steam-heated. Here 
 cases frequently arrived within two hours or less, the patients 
 being carried straight from the spot where they were wounded 
 to the hospital, irrespective of what Division they belonged to 
 This hospital was never pressed and never had the strain of a 
 large fight placed upon it. It continued to do its good work 
 until the enemy began to pay attention to a bridge which 
 crossed a canal on whose banks the mill was situated. Then 
 it was shifted a bit to one side and to another building which 
 was much less commodious. There it remained until the area 
 passed out of the jurisdiction of the Army. The sisters and 
 operating surgeon and anaesthetist were then moved to a
 
 48 War Surgery of the Abdomen 
 
 different part of the line, and were re-established in the ugliest 
 chateau it has been my misfortune to see. It was situated 
 about 9,000 yards behind the line and in a very much more 
 difficult sector as far as evacuation was concerned. Here it 
 continued to do excellent work, although the railhead and a 
 coal-mine near by were continually shelled, many of the shells 
 coming into the garden uncomfortably close to the house. It 
 was closed at last, as a Casualty Clearing Station was opened 
 near by. This hospital was also never pressed ; and the results, 
 as in the last, were very good. 
 
 The third hospital was opened in a Field Ambulance just 
 before the onset of a big battle ; and it was arranged that all 
 the abdominal wounded from a Corps should be brought to it. 
 As a matter of fact, in the stress of battle the wounded from 
 two Corps were carried to it. The result was that the place 
 was heavily worked, and the results were not so good as in the 
 last two. 
 
 A fourth abdominal hospital may be mentioned, because 
 there are some lessons which can be learnt from it. Experience 
 had been gained by the overwork of the last hospital, and 
 adequate arrangements were made to prevent it. The personnel 
 of this particular hospital was adequate for its needs. In 
 addition it was arranged that when the hospital became full 
 the wounded should be sent on to a Casualty Clearing Station 
 situated somewhere farther back. The result of this arrange- 
 ment was that all the abdominals that had the good fortune to 
 be admitted were well and rapidly treated. 
 
 The lesson to be learnt from the experience gained at such 
 hospitals can be summarised as follows : that in quiet 
 times such hospitals opened at Field Ambulances by the 
 provision of an operating surgeon and a few sisters can do 
 magnificent work and save life. If, on the other, hand, such 
 hospitals are to be opened in times of battle, it is necessary to. 
 have very much the same personnel that is allowed to a Casualty 
 Clearing Station. Unless a large number of beds are provided, 
 the hospital soon becomes full, and the personnel is not used to 
 its full capacity* 
 
 On the whole the better plan is to evacuate all the abdominals
 
 49 
 
 to the front line Casualty Clearing Stations, while allowing the 
 less seriously wounded to pass to those in the rear. Care must 
 be taken to make the personnel of the hospital receiving 
 abdominal cases adequate for its work ; otherwise some cases 
 will only be admitted to wait longer than if they had been 
 sent farther back. Taking all cases that enter a Casualty 
 Clearing Station, it is not possible to put many more than 
 twenty-five such cases on an operation table in twenty-four hours. 
 If the proportion of abdominal cases- admitted is high the 
 number of cases that can be operated on is very much lower. 
 
 Arrangements at the Present Time in the French and Belgian Armies. 
 
 It has been said above that the French and Belgians went 
 through the same experience as ourselves. Since the line became 
 fixed operation has been the accepted practice. The French 
 have established advance abdominal hospitals by means of 
 what they call motor surgical ambulances ; these are really 
 hutted theatres which can hfe easily erected, and they are 
 extremely complete in their arrangements. These hospitals, 
 which correspond with our Advanced Operating Centres, are 
 pushed rather farther forward than is the practice in the British 
 Army, and have, I believe, met with a large measure of success. 
 Professor Turner also informs me that the French have tried 
 the experiment of "dug-out" operating centres situated some 
 hundreds of metres behind the trenches, where it is possible to 
 operate on the wounded in from a half to two hours after the 
 accident. He adds which is of considerable interest that, 
 with the very large attacks they have had and the great number 
 of wounded they have had to be dealt with, this arrangement 
 has not given very good results, for the reason that the wounded 
 have arrived late, and very often these ambulances have been 
 unable to deal with the numbers of wounded they have received. 
 The Belgians have followed suit to a certain degree, and have 
 pushed their abdominal operating centres far forward, and have 
 lately provided special ambulances for the transmission of the 
 operated man to the hospitals farther back. I have not so far 
 ascertained what measure of success they have had, but the 
 Belgians are favourably situated in that they have large base 
 
 W.S.A. 4
 
 5o War Surgery of the Abdomen 
 
 hospitals very close behind the firing line. They have, toe, had 
 no large offensives. The Italians have used mobile operating 
 ambulances in the same manner as the French. In the moun- 
 tains where the fighting has taken place evacuation is extremely 
 difficult ; and such centres have, therefore, proved exceedingly 
 useful.
 
 CHAPTER IV. 
 
 DIAGNOSIS AND TREATMENT CONSIDERED GENERALLY. 
 
 
 
 Diagnosis of Intraperitoneal Damage. 
 
 THIS is determined in three ways : (1) by inspection ; (2) by 
 experience ; (3) by symptoms. 
 
 With all possible care, and an extensive experience, and a full 
 appreciation of the numerous fallacies, it is frequently difficult 
 to make sure that the wound is penetrating. If it is difficult 
 when there is an entrance and exit wound, it is still more so when 
 there is only one wound. It may be that shock, haemorrhage, 
 rigidity, or rapid pulse will be present ; in some cases which are 
 received early, there maybe no such guides. It may be said that 
 the wound of a hollow viscus has in itself no symptoms ; it is 
 haemorrhage or peritonitis which give the danger signal. 
 
 (1) BY INSPECTION. Antero-posterior wounds are the easiest 
 to judge. The only point to be remembered is the thickness of 
 the flank muscles. Below the transpyloric plane a wound with 
 the entrance on one side of the middle line, and an exit near the 
 lateral body line of the same side, is very often non-penetrating, 
 or has just opened the peritoneum. Above the transpyloric 
 line such a wound, owing to the rounded form of the thorax, 
 is almost certain to be penetrating. The bullet which passes in 
 and out between the semilunar lines probably does not open the 
 abdomen, while the one that passes in and out outside these 
 lines probably does. In the longitudinal direction, a bullet 
 which enters near the costal margin, and emerges above the 
 groin, will most likely traverse the abdomen. Where it is a 
 question of single wounds, there is really no guide except the 
 symptoms, as it is usually impossible to tell the direction of the 
 projectile. Much help is afforded by an X-ray examination in 
 such cases. One case may be quoted as showing the difficulty of 
 judging where a missile has gone a man was shot beside the 
 umbilicus. The shape of the wound suggested a bullet. The 
 
 42
 
 52 War Surgery of the Abdomen 
 
 area was a dangerous one, so it was determined to explore the 
 abdomen. As the wound was in a convenient situation, the 
 exploratory incision was made through it. It was then found 
 that the rectus muscle was torn the length of the incision. This 
 was enlarged downwards to the pubes, the muscle being much 
 torn down to the bone, but the sheath and peritoneum were 
 intact. The bullet had passed down behind the pubes'. As 
 there were no symptoms, nothing further was done, and the 
 case, after an interval of several days, was sent to the Base 
 doing well. 
 
 The possibility of rupture of underlying organs in such cases 
 must be carried in mind, and it is well to err on the side of 
 opening the abdomen. 
 
 (2) BY EXPERIENCE. This has shown that one has to be very 
 careful in making a negative diagnosis, and it has also shown 
 the wisdom of operation in doubtful cases. 
 
 Bomb wounds require some notice under this heading. The 
 fragments into which a bomb is broken on explosion are often 
 very small, but so high is their velocity that they have very 
 great power of penetration. The wounds may be so small 
 and insignificant that it sometimes takes real strength of mind to 
 explore the abdomen, although the symptoms point to the 
 possibility of visceral involvement. The number of these 
 wounds makes individual exploration impossible, and the only 
 way of settling the matter is to explore the abdomen by a well- 
 placed incision, irrespective of the situation of the wounds. 
 
 (3) BY SYMPTOMS. These may be enumerated as follows : 
 appearance ; pulse ; vomiting ; haemorrhage ; rigidity ; pain ; 
 tenderness ; subjective sensations ; shock. 
 
 Appearance. Usually a man hit in the abdomen looks ill. 
 Sometimes he appears to have no serious lesion. Often he is 
 shocked and cold, in spite of blankets and hot bottles, with which 
 he has been surrounded in the ambulance. Sometimes he is 
 apathetic and quiet, sometimes restless, sometimes from pain, 
 sometimes from distress. He may be blanched or of a fair colour, 
 even normal in appearance. Before rapid evacuation was the rule 
 one was struck by the fallaciously good facial expression of some 
 of these cases, and often experienced a shock, on taking up a
 
 Diagnosis and Treatment Considered Generally 53 
 
 man's hand, to find it cold and clammy, and the pulse running 
 or even not palpable. Such cases invariably die, and operation 
 only hastens their end. 
 
 Pulse. A rapid pulse, a pulse that does not fall, or a rising 
 pulse, is an indication for operation. A slow pulse is not neces- 
 sarily a contra-indication unless the wound is in a non-dangerous 
 area such as the liver.. I have seen a man with a pulse of 60 
 with four holes in his small intestine four hqurs after receipt of 
 the injury. A rapid pulse is caused by loss of blood, and later 
 on by peritonitis and sepsis. It does not seem to have any very 
 definite connection with the number of lesions of the intestine. 
 The pulse often falls with rest and quiet. Often a falling pulse 
 is more an indication of the possibility of operation than a 
 contra-indication to operative measures. 
 
 From Table VII. one can see the general average pulse of a 
 man wounded in the abdomen. A pulse of 100 is very common, 
 and, on the whole, gives a good prognosis. A pulse of 120 seems 
 to be a critical one, for the mortality is here rapidly mounting. 
 Of 145 patients with a pulse over 120 only 16 recovered. 
 
 TABLE VII. To show Effect on Pulse of Prognosis. 
 
 Xumber, 577. 
 
 Total 
 
 1'nlsc up to and 
 including 
 
 60. 
 
 70. 
 
 80. 
 
 90. 
 
 100. 
 
 110. 
 
 120. 
 
 130. 
 
 140 
 and over. 
 
 To Base . . 
 
 1 
 
 7 
 
 23 
 
 30 
 
 108 
 
 27 
 
 37 
 
 7 
 
 9 
 
 Died 
 
 1 
 
 2 
 
 13 
 
 18 
 
 39 
 
 38 
 
 88 
 
 37 
 
 92 
 
 Total . . 
 
 2 
 
 9 
 
 36 
 
 48 
 
 1 17 
 
 65 
 
 12.5 
 
 44 
 
 101 
 
 Mention may be made here of unexpected results which some 
 pulse-rates show. A man having a pulse of 160 with a wound in 
 the liver went to the Base without operation. A pulseless man 
 recovered after his bladder and small intestine had been sutured. 
 A mail with a pulse of 60 died from the effects of haemorrhage 
 although the bleeding was stopped by operation. A man with a 
 pulse of 90 died of gas gangrene in the abdominal wall. Another
 
 54 War Surgery of the Abdomen 
 
 with a pulse of 80 died of peritonitis on the third day. One case 
 with a pulse of 160 recovered, the reason for the rapidity being 
 an extraperitoneal haematoma of the bladder, which was 
 drained. 
 
 Vomiting. Wounds of the stomach nearly always lead to 
 vomiting, and very often to haematemesis ; but vomiting is also 
 met with in all kinds of wounds other than abdominal ; and, 
 beyond the fact that its absence shows that the stomach is most 
 probably not involved, it has no special significance or indication. 
 
 Haemorrhage. This will be dealt with more fully later on 
 (p. 130). It is sufficient to say here that, with the exception of 
 blanching and a rapid pulse, both of which may be produced by 
 other causes, the classical signs, such as restlessness, blindness, 
 or air hunger, are usually absent. Haemorrhage gives the 
 ordinary physical signs ; but, as is well known, these are not 
 very helpful, for to produce them the amount of blood may 
 have to be very great. 
 
 Rigidity. This is a very constant, but varying symptom. 
 It is seen (a) in low thoracic injuries ; (b) in wounds of the 
 abdominal wall, pelvic floor, and even of the thigh ; and 
 (c) with visceral injuries. 
 
 (a) The rigidity produced in the abdomen by low thoracic 
 injuries is well known, and it renders diagnosis very difficult, 
 especially in cases where, from a study of the track, the bullet 
 may or may not have entered the abdomen. One such case I 
 well remember, in which a man, hit in the lower right axillary 
 region, presented a universal rigidity of the abdominal wall, 
 accompanied by considerable pain. His condition otherwise 
 was not bad. It was determined to watch him, and he was put 
 to bed and kept quiet for three hours. At the end of that time 
 the rigidity had become board-like. There was considerable 
 increase in his pain, and his pulse-rate was slightly accelerated. 
 An abdominal exploration showed that, after all, the abdomen 
 was uninvolved, and that the only possible injury was a wound 
 of the liver on its extraperitoneal surface. Curiously enough, 
 this man died of tetanus a week later. A piece of shell loose in 
 the pleural cavity will also harden the abdominal muscles. 
 
 I do not know that there is any royal road to diagnosis
 
 Diagnosis and Treatment Considered Generally 55 
 
 between a thoracic and abdominal wound. It is often noticed 
 that, if a man is placed in a semi-recumbent position, the 
 abdominal rigidity tends to abate if the injury is only thoracic. 
 Captain B. C. Maybury has an idea that superficial abdominal 
 tenderness is rather a feature of thoracic wounds. 
 
 (b) In the wounds of the abdominal wall the rigidity is apt to 
 be local, and, as a rule, does not give rise to very much con- 
 fusion. Contusions of the abdomen do present considerable 
 difficulty, and in cases which recover without operation marked 
 rigidity, an extremely rapid pulse, and pallor may all be com- 
 bined. Wounds of the pelvic floor, even when not penetrating, 
 will produce a reflex hardness of the anterior wall, as may 
 wounds of the upper thigh. 
 
 (c) Injuries both of the solid and hollow viscera are accom- 
 panied by rigidity. This rigidity seems to be brought about in 
 two ways : (1) it is a reflex protective measure after the receipt 
 of any wound ; (2) it is also brought about by irritation of the 
 peritoneum, either by blood or infection. It is largely inde- 
 pendent of the amount of peritoneal infection, and occurs in an 
 extreme form without any naked-eye appearance of inflamma- 
 tion. Under such conditions it is generally accompanied by very 
 great pain. 
 
 Rigidity often occurs when there is blood in the abdomen the 
 source of which is only a wound of the mesentery or omentum. 
 It is not, as a rule, very marked in these cases, and tends to sub- 
 side with time, in contradistinction to that due to peritonitis, 
 which is progressive. One occasionally sees a somewhat rigid 
 and tumid condition of the abdomen in cases arriving late ; 
 such a condition is usually only a sign of haemorrhage which 
 has been arrested ; such cases are usually best left unoperated. 
 
 Considered clinically, (1) rigidity may be slight, and this 
 generally or locally. (2) It may be confined to one part, and if 
 this spreads it generally means an intestinal lesion. (3) Alter- 
 nating rigidity. During examination the abdomen is sometimes 
 soft and sometimes hard. This is a very puzzling condition, and 
 its indication is not very clear ; it is sometimes accompanied by 
 extensive injuries. (4) Apprehensive rigidity, if one may use 
 the term. Here, although the abdomen looks soft and moves on
 
 56 War Surgery of the Abdomen 
 
 respiration, it at once hardens when the hand approaches to 
 palpate. As a rule it is accompanied by no serious injury. 
 (5) Board-like rigidity is most puzzling when accompanied by a 
 slow pulse. If there is extreme pain, it nearly always means 
 that there is a wound of the intestine. (6) Complete absence of 
 rigidity ; this, when accompanied with obvious penetration of 
 the abdomen, is often, as has been pointed out by Taylor and 
 Meyer, a very bad sign. One case of such a condition may be 
 quoted : A man was hit in several places on the abdominal 
 wall by small fragments of an aerial bomb within a few yards 
 of an Advanced Operating Centre. He was admitted within a 
 few minutes of the injury. He was shocked, but not cold. His 
 pulse was 130 and very poor. His abdomen was perfectly lax, 
 and continued so till death, about twelve hours later. He 
 complained of much epigastric pain. Three hours after wounding 
 his condition seemed hopeless, as his pulse was small and feeble 
 (130), and his extremities blue and cold in spite of artificial 
 warmth. Notwithstanding his bad condition, he lingered on 
 for many hours. A post-mortem showed that he had three small 
 holes in the jejunum and about two pints of blood in the belly 
 cavity. This case shows the difficulty in determining whether 
 to operate or not. Had he been transfused, he might have stood 
 an operation. A lax abdomen may exist with hollow viscera 
 lesions and the patient be in good state. 
 
 It may be here stated that morphia in moderate doses seems 
 to have very little effect on the state of the abdominal wall. 
 
 The Spinal Abdomen. One has to be on one's guard not to be 
 misled by the slightly rigid and tumid abdomen which is met 
 with in cases of spinal injury, and especially when such injuries 
 are accompanied by vomiting. This state of the abdomen is 
 sometimes caused by a distended bladder, but it may be present 
 without it. 
 
 Tenderness. This has very much the same value as the 
 tenderness met with in penetration of the intestine due to 
 disease. The point of maximum tenderness may coincide with 
 the position of the gut lesion. 
 
 Pain. Is nearly always present in some form or another ; it 
 varies from almost uncontrollable agony to nothing more than
 
 Diagnosis and Treatment Considered Generally 57 
 
 discomfort. It usually comes on at once. There does not seem 
 to be any particular relation between the amount of pain and the 
 amount of injury. 
 
 Subjective Sensations and Shock. Are dealt with later (p. 135). 
 
 Care of the Patient before Operation. 
 
 IN TRANSIT TO HOSPITAL. Captain Moore has pointed out 
 that a man wounded in the abdomen is more comfortable if he 
 can be put in such a position that his abdominal muscles are 
 relaxed. The patient should be covered up as soon as possible 
 and kept warm by adequate blankets and hot water bottles or 
 hot bricks (see " Treatment of Shock," p. 138). 
 
 Morphia. The subcutaneous method of administration is 
 the best. The buccal method is not reliable. If the tabloid 
 is dissolved in the mouth and absorbed by the mucous mem- 
 brane, it acts quickly. There is, however, the risk that the 
 tabloid is swallowed and action thereby delayed. It thus 
 happens that a further subcutaneous dose is given to allay the 
 continuing pain. After a time the swallowed morphia begins 
 to act and produces its own effect in addition to that of the 
 dose given under the skin. 
 
 Soldiers have in addition carried morphia, with which they 
 have dosed themselves, unknown to the medical officer. Morphia 
 used beyond the point of relieving pain is, in my opinion, 
 prejudicial to the patient. 
 
 Initial ^-grain doses are to be avoided ; a | or ^-grain dose is 
 nearly always sufficient. 
 
 It is very important that the amount, the method of adminis- 
 tration, and the time be all entered in the patient's tally. 
 
 Morphia should be given as soon as possible after receipt of 
 the wound. It allays the apprehension that men feel when 
 lifted high on a stretcher, possibly above the edge of the 
 trench. 
 
 The Withholding of Fluids. There is no reason why fluid 
 should not be given in reasonable amounts ; its withholding 
 causes great distress to the patient, who is very likely suffering 
 already from a lack of fluid in his body. Bicarbonate of soda 
 can with advantage be given at this stage.
 
 58 War Surgery of the Abdomen 
 
 IN HOSPITAL. When a patient arrives at an operating 
 hospital, the question of immediate operation has to be con- 
 sidered. It is better to put the man to bed and watch his condi- 
 tion for a little than to immediately subject him to operation. 
 It is quite true that haemorrhage is the great danger, but still 
 experience has led me to think that on the whole a little rest 
 does more good than harm. The interval is used to improve the 
 man's condition. 
 
 First and foremost as a remedial measure is the warming of 
 the patient. This is by far the best treatment of shock, and 
 greatly transcends in importance' the administration of stimu- 
 lants, of whatever nature, either by the mouth or hypoder- 
 mically. It is very remarkable to what an extent the treatment 
 by drugs has fallen in favour. 
 
 It is often wise to warm the patient up on the stretcher on 
 which he arrived by placing a lamp beneath it and forming a 
 hot chamber by hanging blankets over the sides and ends. If 
 it should be decided to undress him, this should be done on 
 such a stretcher. When undressed he can be placed in bed and 
 heated by the electric or hot air cradle. If heat, rest, and 
 morphia do not improve a man's condition, it is doubtful if 
 transfusion or infusion will produce any effect. 
 
 Fluid can be introduced into the system by the mouth, by the 
 rectum, subcutaneously, or intravenously ; it depends upon the 
 state of the patient and his capabilities of reception. If the 
 patient cannot drink the intravenous method is by far the best 
 and surest. The fashionable method of subcutaneous saline is 
 practically valueless in a shocked man. If the patient can 
 drink, it is well to increase his alkaline reserve by giving a 
 drachm of bicarbonate of soda in water and follow it up with 
 sweetened tea or coffee. If unable to retain fluids by the mouth, 
 an infusion of bicarbonate of soda, 2 4 per cent., is recom- 
 mended, unless there has been much bleeding. If haemorrhage 
 is feared, transfusion of blood is by far the best restorative. 
 Many believe that transfusion is best given during or at the 
 end of the operation. If blood is given before operation, the 
 opening of the abdomen should not be delayed for long. The 
 same applies to all intravenous injections on account of their
 
 Diagnosis and Treatment Considered Generally 59 
 
 tendency to retard haemorrhage. The transfusion may be 
 followed by an infusion of bicarbonate of soda (2 4 per cent.). 
 If blood is not available, an infusion of 6 per cent, gum acacia 
 in a 2 per cent, bicarbonate solution is a good substitute. 
 
 The actual moment for performing the operation must be left 
 to the individual judgment of the operator. If the man does 
 not respond at all, the question must be decided whether it is 
 best to operate at once or whether it is worth operating at all. 
 The pulse (see Table VIII.) will give some help. Frequently 
 even as much as six or eight hours' rest will produce such 
 improvement that an operation is possible where at first the 
 case seemed hopeless. 
 
 Operation. The operation table must be adequately warmed, 
 and the length of the operation curtailed, not by undue haste, 
 but by careful preparation. Whatever anaesthetic is used, 
 cyanosis must be avoided. 
 
 Question of Operation. 
 
 Experience has shown the wisdom of operating as a routine 
 measure, and it is now mainly a question of excluding the case* 
 on which it is best not to operate. 
 
 It can be admitted that this line of treatment involves 
 operating on some patients who have no visceral injury and on 
 some in whom the wounded parenchyma of solid organs has 
 ceased to bleed. 
 
 On the whole "Look and see " is a better maxim than "Wait 
 and see." 
 
 It may be useful to enumerate those cases which are best 
 left alone. 
 
 (1) Cases in very Bad Condition.- There are, of course, many 
 cases which no surgeon would feel himself justified in operating 
 on ; but there are many border-line cases, which some surgeons 
 would leave, and others would feel constrained to submit to 
 operation. Here the personal equation comes in, and whether 
 he operates or not must be left to the surgeon to decide. The 
 pulse will be a valuable guide. The bolder surgeon may get the 
 worse operative mortality and yet save more lives. 
 
 (2) Cases shot high up in the Abdomen in the Liver Area. Such
 
 60 War Surgery of the Abdomen 
 
 cases on the whole do very well if left alone, so long as there are 
 no symptoms of haemorrhage ; in fact, haemorrhage and the 
 retention of a large missile are the only reasons for operating on 
 liver cases. 
 
 (3) High Abdomino-thoracic Wounds on the Left Side. The 
 type of wound more especially referred to is that which enters 
 near the mid-line behind, and emerges somewhere towards 
 the posterior part of the axilla about the level of the sixth to 
 the eighth rib. These wounds are sometimes accompanied 
 by symptoms suggesting stomach involvement, but on the 
 whole do not seem to do badly. Operative interference does 
 not afford very much help, as wounds high up in the cardia or 
 near the oesophagus may be almost impossible to close, or, if 
 they can be reached, involve such disturbances as are likely 
 to lead to a fatal result. If operation is decided upon, the 
 transpleural route is the best. 
 
 (4) Cases arriving late. I am inclined to put down twenty- 
 four hours as a usual limit within which a primary operation is 
 likely to be successful ; haemorrhage by this time has ceased, and 
 operation is only likely to spread infection if the bowel has been 
 perforated, and to hasten the end. There are some cases in 
 which operation may be thought advisable, namely, those with 
 a fair pulse but with vomiting, the operation being performed 
 with an idea of getting over the " obstruction " by short-cir- 
 cuiting or an enterostomy. Operations of this class have nearly 
 all been fatal. 
 
 The operation of simple supra-pubic drainage is an absolutely 
 useless disturbance. 
 
 Wounds on Back to be first Treated. 
 
 Marshall has shown that rolling a patient over, after coeliotomy, 
 to reach wounds on the back of the body causes a great fall in 
 blood pressure. Such wounds, if they arc to be treated, should 
 be attended to before opening the abdomen. 
 
 The Incision. 
 
