Beyond these more or less pure perforations, long slits or gutters were occasionally cut. I saw instances of these in the case of the ascending colon, and in the small curvature of the stomach. The comparative fixity of the portion of bowel struck is a matter of great importance in the production of this form of injury.
Fig. 88.
The same piece of Intestine as that shown in fig. 87, laid open to show the ecchymosis on the inner aspect of the Bowel. The two indicating lines lead to the openings, which appear slit-like, and are sunk at the bottom of folds. (St. Thomas's Hospital Museum)
It may be well to add that, although the figures inserted are all taken from small-intestine wounds, the nature of the wounds of the peritoneum-clad part of the large intestine in no way differed from them, except in so far as fixity of the bowel exposed it to a more extensive wound when the bullet took a parallel course to its long axis.
A more important point in the injuries to the large intestine was the possibility of an extra-peritoneal wound. I saw several such lesions of the colon, every one of which ended fatally. I became still more fully convinced of the greater seriousness of extra- to intra-peritoneal rupture of this portion of the gut than I was when I expressed a similar opinion in a former paper.[20] It will be seen later that the results of intra- and extra-peritoneal wounds of the bladder fully confirm this view, as all extra-peritoneal injuries died, while many intra-peritoneal perforations recovered spontaneously.
Wounds of the mesentery.—I had little experience of this injury; in fact, case 169, on which I operated, was my sole observation. It stands to reason, however, that injuries to the mesentery would be much more frequent proportionately to wounds of the gut than is the case in the ruptures seen in civil practice, since the whole area of the mesentery is equally open to injury. Viewing the extreme danger of hæmorrhage into the peritoneal cavity in these injuries, I should be inclined to expect that a considerable proportion of those deaths from abdominal wounds which took place on the field of battle were due to this source.
Wounds of the omentum.—Here, again, I am unable to express any opinion, although the supposition that hæmorrhage from this source took place is natural.
Prolapse of omentum was comparatively rare, except in cases with large wounds; it was apparently seen with some frequency among patients who died rapidly on the field of battle. I only saw it twice, and on each occasion in shell wounds. The wounds from small-calibre bullets were as a rule too small to allow of external prolapse.
Fig. 89, however, illustrates a very interesting observation. A patient in the German Ambulance in Heilbron, under Dr. Flockemann, died as a result of suppuration and hæmorrhage secondary to an injury to the colon. At the autopsy a portion of the omentum was found adherent in the wound of exit, but it had not reached the external surface. The chief interest of the observation lies in the light it throws on the mechanism of these injuries. It is impossible to conceive that a small-calibre bullet coming into direct contact with the omentum could do anything but perforate it. It, therefore, appears clear that in a displacement like that figured, only lateral impact occurred with the omentum, which was carried along by the spin and rush of the bullet into the canal of exit, where it lodged.