Surgical Experiences in South Africa, 1899-1900 / Being Mainly a Clinical Study of the Nature and Effects of Injuries Produced by Bullets of Small Calibre

by George Henry Makins

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

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

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

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

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

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

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

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

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

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