 (1) Its Site. This must be planned rather with a view to dealing 
 with the probable nature of the injury than with any reference
 
 Diagnosis and Treatment Considered Generally 61 
 
 to the wounds. With an in-and-out wound we know the course 
 of the projectile, and can form a fair estimate of the organs 
 likely to be involved. With a single wound this is practically 
 impossible, and here an X-ray apparatus is invaluable, as it 
 enables us to place the abdominal incision in the best possible 
 situation. 
 
 To give an instance of the value of X-rays : suppose there is 
 a single entry wound near the semilunar line. Without an 
 X-ray examination the only thing is to open the abdomen in 
 the middle line and ascertain the course of the missile ; this 
 involves an exploration of the entire abdomen, and in the end it 
 may be found that the only viscus injured is the colon at its 
 peritoneal reflexion. The exploratory procedure will have 
 exposed the whole abdomen to the danger of contamination. 
 On the other hand, an X-ray picture would have located the 
 missile in the loin, and shown at once that a horizontal explora- 
 tory wound would have met all the circumstances of the case, 
 and possibly saved a life. 
 
 Vertical Incisions. A paramedian incision is the standard 
 method of opening the abdomen, and it should be used in all 
 cases unless there is some distinct indication to the contrary. 
 It is always better to prolong it than to make lateral right-angle 
 extensions. The length should be about 8 inches ; if in doubt, 
 it is better to use a longer one, as free access means a great 
 increase in celerity and less manipulation of the intestines 
 outside the belly cavity. 
 
 In some antero-posterior wounds towards the lateral line of 
 the body, a rectus-sheath incision has something to recommend 
 it : the colon can be reached and the field of operation limited. 
 It is not, however, a good incision to close, and divides many 
 nerves. 
 
 Transverse Incisions. In those cases where the missile has 
 perforated the body from near the mid-line to the loin, whether 
 this direction is shown by an entrance or an exit wound or by 
 the aid of a skiagram, the transverse incision, either horizontal 
 or parallel to the upper or lower abdominal limits, is much to be 
 recommended. If more room is required, it can be obtained by 
 cutting the rectus sheath, but leaving the rectus muscle intact.
 
 62 War Surgery of the Abdomen 
 
 Sueh an incision allows free access to the hepatic and splenic 
 flexures and the vertical colons, to the kidney, and to thes pleen. 
 It allows removal or exploration of the kidney without rolling 
 the patient far over a great advantage, for Marshall has shown 
 that such movement is followed by an alarming drop in the blood 
 pressure at the close of an abdominal operation. It also permits 
 an easy examination of the upper small intestine, and of the 
 lower with a little more difficulty, if necessary. It is the only 
 incision that allows the ascending and descending colons to 
 be easily and properly repaired, and, in addition, is a con- 
 venient situation for an artificial anus. It is not a convenient 
 incision for the stomach, except for that portion situated near 
 the spleen. 
 
 A similar incision starting behind, and prolonged forward if 
 necessary, can be used with advantage in exploring postero- 
 lateral wounds of the body. A subcostal incision is also good in 
 some liver wounds. Such incisions suture easily and heal 
 kindly. In some cases of wounds in the back of the loin, it is 
 better to open the abdomen in the mid-line and make sure that 
 the peritoneum has not been involved. If it has, the wound is 
 closed and the loin opened up, and the necessary steps are taken 
 to deal with the condition found. It is always very important, 
 when there is a possibility of a colon wound, to do everything to 
 prevent contamination of the general abdominal cavity. 
 
 (2) Its Closure. The method of closure must depend on the 
 condition of the patient. If this is critical, it must be by through - 
 and-through sutures. If there is time, an attempt should be 
 made to close the peritoneum separately ; many of these 
 wounds suppurate, and it is impossible to prevent the suppura- 
 tion extending to the intestines if the peritoneum is unsutured. 
 If the patient's condition allows, the wound can be closed in 
 layers, but in every case there should be at least three through - 
 and-through supporting stitches which only miss the peri- 
 toneum. 
 
 Suppuration in the operation wounds has been a trouble. It 
 may be partly due to defective technique ; but in many cases 
 one has to remember that the blood in the abdomen, which must 
 well out when the cavity is opened, is full of micro-organisms.
 
 Diagnosis and Treatment Considered Generally 63 
 
 Various methods have been tried to prevent infection, but with 
 no great success. On the whole, however, there has been a good 
 deal of improvement. It is curious that the same difficulty is 
 found on operating on acute appendix abscess, where the peri- 
 toneum can readily combat the septic condition in which it is 
 left, while the abdominal wound falls a victim to the bacilli. 
 
 Treatment of the Peritoneal Cavity. 
 
 (3) Abdominal Drainage.- Opinions differ about this, and 
 personally I never use it, nor do I believe that it has any points 
 to recommend it. When speaking of abdominal drainage, I 
 mean the ordinary drain to the pelvis or loin. It is quite another 
 thing to tie a small drain to a suture line which one mistrusts, 
 the idea of which is to form a local track in the case of a leak. 
 
 (4) Flushing the Abdomen. Some surgeons favour this pro- 
 cedure, and it has something to be said for it when the abdomen 
 is full of septic blood. At the same time it is difficult to carry 
 out efficiently without exposure of the intestines. In small local 
 infections without blood it is not to be recommended. . The 
 cold produced by ether is sufficient to damn it, even if it could 
 cleanse the abdomen ; a small amount used to produce leucocy- 
 tosis may find favour with some. 
 
 Post-operative Treatment. 
 
 I do not know that there is anything particular to be done 
 to the patient after the abdomen is closed. Rest and quiet 
 and the avoidance of all needless disturbance are to be aimed at. 
 The question of infusion or transfusion will naturally arise, and 
 in some cases may be beneficial. Most people treat their cases 
 in a semi-recumbent position. Personally, I would let the 
 patient choose his own posture. As to the administration of 
 morphia, it is better to give it than withhold it if the patient is 
 restless or in pain. 
 
 Most interest turns on the condition of the bowels. Castor 
 oil, calomel, and pituitrin, all have their advocates. There can 
 be no doubt that pituitrin is a very fine purgative, especially if 
 injected into the muscles ; sometimes it requires to be helped 
 by a glycerin enema. Like all other purgatives, it is dependent
 
 64 War Surgery of the Abdomen 
 
 for its action on a healthy condition of the musculature of the 
 bowels, and if this is paralysed either by shock or sepsis, it will 
 fail to act. For my own part, I am not particularly anxious 
 about the opening of the bowels, and am fairly convinced that 
 the bowels will not give trouble if the case is going to do well ; 
 if not and it is mostly a question of peritoneal sepsis no 
 purgative is of any real avail. A good deal of discomfort has 
 been needlessly inflicted by attempts to make the bowels act. 
 
 Dilatation of the stomach is a fairly common complication, 
 and is to be treated by gastric lavage, repeated if necessary. 
 
 A word may be said here about the progress of the patients 
 after operation. Putting aside those who do well from the first, 
 and those who never look like recovering, the post-operative 
 cases may be roughly divided into three classes : (1) Patients 
 who do well for thirty-six hours or so, then go through a critical 
 period, with abdominal distension, vomiting, and a rising pulse. 
 They may eventually recover or succumb. (2) Those who are 
 troubled by sickness continuing from the operation, but in whom 
 the sickness diminishes and the pulse-rate falls. (3) Those who 
 vary in an astounding manner from day to day, so that one 
 can have no certainty of the ultimate result. This condition is 
 often independent of the condition of the bowels, which may be 
 acting. These are the cases spoken of by Sampson Handley 
 in his paper in the Lancet, April 8th, 1916. The cases referred 
 to by him were those of pelvic peritonitis, in which the lower 
 segment of the bowel is mostly affected ; in the cases under 
 discussion, unfortunately, the infection is often in the upper 
 portion of the abdomen. The two classes of case do not seem 
 to be quite on a level, even if we admit that the dilatation of 
 the upper segment is a septic and not a nervous phenomenon. 
 However this may be, it is a most difficult point to determine 
 whether operation is likely to do good or not. One sees so 
 many patients go through a critical period and recover that one 
 fears to proceed to secondary operation for fear of turning the 
 balance against them. It has been tried on several occasions, 
 with very little success. If it is done, the method advocated by 
 Sampson Handley seems to be the method of choice.
 
 CHAPTER V. 
 
 WOUNDS OF HOLLOW ALIMENTARY ORGANS AND THEIR 
 
 TREATMENT. 
 
 Wounds of Particular Organs.* 
 
 (Esophagus. Wounds of the oesophagus are rarely seen, 
 while those of the pharynx and trachea are more common. 
 The rarity of such wounds is due to the fact that antero- 
 posterior wounds involve the spine and transverse wounds 
 the great vessels. Some of the lower thorax wounds which are 
 accompanied by vomiting may be wounds of the oesophagus. 
 In one case of a fatal abdomino-thoracic wound it was found 
 that the oesophagus had been torn just as it passed through the 
 diaphragm. Such wounds must always be dangerous, as, even 
 if diagnosed, access to them is exceedingly difficult either by 
 way of the abdomen or across the chest. 
 
 One curious case may be quoted where a man was hit in the 
 back about the fourth right interspace. He was treated for a 
 thoracic wound, as there were no localising symptoms. Two 
 days later he passed per anum the core of a bullet, and the day 
 following the mantle. 
 
 Stomach. 
 
 FREQUENCY. In 965 operated cases the stomach was 
 perforated eighty-two times. In fifty-five instances it was the 
 only hollow viscus damaged. 
 
 * (a) The number of times that injuries of solid organs complicate injuries of 
 other organs (both hollow and solid) is probably understated, though the proportion 
 of such complicating injuries of solid organs to one another is approximately correct. 
 
 (6) In speaking of the causes of death, no reference has been made to injuries other 
 than abdominal ; but in many cases the fatal result must be largely put down to 
 injuries other than those of the abdomen. 
 
 (c) The lesions of hollow organs enumerated in the tables and in the text are per- 
 foritive lesions. Every single viscus was bruised or had its outer coats injured on 
 many other occasions. 
 
 W.S.A. 5
 
 66 War Surgery of the Abdomen 
 
 SITUATION OF THE INJURY. This is shown in Table VIII. : 
 TABLE VIII. 
 
 Site of Wound. 
 
 Alone. 
 
 With other 
 Hollow Viscera. 
 
 Anterior wall 
 
 27 
 
 8 
 
 Posterior wall 
 
 5 
 
 1 
 
 Anterior and posterior walls 
 
 14 
 
 10 
 
 Greater curvature 
 
 2 
 
 1 
 
 Lesser curvature 
 
 2 
 
 1 
 
 Cardia 
 
 2 
 
 1 
 
 Near oesophagus 
 
 2 
 
 
 
 Lesser curvature and posterior wall . . 
 
 1 
 
 
 
 Wall, not stated 
 
 
 
 5 
 
 Total 
 
 55 
 
 27 
 
 The number of times both walls have been perforated and 
 other hollow viscera (both small and large gut) wounded is rather 
 remarkable, when one remembers how innocuous antero- 
 posterior epigastric wounds were supposed to be. 
 
 The fact that the posterior wall may be wounded alone, or in 
 conjunction with the posterior surface of the transverse colon, is 
 of importance, as neither of these places is visible unless a special 
 search is made ; such wounds have been missed at operation. 
 
 ASSOCIATED WOUNDS OF OTHER ORGANS : 
 
 Hollow Viscera. Small gut, 19 ; colon, 13 (colon and small 
 gut together, 5). 
 
 The jejunum is the part of the small gut most frequently hit, 
 very often within a short distance of its commencement. These 
 high injuries are especially caused by side-to-side wounds which 
 catch the bowel as it lies high up jn the abdomen in front of the 
 kidney. When the projectile pursues a more vertical course, 
 the ileum is also injured, or injured alone. 
 
 The transverse colon is, more frequently than any other part 
 of the great gut, injured along with the stomach ; but parts so 
 far distant as the pelvic colon and caecum have also been hit. 
 The splenic flexure escapes more often than one would expect. 
 Sometimes, in addition to the transverse, the ascending or
 
 Wounds of Hollow Alimentary Organs 67 
 
 descending colon is wounded. Such wounds are caused by pro- 
 jectiles having a highly inclined side-to-side course. 
 
 Solid Viscera. Liver, 15 ; spleen, 5 (4 fatal) ; pancreas, 3 ; 
 kidney, 4. 
 
 A few examples of complicated injuries may be given : 
 
 Anterior wall spleen kidney (died). 
 
 Stomach pancreas kidney (died). 
 
 Stomach liver kidney (died). 
 
 Anterior and posterior walls transverse colon small gut 
 (died). 
 
 Anterior wall transverse colon jejunum (died). 
 
 Lesser curvature descending colon liver (died). 
 
 Anterior wall caecum. 
 
 Anterior wall descending colon (died). 
 
 Lesser curvature near oesophagus top of spleen (died). 
 
 Anterior wall lower pole of left kidney. 
 
 The few occasions on which a stomach and spleen wound 
 occurs, considering the close association of these viscera, are 
 remarkable and suggest that such injury is very fatal. 
 
 NATURE OF THE WOUNDS.- The stomach affords many types 
 of wound, nearly all easily explained by the nature of the 
 projectile and the course it takes. Sometimes the stomach wall 
 is exposed by the carrying away of the anterior abdominal wall. 
 At other times prolapse of the stomach takes place, accompanied 
 by that of the colon, small gut, and spleen. 
 
 Bullets passing in an antero-posterior direction make small 
 perforations. Shrapnel balls cause larger perforations, the edges 
 of which are more excoriated than is the case with bullet wounds ; 
 the larger size and rounder form of the ball cause it to bruise 
 the wall before it bursts its way through. Shell and bomb 
 fragments make wounds commensurate with their size and 
 shape. When the axis of the flight of the projectile is more or 
 less parallel to the walls of the stomach, the wounds become 
 larger ^sometimes a linear slit, sometimes a linear slit followed 
 by a perforation, to which the name of " note of exclamation 
 wound " may be given. The linear type of wound is nearly 
 always on the anterior surface. When the projectile passes in 
 through the epigastrium and out by the axilla, the slits tend to 
 
 0-2
 
 68 
 
 War Surgery of the Abdomen 
 
 become parallel to the greater curvature. When the missile 
 takes a more vertical course, the wounds are inclined at an angle 
 to the greater curvature, and the anterior wall of the stomach, 
 or its antral portion, may be almost completely divided. Pro- 
 jectiles hitting the greater or lesser curvature in an antero- 
 
 FIG. 10. Bullet wound of anterior wall of stomach. The wound extended half an 
 inch on to the posterior wall. The right gastro-cpiploic artery was divided. 
 Under care of Captain Hamilton Drummond. (Medical Society and Brit. 
 Journ. of Surgery.) 
 
 posterior direction sometimes cause rather extensive V-shaped 
 injuries involving both walls. Occasionally the wound is a 
 valvular one, preventing the escape of the contents. 
 
 Bruises or 'cuts in the peritoneum or muscular coats are not 
 infrequently met with.
 
 Wounds of Hollow Alimentary Organs 69 
 
 Gangrene of the wall has resulted from injury to the gastro- 
 splenic omentum. 
 
 The mucous membrane does not pout when the wounds are 
 small ; but in the case of linear wounds it becomes extruded 
 just as it does when one incises the stomach wall in doing a 
 gastro-jejunostomy. 
 
 Bleeding. Wounds of the stomach are accompanied by very 
 severe haemorrhage, which may come from the organ itself or 
 from vessels or organs near it. The haemorrhage, as a rule, does 
 not come from the actual wall, but from the vessels as they run 
 up and down its surface. The bleeding may take place either 
 into the stomach or into the peritoneal cavity. 
 
 SYMPTOMS. Vomiting is a very constant feature ; in fact, the 
 stomach is the only viscus which almost always furnishes this 
 symptom. One is often surprised that vomiting is possible, 
 when the size of the wound in the organ is considered. There is 
 sometimes an escape of gas from the wound, but no particular 
 diagnostic value is to be attached to the presence or absence of 
 liver dulness. The escape of contents has already been dealt with. 
 It should be noted that bile may escape from a stomach wound. 
 
 TREATMENT. Operation is to be advised in almost all cases. 
 The only possible exceptions are those cases of low thoracic 
 wounds where it is judged from the track of the missile that 
 the stomach is wounded near the oesophagus or in the upper 
 air-containing part. Some such cases do get well by them- 
 selves, and one rather hesitates to operate because of the 
 difficulty encountered and disturbance caused. 
 
 The standard incision is a paramedian one. The closure of 
 wounds of the horizontal portion is easy, but the farther to the 
 left and the nearer to the cardia the more difficult does the 
 operation become. This difficulty points to the advisability of 
 using the transpleural route when wounds of the cardia are in 
 question, especially if the missile has entered through the thorax 
 and has only involved the immediate neighbourhood. 
 
 As a rule, one can tell if the posterior wall is likely to have 
 been involved. If this is the case, or if there is any doubt, the 
 posterior surface must be explored through the gastro-colic 
 omentum in the usual way. The suture of such wounds may be
 
 yo War Surgery of the Abdomen 
 
 very difficult. Wounds of the lesser curvature involving both 
 coats are also troublesome to suture. There is no need to excise 
 the wounds unless they happen to be very ragged. Gastro- 
 enterostomy may be necessary in cases of wounds dividing 
 the antral portion or the duodenum, or in some cases of narrowing 
 of the stomach ; this should only be done in cases of very 
 evident necessity. 
 
 PROGNOSIS. The maximum period of successful suture after 
 receipt of the wound is thirty-six hours, and the prognosis 
 depends largely on the amount of haemorrhage that has taken 
 place, and on the association of other wounded organs. The 
 amount of peritonitis present does not depend very directly on 
 the length of time between the injury and the operation. 
 
 Possibility of Spontaneous Recovery. This has already been 
 admitted. 
 
 SECONDARY COMPLICATIONS. A secondary haemorrhage was 
 not a very uncommon event, and was met with as early as the 
 fifth day ; it is much less frequently seeji now than formerly. 
 
 In the British Medical Journal of April 8th, 1916, Lieutenant- 
 Colonel T. R. Elliott and Captain Herbert Henry made some 
 important remarks on the " After-history of both Operated and 
 Unoperated Gastric Wounds." They showed that sutured and 
 non-sutured wounds and contusions are subject to ulceration, 
 secondary haemorrhage, and perforation. Secondary haemor- 
 rhage occurred on the sixth, twelfth, and fifteenth days 
 respectively ; death occurred on the ninth, twenty-sixth, and 
 twenty-fifth days, the first from haemorrhage and the last 
 two from peritonitis. Colonel Elliott thinks this points to 
 the necessity of careful feeding, and especially to the with- 
 holding of extractives. Sub-diaphragmatic abscesses have been 
 met with, but are not so common as might be supposed even 
 in the pre-operative days, according to Sir George Makins. 
 
 MORTALITY AND CAUSES OF DEATH. The mortality in all 
 cases where the stomach was wounded is 60 '9. In cases un- 
 complicated with wounds of other hollow viscera, the mortality 
 is 52'7 per cent, (in the first 500 cases the mortality was 43 '7 
 per cent.). In those complicated with lesions of other hollow 
 organs, the mortality rises to 77*8 per cent.
 
 Wounds of Hollow Alimentary Organs 71 
 
 The increased gravity of multiple wounds of different organs 
 is well shown, for while the stomach has a mortality of 52 '7 
 per cent., the small intestine of 65 '9 per cent., and the great gut 
 of 58'7 per cent., the combination of such injuries shows a mor- 
 tality of 100 per cent, in this series of cases. 
 
 If all the published statistics are massed one gets 138 cases 
 in which the stomach was wounded, with 88 deaths and 50 
 recoveries a mortality of 63*7. The numbers of cases, in which 
 the stomach was the only viscus wounded are not sufficient to 
 furnish any reliable inference, but the deaths and recoveries are 
 almost equal. 
 
 When the effect on the mortality of an associated wound of a 
 solid organ is considered, the result is not so clear. Thus in 
 38 cases, of which 17 recovered and 21 died, we find that there 
 were 5 cases of liver wound among the recoveries, and 5 among 
 the deaths. Among the deaths there were also 4 cases of 
 injury of the spleen, 1 of the pancreas and liver, 1 of the pancreas 
 and kidney, and 1 of the pancreas. The complication of spleen 
 injury would appear to be a grave one. 
 
 Out of 29 fatal cases uncomplicated with injuries of hollow 
 organs, the actual cause of death in 25 cases was as follows : 
 shock and haemorrhage, 15 ; peritonitis, 5 ; lung trouble, 2 ; 
 gas gangrene, 3. 
 
 Small Intestine. 
 
 FREQUENCY. In 965 operated cases the small gut was found 
 wounded 363 times. In 255 instances it was the only hollow 
 viscus wounded. 
 
 ASSOCIATED WOUNDS OF OTHER ORGANS. Stomach, 19 
 (5 with colon) ; colon, 89 (5 with stomach) ; rectum, 4 ; bladder, 
 16 ; liver, 8 (gall-bladder twice involved) ; kidney, 7 ; spleen, 3. 
 
 The sites of the colon wounds were as follows : caecum, 13 ; 
 ascending colon, 6 ; hepatic flexure, 7 ; transverse colon, 23 : 
 splenic flexure, 3 ; descending colon, 13 ; pelvic colon, 18. 
 
 NATURE OF THE WOUNDS. There does not seem to be any 
 great difference in the frequency with which the jejunum and 
 ileum are wounded, though perhaps the figures at my disposal 
 are too small to draw a comparison, as the site of the lesion has
 
 72 War Surgery of the Abdomen 
 
 not been stated with sufficient frequency. In the case of the 
 duodenum, one may state with accuracy that it was wounded 
 16 times among 363 small-gut injuries. 
 
 The injuries of the ileum would appear to be more serious 
 than those of the jejunum. This is also supported by the fact 
 that cases suitable for suture are more common in the upper 
 than in the lower part a circumstance to be expected when the 
 size of the tube and thickness of the walls of the jejunum are 
 compared with the smallness of the tube and the thinness of 
 the walls of the ileum. The multiplicity of the coils in the latter 
 also favours more extensive injury. 
 
 The character of the small-gut wounds varies in some degree 
 with the projectile that caused them, but not to the extent that 
 one might expect. A bullet may inflict as Severe an injury as a 
 piece of high-explosive shell. It used to be thought that a 
 patient shot with a bullet had a better chance than one injured 
 by a shell fragment. The present war has proved this to be a 
 mistake. As a matter of fact, the least severe wounds are 
 caused by the small fragments of bomb and shell. 
 
 Bullet Injuries.' The injury may be complete or incomplete ; 
 i.e., it may open the lumen, or it may only score, bruise, or tear 
 the outer coats. 
 
 The most common injuries are the perforations made by the 
 bullet striking the intestine at right angles to its long axis. Here 
 there are two perforations, through which the mucous mem- 
 brane pouts to form a small round rosette. Some holes are so 
 small as to hardly admit the kind of bullet that made them ; 
 through such holes the mucous membrane does not pout. 
 As the flight of the bullet becomes more inclined to the transverse 
 or long axis of the gut the perforations become slits, but there 
 are still two separate wounds. These wounds gape somewhat, 
 and the mucous membrane overlaps the cut muscular coat, so 
 that a considerable mucous surface meets the eye. The general 
 appearance still suggests a rosette, but with one axis longer 
 than the other. The two slits may enlarge until the continuity 
 of the intestine is only maintained by two narrow strands of 
 the wall. 
 
 In other cases there is only one wound, involving different
 
 Wounds of Hollow Alimentary Organs 73 
 
 portions of the circumference of the intestine ; it may reach 
 from near the mesenteric border to near the free margin, or 
 involve the free margin only. In other cases the free margin is 
 slit right back to the mesenteric border, so that only a narrow 
 strip of wall remains. The last piece to be divided is usually 
 the attached portion ; here thece is a wide gaping wound with 
 
 FIG. 11. Jejunum: gunshot perforation, resected nine hours after injury. It 
 shows the protrusion of the mucosa which usually occurs. Death. (Captain 
 Hamilton Drummond.) 
 
 an extensive exposed mucous surface. In extreme cases the gut 
 is completely divided. In another extreme form of injury the 
 intestine is only represented by a long, narrow, and ragged strip 
 of bowel. 
 
 The explanation of the transverse direction of the lesions is to 
 be found in the looped arrangement of the small intestine, 
 whereby the greater part of the tube lies in a vertical direction.
 
 74 
 
 War Surgery of the Abdomen 
 
 As a man is usually shot cither from side to side or from before 
 backwards, the missile will hit the intestine at right angles. If 
 the bullet takes an up-and-down direction, one meets with 
 longitudinal lesions of the gut. 
 
 Fid. 12. Wounds of small intestine caused by a bullet. P.M. specimen. Under 
 care of Captain J. B. Haycraft. (Medical Society of London and Brit. Journ. 
 of Surgery.) 
 
 In any one case all types of injury may be encountered. 
 Shell Fragments. These cause wounds of all varieties, gene- 
 rally commensurate with their size. Perhaps the wounds are
 
 Wounds of Hollow Alimentary Organs 75 
 
 more irregular than those caused by bullets, and the clean 
 transverse divisions of the gut more rare. 
 
 Shrapnel Balls. These cause ragged perforations or tears of 
 moderate size. 
 
