cept in cases with large
wounds; it was apparently seen with some frequency among patients who
died rapidly on the field of battle. I only saw it twice, and on each
occasion in shell wounds. The wounds from small-calibre bullets were as
a rule too small to allow of external prolapse.

Fig. 89, however, illustrates a very interesting observation. A patient
in the German Ambulance in Heilbron, under Dr. Flockemann, died as a
result of suppuration and haemorrhage secondary to an injury to the
colon. At the autopsy a portion of the omentum was found adherent in the
wound of exit, but it had not reached the external surface. The chief
interest of the observation lies in the light it throws on the mechanism
of these injuries. It is impossible to conceive that a small-calibre
bullet coming into direct contact with the omentum could do anything but
perforate it. It, therefore, appears clear that in a displacement like
that figured, only lateral impact occurred with the omentum, which was
carried along by the spin and rush of the bullet into the canal of exit,
where it lodged.

[Illustration: FIG. 89.--Great Omentum carried by the bullet into an
exit track leading from the abdominal cavity. A. Outline of opening in
the peritoneum]

_Results of injury to the intestine._ 1. _Escape of contents and
infection of the peritoneal cavity._--I think there is little special to
be said on this subject. The escape of contents into the peritoneal
cavity was by no means free, unless the injury was multiple. Thus in one
case of injury to the small intestine, No. 166, on which I operated,
there was absolutely no gross escape until the bowel was removed from
the abdominal cavity, when the contents spurted out freely. In one case
of very oblique injury to the colon there was a considerable quantity of
faecal matter in a localised space, but as a rule the ordinary condition
best described as 'peritoneal infection' from the wound was found. The
bad effect of anything like free escape was well shown in multiple
perforations; in these suppurative peritonitis rapidly developed and the
patients died at the end of thirty-six hours or less. A typical case is
quoted in No. 168.

2. _Peritoneal infection, and general septicaemia._--As is evident from
the results quoted among the cases, the degree which this reached varied
greatly. It may of course be assumed that in some measure it occurred in
every case in which the bowel was perforated, but it was so