 Bombs.- Bomb injuries often cause small multiple wounds, 
 which are frequently collected together over a short length of the 
 gut. The mucous membrane very often does not pout, as the 
 hole is so small. 
 
 FIG. 13. Jejunum : lacerated wounds caused by fragment of rifle grenade shown 
 
 in the drawing. 
 
 Lesions of the Mesentery. These are of all sorts and varieties, 
 from simple perforations to irregular tears. Destruction of the 
 mesentery may occur without a lesion of the bowel and of itself 
 necessitate resection. 
 
 Intimate Nature of the Lesion. The eversion of the mucous 
 membrane is due to its redundancy, and also, apparently from 
 an examination of microscopic sections, to a retraction of the 
 longitudinal coat (Captain J. W. McNee and Captain J. S. Dunn). 
 Microscopic examination of the wounded edges shows, further,
 
 76 War Surgery of the Abdomen 
 
 that the lesion is a very local one ; in fact, the appearance is no 
 more remarkable than one would expect if the intestine had been 
 cut with a pair of scissors : it usually consists of a blood infiltra- 
 tion in the neighbourhood of the wound. The mucous coat 
 stains well and distinctly right up to the tear. 
 
 There is nothing to suggest " remote disturbance " or the 
 necessity for a wide excision of tissue. 
 
 NUMBER OF INJURIES. In 124 cases the average number of 
 lesions was 4 '8 ; in 40 cases in which resection was performed the 
 average number was 6 '8, and in 84 cases treated by suture it 
 was 4*1 . Single lesions are the exception. The greatest number of 
 lesions was 20, and 6 feet of intestine were successfully resected 
 by Captain Owen Richards. Captain John Fraser also success- 
 fully sutured 14 individual lesions and a hole in the bladder. 
 The lesions are usually collected close together, but sometimes 
 they are disposed in two or three groups which necessitate 
 multiple resections. Occasionally they are scattered over the 
 entire length of the small intestine with wide spacings. 
 
 The length of bowel involved may be gathered from the 
 following figures, which represent in 25 consecutive cases the 
 amount resected (in inches) : 30, 48, 18, 24, 30, 48, 48, 108, 30, 
 18, 48, 8, 20, 24, 36, 5, 48, 48, 24, 30, 48, 24, 16, 30, 24. In 
 some of these cases, in addition, other lesions were sutured when 
 they lay at some distance from the more severe injury. 
 
 SYMPTOMS. There is nothing more to be added to what has 
 been said under the heading of " Diagnosis of Intraperitoneal 
 Damage " (see p. 51). 
 
 TREATMENT. A long paramedian incision is the rule, except 
 in those cases which have been dealt with when the site of the 
 incision was discussed. 
 
 The actual operative technique in the abdomen is as follows : 
 Any blood present must be got rid of, and the bleeding stopped. 
 As a rule, the whole length of the small intestine must be 
 explored, with the possible exception of those cases of side-to- 
 side wounds involving one-half of the abdomen where a trans- 
 verse incision has been used. In such cases, if there is no blood, 
 and the whole length of the missile track can be seen, it may be 
 possible to dispense with the routine examination.
 
 Wounds of Hollow Alimentary Organs 77 
 
 FIG. 14. Section of wound of small gut. It shows the eversion of the edge of the 
 lesion. The mucous membrane and other coats are, except for some blood 
 infiltration, normal right up to the cut edge. (Specimen by McNee and Dunn.) 
 (Medical Society of London and Brit. Journ. of Surgery.)
 
 78 War Surgery of the Abdomen 
 
 The caecum or duodeno-jejunal junction is first picked up and 
 brought out of the wound ; then the intestine is inspected, 
 
 Flu. 15. -Jejunum from the same case as Fig. 11 : thrombosis of vessels from injury 
 to the mesentery at two points. There were twelve perforations of the small gut. 
 Resection of 4 feet ; end-to-end union. Death. (Captain Hamilton Drummond.) 
 
 taking care to look at both sides and to replace the examined 
 part within the abdomen. If a small hole is found, and the gut 
 beyond it for 6 or 8 inches is intact, the hole is sewn up. If the
 
 Wounds of Hollow Alimentary Organs 79 
 
 next lesion that is encountered is a small one, the process may 
 be repeated. If, however, the first lesion is a large one, it is 
 better to cover it up with gauze and a clamp, and then proceed 
 with the examination of the whole length, for a big lesion, 
 if quickly followed by another, may necessitate resection, and the 
 amount to be resected can only be determined when the total 
 injuries are known. 
 
 When the small intestine has been dealt with, the stomach is 
 explored, if there is any likelihood of its being injured. The 
 colon is dealt with last of all, as it is here that an artificial 
 anus may be very likely necessary. If, however, a transverse 
 incision has been used, it is best to deal with the great-gut 
 lesion first, and so limit the possibility of further spreading the 
 infection. 
 
 Suture or Resection. Suture should be practised when possible ; 
 small discrete injuries, however numerous, should be sutured ; 
 and it is probably best if the injuries are severe, or even com- 
 plete, provided they are not too near together. It is also 
 better to narrow the bowel than to resect, even if it involves a 
 lateral anastomosis. 
 
 Resection should be reserved for cases where the bowel is 
 practically destroyed, where there are several severe injuries 
 or complete divisions close together, and where injuries 
 extending into the mesentery, or infarction of vessels, give no 
 choice. 
 
 The following figures show the length in inches resected in 
 some successful cases taken in order : 36, 15, 36, 8, 8, 44, 12, 36, 
 9, 18, 8. 
 
 Multiple resections in this series have always been fatal, 
 though there have been some successful cases in other series. 
 
 TABLE IX. To show the Results of Suture and Resection in Cases 
 uncomplicated by Wounds of other Hollow Viscera. 
 
 Operation . 
 
 To Base. 
 
 Died. 
 
 Mortality. 
 
 Resection 
 
 26 
 
 87 
 
 76-9 
 
 Suture 
 
 59 
 
 71 
 
 54-6
 
 8o War Surgery of the Abdomen 
 
 The greater fatality of the resection cases depends largely on 
 the initial injury, especially on the loss of blood ; but in reading 
 over the cases, one finds many instances of resection where the 
 condition of the patient was at any rate fair, and yet a fatal 
 result followed. It seems as if resection definitely increased the 
 shock. 
 
 Circular v. Lateral Suture. The old controversy is still 
 unsettled. Results are as follows (Table X.), the balance being 
 in favour of lateral anastomosis, but the numbers are small : 
 
 TABLE X. Circular and Lateral Suture compared. 
 
 Operation. 
 
 To Base. 
 
 Died. 
 
 Circular enterorrhaphy 
 
 18 
 
 69 
 
 Lateral anastomosis 
 
 8 
 
 18 
 
 If a lateral suture is used, it would seem best to let the two 
 portions of the bowel overlap well, so as to get the lateral 
 opening in the gut a little distance away from the ends, where 
 motility is last to return. 
 
 Technique of Suture or Resection. A single row of stitches is 
 practically always sufficient in suture. Care should be taken to 
 close the rent in a transverse direction to save narrowing the 
 lumen. 
 
 Many operators have found that a single suture line is suffi- 
 cient also in resection. 
 
 Owing to the nature of the contents of the upper bowel, 
 greater care is probably needed in suturing the jejunum than 
 the ileum. 
 
 Primary Short-circuiting; Entcrostomy. These operations 
 have been done at the primary operation to relieve a dilated 
 upper segment, or as purely prophylactic measures. They are 
 not to be recommended, though possibly useful if the upper 
 part of the bowel is distinctly dilated from sepsis. They have, 
 I believe, been abandoned. 
 
 Secondary Short Circuit. This has been done on several 
 occasions, but with little success (one in this series).
 
 Wounds of Hollow Alimentary Organs 81 
 
 Treatment of a Prolapsed Knuckle. In the early days there 
 was some difference of opinion as to what was the best treat- 
 ment for this condition. Nowadays, with the establishment 
 of the operative treatment, most probably the right thing to 
 do is to open the abdomen and deal with the lesions which are 
 found. 
 
 Sepsis. To judge from the peritonitis present, it may have 
 made considerable headway in four hours, or it may be prac- 
 tically absent after twenty-six hours. 
 
 MORTALITY AND CAUSES OF DEATH : 
 
 TABLE XI.- To show Increasing Mortality of Complications. 
 
 Sits of Wound. 
 
 To Base. 
 
 Died. 
 
 Mortality. 
 
 
 
 
 Per cent. 
 
 Small gut 
 
 87 
 
 168 
 
 65-9 
 
 Small gut and stomach 
 
 4 
 
 10 
 
 ) 
 
 Small gut and colon 
 
 22 
 
 63 
 
 \ 7-1-1 
 
 Small gut and rectum 
 
 
 
 4 
 
 
 Small gut, stomach, and colon 
 
 
 
 5 
 
 
 Small gut and bladder 
 
 1 
 
 15 
 
 
 TABLE XII. To show the Causes of Death in a Consecutive 
 Series of Resections and Sutures respectively (uncomplicated). 
 
 L/Ause oi ueatn. 
 
 Kesection. 
 
 Suture. 
 
 Peritonitis . . 
 
 
 14 
 
 14 
 
 Missed lesion 
 
 
 
 1 
 
 3 
 
 Shock and haemorrhage 
 
 15 
 
 11 
 
 Gas gangrene of belly wall 
 
 5 
 
 4 
 
 Asthenia 
 
 . . . . 
 
 1 
 
 1 
 
 Paralytic ileus 
 
 , . 
 
 
 
 2 
 
 Pulmonary embolism 
 
 
 
 2 
 
 Pneumonia . . 
 
 . . 
 
 - 
 
 1 
 
 Bronchitis . . 
 
 . . . . 
 
 
 
 .2 
 
 Gangrene of lung 
 
 . . 
 
 
 
 1 
 
 The suture line has on very few occasions shown any fault, 
 and where peritonitis has supervened, it must be put down to 
 other causes. 
 
 W.S.A. 6
 
 82 War Surgery of the Abdomen 
 
 TABLE XIII. To show the Average Number of Lesions in Fatal 
 and Successful Cases respectively. 
 
 Operation. 
 
 To Base. 
 
 Died. 
 
 Resection 
 
 4-1 
 
 7-1 
 
 Suture 
 
 3-45 
 
 4-27 
 
 The Different Parts of the Small Intestine compared. When 
 the comparative dangers of a wound of the duodenum, jejunum, 
 and ileum are considered, the figures at my disposal are not very 
 adequate, since the jejunum and ileum have not been distin- 
 guished a sufficient number of times. A wound of the duodenum 
 is a fatal injury, as in eleven cases of wound of this viscus only 
 two recovered. As regards the lower part of the small gut, a 
 wound of the jejunum would appear to be the least dangerous. 
 
 High Mortality of Associated Bladder Wounds. A wound of 
 the bladder seems to be an extremely serious complication of 
 the wounds of the small gut. In the present series there were 
 sixteen instances of wounds of this viscus. and all but one died. 
 This is due, partly at any rate, to the fact that when the bladder 
 is injured the lesion of the small gut is generally very serious 
 and situated in the closely coiled ileum. On the other hand, 
 half the fatal cases complicated lesions of the small gut that 
 were treated by suture, and presumably, therefore, were not 
 very serious. This would tend to show that there is an inherent 
 danger in a wound of the bladder itself. Very likely the extra 
 time taken to deal with the lesion is a great factor in the result. 
 In addition, there is often a fractured pelvis with these injuries. 
 
 Complicating Wounds of the Spleen. There were three cases 
 complicated by splenic injury, and two of them were fatal. 
 With this exception, the solid organs do not seem to have played 
 a great part in the mortality. 
 
 Large Intestine. 
 
 FREQUENCY. In 965 operated cases the colon was wounded 
 252 times. In 155 cases it was the only part of the alimentary 
 tract hit.
 
 Wounds of Hollow Alimentary Organs 83 
 
 ASSOCIATED WOUNDS OF OTHER VISCERA : 
 
 Hollow Viscera. Table XIV. gives the number of times that 
 the stomach and small gut suffered together with the colon. 
 
 The comparatively small number of times that the splenic 
 flexure was injured is somewhat remarkable. It may be that 
 the difficulty of differentiating between transverse and descend- 
 ing colons and splenic flexure may have something to do with 
 this, and that some of the injuries of the two former parts should 
 really have been described as lesions of the latter ; the observa- 
 tions were made, however, by a number of operators. 
 
 TABLE XIV. To show Hollow Viscera injured with Different 
 
 Parts of Colon. 
 
 Site of Wound. 
 
 Wounded with 
 Stomach. 
 
 Wounded with 
 Small Gut. 
 
 Alone. 
 
 Total. 
 
 Caecum 
 
 2 
 
 13 
 
 16 
 
 31 
 
 Ascending colon . . 
 
 . - 
 
 5 
 
 36 
 
 41 
 
 Hepatic flexure 
 
 1 
 
 7 
 
 24 
 
 32 
 
 Transverse colon . . 
 
 4 
 
 22 
 
 15 
 
 41 
 
 Splenic flexure 
 
 
 
 3 
 
 18 
 
 21 
 
 Descending colon . . 
 
 2 
 
 9 
 
 17 
 
 28 
 
 Pelvic colon 
 
 
 
 18 
 
 23 
 
 41 
 
 Position not stated 
 
 4 
 
 12 
 
 6 
 
 22 
 
 Totals 
 
 13 
 
 89 
 
 155 
 
 257 
 
 (a) There were several cases in which two parts of the colon were wounded; the 
 highest wound only has been given. (6) There were five cases in which the stomach 
 and small gut were both wounded along with the colon. The total colon wounds 
 therefore number five less than the grand total given in the table. 
 
 Solid Organs. The solid organs do not often seem to be injured 
 at the same time as the colon. The kidney was hit seven times, 
 the liver seven, and the spleen seven. The bladder was injured 
 four times (for two cases of associated wounds of the bladder 
 and rectum see "Rectum"). The ureter was injured in two 
 cases. 
 
 NATURE OF INJURIES. The injuries of the large intestine are 
 really similar to those of the small gut. The differences that are 
 to be noted are due to (1) its larger size, (2) its absence of coils, 
 
 6-2
 
 84 War Surgery of the Abdomen 
 
 (3) its absence of mesentery, and (4) its proximity, in some 
 portion of its extent, to bone. 
 
 (1) The large size of the tube leads to a preponderance of tears 
 or perforations ; but instances are met with in which the whole 
 lumen is completely divided, and this happens both in the fixed 
 portion and in that endowed with the mesentery. Complete 
 division is due to a collapsed condition of the gut, when it may 
 be, as is well known, but little bigger than the small intestine ; 
 the transverse, descending, and pelvic colons are the parts most 
 frequently divided. 
 
 (2) The absence of coils means that multiple injuries are not 
 common, and, when they occur, are not so numerous as in the 
 small intestine. The multiple injuries are found at the bends. 
 In one case which may be mentioned there were six perforations : 
 two in the ascending colon, two in the hepatic flexure, and two 
 in the transverse colon. In another case there were three 
 wounds in the caecum and ascending colon, and two in the hepatic 
 flexure. In a third case there were five wounds in the pelvic 
 colon. 
 
 (3) The absence of the mesentery, over the great part of the 
 colon, means a frequent occurrence of retroperitoneal wounds. 
 These are difficult to find, and are largely responsible for the 
 heavy mortality. The partially covered portion of the small 
 intestine namely, the duodenum has likewise a very large 
 mortality. 
 
 (4) The proximity to bone leads to wounds of the caecum, the 
 two vertical colons, and the pelvic loop, by spicules of bone ; 
 and, as has been pointed out, these injuries are apt to be over- 
 looked, because the perforations in the peritoneum are not 
 conspicuous. 
 
 Infarction. This type of injury is met with in the small 
 intestine, but I think it is rather commoner in the large. The 
 caecum with the ileum and the descending and iliac colons have 
 all been found in this state. 
 
 Ulcer ation of the Mucous Membrane associated with Rupture of 
 the Muscle Coats. Captains H. Drummond and J. S. Dunn have 
 called attention to this condition.* The ulceration may occur 
 
 * Brit. Journ. of Suegrry, vol. v., No. 17, 1917.
 
 Wounds of Hollow Alimentary Organs 85 
 
 Fu;. 16. Mucous surface of caput 
 coecum and part of ascending 
 colon in Case 5. There are three 
 fairly extensive ulcers on the 
 posterior wall, one being in the 
 caput. The base of each ulcer 
 is formed by the submucous 
 layer, and is much infiltrated 
 with blood. (Brit. Journ. of 
 Surgery.) 
 
 FIG. 17. The muscular wall of the colon 
 underlying the ulcers shown in 
 Fig. 16. The posterior longitudinal 
 band of muscle is torn across in 
 two places (B and C), and the torn 
 ends have retracted, drawing with 
 them the fibres of the circular layer. 
 It is seen that these lesions in the 
 muscle correspond exactly in site 
 with the two ulcers in the ascending 
 colon. The tear in the outer longitu- 
 dinal band, marked A, was un- 
 associated with ulceration. The 
 arrangement of the muscular lesions 
 in this case affords good evidence 
 that they were produced by indirect 
 violence, as all of them were caused by 
 one rifle bullet. (Brit. Journ. of 
 Surgery.)
 
 86 War Surgery of the Abdomen 
 
 as soon as seven hours after wounding. It seems to be caused 
 by a cutting off of the blood supply to the mucous membrane 
 by rupture of the underlying muscle coat. It is especially 
 interesting because the ruptured muscle may be separated from 
 the actual track of the missile by a layer of undamaged tissue. 
 The authors attribute the damage to a dragging effect pro- 
 duced by the projectile and transmitted through strands of 
 fibrous tissue or to sudden impact on a gas-filled sac. 
 
 The rapidity with which the mucous membrane ulcerates 
 after losing its blood supply is very remarkable. 
 
 These lesions may account for some of the fistulse that form 
 in the colon when it has apparently escaped injury. 
 
 One case may be quoted from the original article : 
 
 " Case 5. G. was wounded by a rifle bullet at 11.30 p.m. on 
 June 17th, 1916, and was admitted to hospital six hours later, 
 much collapsed. A small round entry wound was present in 
 the left buttock, and the exit wound, which was larger and 
 irregular, was in the right mid-axillary line at the level of the 
 costal margin. 
 
 " Laparotomy was performed shortly after admission. There 
 was no evidence of injury of the abdominal viscera, except some 
 haemorrhage on the wall of the caecum and behind the perito- 
 neum of the right flank. Some blood-stained urine was passed 
 a few hours later. Death occurred twenty-one hours after 
 wounding. 
 
 "It was found that the wound track passed from the left buttock 
 through the sacro-sciatic notch and the upper part of the sacrum, 
 through the belly of the right psoas muscle, and thence between 
 the right kidney and the ascending colon. Neither of the latter 
 viscera had been directly touched ; a layer of retroperitoneal 
 fat a quarter of an inch in thickness intervened between the 
 track and the colon wall. There was cellulitis and gangrene 
 around the wound track in the retroperitoneal tissue, and films 
 and cultures made later from this material showed abyndant 
 gas-forming, anaerobic bacilli. The capsule of the right kidney 
 was intact, but two subcapsular lacerations were present in the 
 cortex on the anterior aspect of the lower pole. The ascending 
 colon exhibited externally only some haemorrhage on its inner
 
 Wounds of Hollow Alimentary Organs 87 
 
 side. When this portion of bowel was opened, two large areas 
 of ulceration were observed on the posterior wall, while a third 
 was seen in the caput caecum (Fig. 16). The two uppermost 
 ulcers lay almost directly over the bullet track. Each ulcer 
 penetrated deeply into the submucous coat, but not quite through 
 it ; the bases were necrotic, and dark with haemorrhage. The 
 mucosa and submucosa were then dissected off from the muscular 
 layers. By this means it was shown (Fig. 17) that underneath 
 the middle and uppermost ulcers the posterior longitudinal 
 band of muscle had been sharply torn across. The torn ends 
 were widely retracted, and the circular fibres, though not 
 lacerated, were drawn apart with them, so as to leave a complete 
 wide gap in the muscular layers. Each of these lesions was 
 associated with some haemorrhage, and the exposed retroperito- 
 neal tissue was foul and gangrenous. A like muscular lesion was 
 also observed in the outer longitudinal band, opposite the level 
 of the upper ulcer, but it was unaccompanied by haemorrhage 
 or by ulceration of the mucosa. In relation to the ulcer in the 
 caput caecum, there was only slight tearing of the circular fibres, 
 with some haemorrhage." 
 
 Escape of Contents.- The large intestine is often laden, but 
 the condition of the contents renders massive escape less frequent 
 than it would otherwise be ; however, taken all in all, escape 
 from the large intestine is more frequent than from the small, 
 especially when the caecum and ascending colon are involved. 
 
 Character of the Lesions in Different Parts of the Colon. 
 
 Ccecum.' There has been a fair number of caecal wounds. 
 Most of them have been small in extent, and have lent them- 
 selves to suture. In other cases the wounds have been so big 
 as to necessitate an artificial anus. In one case there was 
 bruising of a transposed caecum. In a good many cases there 
 was a large retroperitoneal haemorrhage ; this injury was in 
 one instance accompanied by acute dilatation of the sto ach. 
 
 Transverse Colon.' All kinds of wounds are met with here, 
 from a simple single lesion to complete division. True antero- 
 posterior wounds are not very common, and as a rule the 
 transverse colon is struck obliquely, the bullet passing through
 
 88 War Surgery of the Abdomen 
 
 the anterior part of the lumen. It has already been stated that 
 such wounds are often accompanied by lesions of the stomach 
 and small intestine. It was owing to this association that so 
 few wounds of this portion of the colon arrived at the Base in 
 the preoperative days. 
 
 The posterior surface is sometimes wounded, and this may be 
 overlooked unless it is borne in mind that such an injury is 
 possible, for it is not obvious unless a special search is made. 
 Bleeding from the vessels supplying this portion of the bowel is 
 fairly frequent. 
 
 Vertical Colons (Ascending and Descending Colon). It is 
 convenient to take these two portions together, as they have no 
 mesentery. Both, and especially the descending colon, lie rather 
 farther from the lateral line than would appear. The wound 
 may be completely intraperitoneal or extraperitoneal, or both 
 combined. The actual lesions are perforations, slits, tears, or 
 complete divisions. Perforations are most commonly met with 
 in side-to-side wounds, and complete division in antero-posterior 
 wounds. All varieties may be complicated with small-gut 
 injuries. At the Base, Makins noticed that wounds of the 
 ascending colon were more common than other colon wounds ; 
 and he attributed the frequency of the ascending colon wounds, 
 compared with those of the descending, to the latter being more 
 often accompanied by small-gut injuries, owing to the fact that 
 the small gut overlies it. This explanation seems to a certain 
 degree just. Out of forty-one wounds of the ascending colon, 
 only five were complicated by small-gut lesions ; whereas 
 twenty-eight wounds of the descending colon had associated 
 small-gut injuries in nine instances. On the other hand, wounds 
 of the ascending colon are actually more frequent than those of 
 the descending forty-one to twenty-eight. The comparative 
 rarity of descending colon wounds may also be due to the fact 
 that the descending colon lies so deep that any bullet passing 
 from side to side and involving it would traverse a coronal 
 plane situated so far back in the body as to involve the spine 
 and great vessels. Again, the descending colon is usually much 
 smaller than the ascending, so that it offers less of a mark for 
 the missile.
 
 Wounds of Hollow Alimentary Organs 89 
 
 The intraperitoneal wounds of the vertical colons are fairly 
 easy to find and to deal with if a suitable incision is used. The 
 extraperitoneal are very difficult, and most probably are more 
 often missed than any other. The extraperitoneal wound, 
 which may be small and valvular, is difficult to find because 
 it lies in a mass of areolar tissue ; and the difficulty will be 
 greatly increased when this tissue is infiltrated with blood, as 
 it so often is. 
 
 Hepatic Flexure.- Next' to the transverse colon the hepatic 
 flexure is the easiest of all to deal with, as it lies fairly superfi- 
 cially. Its form leads to multiple injuries. 
 
 Splenic Flexure. This, from its position, is the hardest 
 of all the large intestine to deal with, and even with the best- 
 placed incision it is difficult to examine properly without 
 mobilisation. 
 
 Pelvic Colon. This portion of the large intestine is anatomi- 
 cally more like the small intestine than any other part of the 
 colon, and the lesions are somewhat similar. There are slits, 
 perforations, or complete divisions ; and it is, next to the trans- 
 verse colon, most often complicated with multiple small-gut 
 injuries. Fracture of the pelvis, so often associated, increases 
 the gravity of the case. I have been struck with the great 
 variations in position, as shown by the different situations of 
 the wounds of the gut in different cases in which the bullet has 
 taken a similar direction . 
 
 SYMPTOMS. The symptoms of intraperitoneal wounds of the 
 large gut are similar to those of the small intestine. A great 
 difference lies in the behaviour of the extraperitoneal wounds, 
 where all grades of infection are met with. Sometimes we have 
 cases of acute sepsis, with or without gas formation, which are 
 fatal in a few hours. Such cases are often past help when they 
 arrive. They are cold, blanched, and clammy, and the pulse is 
 running ; in fact, their appearance often suggests acute haemor- 
 rhage. To this class of case Captain John Fraser, M.C., has 
 given the apt name of " colon septicaemia." 
 
 The dangerous sepsis shown by the high mortality of the 
 colon anus, when formed in the vertical colons, has led some 
 operators to always make an attempt to close the bowel. Un-
 
 90 War Surgery of the Abdomen 
 
 fortunately the damage is already done when the case has come 
 under treatment. In other cases the symptoms are less acute, 
 or are not seen when the case has arrived. Some with a small 
 single loin wound, arriving late and left, do well even though a 
 faecal fistula forms. In others signs of intoxication and local 
 infection appear, both of which may be relieved by incision, 
 with the possible establishment of a fistulous opening. Sepsis 
 is sometimes due to infective material carried in with the 
 missile, and not to a communication with the bowel. 
 
 In all cases it is well to err on the side of making a good 
 opening for drainage. 
 
 TREATMENT. The fact that . some unoperated colon cases 
 did arrive at the Base and recover cannot now be advanced as 
 a ground for abstention except in cases which arrive late. 
 
 Incision. It may still be necessary to use a paramedian 
 incision for a general exploration of the abdomen, for the 
 exclusion of, or for dealing with, other injuries. The transverse 
 and pelvic colons are best dealt with from such an incision, as 
 these lesions are commonly associated with those of the small 
 gut. It may be necessary to supplement this median incision 
 with one toward the side of the body when either of the 
 vertical colons is found wounded. When the missile has only 
 traversed the loin, the horizontal incision is by far the best. 
 The rectus sheath incision may be preferred by some for 
 exploration of the hepatic and splenic flexures ; but the asso- 
 ciation of kidney injuries with these wounds makes a hori- 
 zontal incision more expedient, as the kidney can be clealt with 
 in the posterior extremity of the wound, whereas an attempt 
 to remove the kidney through the anterior incision is not very 
 convenient. 
 
 Open wounds involving the loin, and possibly involving the 
 colon, may be dealt with by local enlargement ; but, in the 
 absence of X-rays, a median incision, to exclude other injuries, 
 will most probably be required. 
 
 Method of dealing with the Lesions. This is largely deter- 
 mined by three factors : (a) the size of the tear ; (b) the 
 situation of the tear ; and (c) the state of the patient, in whom 
 other injuries may have been dealt with.
 
 Wounds of Hollow Alimentary Organs 91 
 
 Ccecurr, . Here it is better to suture if possible, but to provide 
 adequate drainage if there is any possibility of an extraperito- 
 neal wound. In wounds of the extraperitoneal part which have 
 only been found after mobilisation of the colon, even if suture 
 is possible, it is advisable to shut off the general peritoneal 
 cavity by a line of sutures joining the anterior surface of the 
 bowel to the lateral abdominal wall and provide good posterior 
 drainage. 
 
 Transverse Colon. The transverse colon is the most easily 
 dealt with of all the colon lesions. When the wound is large, 
 the question is really one of whether suture or an artificial anus 
 is the quicker method of dealing with the case, for here probably 
 other lesions have been dealt with, and the condition of the 
 patient is not likely to be very good. 
 
 Vertical Colons. Small lesions are easily closed if intra- 
 peritoneal. Wounds involving the extraperitoneal portions of 
 the gut are dangerous, and, even if they are closed by suture, 
 adequate external drainage must be provided. No doubt suture 
 is the ideal method, but it is often very difficult, and in some cases 
 impossible, owing to the loss of substance. Here the only plan 
 is to make an artificial anus. In the retrocolic haematomata so 
 often met with, it is often impossible to exclude colon injuries ; 
 these therefore must be freely drained. 
 
 Hepatic Flexure. The same rules apply here as to the trans- 
 verse colon, the only point being that mobilisation of the flexure 
 may be necessary to get at the lesion. 
 
 Splenic Flexure. This is the hardest of all to manage satis- 
 factorily, both on account of the difficulty in reaching it, and of 
 the mobilisation necessary to find the hole. An artificial anus is 
 often necessary. 
 
 Pelvic Colon. This is easily dealt with in its upper portion. 
 Care must be taken to exclude wounds on the border of the 
 gut uncovered with mesentery. In one case a minute frag 
 ment of bomb had entered the mesentery, which was here 
 loaded with fat, at a little distance from the bowel, and had 
 penetrated into the bowel at the mesenteric attachment. The 
 Trendelenburg position greatly facilitates treatment of low-lying 
 injuries.
 
 92 War Surgery of the Abdomen 
 
 TABLE XV. Showing Colon Injuries uncomplicated with 
 Wounds of other Hollow Viscera, the Site of the Lesion and 
 the Treatment. 
 
 Site of Lesion. 
 
 Sutured. 
 
 Artificial 
 Anus. 
 
 Total. 
 
 Caecum 
 
 13 
 
 3 
 
 16 
 
 Ascending colon 
 
 25 
 
 11 
 
 36 
 
 Hepatic flexure 
 
 16 
 
 8 
 
 24 
 
 Transverse colon 
 
 13 
 
 2 
 
 15 
 
 Splenic flexure 
 
 10 
 
 8 
 
 18 
 
 Descending colon 
 
 9 
 
 8 
 
 17 
 
 Pelvic colon 
 
 16 
 
 7 
 
 23 
 
 Position not stated 
 
 
 
 6 
 
 6 
 
 An interesting fact in the above table is the small number of 
 artificial ani that it was found necessary to establish at the site 
 of a lesion in the transverse colon when no other hollow viscus 
 had been damaged. 
 
 Proximal Colostomy. It seemed probable, when starting work, 
 that proximal colostomies would have a much wider application 
 than has been found to be the case. They are, of course, useful 
 in limiting the amount of septic absorption in cases of wounds 
 of the vertical colons ; but, as has been pointed out, this tissue 
 is already infected at the time the cases come under treatment. 
 One does not feel inclined to make an extra opening in the bowel, 
 often at the end of a long operation. Proximal colostomy to 
 be of any use must be complete, and it probably finds its best 
 application in those cases of loin wounds on the left side in which 
 sepsis develops late, and in rectal injuries. It has been used 
 considerably at the Base for faecal fistulas developing from 
 colon wounds when suture has failed to close the rent. 
 
 Of ten proximal colostomies done at the Front five were for 
 rectal wounds and five for colon injuries distal to the trans- 
 verse colon. 
 
 A transverse colostomy is to be recommended. A csecostomy 
 has proved of little value at the Front, but has been useful, I 
 understand, at the Base. 
 
 MORTALITY AND CAUSES OF DEATH. The mortality of colon
 
 Wounds of Hollow Alimentary Organs 93 
 
 wounds, uncomplicated with other lesions of the alimentary 
 tube, is 58 "7 per cent. ; it may be compared with that of the 
 small intestine, which is 65 '9 per cent. The colon mortality is 
 greatly raised by that of the colon anus, for, whereas suture of 
 the colon has a mortality only just over 50 per cent., that of colon 
 anus is 73 - 5 per cent. 
 
 These figures must not be taken to mean that a colostomy is 
 a necessarily dangerous operation, but only that sepsis is likely 
 to cause death in those injuries that require a colostomy. Infec- 
 tion has already started where the colostomy has been performed. 
 
 It is interesting to compare the above figures with those given 
 by Makins in the preoperative days. 
 
 Table XVI. clearly indicates that in the preoperative period 
 a man with a colon wound had the better chance, and this 
 advantage still continues, though the margin is narrower. 
 
 TABLE XVI. Showing the Difference between the Mortality of 
 Small and Large Intestine Wounds in the Preoperative 
 and Operative Periods respectively. 
 
 Site. 
 
 Preoperative 
 Period (Base). 
 
 Operative 
 Period (Front). 
 
 
 Per cent. 
 
 Per cent. 
 
 Small intestine 
 
 86 
 
 65-9 
 
 Great intestine 
 
 38-7 
 
 58-7 
 
 No definite comparison can be made between the different 
 parts of the colon, as the figures are not large enough. 
 
 TABLE XVII. Showing Comparative Mortality of Different 
 Portions of the Colon (Suture and Artificial Anus). 
 
 Site of Lesion. 
 
 To Base. 
 
 Died. 
 
 Caecum. ... 
 
 8 
 
 7 
 
 Ascending colon 
 
 14 
 
 16 
 
 Hepatic flexure 
 
 8 
 
 11 
 
 Transverse colon 
 
 5 
 
 10 
 
 Splenic flexure 
 
 4 
 
 7 
 
 Descending colon 
 
 8 
 
 6 
 
 Pelvic colon 
 
 8 
 
 10
 
 94 
 
 War Surgery of the Abdomen 
 
 Rectum (the last 12 cm. of the Alimentary Canal). 
 
 FREQUENCY.- In 965 operated cases, the rectum was wounded 
 21 times. 
 ASSOCIATED INJURIES : 
 
 TABLE XVIII. A Table of Rectal Injuries. 
 
 Viscera wounded. 
 
 To Base. 
 
 Died. 
 
 Remarks. 
 
 Rectum alone 
 Rectum and small gut 
 
 7 
 
 10 
 4 
 
 Three were intraperi- 
 toneal entirely. 
 All intraperitoneal, all 
 sutured. 
 
 It is remarkable that the bladder was only wounded twice 
 in conjunction with the rectum. The same thing is to be noted 
 in the case of the pelvic colon, which was only wounded once in 
 association with the bladder. 
 
 CHARACTER OF THE LESIONS. Wounds of the rectum can be 
 roughly divided into three classes : (1) those that may be said 
 to complicate wounds of the buttocks, the ischial fossae, or the 
 perineum ; (2) those caused by missiles that traverse the pelvic 
 portion of the abdomen ; (3) the ulcerative lesions described by 
 Drummond and Dunn (see p. 84). All these are likely to be 
 accompanied by fractures of the pelvic bones, spicules of which 
 may wound the gut. 
 
 (1) The missile may be a bullet or a small or large shell frag- 
 ment. In the last case especially the external damage may be 
 very great, and a large portion of the gluteal region torn away ; 
 the anus and lower portion of the rectum may be completely 
 avulsed, or the lumen opened on one side only. If the pro- 
 jectile is small, the sphincter may be left intact, and the lumen 
 of the tube perforated above that muscle. The peritoneum 
 may or may not be opened. The danger most to be feared 
 is septic absorption, but on the whole extensive wounds of 
 the buttocks do not do so badly now. On the other hand, 
 there is still considerable danger of gas gangrene in the gluteus 
 maximus. 
 
 Wounds involving the sacrum, although not opening the gut,
 
 Wounds of Hollow Alimentary Organs 95 
 
 have proved very fatal from septic infection of the presacral 
 areolar tissue. On the other hand, it has happened on several 
 occasions that pieces of shell, which have been felt protruding 
 into the rectum on its postero-lateral aspect, have been removed 
 from rectum and recovery followed without any further surgical 
 procedure. 
 
 (2) The partially covered rectum may be wounded extraperi- 
 toneally or intraperitoneally, or both. Missiles that cause 
 such injuries take a side-to-side, antero-posterior, or semi- 
 vertical direction. If side to side, the entrance and exit wounds 
 lie on the postero-external aspect of the buttocks, and whether 
 the missile catches the extraperitoneal or intraperitoneal surface, 
 or both, depends on the plane traversed and the obliquity of 
 this plane to the coronal plane of the body. 
 
 The side-to-side wounds are deceptive, leading one to think, 
 from the posterior situation, that they have missed the bowel. 
 
 TREATMENT. The two classes of cases require separate 
 consideration. 
 
 (1) The treatment of injuries complicating buttock wound 
 follows the ordinary lines of treatment of wounds in general, 
 and consists in excising all damaged tissue. In some cases it 
 may be possible to close the rent in the bowel or sphincter ; in 
 other cases it may be beneficial to lay open the lower end of the 
 canal by dividing the sphincter (Makins). If the peritoneum 
 has been opened, something may be done by shutting off the 
 abdominal cavity by sutures. The question of colostomy must 
 be considered, and its expediency must be determined by the 
 difficulty or otherwise of keeping the patient clean and com- 
 fortable. It will be mostly called for in those cases in which 
 the whole lower segment of the bowel has been carried away 
 and the torn bowel is lying patent in the pelvis. In such cases 
 the lumen may be closed by sutures or a purse-string ligature, 
 which device will, at all events, tend to limit contamination 
 of the pelvis while adhesions are forming. If a colostomy is 
 necessary, transverse colostomy is the operation of choice, 
 because of the ease of cleansing the opening, of fitting a belt 
 (which will then lie on the natural line of the waist), and of 
 subsequent closure if this is desirable.
 
 96 War Surgery of the Abdomen 
 
 (2) Treatment of wounds of the rectum caused by projectiles 
 that have traversed the pelvis. There will not be, as a rule, 
 much doubt that an exploratory coeliotomy is the correct pro- 
 cedure ; but if any doubt exists, as in side-to-side and semi- 
 vertical wounds, it will be well to err on the side of operation. 
 If the peritoneal surface has escaped, the abdomen can be 
 closed and the wound opened up from the exterior. Anterior 
 wounds can often be sutured, though, from their depth in the 
 pelvis, great difficulty may be experienced. A drain down to 
 the lesion is a wise precaution in all cases. The most difficult 
 cases of all are those which involve the rectum at the very 
 bottom of Douglas' pouch, as here a reliable suture is often 
 practically impossible. It has been suggested that it might be 
 good treatment to introduce a tube through the anus up to the 
 site of the lesion, and to cut off the bottom of Douglas' pouch, 
 by suturing the peritoneum over it. 
 
 The question of a colostomy must be determined by the 
 probability or not of the suture holding. 
 
 Fortunately, associated bladder wounds are rare, but a 
 simultaneous suprapubic cystostomy and a colostomy must be 
 avoided if possible. 
 
 Protrusion of Omentum and Viscera. 
 
 By this is meant, not the exposure of the abdominal contents 
 through a gap in the abdominal wall, but their prolapse through 
 a wound, often comparatively small. 
 
 OMENTUM.- As would be expected, the omentum is most 
 frequently seen in this connection. It appears in large or small 
 amounts in wounds situated all over the abdomen, also in those 
 situated in both hypochondriac regions, where it reaches the 
 outside of the body through the interspaces or through broken 
 ribs where one hardly would expect to see it. Sometimes in 
 abdomino-thoracic wounds it passes into the pleura and plugs 
 the hole in the diaphragm. There are two methods by which 
 it is extruded: it is either (1) carried out by the projectile, or 
 (2) driven out through the entrance or exit wound by the intra- 
 abdominal pressure. The latter is the most common. 
 
 In one case, where a shell fragment had entered above the
 
 Wounds of Hollow Alimentary Organs 97 
 
 FIG. 18. Rectum showing large perforation on its anterior or vesical aspect caused 
 by fragment of shell entering over the sacral region and lodging at the base 
 of the prostate. 
 
 umbilicus In the mid-line and had come out in the right loin 
 behind the lateral line of the body, the omentum was so firmly 
 carried into the long obliqwe exit wound that it required consider- 
 
 W.S.A.
 
 98 War Surgery of the Abdomen 
 
 able force to release it ; it was, in fact, strangulated within the 
 abdominal wall, though none of it showed externally. 
 
 Before operation became the rule it was usual to leave omental 
 tags to slough off, and probably this is still the best course to 
 pursue if the cases are seen late. If seen early, it is best to treat 
 such cases as other abdominal wounds, and explore. In several 
 instances where this has been done the intestine has been found 
 wounded. 
 
 STOMACH.- This has been found herniated by itself, and in 
 association with the spleen, splenic flexure, and small intestine. 
 In one case where it was wounded and prolapsed, it was success- 
 fully sutured and replaced, though too much of the abdominal wall 
 had been carried away to allow the external opening to be closed. 
 
 Protrusions of the upper viscera are accompanied by a good 
 deal more shock than is protrusion of the small gut. 
 
 LIVER.' This organ has also been partly herniated. 
 
 SMALL INTESTINE. Next to the omentum, the small gut is 
 most frequently herniated, and, as in the case of the omentum, 
 it may be carried out or expelled. Sometimes a knuckle lying 
 outside has been actually wounded ; in other cases the extruded 
 part has remained intact, but there have been numerous lesions 
 in the small gut within the abdomen. 
 
 If seen early, the ordinary rules apply, and the abdomen 
 should be opened and the lesions repaired ; if seen later 
 over twenty-four hours it is not probable that anything can 
 be done, but still it is better perhaps to explore if the condition 
 of the patient justifies it. A great deal of small gut can be 
 prolapsed without excessive shock. A man* wounded six hours 
 previously, with the greater part of his small gut on his belly 
 wall, had a pulse of 100, and was in very fair condition. 
 
 COLON. The transverse colon has been herniated, and in one 
 case the gut was tightly constricted in the wound ; as the 
 injury was two days old, the constriction was relieved, and an 
 aritficial anus established. 
 
 Behaviour of the Omentum in Abdominal Wounds. 
 
 Some attempt has been made to study the movements of this 
 organ, and some observations have ..been made by Captains
 
 Wounds of Hollow Alimentary Organs 99 
 
 Drummond and Fraser. Where the wounds are in the upper 
 part of the abdomen the omentum rolls itself up into a transverse 
 pillow. If the wounds are in the lower part it remains spread 
 out over the intestines. Cases are operated on so quickly now 
 that the omentum has no time to find the leak and attach itself. 
 In the early days it was constantly found glued to the lesion, 
 and it was not .until the parts were disturbed that the contents 
 of the upper dilated intestine escaped. 
 
 72
 
 CHAPTER VI. 
 
 WOUNDS OF SOLID ALIMENTARY ORGANS AND SPLEEN. 
 
 Liver. 
 
 FREQUENCY. In 965 abdominal operations the liver was 
 wounded 163 times, and 148 of these were uncomplicated. To 
 these must be added 23 cases in which no operation was done, 
 but in which the liver was almost certainly wounded. 
 
 ASSOCIATED WOUNDS OF OTHER ORGANS. These are shown 
 in Table XIX. It is probable that the liver was wounded in 
 association with other organs rather more frequently than the 
 table shows. A liver wound is often a minor complication of a 
 much more grave lesion, and in the pressure of work it is natural 
 that only the more serious injury should have fixed itself in the 
 operator's mind. But when allowance has been made for this, 
 the small number of associated injuries is somewhat remarkable. 
 
 NATURE OF INJURIES. A good many cases of rupture by 
 horse kicks have been seen (though not included in this series) ; 
 but most of the wounds are caused by projectiles, sometimes 
 aggravated by fractured ribs driven in by the missile. The 
 wounds are of all types, from a simple perforation or an avulsion 
 of fragments, especially of .the anterior edge, to an almost 
 complete disruption. 
 
 TABLE XIX. The Number of Times Different Organs were 
 injured in conjunction with the Liver. 
 
 Viscus injured with Liver. 
 
 To Base. 
 
 Died. 
 
 Result not 
 known. 
 
 Stomach 
 
 5 
 
 6 
 
 4 
 
 ,, and small gut. . 
 
 
 
 1 
 
 
 
 ,, small gut, and colon 
 
 
 
 a 
 
 
 
 ,, and colon 
 
 ' 
 
 i 
 
 
 
 Small gut 
 
 
 
 i 
 
 
 
 .. and colon 
 
 
 
 4 
 
 
 
 Colon 
 
 2 
 
 5 
 
 
 
 Kidney 
 
 3 
 
 9 
 
 2 
 
 Pancreas 
 
 
 
 2 
 
 -
 
 Solid Alimentary Organs and Spleen IOT 
 
 The wounds arc- usually commensurate with the size of the 
 projectile : thus bullets, and small shell and bomb fragments, 
 make perforations or scores ; larger shell fragments cause more 
 ragged wounds. The friable nature of the liver, as would be 
 supposed, lends itself to tearing and fragmentation ; thus 
 there may be radiating fissures from a central hole, crater-like 
 exits, or pieces nearly or completely torn off. In a few cases a 
 bullet produces the most extensive destruction (see Fig. 9). A 
 case mav be mentioned in which the whole liver was shattered 
 
 FIG. 19. Vertical wound of liver, with missile in situ. 
 
 An eleven-days-old penetrating shell-wound of the liver. The point of entry was a large septic 
 wound on the right anterior axillary fold. The thoracic wall was penetrated in the right fourth 
 interspace in the mid-axillary line, with slight tearing of the intercostal muscles and of the 
 parietal pleura, but with no rib damage. A larg-e hwmothorax on the right side was found on the 
 sixth day heavily infected with a streptococcus. 
 
 The missile lias penetrated the right lobe of the liver, and is lying embedded in, and partly protruding 
 from, the inferior surface of the organ. The centre of the wound track was filled with septic 
 liquid material, heavily bile-stained. Outside this lies a zone of necrotic liver, the necrosis having 
 supervened on infarction, followed by sepsis. This is separated from healthy liver by a well- 
 developed strong capsule of inflammatory fibrous tissue, (llrit. Jouin. of Surgery.) 
 
 by a rifle bullet, and a piece 4 inches by 3 inches lay loose in 
 the abdomen. 
 
 The track or torn surface is at first ragged and bloody ; seen 
 after twelve or twenty-four hours, it becomes a dirty yellow- 
 brown ; and later it may be a vivid yellow colour, due to 
 bilious staining. 
 
 The injury, to judge from microscopic sections, is usually limited
 
 102 
 
 War Surgery of the Abdomen 
 
 to the vicinity of- the wound ; and in those cases where destruction 
 of cells is found at some distance from the wound it is most 
 probably due to an infarction phenomenon (Captain J. S. Dunn). 
 At any rate, these infarcted areas are by no means uncommon. 
 
 The gall-bladder and the common and cystic ducts have all 
 been wounded, but the larger bile-passages do not seem to be so 
 often wounded as one might expect. 
 
 SYMPTOMS. The symptoms are often slight, and one has no 
 doubt in deciding that the right course is the " expectant " 
 one. Sometimes the symptoms seem surprisingly severe, and I 
 
 Fio. 20. Penetrating wound of liver caused by a fragment of shell. (Brit. Journ. 
 
 of Surgery.) 
 
 can recall two cases of tangential wounds of the liver which could 
 not have involved the liver deeply, and in which there was no 
 sign of blood in the abdomen, both of which were extremely 
 shocked, one ending fatally ; unfortunately, there was no 
 post-mortem. In two other unoperated cases, men with pulses 
 of 160 recovered. 
 
 There are the usual signs of abdominal injury. 
 
 Hcemorrhage. This is not altogether commensurate with 
 the size of the wound, and its amount largely depends on 
 whether a big vein has been opened or not; if not, bleeding 
 usually ceases spontaneously in from six to ten hours.
 
 Solid Alimentary Organs and Spleen 103 
 
 Secondary Haemorrhage.' This is seen at the base as a rule. 
 " It is always associated with sepsis. The advent of such 
 haemorrhage is commonly accompanied by pain, distension of 
 the belly, rise of temperature, and acceleration of the pulse, 
 associated with pallor, restlessness, and a rapid loss of strength. 
 With these general symptoms a localised swelling usually 
 develops, if the patient survives the immediate loss of blood, 
 and this may be indistinguishable from a secondary abscess " 
 (Makins). 
 
 Biliary Function. An escape of bile into the abdomen is 
 sometimes met with. In one case biliary peritonitis was found 
 at the primary operation and ended fatally ; no hollow viscus 
 had been wounded. Makins mentions one case in which a col- 
 lection of bile in the pelvis required operation on the eighth day ; 
 the case ended fatally. In this case the bile came from the 
 hepatic duct. Usually the bile does not escape from the torn 
 liver surface to any extent and need not be feared. It may, 
 however, stain the dressings a brilliant yellow. Bile is also 
 met with in the pleura in abdomino-thoracic wounds without 
 any special detriment to the patient. 
 
 Jaundice of a slight and evanescent character is seen in the 
 first few days after wounding; it has no special significance. 
 Seen later, it is of more serious import, as it implies sepsis. 
 Makins says* : 
 
 " This symptom was noted as an early sign in twelve of the 
 thirty-seven cases. It is therefore a common sign, but it is 
 variable in degree. In some cases it is early and deep, in others 
 slight and evanescent, and it is usually deepest when developing 
 in association with serious septic infection. 
 
 " The fasces retain their normal colour, and deep staining of 
 the urine is rare. Again, in fatal cases no sign of gross mechanical 
 biliary obstruction is met with. These features raise the question 
 of the actual nature of the jaundice, as does also its close 
 resemblance to the haemolytic jaundice often accompanying the 
 gravest forms of general toxaemia. It is, moreover, often 
 associated with a considerable degree of fever. The sign is, of 
 course, a classical one in the course of any case of rupture of the 
 
 * Brit. Journ. of Surgery, vol. iii.,No. 12 (1916).
 
 IO4 
 
 War Surgery of the Abdomen 
 
 liver substance, whether due to gunshot injury or any other 
 cause, and in all it is probably haemolytic in origin. It is at 
 any rate a striking fact that, in the obvious absence of serious 
 infection, jaundice is either very slight, or, as in the great 
 majority of cases, it is not observed." 
 
 TREATMENT. Some cases require no operation, as there are 
 obviously no other organs wounded, and the patient's condition 
 is good. Many cases are operated on solely because of the 
 possibility of injury to other organs. If such injuries could be 
 excluded, I am inclined to think that the best results would be 
 obtained by non-interference in the great majority of cases. 
 When, however, the projectile is a large one, it should be 
 removed if at all accessible. If the projectile has entered 
 through the thorax and lodged in the liver the transpleural 
 route will be the best ; it is possible to deal with both the pleural 
 and liver injury. If the abdomen has been traversed the case 
 is not so clear, and most probably the standard paramedian 
 incision is best in the first instance. A subcostal incision may 
 at times be useful. As to the treatment of the liver itself, it 
 is often unnecessary to do anything. In other cases packing is 
 required ; suture has not proved very satisfactory. Ragged 
 edges may be trimmed and any semi-detached portions of 
 tissue removed. The big bile-passages can be dealt with on 
 ordinary lines by suture and drainage. 
 
 MORTALITY AND CAUSES OF DEATH : 
 
 TABLE XX. To show Mortality of Liver Wounds. 
 
 Treatment. 
 
 To Base. 
 
 Died. 
 
 Not known. 
 
 Operation, complicated 
 
 14 
 
 26 
 
 4 
 
 ,, uncomplicated 
 
 72 
 
 32 
 
 
 
 No operation (no indication) . . 
 
 23 
 
 
 
 
 The mortality of the uncomplicated wounds is therefore 29'18 
 per cent. 
 
 The causes of death at the front may be seen in the follow- 
 ing list, which shows the clinical cause of death in a series 
 of consecutive cases : jaundice and sepsis, 1 ; shock and
 
 Solid Alimentary Organs and Spleen 105 
 
 haemorrhage, 9 ; " biliary " peritonitis, 1 ; lung trouble, 4 ; gas 
 gangrene, 1. 
 
 Speaking of causes of death at the Base Makins says that in 
 twenty-five cases in which a liver wound was the principal 
 cause of death 60 per cent, of the cases died of sepsis and 
 40 per cent, of secondary haemorrhage. Death in a certain 
 number was also in part due to infection of the pleura. 
 
 In uncomplicated wounds, the mortality has a distinct relation 
 with the amount of injury, both because of the quantity of 
 blood lost and on account of the amount of injured substance. 
 No connection has been traced between the direction of the 
 projectile and the fatality ; side-to-side lesions were said to be 
 commoner at the Base. Injuries of the big bile-passages do 
 not seem to increase^ the gravity to any appreciable extent. 
 
 Pancreas. 
 
 FREQUENCY. In 965 operated cases, the pancreas was 
 wounded 5 times. Very few of such injuries have been noted. 
 Possibly many are missed, and diagnosed as retroperitoneal 
 haematoma. In addition, many may be rapidly fatal ; the 
 association of the gland with the big vessels need hardly be 
 mentioned. 
 
 ASSOCIATED IN JURIES. The organ was found wounded three 
 times with other viscera namely, stomach, stomach and liver, 
 and stomach and kidney. All three were fatal. It was wounded 
 alone on two occasions, one of which went to the Base without 
 symptoms. 
 
 SYMPTOMS. There are no distinctive symptoms ; the lesions 
 are found at explorations, and are sometimes accompanied by 
 fat necrosis. 
 
 PROGNOSIS. One case was sent to the Base in which the 
 pancreas was obviously perforated by a bullet ; the other cases 
 were fatal. 
 
 Makins has published some cases of wounds of this organ 
 which he has seen at the Base. He says that they were dis- 
 covered during the performance of operations for intestinal 
 injuries, and that the typical results of the escape of the pan- 
 creatic juice have been observed. They have usually proved
 
 io6 
 
 War Surgery of the Abdomen 
 
 fatal. He mentions one interesting case in which an abscess 
 formed and was opened, in which the patient eventually 
 recovered and was discharged to England. The man walked 
 six miles after his wound. He had been detained at a Casualty 
 Clearing Station on suspicion of an injury to the alimentary 
 tract. 
 
 Spleen. 
 
 FREQUENCY. In 965 abdominal operations, the spleen was 
 found wounded 54 times. In 32 instances it was the only organ 
 damaged. 
 
 ASSOCIATED INJURIES : 
 
 TABLE XXI. Showing the Complicating Injuries of the Spleen. 
 
 Other Viscera wounded. 
 
 To Base. 
 
 Died. 
 
 Stomach 
 
 1 
 
 3 
 
 and colon 
 
 
 
 1 
 
 Small gut . . 
 
 
 
 1 
 
 ,, and colon 
 
 
 
 1 
 
 kidney 
 
 1 
 
 
 
 Colon 
 
 
 
 3 
 
 ,, and kidney 
 
 
 
 2 
 
 Kidney 
 
 7 
 
 > 
 
 NATURE OF IN JURIES. These consist of perforations, tears, 
 slits in the capsule, avulsion of poles, hemisection, division of 
 pedicle, and almost complete disruption. 
 
 SYMPTOMS. The symptoms are mainly those of haemorrhage, 
 and the diagnosis is made on these and on the position of the 
 wound. Very often the organ is only found wounded in the 
 course of an exploratory operation. There is nothing special 
 about the haemorrhage, and the damming up of blood in the left 
 loin, which has been said to be a feature of this injury in civil 
 practice, has not been conspicuous in the present campaign. 
 The amount of haemorrhage varies very much, and depends 
 mainly upon whether the vessels are injured. The splenic 
 pulp has been found bleeding forty-eight hours after injury, 
 but usually ceases after ten hours.
 
 Solid Alimentary Organs and Spleen 107 
 TREATMENT : 
 
 TABLE XXII. To show Treatment of Splenic Wounds. 
 
 Association with other Wounds. 
 
 Packed, sutured, or 
 left alone. 
 
 Excised. 
 
 To Base. 
 
 Died. 
 
 To Base. 
 
 Died. 
 
 With other organs 
 Spleen alone wounded 
 
 6 
 12 
 
 8 
 4 
 
 3 
 
 4 
 
 5 
 12 
 
 Total 
 
 18 
 
 12 
 
 7 
 
 17 
 
 There were five cases in which the spleen and kidney were both 
 excised ; two of these were fatal. The other three fatal cases of 
 excision in complicated wounds were instances of wounds of stomach 
 and spleen (1), and colon and spleen (2). 
 
 The spleen is often found wounded after the standard para- 
 median exploration, and can be dealt with through this, though 
 not very conveniently. A rectus sheath incision with a trans- 
 verse extension or a subcostal one are perhaps more convenient. 
 
 If associated with a thoracic wound which requires attention, 
 it can be dealt with through the diaphragm by extending the 
 rib incision to or through the costal margin. If, however, the 
 missile has passed across the abdomen, this incision will not 
 suffice, though the cardiac part of the stomach and the 
 splenic flexure of the colon can be dealt with. As a matter of 
 fact, the association of splenic and gastric injuries is not 
 common. 
 
 If the haemorrhage has ceased, the organ is best left alone. 
 Suturing or packing will control the haemorrhage if this is going 
 on. As a matter of fact, sutured holes are apt to bleed almost 
 as much as a raw surface, unless the haemorrhage is fairly free. 
 Excision should only be resorted to if the organ is badly injured 
 or the vessels are torn. 
 
 One point has to be borne in mind in operating on these cases, 
 especially if associated with wounds of the kidney vessels. The
 
 io8 
 
 War Surgery of the Abdomen 
 
 haemorrhage, which very likely has been controlled or diminished 
 by the clotting, is likely to restart in an alarming manner 
 directly the clot is disturbed. It is therefore absolutely neces- 
 sary to have everything ready for the arrest of haemorrhage. 
 
 Fia. 21. Bullet wound of spleen. The organ was almost completely divided. The 
 vessels ruptured in the hilum. Under care of Captain Owen Richards. (Brit. 
 Journ. of Surgery and Medical Society of London.) 
 
 MORTALITY AND CAUSES OF DEATH. Shock and haemorrhage 
 are the main causes of death. The mortality in uncomplicated 
 cases was 50 per cent. One curious case may be quoted, that 
 of a simple perforation of the spleen, where death occurred 
 suddenly without cause on the fifth day.
 
 CHAPTER VII. 
 
 GENITOURINARY ORGANS. 
 
 Kidney. 
 
 FREQUENCY. This organ was wounded 73 times in 965 
 abdominal injuries. It was the only viscus wounded in 37 
 instances. 
 
 ASSOCIATED INJURIES. The following table shows the 
 number of times each complicating organ was hit : 
 
 TABLE XXIII. Kidney Wounds complicated with Wounds of 
 
 other Organs. 
 
 Other Viscera wounded. 
 
 To Base. 
 
 Died. 
 
 Result not 
 known. 
 
 Stomach 
 
 1 
 
 3 
 
 
 Small gut 
 
 4 
 
 3 
 
 
 
 Colon 
 
 3 
 
 4 
 
 
 
 Pancreas 
 
 . . 
 
 1 
 
 
 
 Liver 
 
 3 
 
 9 
 
 2 
 
 Spleen 
 
 8 
 
 4 
 
 
 
 NATURE OF LESIONS. In two cases both kidneys were hit by 
 the same missile. Both were fatal ; one had paraplegia. The 
 nature of the projectile has no particular effect on the injury. 
 As is the case with other solid organs, the kidney is liable to 
 extensive rupture. The actual lesions may be perforations, 
 scores, furrows, cracks in the capsule, avulsion or pulping of 
 the poles, hemisection, and almost complete disruption. 
 
 Sometimes the kidney is found lying loose, the pedicle having 
 been ruptured ; sometimes the pelvis is alone perforated ; at 
 other times the vessels are completely divided, the ureter remain- 
 ing intact. The amount of haemorrhage depends upon whether 
 a vessel has been injured or not ; there is very often a consider-
 
 no War Surgery of the Abdomen 
 
 able perinephric haematoma. In contradistinction to civil 
 injuries, intraperitoneal haemorrhage is very frequent. 
 
 Microscopic examination shows that the destruction of 
 kidney cells is limited to the immediate vicinity of the wound 
 or of the fissures that extend from it. Infarction phenomena 
 are not rare (see Fig. 23), and in some instances considerable 
 portions of the kidney necrose if the artery supplying such 
 part is divided outside the organ. The reader is referred to 
 
 FIG. 22. Bullet wound of the kidney. 
 
 The small aperture of entry is seen in the inset. The larger exit wound at the 
 opposite surface exhibits well the protrusion of the renal tissue and a moderate 
 degree of destruction. The lacerated capsule has receded some distance on the 
 surface of the organ. (Brit. Journ. of Surgery.) 
 
 papers on these subjects by Captain Bashford and Colonel A. 
 Fullerton.* 
 
 SYMPTOMS. The shock is not as a rule very great, and 
 depends largely on the amount of blood lost ; this, perhaps, is 
 peculiar, when one remembers the effect produced by the kidney 
 blow in boxing. On the other hand, one sees cases of kidney 
 injury which recover without operation, in which the pulse 
 
 * Brit. Journ. of Surgery, vol. iv., No. 15, and vol. v., No. 18.
 
 Genito-urinary Organs 1 1 1 
 
 may be as high as 140 and the shock extreme. The dulness due 
 to free fluid in the abdomen is more common than in civil 
 injuries, and manifests itself in the right or left side according 
 to the organ injured. 
 
 Hcematuria.- This is usually present, but it may not occur at 
 once. The absence of this sign is due either to suppression, or 
 to the presence of clots or pieces of kidney in the ureter. Profuse 
 
 FIG. 23. Oblique perforation of the kidney caused by a bullet. The glass rod 
 projects from the exit aperture. (Brit. Journ. of Surgery.) 
 
 haemorrhage into the bladder is not common in the early stages. 
 Haematuria usually clears up in a few days, but may persist. 
 
 Extravasation of Urine. This is not usually marked, and is 
 most probably limited to those cases in which the pelvis is 
 involved. 
 
 Gas Infection. This has occurred in the perinephric haema- 
 toma in a certain number of cases. 
 
 Excretion of Urine. The escape of urine through the loin 
 wound is often delayed. This may be due, like the absence of 
 haematuria, to suppression, or blocking of the duct. In two
 
 U2 War Surgery of the Abdomen 
 
 cases of double wound no urine was passed into the bladder, 
 though it is doubtful whether there was not some from the loin 
 wounds. Anyhow the double wound seriously interfered with 
 this function. It is possible, therefore, that if only one kidney is 
 wounded, it ceases secreting. 
 
 I asked Captain Sampson, who had a rather extensive 
 experience with these injuries, to measure the urine after the 
 excision of the kidney ; the amount was about 25 oz. in the day. 
 
 FIG. 24. Bullet wound of the right kidney. This has practically bisected the 
 organ, extending into the renal pelvis. Haematuria was a marked feature of 
 the symptoms. (Brit. Journ. of Surgery.) 
 
 The patients were not thirsty, and did not demand water ; but 
 if they were put on a forced hydropathy, the remaining kidney 
 at once responded, and passed up to 80 or 90 oz. 
 
 SECONDARY COMPLICATIONS. A secondary haemorrhage is a 
 fairly frequent, and often fatal, late complication. It occurs 
 most often during the second and third weeks after injury. 
 The urine is generally contaminated. Secondary haemorrhage 
 may start afresh, or it may manifest itself as an exacerbation
 
 Genitourinary Organs 113 
 
 of a persistent primary haemorrhage. Unlike primary haemor- 
 rhage, it is often accompanied with clotting of the blood in the 
 bladder. 
 
 An interesting case reported by Makins * may be quoted 
 here : 
 
 " Case 2. (Under the care of Captain Buxton.) 
 "A man was wounded by a bullet which entered just below the 
 right costal margin in the nipple line, and emerged below the 
 
 FIG. 25. Comminution of the upper half of the kidney. The organ has been 
 reconstructed by assembling a number of fragments enclosed in blood clot. 
 (Brit. Journ. of Surgery.) 
 
 twelfth rib behind. Primary haematuria followed, and con- 
 tinued, except for one day's interval, until the patient's arrival 
 at the General Hospital on the eighth day. Some dysuria from 
 the presence of blood clot in the bladder had necessitated 
 occasional catheterisation. 
 
 "On the ninth day the patient's general condition was good; 
 he looked sallow, but the pulse was of fair strength and not 
 rapid. The haematuria and dysuria persisted, and on this and 
 
 * Brit. Journ. of Surgery, vol. iii., No. 12 (1910).
 
 114 War Surgery of the Abdomen 
 
 the following day 90 ounces of urine and blood were voided, 
 the urine containing streptococci. 
 
 "On the twelfth day, as no improvement had taken place, a 
 type right lumbar nephrectomy was performed. The perirenal 
 tissues were infiltrated with blood and some urine, but no 
 extensive extravasation of urine had occurred. The bladder was 
 full of blood clot, which was removed with a lithotrity evacuator. 
 
 Fiu. 26. Minimal injury to the right kidney accompanying a retroperitoneal per- 
 foration of the duodenum. A second exactly similar injury was also met with. 
 In neither case was any sign of the renal lesion observed, and in both the injured 
 duodenum contracted adhesions to the groove in the kidney. (Brit. Journ. of 
 Surgery. ) 
 
 The kidney was practically bisected, and was large, probably 
 partly as a result of infection. 
 
 "For the next three days seven pints of urine were voided 
 daily, the quantity then decreasing until the normal was reached 
 on the seventh day. 
 
 " The patient meanwhile was ill from the streptococcic infec- 
 tion, and made a very slow recovery." 
 
 TREATMENT.- The method of treatment adopted in the cases 
 enumerated under " Kidney explored " (Table XXIV.) was 
 packing, suture, or nothing, the actual procedure depending on
 
 Genito-urinary Organs 
 
 whether the organ was bleeding or not. A loin drain was used in 
 many cases. In a large number of instances it is probable that 
 the cases would have recovered without operation, which had 
 to be undertaken to exclude other injury. Nephrectomy should 
 be reserved for those cases in which the vessels are torn or the 
 organ is greatly shattered. If a pole is shattered a local 
 trimming of the devitalised tissue is worthy of trial. 
 
 If the kidney is probably the only organ wounded, or if the 
 missile track only crosses one side of the abdomen in a horizontal 
 direction, the transverse incision is the best. 
 
 TABLE XXIV. Table of Operations to show Treatment and 
 
 Results. 
 
 Operation. 
 
 To Base. 
 
 Died. 
 
 Kidney explored * 
 
 25 
 
 7 
 
 Nephrectomy (uncomplicated) 
 
 2 
 
 3 
 
 (spleen wounded) 
 
 3 
 
 
 
 (liver wounded) 
 
 1 
 
 1 
 
 (bladder wounded) 
 
 
 
 1 
 
 (colon wounded) 
 
 
 
 1 
 
 and splenectomy 
 
 3 
 
 2 
 
 * In these cases the kidney was considered the principal wound, and 
 so the operation is entered under this head ; the kidney was found 
 wounded in many other cases in the course of an abdominal explora- 
 tion, but these cases arc not shown in this table. The organ was 
 wounded seventy-three times, and the difference between this number 
 and the number (forty-nine) shown in this table represents the number 
 of times that the kidney wound was a secondary consideration. 
 
 As was stated in speaking of splenic injuries, the haemorrhage 
 from wounded kidney vessels is very liable to restart with 
 alarming rapidity directly the clots are disturbed. It is rather 
 interesting here to mention that the number of kidney wounds 
 treated at an advanced operating centre seems -to be larger than 
 in the Casualty Clearing Station. This is most probably due to 
 the fact that the cases arriving earlier have not suffered so much 
 from haemorrhage. 
 
 MORTALITY AND CAUSES OF DEATH. In thirty-seven uncom- 
 
 82
 
 ii6 War Surgery of the Abdomen 
 
 plicated cases, there were ten deaths. Shock and haemorrhage 
 are by far the most common causes at the Front. Associated 
 wounds of the liver and kidney seem to constitute a very 
 dangerous combination. At the Base, secondary haemorrhage 
 and sepsis play the chief part in the fatal result. 
 
 Ureter. 
 
 The ureter is not very frequently injured, but the cases have 
 done well. The injury was found in the course of an exploratory 
 coeliotomy. Suture or drainage formed the methods of treatment. 
 
 Colonel Andrew Fullerton, speaking of the experience at the 
 Base, says that the urinary fistulae resulting from wounds of the 
 ureter heal well if left alone. 
 
 Bladder. 
 
 FREQUENCY. This organ was perforated forty-five times in 
 965 operated cases. In twenty-five instances it was the only 
 organ injured. 
 
 ASSOCIATED INJURIES. The small intestine is the organ 
 most frequently wounded in association. It is remarkable how 
 seldom the pelvic colon or rectum is perforated at the same time. 
 The pelvis is fractured in a large proportion of cases. 
 
 TABLE XXV. Table of Bladder Wounds. 
 
 Association with other Wounds. 
 
 To Base. 
 
 Died. 
 
 Result not 
 known. 
 
 Small gut (resection), intraperitoneal . . 
 
 
 
 5 
 
 _ 
 
 ,, (suture), one extraperitoneal 
 
 1 
 
 6 
 
 
 
 ,, (resection), colon anus 
 
 
 
 1 
 
 - 
 
 ,, rectum (suture) 
 
 
 
 1 
 
 
 
 Colon* 
 
 
 
 2 
 
 1 
 
 Rectum, extraperitoneal 
 
 
 
 1 
 
 
 
 . . , f extraperitoneal 
 Bladder alone mjured^^^^ 
 
 9 
 2 
 
 11 
 3 
 
 
 
 Total 
 
 12 
 
 30 
 
 1 
 
 * Transverse colon, 1 ; pelvic colon, 1 ; wound of bladder extra- 
 peritoneal, 1.
 
 Genito-urinary Organs 117 
 
 NATURE OF IN JURIES. These may be either intraperitoneal 
 or extraperitoneal, or both. The intraperitoneal lesions 
 perforations, tears, or slits are very often not extensive. The 
 extraperitoneal wounds, often accompanied by much haematoma, 
 are slits or tears. They are usually situated at the sides of the 
 bladder, and are often caused by bony spicules. There is only 
 one instance in this series where the rectal surface was wounded. 
 It is also remarkable how few have been the observed cases of 
 prostatic wounds, so few that there is really nothing to be 
 said about them. The combined intraperitoneal and extra- 
 peritoneal injuries are usually caused by oblique wounds, the 
 missiles entering by the lower lateral part of the bladder and 
 passing out through the peritoneal surface. Projectiles some- 
 times lodge within the bladder, and cause pain at a later period. 
 Bone spicules have also been formed in the viscus. One interest- 
 ing case was under the care of Captain Luker in which a pro- 
 jectile, passing in by the buttock, wounded the postero- 
 external angle. It pushed a piece of cloth into the viscus and 
 then passed on and lodged behind the pubis. 
 
 SYMPTOMS. These are not of great importance, as most cases 
 are submitted to operation on principle. Intraperitoneal wounds 
 are found in the case of an abdominal exploration. The 
 extraperitoneal wounds may be accompanied by obvious swelling 
 above Poupart's ligament, but this sign may be absent. 
 
 There may be haematuria, or micturition may be impossible. 
 Haematuria also occurs with bruising of the bladder without 
 penetration. The cystoscope has not been used, and perhaps 
 would not be of much use in the intraperitoneal wounds, as the 
 bladder cannot be distended. 
 
 Vomiting is not an infrequent symptom in extraperitoneal 
 wounds, and has occurred in simple extravesical haematoma. 
 It is of no great value as a symptom. Extraperitoneal wounds 
 are often accompanied with severe constitutional disturbance, 
 the pulse mounting to 120. This phenomenon is apparently 
 septic in origin. 
 
 TREATMENT. Intraperitoneal Wounds.- These are, as a rule, 
 easily sutured, except those which occur at the very bottom of 
 Douglas' pouch. The bladder should be explored for a foreign
 
 n8 War Surgery of the Abdomen 
 
 body. Suprapubic drainage is not necessary here. Catheterisa- 
 tion for a few days may be necessary, or a catheter may be 
 tied in, though this treatment is not to be continued for long, 
 and is not favoured by some. 
 
 Extraperitoneal Wounds. These are treated by an incision 
 down to the wound in the bladder, which latter may be sutured 
 if possible, and a drain left in the space formed by the operation. 
 If the wound in the bladder cannot be sutured, it is most 
 probable that a drain down to the wound will be sufficient ; 
 if there is any doubt, a drain into the bladder through the 
 wound is probably the safest course. It occasionally happens 
 that one meets with urinary extravasation in an extravesical 
 haematoma and cannot find the hole into the viscus. Under 
 these conditions it is somewhat doubtful whether the right 
 course is to be content with an extravesical drain or to do a 
 suprapubic cystostomy in addition. I am rather inclined 
 myself to advocate the latter, as I have seen bad results follow 
 such extravasation. 
 
 In those cases where the bladder is wounded on the rectal 
 surface it would appear well to open the bladder and suture the 
 rent from the inside, as has been done by Captain Hamilton 
 Drummond. 
 
 MORTALITY AND CAUSES OF DEATH. The uncomplicated 
 bladder wounds show a mortality of 56 per cent., fourteen 
 deaths in twenty-five cases. Shock and haemorrhage form the 
 causes in the majority. Fracture of the pelvis seems to greatly 
 increas the shock, and wounds of the pelvic veins are respon- 
 sible for a great deal of the haemorrhage. 
 
 In the case of complicating small-gut injuries, the picture is 
 dismal in the extreme. There were sixteen instances with only 
 one recovery. Most of these cases are intraperitoneal wounds, 
 which in civil practice, and uncomplicated, are not greatly 
 feared. It would appear that the increase in time necessary 
 to repair the bladder, after other serious injuries have been dealt 
 with, was able to turn the balance against the patient, for the 
 mortality is much worse than in intestinal injuries alone.
 
 CHAPTER VIII. 
 
 ABDOMINO-THORACIC WOUNDS AND DIAPHRAGMATIC HERNIA. 
 Abdomino-thoracic Wounds. 
 
 A GOOD deal has been written about these wounds, and there 
 is perhaps an inclination to regard them as a type apart and 
 as possessing peculiar properties. It has been shown that the 
 mortality of wounds increases in proportion to their multipli- 
 city ; it is not therefore to be wondered at that abdomino- 
 thoracic wounds should have a heavier mortality than either 
 chest or abdominal wounds alone. It will be seen later on that 
 in a series of cases the total operative abdominal mortality 
 (excluding abdomino-thoracic wounds) was 49 per cent., while 
 that of abdomino-thoracic wounds was 55 '5 per cent. This is 
 not such a large increase when it is remembered that chest 
 wounds within the period before evacuation to the Base produce 
 a mortality of about 22 per cent, in themselves. Another point 
 to be borne in mind in considering the increased mortality 
 supposedly due to the thoracic complication is that such 
 thoracic wounds are accompanied by wounds in a region of the 
 abdomen that has been shown (see Fig. 4) to be especially 
 dangerous to life. 
 
 Frequency. In 839 cases of abdominal wounds there were 
 101 cases in which the missile penetrated the thoracic in addition 
 to the abdominal cavity. The percentage of wounds involving 
 both cavities is therefore about 12 per cent. If only operated 
 cases are taken into account the ratio is 550 to 70, or, again, 
 about 12 per cent. 
 
 Side. These wounds are mostly confined to one side of the 
 diaphragm, though the opposite chest may be involved. Wounds 
 low enough to involve both sides of the diaphragm have 
 usually been fatal, though some reach hospital. In this series 
 both sides are equally affected and show an equal mortality.
 
 i2o War Surgery of the Abdomen 
 
 Nature of Projectiles. As in all abdominal wounds, shell 
 fragments are the most frequent causal agents. 
 
 TABLE XXVT. 
 
 
 Tn T?acf 
 
 THoH 
 
 
 
 
 Bullet 
 
 2 
 
 8 
 
 High-explosive fragments 
 
 23 
 
 47 
 
 Shrapnel ball 
 
 5 
 
 4 
 
 Grenade 
 
 2 
 
 1 
 
 Aerial bomb 
 
 
 
 1 
 
 Bayonet . . . . . . . . 
 
 2 
 
 1 
 
 Diaphragmatic Lesions. These are mostly found on the sloping 
 muscular portion. A large proportion involve only that part 
 which is in contact with the thoracic wall. The following 
 figures, taken in a consecutive series of cases, show the extent 
 and form of the rent as described by the operator : 
 
 Linear tear (in inches), 3, 1J, 1, 1J, 1, 1, 1, , ^, 1, 
 
 , 
 
 Irregular hole, size of, 5s., Is., Qd., 2s. 6d., 2s. Qd. ; (in inches), 
 1, 2 x 1, 2J x 1, 2, |, 1, 1, f, small, small. 
 
 Puncture, described thus in ten cases. 
 
 The nature and extent of the lesion depend on the size of the 
 missile and on its inclination to the plane of the diaphragm at 
 the point of impact. Small missiles may make large tears if 
 their course lies in the plane of the organ. Fractured ribs are 
 also responsible for a certain amount of damage. 
 
 Organs herniated. In a certain number of cases on the left 
 side some of the abdominal viscera pass through the gaps. 
 There was herniation in eight cases in the above series, which 
 were mostly explored in the first instance through the abdomen. 
 According to some observers, this number of herniations is 
 below the average. The omentum is the organ most often 
 involved, and the first part to pass through is the left side or the 
 gastro-splenic fold. It nearly always accompanies other organs 
 when they are protruded. In one unoperated case that died 
 from other injuries about a week after wounding, the omentum 
 protruded through the rent, effectually plugging it, and formed
 
 Abdomino-thoracic Wounds 
 
 121 
 
 the same granular-looking, mushroom-like button that one used 
 to see on the abdominal wall in the preoperative days. As in 
 other cases, it is both carried out or expelled by abdominal 
 pressure. The spleen, stomach, and left part of the transverse 
 colon are the organs next most frequently herniated. The 
 following combinations occur : stomach and spleen ; stomach 
 and transverse colon ; stomach, transverse colon, and small 
 gut. The stomach does not in the early stage pass through 
 unless the rent is of considerable size, but is at a later period 
 herniated through a comparatively small rent. 
 
 Abdominal Organs wounded. This is an important subject 
 because, as will be pointed out later, it has a direct bearing on 
 the treatment to be adopted and the route employed. Hollow 
 viscera were wounded 28 times in 70 cases. 
 
 TABLE XXVII. To show Abdominal Viscera wounded in 
 Abdomino-thoracic Injuries. 
 
 Organ wounded. 
 
 To Base. 
 
 Died. 
 
 Stomach 
 
 
 4 
 
 and liver 
 
 1 
 
 1 
 
 ,, spleen 
 
 
 
 2 
 
 ,, transverse colon 
 
 - 
 
 1 
 
 ,, jejunum and spleen . . 
 
 
 
 1 
 
 kidney 
 
 1 
 
 
 
 Jejunum 
 
 1 
 
 1 
 
 and liver 
 
 
 
 1 
 
 kidney 
 
 
 
 1 
 
 ,, spleen and colon 
 
 
 
 1 
 
 ,, transverse colon 
 
 - . 
 
 2 
 
 Colon 
 
 3 
 
 1 
 
 ,, and spleen 
 
 
 
 2 
 
 liver 
 
 1 
 
 2 
 
 ,, ,, ,, and oesophagus 
 
 
 
 1 
 
 Liver 
 
 10 
 
 7 
 
 ,, and kidney 
 
 3 
 
 3 
 
 Kidney. . 
 
 2 
 
 1 
 
 Spleen . . 
 
 G 
 
 5 
 
 ., and kidney 
 
 
 1 
 
 Pancreas and splenic vein 
 
 
 
 1 
 
 No viscus 
 
 3 
 
 
 
 Total 
 
 31 
 
 39
 
 122 War Surgery of the Abdomen 
 
 TABLE XXVIII. To show the Number of Times Individual 
 Organs were wounded. 
 
 Organ. 
 
 Frequency. 
 
 Liver 
 
 30 
 
 Spleen 
 Colon 
 
 18 
 18 
 
 Kidney . . . . 
 Stomach 
 
 13 
 11 
 
 Jejunum 
 (Esophagus 
 Pancreas 
 
 
 1 
 1 
 
 No viscus 
 
 3 
 
 TABLE XXIX. To show Influence of a Wound of a Hollow 
 Viscus on the Mortality. 
 
 
 
 Base. 
 
 Died. 
 
 Hollow viscera wounded 
 No hollow viscera wounded 
 
 7 
 21 
 
 21 
 
 18 
 
 Total 
 
 31 
 
 39 
 
 TREATMENT. In all cases it is very necessary to know the 
 track of the projectile and where it has lodged. If the wound 
 only involves the neighbourhood of the diaphragm there is no 
 need for a complete abdominal exploration. A transpleural 
 incision will here allow of repair to the thoracic region, and an 
 extension of it will very likely be a convenient way of treating 
 the abdominal viscera. If the projectile has passed farther 
 afield it is obvious that an enlargement of the transpleural 
 incision will not suffice, and that a separate coeliotomy will be 
 necessary. It is in these cases that one has to determine whether 
 the thoracic wound requires operative treatment and, if it does, 
 whether preference should be given to it or the abdominal 
 wound. 
 
 In making up one's mind certain facts have to be considered.
 
 Abdomino-thoracic Wounds 123 
 
 (1) It has been shown that the mortality is still largely 
 dependent on the abdominal injury. (Table XXIX.) 
 
 (2) The chief indications for immediate operative treatment 
 of a thoracic wound that have been advanced are as follows : 
 (a) an open " blowing wound " ; (6) a " stove-in " chest wall ; 
 (c) the retention in the thorax of a large missile ; (d) a wound 
 of the diaphragm. 
 
 (a) and (b) Under these conditions the chest injury will 
 demand to be first dealt with. 
 
 (c) In an abdomino-thoracic wound the missile will have 
 
 usually passed out of the chest. 
 
 (d) Suture of the diaphragm is advocated for the following 
 
 reasons : (1) to render respiration more easy ; 
 (2) to retain the blood in the pleura and thus assist 
 the arrest of haemorrhage from the lung ; (3) to pre- 
 vent or reduce herniation. 
 
 (1) It is still doubtful how far a wound paralyses 
 
 the diaphragm or if suture will restore 
 function. 
 
 (2) It is unsettled if pressure by effused blood is a 
 
 potent cause of arrest of haemorrhage. 
 
 (3) It is impossible to gauge the size of the hole in 
 
 the diaphragm ; the average size can be seen 
 above. Large herniation does not seem to be 
 the rule, and small ones of the omentum are 
 not an immediate danger to life. 
 
 Although suture of the diaphragm is the ideal treatment, the 
 universal acceptance of the transpleural route for its accom- 
 plishment as a primary measure would seem in many cases to 
 involve a lengthening of the operation which may be pre- 
 judicial to the wounded man. 
 
 It would, therefore, seem reasonable to advance the following 
 recommendations : 
 
 (1) That many small thoracic wounds may be disregarded ; 
 
 (2) That when there is an open " blowing wound," or respira- 
 tory distress, or if the hypochondrium is alone involved, the 
 lung condition should first be attended to and the transpleural 
 route used to treat the abdominal lesion if possible.
 
 124 War Surgery of the Abdomen 
 
 (3) In other cases the abdominal exploration should come 
 first and the lung and diaphragmatic lesions be attended to, 
 if advisable, and time permits. 
 
 Mortality and Causes of Death : 
 
 Total cases 
 
 Operated and evacuated 
 Operated and died 
 Unoperated and evacuated 
 Unoperated and died 
 
 101 
 
 31 
 
 39 
 
 7 
 
 24 
 
 In this series neither suture of the diaphragm nor the trans- 
 pleural route as a primary measure was pushed. 
 
 TABLE XXX. To show the Influence of Abdomino-thoracic 
 Wounds on the Total Mortality. 
 
 
 
 All Cases. 
 
 Abdomino- 
 thoracic. 
 
 Excluding 
 Abdomino- 
 thoracic. 
 
 Mortality, including moribunds 
 Mortality, excluding moribunds 
 Mortality, operative 
 
 59-5 
 49-2 
 51-4 
 
 63-0 
 50-6 
 55-5 
 
 59-2 
 48-9 
 50-9 
 
 Diaphragmatic Herniae. 
 
 Considering the number of times the diaphragm must have 
 been injured, the number of cases that have come to light is 
 small. 
 
 Putting aside those herniae (immediate) that are found at the 
 primary operation there are others that occur later. They may 
 be divided into two classes, namely those that occur within 
 a short time (intermediate) and those that come to light after 
 a lapse of time (remote). 
 
 The intermediate variety has usually been found within ten 
 days or so of the wound, when an abdominal operation has been 
 called for on account of obscure symptoms or at a post-mortem 
 examination. The remote form has been found under similar 
 conditions up to twenty-four months after the wound. 
 
 In the intermediate variety the abdominal viscera pass
 
 Diaphragmatic Herniae 125 
 
 through when the rent is made or soon after. In the remote 
 form the herniation takes place at a later period. 
 
 Morbid Anatomy. The cases have all been left-sided. The 
 track of the missile has often been across both chests from side 
 to side. In the intermediate form the rent in the diaphragm is 
 large, often irregular. In the remote form it is often much smaller, 
 although there is considerable herniation of viscera. In the 
 recent state the edges are soft and irregular, but later on become 
 well defined and somewhat unyielding. The shape, whatever 
 it was at first, becomes lenticular or ovoid ; the prolapsed 
 viscera tend to dilate and round off the irregularities. As a 
 rule there is no sac, but this has been described in one case 
 and may have been due to an incomplete division of the 
 diaphragm. 
 
 There may be many adhesions or none. If present they are 
 usually found at the hiatus, where there may be a few points of 
 adherence or a complete marginal attachment. The omentum 
 is mostly concerned. Within the pleura there are not usually 
 many adhesions. 
 
 The amount of lung collapse is very various. Often there is 
 a good negative pressure in the thorax in the remote variety. 
 
 Organs herniated. These are the same as in the immediate 
 form, and the omentum again is most often found to have 
 passed through the hole. Of the hollow viscera the stomach 
 seems to be frequently involved in the intermediate form, and 
 the colon and stomach, sometimes accompanied by the small 
 intestine, in the remote form. In the intermediate variety the 
 stomach has been found wounded as it lay within the pleura 
 and its contents extravasated. In the remote form it may 
 have a very distinct hour-glass shape, the neck corresponding 
 to the rent in the diaphragm. 
 
 In some cases the hernia is spontaneously reduced to be again 
 protruded. 
 
 SYMPTOMS. These are often obscure and puzzling. In the 
 intermediate form all that usually attracts attention is rapidity 
 of the pulse and respiration rate, the reason for which cannot 
 be determined. 
 
 In the remote form the symptoms consist of abdominal
 
 126 War Surgery of the Abdomen 
 
 pain combined with a disturbance of the gastric or intestinal 
 function. Sudden exacerbation of symptoms followed by an 
 amelioration points to an involvement and release of the viscera. 
 
 When the stomach is involved, disturbances connected with 
 the ingestion of food are the most marked, and when the large 
 bowel is prolapsed obstruction is the predominant feature. 
 
 Gastric Form. In the gastric form there is pain on taking 
 food, sometimes trifling, sometimes severe. There may be 
 difficulty in swallowing, which difficulty can be overcome by 
 position, such as a dorsal or left-sided posture. Vomiting is 
 frequent ; it may be spontaneous or purposely induced to give 
 relief. If the hernia has been of long standing there may be great 
 emaciation. 
 
 Colic Form. Here there is usually a history of attacks of 
 abdominal pain and constipation, with intervals of complete 
 freedom from both. The intervals between the attacks are 
 very various and often, in the early stage, amount to months. 
 Later on the intervals become shorter. The patient is usually 
 in good health and well nourished. The pain is the same as 
 that met with in chronic obstruction, but is sometimes ex- 
 perienced in the left chest as well as in the abdomen. Some- 
 times the obstruction becomes acute. 
 
 Physical Signs.- If acute intestinal obstruction is not present 
 the abdomen is nearly always normal. Even if the symptoms 
 have suggested a hernia it is possible that the physical signs 
 may be quite unconvincing. Whether the examination is helpful 
 or not depends lipon whether the hernia is large enough to 
 displace or compress lung, or whether it contains air or fluid 
 and so gives rise to abnormal noises. As a rule it is the stomach 
 that produces the most pronounced physical sounds, both from 
 its bulk and its air and fluid contents. The colon, if the obstruc- 
 tion is at the distal point of the involved bowel, will cause very 
 much the same signs as the stomach. 
 
 The actual physical signs noted are as follows : 
 
 (1) Dulness and absence of breath sounds. 
 
 (2) Feeble respiratory murmur and increased resonance. 
 
 (3) Tinkling, gurgling, or splashingsounds. These occur with 
 the colon, but are more usually found with the stomach, where
 
 Diaphragmatic Hernise. 127 
 
 ingestion of fluid may produce or increase them. There has been 
 a difficulty in telling whether these signs originate in the 
 abdomen or thorax. When heard they have not been appre- 
 ciated at their proper value. 
 
 The diagnoses actually made have embraced the following : 
 massive collapse of lung, subdiaphragmatic abscess containing 
 air, and pneumothorax and haemothorax. 
 
 X-ray Examination. This has shown an absence of the usual 
 lung shadow and an alteration in the position, form, and motility 
 of the diaphragmatic vault. If the stomach is the organ involved 
 a bismuth meal quickly makes the diagnosis, provided that it 
 is herniated at the moment. 
 
 TREATMENT. This is operative. If the diagnosis has been 
 made, and there are no acute symptoms, the transpleural route 
 is the best, and should be used in the first instance, though diffi- 
 culties of reduction may necessitate a coeliotomy. When, how- 
 ever, the diagnosis is doubtful (and up till now it has seldom 
 been made), the abdomen should be opened and the actual 
 condition of things ascertained. 
 
 A paramedian incision is best. There may be an absence or 
 a perfectly obvious" displacement of stomach, colon, and omen- 
 turn. On the other hand, all may appear normal. A manual 
 examination of the diaphragmatic vault will quickly show the 
 presence and site of the hernia, provided the contents are not 
 reduced. 
 
 One must be on one's guard not to miss a small colic hernia. 
 Such a hernia produces no obvious displacement of the viscera, 
 and may be missed unless the continuity of the transverse and 
 descending colon be carefully traced. The approximation 
 at the hernial opening of the proximal and distal ends of the 
 herniated loop may lead to the belief that the bowel is con- 
 tinuous within the abdomen, and that the only abnormality is a 
 highly placed splenic flexure. If there are but few adhesions 
 reduction may be effected from the abdomen, but if there are 
 many it will be necessary to do this by the transpleural route. 
 A finger introduced through the rent will indicate the best 
 position in which to perform thoracotomy. Cowell's method 
 is to be recommended.
 
 128 War Surgery of the Abdomen 
 
 Even after an abdominal reduction of the hernia contents 
 a thoracotbmy may be necessary to close a rent which is not 
 suturable from beneath the diaphragm. 
 
 Obscure abdominal symptoms in a man previously shot 
 through the lower chest should suggest the possibility of a 
 diaphragmatic hernia. If this possibility is borne in mind a 
 diagnosis will almost always be made, although the physical 
 signs are puzzling. With the greater attention now paid to 
 wounds of the diaphragm, the number will decrease, but some are 
 still likely to occur and offer difficulties in diagnosis.
 
 CHAPTER IX. 
 
 CAUSES OF FAILURE. 
 
 COMPLICATING INJURIES. One need say very little on this 
 subject, except that every kind of bodily injury may be added 
 to that of the abdomen. Compound depressed fractures of 
 the skull, fractured long bones, multiple wounds, fractured 
 spine, and avulsed limbs, are among such complicating injuries. 
 In considering the total mortality, and in appraising the worth 
 of abdominal surgery, one must take these injuries into account ; 
 but for such extraneous injuries the mortality would be con- 
 siderably lower. 
 
 MENTAL AND PHYSICAL STRAIN. It is commonly said that the 
 surgeon in war has an advantage over his peace colleague in 
 that his subjects are healthy young adults. This, of course, is 
 true ; but there is the strain caused by days of watching and 
 alertness, and nights when sleep is difficult, interrupted, or 
 impossible to obtain. Then there is the exertion of battle, 
 which, for the time being at any rate, obliterates all sense of 
 fatigue, so that many men do not know how tired they are 
 until some wound is received which prevents them going farther. 
 Next, there is the journey to the Casualty Clearing Station. 
 Sometimes the men arrive practically asleep, and resent any 
 interference or examination. Other men arrive in whom a state 
 of excitement is still present, and they are willing and anxious to 
 chatter about their experiences. Then, after being fed, they 
 are dressed, and if they do not fall asleep in the process they do 
 so immediately afterwards ; and it is one of the most striking 
 sights of the medical side of war to see a large room filled with 
 men lying on stretchers, some slightly wounded, some severely, 
 some mortally, but all asleep, and asking for nothing but sleep. 
 It is on such patients that the surgeon has to work, and it may 
 well be imagined how much the mental and physical strain may 
 increase the effect of injury. 
 
 W.S.A. 9
 
 130 War Surgery of the Abdomen 
 
 HAEMORRHAGE. Haemorrhage stands out as a great enemy of 
 the surgeon. It comes from all sorts of places. 
 
 (1) Stomach. Injury to the actual wall of the stomach appa- 
 rently does not cause much haemorrhage ; but damage to the 
 vessels running on the stomach wall before they penetrate it, 
 and to the big vessels lying on the two curvatures, does give 
 rise to very great haemorrhage. 
 
 (2) Omentum. There may be a fair amount of haemorrhage 
 from this structure. 
 
 (3) Small-intestine Wall. This is a source of considerable 
 haemorrhage, and in this way is perhaps a contrast to the 
 stomach wall. It is not very unusual to see coils of the intestine 
 filled with blood in addition to that which has escaped into the 
 peritoneum. 
 
 (4) Mesentery. The mesenteric vessels give rise to very, 
 considerable haemorrhage. A mesentery wound often includes 
 also a wound of the big vessels, such as the colics, and 
 it is most probable that haemorrhage from these vessels is 
 the most common source of blood in the abdomen when the 
 cases come to operation. The vessels in the mesentery are 
 unsupported by masses of muscle, as are the vessels in the 
 limbs, and for this reason one of the natural processes of 
 haemostasis is wanting, namely the pressure produced by the 
 effused blood. 
 
 (5) Retroperitoneal Tissue. Here haemorrhage is a source of 
 great trouble ; it often raises the posterior abdominal peri- 
 toneum so as to touch the anterior wall when the abdomen is 
 open. It may look like a large purple intra-abdominal tumour. 
 This surface shows cracks, through which the blood oozes slowly. 
 If left, it may become infected and the seat of gas production. 
 If, on the other hand, any attempt is made to find the bleeding 
 point, the difficulty may be very great, even if the surgeon is 
 successful. Whether this attempt is made must depend on the 
 situation of the haematoma and the likelihood of injury to the 
 big vessels. Most probably the best thing is to leave it alone, 
 and to drain it through the loin if sepsis intervenes. There is 
 often considerable shock, out of proportion, I should say, to the 
 amount of blood lost. The sources of bleeding are the local
 
 Causes of Failure 131 
 
 vessels, and sometimes the renal vessels or pelvic veins, or even 
 the abdominal cava. 
 
 (6) Abdominal Wall. In these cases the deep epigastric artery 
 is the usual source of the trouble ; and in one case the whole 
 abdomen was filled from a wound of this artery. 
 
 (7) Great Vessels. The big vessels injured are the vena cava 
 and the iliac veins, in addition to the renal and splenic veins. 
 The abdominal cava has been closed by sutures by Captain 
 Sampson, but the patient died. On another occasion the rent 
 was successfully brought together by forceps by Captain Taylor ; 
 the forceps were left on for the time being, and the patient 
 was sent to the Base after their removal. The iliac arteries 
 have been wounded and secured. So far no wound of the 
 abdominal aorta has been dealt with at operation, but one was 
 found at a post-mortem. 
 
 (8) Solid Organs. The parenchyma of all solid organs bleeds 
 freely at first ; but it is probable that if no large vessel is 
 injured, the haemorrhage will cease spontaneously in a few hours 
 (four to eight). In one case, however, the splenic pulp was still 
 found bleeding after twenty-four hours. 
 
 Within limits it is not so much the amount of blood lost that 
 causes collapse as the suddenness of the loss. 
 
 Again, it is difficult to detect any definite relation between 
 the amount of blood loss and the effect produced. A man can 
 without detriment lose by the surgical operation of transfusion 
 an amount of blood the loss of which would produce a 
 decidedly bad effect on a wounded soldier. 
 
 SEPTIC ABSORPTION. This takes place in four ways : (1) from 
 the peritoneum, (2) from the retroperitoneal tissue, (3) from 
 the wound itself, and (4) from the operation wound. 
 
 (1) Peritonitis. There is nothing peculiar about the perito- 
 nitis compared with that seen in civil practice. 
 
 Peritonitis is the usual cause of death after the period of 
 shock and haemorrhage is over ; death may occur within twenty- 
 four hours, or be delayed for a week or ten days. The first 
 variety may be called the fulminating type, the second the 
 dormant. It was the latter class which was seen so often at the
 
 132 \Var Surgery of the Abdomen 
 
 beginning of the war. These cases might or might not show 
 signs of peritoneum involvement when first seen. If there were 
 such signs, with rest in bed they would improve for a day or two 
 and give the impression that things were quieting down. There 
 might have been some vomiting, but this often subsided, and the 
 tongue kept clean. Then the abdomen became tumid. But 
 the general condition remained fair, and the pulse, if somewhat 
 rapid, was not of bad quality. In some cases the patients 
 then became obviously worse and died. In others the 
 patients remained moderately well, or even appeared to have 
 improved, and were sent to the Base, with the belief that 
 they would recover. In some cases the journey to the Base 
 seemed to light up the septic process, and they died soon after 
 arrival. Others struggled on for some time further. One case 
 may be mentioned in this connection : A man was shot in the 
 abdomen, kept at a Casualty Clearing Station for eight days, 
 and then evacuated, apparently doing well. On arrival at the 
 Base he was ill, and was found to have a large iliac abscess, 
 which was incised. He died on the following day. A post- 
 mortem showed that into the faecal abscess there opened two 
 moderate-sized holes in the small intestine. It is a remarkable 
 fact that in this case the bowels had acted normally on several 
 occasions. 
 
 The amount of peritonitis present when operation is done at 
 an early stage is very various, and within certain limits to 
 judge by the naked-eye appearances, which are known to be 
 deceptive it is not so dependent on the time elapsed since the 
 wound as might be supposed. It has been found present in a 
 marked degree in the case of a wound of the upper ileum after 
 three hours and a half, and has been practically absent in the 
 case of wounds of the jejunum after twenty-six hours. It 
 is not altogether commensurate with the amount of faecal 
 escape. As regards prognosis, distension of the intestine is 
 a better guide than the amount of visible inflammation. If 
 the pulse is good when the abdomen is closed, the prognosis is 
 good. 
 
 Peritonitis is, of course, brought about in some instances by 
 contamination from the bowel ; but one must remember that
 
 Causes of Failure 133 
 
 the projectile carries in dirt, even if it does not carry any cloth- 
 ing, and may in this way cause peritonitis apart from any 
 bowel injury. The fatal micro-organism is the streptococcus. 
 The anaerobes do not seem to be able to flourish in the abdominal 
 cavity. In this way the peritoneum resembles the synovial sacs 
 of joints. 
 
 The removal of the projectile is, of course, to be desired, but 
 it is almost impossible to find it in the posterior abdominal 
 wall, and the search for it may result in a great expenditure 
 of time. 
 
 The dissemination of infection is more a vital than a physical 
 process, though of course septic fluid and stomach contents 
 do gravitate to the pelvis. Bleeding of the mesentery, when in 
 conjunction with a wound of the bowel, must have a definite 
 influence in the spreading of infection. In two cases, Captain 
 Sampson had the blood in the abdomen examined, and this was 
 full of streptococci. 
 
 (2) Rctroperitoneal Sepsis. A series of post-mortem examina- 
 tions after abdominal injuries (made by Captain McNee and 
 Captain J. S. Dunn) has demonstrated the frequency of gas 
 gangrene and retroperitoneal sepsis in cases supposedly dead of 
 peritonitis or shock. It seems to be proved that this cause of 
 death is much more crmmon than one supposed. The condition 
 may occur in two foims : (1) gaseous or (2) non -gaseous. It 
 may occur with or without a bowel lesion, but more usually 
 with one. The colon is generally the portion of the bowel impli- 
 cated, but it may follow wounds -of the duodenum. The infec- 
 tion is often one of extreme virulence, so that a man on admis- 
 sion is dying, and this even with an open wound. In other 
 cases it may follow a small innocent-looking wound in the 
 flank. When, on account of symptoms, such a wound is 
 explored, the retroperitoneal tissue may be black and stinking 
 or full of gas. At other times an incision shows only some blood- 
 stained areolar tissue without smell. A simple incision may be 
 all that is necessary, and the symptoms subside without any 
 signs of violent infection. At other times the discharge becomes 
 foul and evil-smelling, and the patient may succumb. Again, a 
 loin wound may go on well for a time ; then the patient may
 
 134 War Surgery of the Abdomen 
 
 * 
 
 show signs of absorption, develop a faecal fistula, and recover. 
 At another time the skin of the loin becomes bronzed and 
 crepitant, and the man dies rapidly in spite of incision. Bronzing 
 of the skin is a curious manifestation, and its causation is not 
 altogether obvious. In certain cases it subsides without any ill 
 effects even if left alone ; but it is so often accompanied by 
 " gas infection " that it is well to incise it at the earliest possible 
 moment. 
 
 It is this sepsis which causes the high mortality in cases where 
 a colon anus has been found necessary. Here the bowel has 
 been widely wounded by the projectile, and the retroperitoneal 
 tissue and muscles have been badly damaged. It seems impos- 
 sible to stop such infection ; by the time the case comes under 
 treatment it has got too far ahead, even though the patient at 
 the time does not seem gravely ill. Even widely open drainage 
 may be impotent. 
 
 A rather striking manifestation of the gaseous variety is seen 
 when a retroperitoneal haematoma becomes infected. This may 
 be palpable from the abdomen as a well-defined tumour, but 
 resonant on percussion. Exploration reveals the cause^ a 
 gaseous haematoma. 
 
 (3) Sepsis from the Projectile Wound.- The wound caused 
 by the missile may at any time show signs of sepsis and gas 
 gangrene. In fact, it behaves just like the wounds of muscle in 
 other parts of the body, and must be dealt with in the same way. 
 It has caused death in a certain number of cases in which the 
 intestinal lesion has been successfully dealt with. It used to 
 be said that gas gangrene was not common in the trunk ; 
 experience has shown that this immunity has been much over- 
 stated. 
 
 (4) Sepsis from the Operation Wound. This, too, becomes 
 badly infected in many cases. The cause may be a faulty 
 technique, but I think it is nearly always due to infection from 
 the abdomen. This is not to be wondered at, when nearly all 
 abdominal wounds are accompanied by blood effusion, which is 
 itself grossly infective. Very often- the operation wound is the 
 seat of intense infection, although the intestinal lesion does well. 
 This is comparable with what is seen in the behaviour of the
 
 Causes of Failure 135 
 
 operation wound and peritoneum respectively in cases of acute 
 appendicitis. 
 
 RELATION BETWEEN THE AMOUNT OF INJURY AND THE 
 AMOUNT OF COLLAPSE. Something may be learnt from studying 
 a man's sensations when hit. They vary in a remarkable 
 degree. 
 
 Avulsion of portions of the abdominal wall may cause but 
 little disturbance ; on the other hand, it more usually produces 
 great shock, which may be suddenly fatal, either at once or after 
 a short interval of time. As an example of a slight effect the 
 following may be quoted : A man had his abdomen ripped open 
 by a bullet just as we were compelled to evacuate a trench. He 
 was bandaged up with a' field dressing, and insisted on walking 
 to a trench in the rear, where he lay on the fire step till things 
 had quietened down. He was then evacuated, and made a 
 good recovery. The following shows the opposite effect : A 
 party of men were marching along a road just outside an 
 advanced operating centre when an aerial bomb exploded in 
 their midst. Twenty-two were brought in dead within a few 
 minutes. Twelve had abdominal wounds, and of these the 
 intestines were exposed in ten instances. 
 
 Sometimes a man is unconscious that his intestine is pro- 
 lapsed. A soldier was hit just above the pubes ; he experienced 
 very little inconvenience. When the first dressing was applied 
 some of the small gut lay on the abdominal wall. He was 
 taken to hospital, where he arrived in good condition and free 
 from pain. Six to seven feet of the small gut lay outside the 
 abdomen and perforated in several places. He made a good 
 recovery. 
 
 Sometimes a man hit in the abdomen will believe that the 
 injury is in the leg, a nerve having been injured and giving rise 
 to reflected pain. 
 
 Another man, who subsequently died of peritonitis from a 
 perforated ileum, when seen six hours after the injury was in 
 good condition, free from pain, cheerful, and smoking a 
 cigarette. 
 
 As a rule a man hit in the abdomen does, however, suffer 
 pain, often intense, which dates from the moment of infliction.
 
 136 War Surgery of the Abdomen 
 
 The suddenness of the pain recalls that experienced in gastric 
 perforation ; it may be accompanied by collapse, transient or 
 persistent. 
 
 Blows from large objects, such as shell caps, produce the 
 same sensation as does any violent blow, such as a kick from the 
 heels of a horse. 
 
 Small missiles may either cause a sharp stab or the feeling 
 as if a tremendous blow had been administered. This sensation 
 is also experienced in wounds of other parts of the body, and it 
 is interesting to remember that it is also felt by those that 
 rupture muscles while playing games. 
 
 The actual comparison of the amount of injury and the amount 
 of disturbance is a very difficult subject. There are many 
 obstacles in the way of accurately gauging the bearing that 
 trauma has on collapse. Regimental officers who see the cases 
 early can form no judgment beyond gross lesions as to the 
 amount of intraperitoneal damage, and by the time the cases 
 reach hospital it is impossible to exclude other factors in most 
 cases. 
 
 Exposure or prolapse of the upper hollow viscera causes 
 collapse, and so does avulsion of large portions of the abdominal 
 wall. 
 
 Multiple lesions of hollow viscera produce a high mortality, 
 but multiple lesions mean a long operation and are usually 
 accompanied by much bleeding. It seems that multiple lesions 
 are not great producers of collapse provided haemorrhage and 
 sepsis are absent. Recovery has followed as many as twenty 
 lesions. 
 
 Shattering wounds of spleen and kidney cannot be said to be 
 alarming injuries in themselves. Extensive wounds of the liver 
 are. Where both kidneys are involved death follows, but this 
 cannot be attributed to collapse. 
 
 Finally, three cases may be quoted to show that abdominal 
 injuries may at one time completely incapacitate a man and at 
 another do not at once prevent the individual from continuing 
 his work : 
 
 (1) An ambulance driver was hit in the abdomen by a shell 
 fragment. He experienced severe pain, became collapsed,
 
 Causes of Failure 137 
 
 broke out into a profuse sweat, and vomited. He continued 
 collapsed until the operation, which revealed perforative 
 lesions in the small gut and a considerable amount of blood in 
 the belly. He recovered. 
 
 (2) A bearer in the Royal Army Medical Corps wounded in 
 the intestine, as a subsequent operation proved, was brought 
 to an Advanced Dressing Station on a stretcher. As there 
 were many wounded to be attended to, he got up and gave a 
 hand. 
 
 (3) An airman was hit by a shell fragment far behind the 
 German lines. He brought his machine safely back and made a 
 good landing. He reached a hospital in good condition. Two 
 holes in the small gut were sewn up. He died of acute sepsis 
 of the retroperitoneal tissue after forty-eight hours. 
 
 Clinical Shock. 
 
 All the above-mentioned factors, namely mental and 
 physical strain, want of sleep, exposure to cold and wet, hunger, 
 thirst, horror, disturbance, sepsis, haemorrhage, and possibly in 
 addition " pure shock," acting singly or together in varying 
 proportions, cause shock as seen by the clinical surgeon. They 
 are operative both before and after operation, so that no dis- 
 tinction need be drawn. 
 
 Clinical shock * is usually characterised by a rapid, weak, 
 and sometimes imperceptible pulse, a low blood pressure, a 
 depressed body temperature. 
 
 As may be gathered from what has been said on a man's 
 sensations on being hit, shock commences in two ways. It may 
 come on soon after the receipt of the wound, the patient suddenly 
 collapsing, breaking out into a cold sweat, and vomiting. This 
 condition may pass off altogether, or pass off and again become 
 established, or may persist and deepen. In other cases it is 
 absent at first, but gradually develops, especially if the patient is 
 not artificially warmed. 
 
 A shocked man has a lowering of his blood alkalinity, and 
 
 * See report on shock to the Medical Research Committee by Messrs. Cannon, 
 Fraser, and Cowell.
 
 138 War Surgery of the Abdomen 
 
 this fall in alkalinity is accompanied by a fall in blood pressure. 
 What the actual relation between the two may be has not yet 
 been established. This loss of alkalinity is increased by opera- 
 tion and the administration of an anesthetic. 
 
 There are then three conditions to be combated in the 
 shocked man : a low body temperature, a low blood pressure, 
 and a low blood alkalinity. 
 
 A Low Body Temperature. The low temperature is due to a 
 decreased production of heat. A shocked man is almost like a 
 cold-blooded animal and tends to take the temperature of his 
 surroundings. The chill that a man feels when he suddenly 
 breaks out into a cold sweat is due to a constriction of surface- 
 vessels, but this subjective sensation of cold is soon replaced by 
 an actual fall in the body heat. The men wounded in the bomb 
 attack mentioned above were admitted into hospital so quickly 
 that they were actually warm when put to bed, but got cold 
 there before the artificial heat had time to act. 
 
 Observations have shown that if a man is adequately warmed 
 shock may be averted in many instances. The first place where 
 this can be properly done is the Regimental Aid-Post. It some- 
 times takes an hour and a half to reach this, even if evacuation 
 is possible. It is important, therefore, that blankets should be 
 attached to all stretchers. Morphia should be given as soon after 
 injury as possible. All Regimental Aid-Posts should, if possible, 
 be well warmed, and arrangements made for heating the wounded 
 man by placing him on a stretcher, which is converted into a 
 warm bed as follows. The stretcher is placed on trestles. The 
 blankets covering the stretcher are allowed to hang down over 
 the sides. The space beneath the stretcher is then converted 
 into a hot air chamber by placing a lamp in it. The man is laid 
 on a folded blanket, and the patient when sent on his journey is 
 covered, in addition, by the portions of the two blankets that 
 have so far hung down. He has thus four thicknesses of blanket 
 above and below him. At the Regimental Aid-Post wet clothes 
 are removed provided the atmosphere is warm and there are 
 substitutes. Hot fluids and a drachm of bicarbonate of soda 
 are also to be administered. 
 
 When the patient arrives at the Advanced Dressing
 
 Causes of Failure 139 
 
 Station he is again placed on a warmed stretcher and fluids 
 administered. 
 
 When the hospital is reached the man may be undressed and 
 put to bed if not in bad state. If in bad state he should again 
 be placed on a warmed stretcher, and when sufficiently recovered 
 undressed while still on the stretcher and then placed in bed 
 and the heating continued by means of the electric or hot air 
 cradle. Alkali should again be given by the mouth, if possible, 
 if there is no vomiting. 
 
 Warmth is the most potent restorative we have. 
 
 A Low Blood Pressure and Loss of Blood Alkalinity. The 
 weak and rapid pulse and low blood pressure are due (in some 
 cases, at all events) to a loss of blood volume. 
 
 This loss of blood volume may be caused by a direct haemor- 
 rhage, by stagnation of blood in certain vessels, or by the blood 
 fluids passing through the vessel walls into the body tissues. 
 
 As to stagnation of the blood in certain areas, it can be said 
 that there is no clinical evidence that it is stored up in the 
 abdominal viscera. 
 
 A discrepancy that has been noticed between the cutaneous 
 capillary and venous count may be caused by an extra-vascular 
 accumulation of blood fluids in the skin area. The pressure 
 may be raised by rest and quiet and by fluids administered by 
 the mouth or rectum. If no result occurs, the question of 
 infusion or transfusion will arise. It is somewhat doubtful 
 if either is worth doing if the patient shows no signs of 
 rallying after treatment by warmth and rest unless the patient 
 is obviously suffering from loss of blood. 
 
 Isotonic and hypertonic solutions are well nigh useless as 
 means of raising and sustaining the pressure, though they are 
 of use in increasing the blood alkalinity if bicarbonate of soda 
 is used instead of sodium chloride. 
 
 The choice therefore seems to be between blood transfusion 
 and Bayliss' 6 per cent. gu;ii in a 2 per cent, sodium bicarbonate 
 solution. 
 
 If a man has bled much transfusion is by far the best, but 
 Bayliss' solution is a good substitute if a donor is not available 
 or if the case is not thought sufficiently grave.
 
 140 War Surgery of the Abdomen 
 
 A question arises as to whether injection of fluids into^the 
 veins should be done before an operation centre is reached. In 
 deciding this point it may be doubted if it is wise to raise the 
 blood pressure before the source of the bleeding can be checked 
 by operation.
 
 CHAPTER X. 
 
 STATISTICS, RESULTS, AND THE FUTURE. 
 Mortality in the Preoperative Days. 
 
 THE expectant treatment of abdominal injuries was the method 
 of choice in the armies of all the combatants at the beginning of 
 the war. Gradually, on every side, the operative has replaced 
 the older method. 
 
 Although it is very difficult to compare the results of the two 
 methods, expectant and operative, some interest attaches to the 
 figures obtained in the two periods respectively. The figures 
 in the preoperative periods had to be taken from the admission 
 and discharge books of the Field Ambulances and Casualty 
 Clearing Stations, as no separate books were kept ; consequently 
 the figures could only be computed. In the second period special 
 books were used, and the figures may be taken as approximately 
 correct. 
 
 Into nine Field Ambulances over a period of six months there 
 were admitted 1,098 abdominal wounds, with 333 deaths a 
 mortality of 30 per cent. In the six Casualty Clearing Stations 
 during the same period there were admitted 131 cases of per- 
 forating abdominal wounds, with 73 deaths. From these figures 
 it appears that the total mortality in the Field Ambulances and 
 Clearing Stations was about 70 per cent. 
 
 There were also the deaths at the Base in France to be added, 
 and in the preoperative days to which we now allude many such 
 deaths occurred, which would, as far as can be judged, bring the 
 mortality up to about 80 per cent. Makins gives the death-rate 
 at the Base among small-gut wounds as 84 per cent., and among 
 colon wounds as 46 '4 per cent, in this period. 
 
 The period covered by these figures was the first six months 
 of 1915.
 
 142 War Surgery of the Abdomen 
 
 Method of recording Cases. 
 
 The figures quoted in this book (unless stated otherwise) are 
 based on all the abdominal wounds which reached an operating 
 hospital from a certain sector of the line over a period of 
 eighteen months (July 1st, 1915, to December 31st, 1916). The 
 beginning of this period coincided with the commencement of 
 the operative treatment. 
 
 In forming an estimate of the mortality of abdominal wounds, 
 and what can be done for them by operative treatment, it is 
 necessary to include all the cases, no matter at what hospital 
 they are treated. Results differ in different hospitals, more or 
 less depending upon their distance from the firing line ; they 
 will also differ according to the nature of the fighting ; they are 
 nearly always worse at the end of a fight than at the beginning, 
 for the cases admitted at the end have often been difficult to 
 collect and are therefore late in arriving. Again, if times are 
 quiet, there is plenty of time to treat all cases adequately and 
 deliberately ; at another time, when active operations are in 
 progress, it may be only possible to pay attention to the most 
 favourable cases. It is therefore necessary not only to reckon 
 the operative mortality, but also to bring into account all 
 cases which die without operation. This has been done in the 
 present series. In the case of the moribund, we have their 
 numbers, but we do not in every case possess details of the 
 injury. 
 
 The statistics were collected in the following way : Every 
 hospital which was called upon to treat abdominal cases was 
 provided with a book, in which certain headings were written 
 down, and these were filled in at the time of operation by the 
 medical officers. These books were provided by the Medical 
 Research Committee. 
 
 Comparative Mortality at Different Hospitals. 
 
 Table XXXI. shows the variations in results which may be 
 obtained in different hospitals.
 
 vStatistics, Results, and the Future 143 
 
 TABLE XXXI. Variations in the Results obtained in Different 
 
 Hospitals. 
 
 
 Mortality. 
 
 Unit. 
 
 Total. 
 
 Operative. 
 
 (1) A Casualty Clearing Station 
 
 54 
 
 45 
 
 (2) .... 
 
 72-7 
 
 
 
 (3) An abdominal hospital 
 
 36-4 
 
 
 
 (!) .... 
 
 82-6 
 
 48-8 
 
 (5) A Casualty Clearing Station 
 
 50 
 
 44-4 
 
 (6) An abdominal hospital 
 
 56-4 
 
 52-6 
 
 Note. (1), (2), (3), (4) During same battle. (5) Same as (1) but in a 
 quiet time. (6) Same as (3) in a quiet time over a six-months period. 
 
 TABLE XXXI.A. Results obtained in 1917 (Fighting and Quiet 
 Times) in Sectors that were adjacent. 
 
 Unit. 
 
 Total. 
 
 Operative. 
 
 A Casualty Clearing Station . . 
 
 >J 55 S> .... 
 
 An advanced operating centre 
 
 44-3 
 68-3 
 65 
 
 39-6 
 62-4 
 56-9 
 
 Mortality. 
 
 TABLE XXXI. B. Some other Results from other Portions of 
 the Line in 1916 during Fighting. 
 
 
 Total. 
 
 Operative. 
 
 (1) An advanced operating centre 
 
 G4-3 
 
 58-5 
 
 (2) A Casualty Clearing Station 
 
 65-8 
 
 51-9 
 
 (3) An advanced operating centre 
 
 
 
 51 
 
 (4) A Casualty Clearing Station 
 
 76-5 
 
 80-9 
 
 Mortality. 
 
 (4) Was situated behind (3) and only took in cases when (3) was 
 full, usually towards the end of a fight. 
 
 Results of Operative Treatment. 
 
 The period during which detailed statistics are available 
 covers the time between July 1st, 1915, and December 31st, 1916.
 
 144 
 
 War Surgery of the Abdomen 
 
 The results of the operative treatment have also been com- 
 piled up to September 30th, 1917. 
 
 TABLE XXXI. c. To show Results in Successive Periods. 
 
 
 
 July 1st, 
 1915, to 
 Dec. 31st, 
 1915. 
 
 July 1st, 
 1915, to 
 Dec. 31st, 
 1916. 
 
 July 1st, 
 1915, to 
 Sept. 30th, 
 1917. 
 
 Jan. 1st, 
 1917, to 
 Sept. 30th, 
 1917. 
 
 Total cases . . 
 
 
 511 
 
 1,288 
 
 2,127 
 
 839 
 
 Moribund cases 
 
 
 145 
 
 250 
 
 420 
 
 170 
 
 Total mortality, 
 
 excluding 
 
 
 
 
 
 moribund . . 
 
 . . . . 
 
 45-8 
 
 50-06 
 
 50-02 
 
 49 
 
 Total mortality, 
 
 including 
 
 
 
 
 
 moribund . . 
 
 , , 
 
 01-25 
 
 60-2 
 
 59-9 
 
 59-5 
 
 Considered with 
 
 view to 
 
 
 
 
 
 operation . . 
 
 . . . . 
 
 366 
 
 1,038 
 
 1,707 
 
 669 
 
 Operation not thought neces- 
 
 
 
 
 
 sary 
 
 . . 
 
 56 
 
 73 
 
 102 
 
 29 
 
 Total operations 
 
 . . 
 
 310 
 
 965 
 
 1,605 
 
 640 
 
 Total operative mortality . . 
 
 53-9 
 
 53-9 
 
 52-9 
 
 51-3 
 
 Hollow viscera 
 
 > 
 
 64-5 
 
 64-7 
 
 
 
 
 
 Stomach* 
 
 > 
 
 43-75 
 
 52-7 
 
 
 
 
 
 Small gut* 
 
 
 
 63-8 
 
 65-9 
 
 . 
 
 
 
 Colon* 
 
 ? 
 
 60 
 
 58-7 
 
 
 
 
 
 " Uncomplicated by any other lesion of the alimentary canal. 
 
 The above table shows the results obtained over extending 
 periods of time, starting from the commencement of the opera- 
 tive treatment. The first and latest periods can be compared in 
 first and last columns. 
 
 The uniformity of the figures is rather remarkable. 
 
 TABLE XXXII. Short Table of Operations, showing also the 
 Number of Operated and Non-operated Cases, July 1st, 
 1915, to December 3lst, 1916. 
 
 Operations. 
 
 To Base. 
 
 Died. 
 
 (1) Suture of stomach 
 (2) ,, ,, and other operations on 
 the intestinal tube 
 (3) Resection of small gut 
 (4) ,, ., and other operations 
 on the intestinal tube not included in (2) . . 
 
 26 
 
 6 
 26 
 
 5 
 
 29 
 
 21 
 
 89 
 
 34
 
 Statistics, Results, and the Future 
 TABLE XXXII. Continued. 
 
 '45 
 
 Operations. 
 
 To Base. 
 
 Died. 
 
 (5) Suture of small gut . . 
 
 (G) and other operations on 
 
 the intestinal tube not included in (2) 
 
 (7) Formation of small-gut anus 
 
 (8) For small-gut fistula 
 
 (9) Suture of colon 
 
 (10) Formation of colon anus 
 
 (11) For wounded rectum (proximal colostomy 
 
 not included) 
 
 (12) Proximal colostomy 
 
 (13) Coeliotomy, no hollow viscus perforated . . 
 
 (14) ,, liver wounded 
 
 (15) Kidney, exploration of 
 
 (10) excision of . . . . 
 (17; For wounded bladder 
 
 (18) Spleen, exploration of 
 
 (19) excision of . . 
 
 (20) Miscellaneous operations 
 
 (21) No operation advised 
 
 (22) ,, moribund 
 
 Totals 
 
 Grand total 
 
 59 
 17 
 
 2 
 
 50 
 13 
 
 3 
 
 4 
 
 89 
 76 
 25 
 
 G 
 
 11 
 12 
 
 4 
 
 10 
 69 
 
 71 
 
 513 
 
 775 
 
 1,288 
 
 TABLE XXXIII. Details of Operations, etc., shown in 
 Table XXXII. 
 
 Operations. 
 
 To Base. 
 
 Died. 
 
 Total. 
 
 Suture of stomach 
 
 26 
 
 29 
 
 55 
 
 ,, ,, and small gut 
 
 4 6 
 
 10 
 
 Suture of stomach and small gut ; gastro- 
 
 
 
 
 jejunostomy 
 
 
 
 2 
 
 2 
 
 Suture of stomach and great gut 
 
 2 
 
 3 
 
 5 
 
 ,, ,, colon ; gastro-jejunostomy 
 
 
 
 1 
 
 1 
 
 ,, ,, small gut, and colon 
 
 
 
 3 
 
 3 
 
 Suture of stomach ; resection of small gut ; 
 
 
 
 
 gastro-jejunostomy 
 
 
 
 2 
 
 2 
 
 Suture of stomach and colon ; resection of 
 
 
 
 
 small gut 
 
 
 
 1 
 
 1 
 
 W.S.A. 10
 
 146 War Surgery of the Abdomen 
 
 TABLE XXXIII. Continued. 
 
 Operations. 
 
 To Base 
 
 Died. 
 
 Total. 
 
 Suture of stomach ; resection of small gut ; 
 
 
 
 
 gastro-jejunostomy ; colon anus 
 
 
 
 1 
 
 1 
 
 Suture of stomach ; colon anus 
 
 
 
 2 
 
 2 
 
 Resection of small gut ; circular enterorrhaphy 
 
 18 
 
 69 
 
 87 
 
 lateral anastomosis . . 
 
 8 
 
 18 
 
 26 
 
 gastro-jcjunostomy . . 
 
 
 
 2 
 
 2 
 
 suture of colon 
 
 4 
 
 17 
 
 21 
 
 colon anus 
 
 1 
 
 14 
 
 15 
 
 suture of rectum 
 
 
 
 3 
 
 3 
 
 Suture of small gut 
 
 59 
 
 71 
 
 130 
 
 ,, ,, and colon. . 
 
 16 
 
 26 
 
 12 
 
 Suture of small gut ; resection of colon 
 
 
 
 1 
 
 1 
 
 ,, ,, colon anus 
 
 1 
 
 5 
 
 6 
 
 Suture of small gut and rectum 
 
 
 
 1 
 
 1 
 
 Small-gut anus . . 
 
 
 
 7 
 
 7 
 
 ,, fistula 
 
 2 
 
 1 
 
 3 
 
 Suture of colon 
 
 
 
 
 Caecum 
 
 8 
 
 5 
 
 13 
 
 Ascending colon 
 
 13 
 
 12 
 
 25 
 
 Hepatic flexure 
 
 7 
 
 9 
 
 16 
 
 Transverse colon 
 
 5 
 
 8 
 
 13 
 
 Splenic flexure 
 
 4 
 
 6 
 
 10 
 
 Descending colon 
 
 6 
 
 3 
 
 9 
 
 Pelvic colon 
 
 7 
 
 9 
 
 16 
 
 Colon anus 
 
 13 
 
 36 
 
 49 
 
 On rectum, intraperitoneal wounds 
 
 1 
 
 2 
 
 3 
 
 ,, extraperitoneal ,, 
 
 2 
 
 3 
 
 5 
 
 Proximal colostomy 
 
 4 
 
 10 
 
 1 I 
 
 Cosliotomy, no hollow viscus perforated 
 
 77 
 
 30 
 
 107 
 
 non-penetrating wounds 
 
 12 
 
 3 
 
 15 
 
 On liver 
 
 76 
 
 38 
 
 114 
 
 On kidney : exploration 
 
 25 
 
 7 
 
 32 
 
 nephrectomy 
 
 6 
 
 7 
 
 13 
 
 For wounds of bladder 
 
 
 
 
 Extraperitoneal 
 
 
 
 
 Suprapubic 
 
 6 
 
 9 
 
 15 
 
 Drainage of wound 
 
 3 
 
 1 
 
 4 
 
 Suture 
 
 
 
 1 
 
 1 
 
 Intrape ritoneal 
 
 
 
 
 Suprapubic 
 
 
 
 1 
 
 1 
 
 Suture 
 
 2 
 
 2 
 
 1 
 
 For wounds of spleen : exploration . . 
 
 12 
 
 \. 
 
 16 
 
 >. ,, N|)lcnectomy 
 
 1 
 
 12 
 
 16 
 
 For faecal abscess 
 
 1 
 
 6 
 
 7 
 
 For loss of belly wall 
 
 
 
 1 
 
 1 
 
 For prolapse of viscera. . 
 
 6 
 
 3 
 
 9
 
 Statistics, Results, and the Future 147 
 TABLE XXXIII. Continued. 
 
 Operations. 
 
 To Base. 
 
 Died. 
 
 Total. 
 
 Tube to pelvis 
 
 
 
 4 
 
 4 
 
 For contusion of belly 
 
 
 
 2 
 
 2 
 
 Loin wound enlarged 
 
 3 
 
 2 
 
 5 
 
 No operation (no indication) 
 
 69 
 
 4 
 
 73 
 
 moribund 
 
 ~ 
 
 250 
 
 250 
 
 Note. This table shows the number of individuals operated upon. 
 In the case of the intestinal tract it shows the number of times the 
 different parts were hit. The bladder and solid organs only appear 
 in the table when they were the principal viscera damaged. 
 
 The Future. 
 
 There can be no doubt that the success obtained has been 
 due to several factors. These are mainly 
 
 (1) The magnificent way in which the wounded are collected 
 by the bearers, both regimental and those belonging to the 
 Field Ambulances. Honestly, one cannot sufficiently express 
 one's admiration for their courage, steadfastness, and endurance. 
 
 (2) The motor ambulances of the Field Ambulances and of 
 the motor convoys. What praise is not due to the drivers 
 who in darkness and shell-fire tenderly pick their way among the 
 holes in the road so as to avoid a needless jolt to their wounded 
 charges ? 
 
 (3) The fixity of the fighting line, which has allowed the 
 Clearing Station to develop to its present condition. 
 
 (4) The wisdom of those that administer the Royal Army 
 Medical Corps in that they have abandoned the old tradition 
 that operations cannot be performed near a fighting area. 
 
 Can the past results be maintained if the fighting becomes 
 open and the armies get on the move ? Motor ambulances can 
 diminish distance, but they cannot entirely obliterate it. 
 
 It all depends on whether the Casualty Clearing Stations can 
 be moved sufficiently quickly.
 
 INDEX 
 
 ABDOMEN, 
 flushing the, 63 
 rigidity in, 54 
 Abdominal drainage, 63 
 hospitals, 46, 49, 143 
 surgery, 1, 9, 13 
 
 causes of failure, 129 
 
 comparative mortality at different 
 
 hospitals, 142 
 complicating injuries, 129 
 future outlook, 147 
 haemorrhage in, 130 
 mental and physical strain, 129 
 method of recording cases, 142 
 mortality in pre-operative days, 141 
 mortality statistics, 6 
 results in 19161917, 143 
 results in successive periods, 144 
 results of operative treatment, 143 
 statistics, results and the future, 141 
 variations in results in different 
 
 hospitals, 143 
 viscera wounded in abdomino-thoracic 
 
 injuries, 121 
 
 wall, haemorrhage from, 131 
 wounds, commencement of operative 
 
 treatment, 9 
 nature of the projectiles causing, 14, 
 
 16 
 
 question of operation, 59 
 relative frequency of, 14 
 relative number of different pro- 
 jectiles and the proportion re- 
 tained, 18 
 
 selection of cases for rapid evacua- 
 tion, 13 
 
 surgical opinion when war started, 4 
 Abdomino-thoracic wounds, 22 
 abdominal organs wounded, 121 
 diaphragmatic lesions, 120 
 frequency of, 119 
 influence of wounds of hollow viscera 
 
 on mortality, 122 
 influence on mortality, 124 
 injuries to individual organs, table, 122 
 mortality and causes of death, 124 
 nature of projectiles, 120 
 organs herniated, 120 
 projectiles causing, 120 
 side wounds, 119 
 treatment of, 122 
 viscera, wounded, table, 121 
 Advanced dressing station, 46 
 
 position of, 13 
 
 Advanced operating centre, 13 
 Alimentary canal, 
 
 state of, in respect of nervo-muscular 
 
 mechanism, 42 
 in respect to its contents, 41 
 wounds of, in respect to contents, 41 
 Alimentary organs, solid, wounds of, 100 
 Allies, experiences of the, 9 
 
 Antero-posterior wounds 
 
 below intertubercular plane, 28 
 between transpyloric and intertuber- 
 cular planes, 27 
 
 Antiseptics, 2 
 
 Anus, artificial, 92 
 
 Armour, defensive, 19 
 
 Asepsis, 2 
 
 BACK, wounds on, to be first treated, 60 
 Base, information from, to the Front, 38 
 Bayonet wounds, 18 
 Belgian Army, abdominal hospitals of, 
 
 49 
 
 Bile, escape of, 103 
 Bladder, wounds of, 
 
 associated injuries, 116 
 complicating small intestine wounds, 
 
 high mortality of, 82 
 frequency of, 116 
 mortality and causes of death, 118 
 nature of injuries, 117 
 symptoms of, 117 
 table of, 116 
 treatment of, 117 
 Blood, 
 
 alkalinity of, 137 
 loss in shock, 139 
 Blood pressure, low, in shock, 139 
 Blood-vessels, injuries of, 131 
 Bomb wounds, 52 
 Bombs, 17, 19 
 
 Bone fragments, indriven, damage by, 32 
 Bullets, 
 
 "explosive effect" of, 37, 39 
 injuries of small intestine by, 72, 74 
 nature of wounds caused by, 15, 19 
 varieties of, 14, 16 
 velocity and stability of, 15, 37 
 wounds, types of, 35 
 Buttock wounds, 22 
 
 CAECUM, wounds of, 83, 84, 87 
 
 treatment of, 91 
 Cases, method of recording, 142 
 Casualty clearing stations, 7, 13, 46, 143 
 Chest, abdomino-thoracic wounds, 22. 
 
 See also Abdomino-thoracic wounds. 
 Clinical shock, 137 
 Coeliotomy, 29 
 Collapse, amount of, relation between 
 
 injury and, 134, 135 
 Collection and evacuation of wounded, 11 
 Colon, 
 
 ascending, wounds of, treatment of, 
 
 88, 91 
 character of lesions in different parts 
 
 of, 87 
 descending, wounds of, treatment of, 
 
 88, 91 
 
 flexures of, wounds of, 89, 91 
 healing of, 31
 
 I ndex 
 
 149 
 
 Colon continued. 
 
 hollow viscera injured in conjunction 
 with, 83 
 
 injuries of, table, 92 
 
 mortality of different parts of, 93 
 
 pelvic, wounds of, 89, 91 
 
 " septicaemia," 89 
 
 transverse, wounds of, 87, 91 
 
 wounds of, mortality of, 92, 93 
 Colostomy 
 
 in rectal injuries, 95 
 
 proximal, 92 
 
 DIAGNOSIS, 
 
 appearance in, 52 
 
 considered generally, 51 
 
 experience in, 52 
 
 inspection in, 51 
 
 intrapcritoneal damage, 51 
 
 symptoms in, 52 
 Diaphragmatic herniae, 124 
 
 colic form, 126 
 
 gastric form, 126 
 
 morbid anatomy, 125 
 
 organs herniated, 125 
 
 physical signs, 126 
 
 symptoms of, 125 
 
 treatment of, 127 
 
 X-ray examination, 127 
 Diaphragmatic lesions, 120 
 Drainage, abdominal, 63 
 Drink before operations, 57 
 
 EPIGASTRIC wounds, 26 
 
 Evacuation of wounded, 11 
 in earlier period of the war, 7 
 rapid, selection of cases for, 13 
 
 Expectant treatment, 1, 4, 6, 9 
 
 " Explosive effect " of bullets, 37, 39 
 
 FIELD ambulance, 47 
 
 Fluids, withholding, before operation, 57 
 
 Flushing the abdomen, 63 
 
 Fractures, compound, 2 
 
 France, abdominal surgery in, 9 
 
 French Army, abdominal hospitals of, 49 
 
 bullets, 15 
 
 Frequency of different projectiles met 
 with and of those retained, 19 
 
 of stoms-ch wounds, 65 
 
 of wounds of different viscera, 24, 41 
 
 relative, of abdominal wounds, 14 
 Front, information to, from Base, 3, 8 
 
 (' \\CUEXE, gas, 133 
 
 Genito -urinary organs, wounds of, 109 
 
 German bullets, 15 
 
 Grenades, 17, 19 
 
 II KMATURIA in wounds of kidney, 111 
 Hemorrhage 
 
 chief cause of early death, 10 
 
 in abdominal surgery, 130 
 
 in diagnosis, 54 
 
 in wounds of liver, 102, 103 
 
 in wounds of stomach, 69 
 Helmets, steel, 19 
 Herniae, diaphragmatic, 124 
 High-explosive shells, 16, 17 
 
 Hospital, 
 
 preparation of patient for operation, 58 
 variation in results, 143 
 Hypochondriac area, wounds of, 21, 22 
 wounds, an tero -posterior, oblique and 
 
 vertical, 26 
 
 lateral and posterior, 27 
 Hypogastric wounds, 21 
 
 INCIDENCE of abdominal wounds, 20 
 
 regional, of wounds, 21, 22 
 Incision, 
 
 closure of, 62 
 site of, 60 
 transverse, 61 
 vertical, 61 
 
 Incisions in intestinal operations, 90 
 Infarction, 84 
 Injuries, relative frequency of organs 
 
 involved, 24, 41 
 Injury and amount of collapse, relation 
 
 between, 134, 135, 136 
 Inspection in diagnosis, 51 
 Intertubercular plane, wounds below, 28 
 Intestine and intestines, 
 
 condition of, post-operative, 63 
 large, associated wounds of other 
 
 viscera, 83 
 wounds of, character in different 
 
 parts, 87 
 
 escape of contents, 87 
 frequency of, 82 
 infarction, 84 
 
 method of dealing with lesions, 90 
 mortality and causes of death, 92 
 in respect to its contents, 42 
 nature of injuries, 83 
 protrusion of, 98 
 proximal colostomy, 92 
 symptoms, 89 
 treatment of, 90 
 
 ulceration of mucous membrane, 84 
 resection of, length involved, 76 
 short-circuiting of, 80 
 small, divided in seven places by rifle 
 
 bullet, 36 
 
 haemorrhage from wall, 130 
 healing of, 31 
 rupture of, 34 
 state of, in respect to nervo-muscular 
 
 mechanism, 43 
 
 state of, in respect to its contents, 41 
 suture of, circular and lateral, table 
 
 of results, 80 
 wounds of, 41, 76 
 
 associated wounds of other organs, 
 
 71 
 
 average number in fatal and suc- 
 cessful cases, 82 
 by bombs, 75 
 by bullets, 72, 74 
 by shell fragments, 74 
 circular v. lateral suture, 80 
 different parts compared, 82 
 frequency of, 71 
 
 intimate nature of the lesion, 75 
 length of bowel involved, 76
 
 Index 
 
 Intestine and intestines continued. 
 1 small, wounds of continued. 
 lesions of mesentery, 75 
 microscopical appearance, 75, 77 
 mortality and causes of death, 81 
 mortality, high, of associated 
 
 bladder wounds, 82 
 mortality of operative and pre- 
 
 operative periods, 93 
 nature of, 71 
 number of injuries, 76 
 results of suture and resection, 79 
 sepsis in, 81 
 
 suture or resection, 79, 80 
 treatment of a prolapsed knuckle, 
 
 81 
 
 traumatic paralysis of, 44 
 wounds of, 4, 66 
 Intraperitoneal 
 
 damage, diagnosis of, 51 
 wounds, 117 
 
 JAUNDICE in wounds of liver, 103 
 Jejunum, 
 
 gunshot perforation, 73, 78 
 
 lacerated wounds caused by rifle 
 grenade, 75 
 
 KIDNEY, 
 
 bullet wound of, 110, 112 
 comminution of upper half of, 113 
 indirect effects of gunshot, 33 
 minimal injury to, 114 
 oblique perforation of, 111 
 wounds of, associated injuries, 109 
 
 complicated with wounds of other 
 organs, 109 
 
 excretion of urine, 111 
 
 extravasation of urine, 111 
 
 frequency of, 109 
 
 hsematuria, 111 
 
 mortality and causes of death, 115 
 
 nature of lesions, 109 
 
 operations for, table, 115 
 
 secondary complications, 112 
 
 symptoms, 1 10 
 
 treatment of, 114 
 
 LIVER, 
 
 penetrating wound of, 102 
 
 rupture and laceration of, by bullet, 38 
 
 vertical wound of, 101 
 
 wounds of, associated wounds of other 
 
 organs, 100 
 biliary function, 103 
 frequency of, 100 
 haemorrhage in, 102, 103 
 mortality and causes of death, 104 
 nature of injuries, 100 
 organs injured in conjunction with, 
 
 100 
 
 symptoms of, 102 
 
 treatment of, 104 
 
 Lungs, wounds of, 123, 125 
 
 MECHANISM of wound production after 
 
 penetration, 34 
 Mental strain and abdominal injuries, 129 
 
 Mesentery, 
 
 haemorrhage from, 130 
 lesions of, 75 
 Mid-line wounds, 21 
 
 Missile, direction of, and position of 
 
 wound, influence on prognosis, 21 
 
 Moribund cases, table showing injuries 
 
 in, 24 
 
 Morphia, administration of, before opera- 
 tion, 57 
 Mortality, 
 
 comparative, at different hospitals, 142 
 effect of time of operation, 45 
 in pre-operative days, 141 
 increased by complications of wounds 
 
 of small intestine, table, 81 
 influence of abdomino-thoracic wounds 
 
 on, table, 124 
 
 .influence of wounds of hollow viscera 
 in abdomino-thoracic injuries, 122 
 of colon wounds, 92 
 of different parts of spleen, table, 93 
 of liver wounds, 104 
 of resections and sutures of small 
 
 intestine, causes of, 81 
 of small intestine and colon wounds, 
 operative and pre-operative 
 periods, 93 
 
 of stomach wounds, 70 
 of various projectiles, 20 
 relative, of different projectiles, 20 
 statistics in abdominal surgery, 6 
 
 NEPHRECTOMY, table of operations, 115 
 Nervo-muscular mechanism in alimentary 
 canal, 42 
 
 (ESOPHAGUS, wounds of, 65 
 Omentum, 
 
 behaviour of, in abdominal wounds, 98 
 
 haemorrhage from, 130 
 
 protrusion of, 96 
 Operating vans, mobile, 47 
 Operation, 
 
 care of patient before, 57 
 
 cases not suitable for, 59 
 
 cases too serious for, 21 
 
 progress of patients after, 64 
 
 question of, decisions, 59 
 
 recoveries without, 25 
 
 wound, sepsis from, 134 
 Operations, table of, 144, 145 
 Operative treatment, commencement of, 
 
 9 
 
 Organs, abdominal, frequency of wounds 
 of, 24, 41 
 
 wounded in abdomino-thoracic in- 
 juries, table, 122 
 
 PAIN in diagnosis, 56 
 Pancreas, wounds of, 
 
 associated injuries, 105 
 
 frequency of, 105 
 
 prognosis, 105 
 Patients, 
 
 care of, before operation, 57 
 in hospital before operation, 58 
 
 progress after operation, 64
 
 Index 
 
 Peritoneal cavity, treatment of, 63 
 
 Peritoneum, care of, 62 
 
 Peritonitis, 131 
 
 Physical strain and abdominal injuries, 
 
 129 
 
 Posterior and lateral wounds of hypo- 
 chondriac regions, 27 
 Post-operative treatment, 63 
 Prognosis, effect of pulse, 53 
 influence of position of wound and 
 
 direction of missile, 21 
 Projectile wound, sepsis from, 134 
 Projectiles causing abdomino-thoracic 
 
 wounds, 120 
 different, relative frequency met with, 
 
 and of those retained, 19 
 nature of, 
 bayonet, 18 
 bombs, 17 
 bullets, 14 
 grenades, 17 
 high-explosive shells, 17 
 shell fragments, 15 
 shrapnel, 17 
 trench mortars, 18, 
 which cause the wounds, 14, 16 
 proportion retained in wounds, 19 
 relative mortality of different, 20 
 Protrusion of omentum and viscera, 96 
 
 of viscera, 120, 125 
 Pulse, 
 
 effect of prognosis on, 53 
 in diagnosis, 53 
 
 RECTUM, 
 
 injuries of, table, 94 
 large perforation of, 97 
 wounds of, associated injuries, 94 
 character of lesions, 94 
 frequency of, 94 
 treatment of, 95 
 Regimental aid -post, 46 
 
 position of, 11 
 
 Regional incidence of wounds, 21, 22 
 Resection, 
 
 in treatment of wounds of small intes- 
 tine, 79 
 of small intestine, causes of death, 81 
 
 table of results, 79 
 Results of operative treatment, 143 
 Retro peritoneal sepsis, 133 
 
 tissue, haemorrhage from, 130 
 Rigidity in diagnosis, 54 
 Rupture and laceration of liver by 
 
 bullet, 38 
 of hollow organs by indirect violence, 
 
 33 
 of solid organs by indirect violence of 
 
 passing projectile, 32 
 of viscera by contusion of stomach, 
 
 32 
 outside actual course of projectile, 32 
 
 SKMI- VERTICAL wounds below inter- 
 tubercular plane, 28 
 Sepsis from operation wound, 134 
 irom projectile wound, 134 
 
 Sep ?is contin ued. 
 
 in wounds of small intestine, 81 
 retro peritoneal, 133 
 Septic absorption, 131 
 Shell-caps, 17 
 Shell fragments, 15, 16 
 Shells, high-explosive, 16, 17 
 
 position of burst in relation to wound, 
 
 17 
 Shock, 
 
 body temperature in, 138 
 characteristics of, 138 
 clinical, 137 
 
 loss of blood alkalinity in, 139 
 low blood pressure in, 139 
 Shrapnel, 17 
 Side-to-side wounds, 21, 22 
 
 below intertubercular plane, 28 
 Solid organs, haemorrhage from, 131 
 South African War, influence on surgical 
 
 opinion, 4, 6 
 Spinal abdomen, significance of, in 
 
 diagnosis, 56 
 Spleen, 
 
 bullet wound of, 108 
 complicating injuries of, 106 
 wounds of, associated injuries, 106 
 frequency of, 106 
 mortality and causes of death, 108 
 nature of injuries, 106 
 symptoms of, 106 
 treatment of, 107 
 Statistics, comparative, 141 
 Stomach, 
 
 bullet wound of anterior wall, 68 
 
 haemorrhage from, 130 
 
 healing of, 30 
 
 protrusion of, 98 
 
 wounds of, associated wounds of 
 
 hollow viscera, 66 
 
 associated wounds of solid viscera, 67 
 frequency of, 65 
 haemorrhage and complications, 69, 
 
 70 
 
 in respect to nervo-muscular mecha- 
 nism, 42 
 
 in respect to its contents, 41 
 mortality and causes of death, 70 
 nature of, 67, 69 
 prognosis, 70 
 
 secondary complications, 70 
 situation of injury, 66 
 symptoms, 69 
 treatment of, 69 
 Strain, mental and physical, 129 
 Stretcher-bearers, 11 
 Stretchers, kinds of, 12 
 Surgery, 
 
 abdominal, causes of failure, 129 
 exchange of knowledge, 3 
 experiences of the Allies, 9 
 opinion when the war started, 4 
 utility of former experience, 2 
 war and civil conditions, 1 
 Suture, 
 
 circular and lateral, of wounds of small 
 intestine, table of results, 80
 
 152 
 
 Index 
 
 Suturo continued. 
 
 in treatment of wounds of small intes- 
 tine, 7!) 
 of small intestine, causes of death, 81 
 
 table of results, 79 
 Symptoms in diagnosis, 52 
 
 TEMPERATURE, body, in shock, 138 
 
 Tenderness in diagnosis, 56 
 
 Thorax. See Chest ; see also Abdomino- 
 
 thoracic wounds. 
 
 Time and mortality, effect of, table, 45 
 Transit to hospital, care of patient 
 
 during, 57 
 Transpyloric and intertubercular planes, 
 
 wounds between, 27 
 Transpyloric plane, wounds above, 25 
 Treatment, 
 
 considered generallj', 51 
 
 expectant, 1, 4, 6, 9 
 
 method of, in earlier period of the 
 war, 7 
 
 of abdomino-thoracic wounds, 122 
 
 of bladder wounds, 117 
 
 of diaphragmatic hernke, 127 
 
 of kidney wounds, 114 
 
 of large intestine wounds, 90 
 
 of liver wounds, 104 
 
 of peritoneal cavity, 63 
 
 of rectum wounds, 95 
 
 of small intestine wounds, 76 
 
 of spleen wounds, 107 
 
 of stomach wounds, 69 
 
 operative, commencement of, 9 
 results of, 143 
 
 post-operative, 63 
 Trench mortars, 18 
 Trenches, carriage of wounded along, 12 
 
 ULCERATION of mucous membrane of 
 
 large intestine, 84 86 
 Units, sympathetic working between, 4, 8 
 Ureter, wounds of, 116 
 Urine, 
 
 excretion of, in wounds of kidney, 111 
 extravasation of, in wounds of kidnev, 
 111 
 
 VEINS, injection of fluids into, 139 
 Velocity and stability of modern bullets, 
 
 15,37 
 
 of shell fragments, 17 
 Viscera, 
 
 abdominal, wounded in abdomino- 
 thoracic injuries, table, 121 
 comparative frequency of wounds of, 
 
 41 
 
 escape of, in penetrating wounds, 29 
 hollow, injured with different parts of 
 
 colon, ,s:{ 
 possibility of spontaneous recovery 
 
 after perforation of, 30 
 rupture of, 33 
 
 wounds of, influence on mortality 
 in abdomino-thoracic injuries, 
 
 122 
 treatment, 65 
 
 Viscera continued. 
 
 injury of, by bone fragments, 32 
 protrusion of, 90, 120, 125 
 rupture of, by contusion of stomach, .'52 
 outside actual course of projectile, 32 
 wounded in abdomino-thoracic in- 
 juries, 121 
 wounds of, associated with wounds of 
 
 stomach, 60, 67 
 Vomiting in diagnosis, f>4 
 
 WAR, 
 
 method of treatment in earlier period 
 
 of, 7 
 
 surgery as distinct from civil surgery, 1 
 surgical opinion at commencement of, 4 
 Water, withholding, before operation, 57 
 Wounded, 
 
 cases too serious for operation, 21 
 collection and evacuation of, 1 1 
 evacuation of, in earlier period of the 
 
 war, 7 
 
 mental attitude of, 8 
 selection of cases for rapid evacuation, 
 
 13 
 Wounds, abdominal, cases recovering 
 
 without operation, 25 
 cases too serious for operation, 21 
 effects of time on mortality, 45 
 general incidence of, 20 
 nature of projectiles causing, 14, 16 
 present arrangements in French and 
 
 Belgian Armies, 49 
 relative frequency of, 14 
 table showing injuries in moribund 
 
 cases, 24 
 
 where to operate, 45 49 
 above transpyloric plane, 25 
 antero-posterior hypochondriac, 20 
 below intertubercular plane, 28 
 between transpyloric and inter- 
 tubercular planes, 27 
 epigastric, 26 
 
 in moribund cases, table of, 24 
 oblique epigastric and hypochondriac, 
 
 26 
 of hollow alimentary organs, treatment 
 
 of, 65 
 
 of oesophagus, <)."> 
 of stomach, frequency of, 65 
 
 situation of, 66 
 of viscera, comparative frequency of, 
 
 41 
 
 on back to be first treated, 60 
 penetrating, possibility of escape of 
 
 viscera, 29 
 position of, and direction of missile, 
 
 influence on prognosis, 21 
 posterior and lateral wounds of hypo- 
 chondriac regions, 27 
 production after penetration, mecha- 
 nism of, 40 
 
 vertical epigastric and hypochondriac, 
 26 
 
 X-RAYS, value of, 01 
 
 THE WHITEHRIAKS I'RESS, LTD., LONDON AND TOJJBB1DGE.
 
 ANGELES, CAUFORN,A9oi 
 
 which it was borrow^
 
 3 1970 00315 1542 
 
 000 450 703 4 
 
 I 
 
 CO 
 
 Wallace, Sir Cuthbert S 
 
 War surgery of the abdomen. 
 
 WO 800 
 
 Wl87v 
 
 1918 
 
 CJ 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664
 
 Univer 
 
 Sou 
 
 Lit