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Chapter 6

Contents

CHAPTER VI

Wounding Agents

Luther H. Wolff, M. D., Samuel B. Childs, M. D., and W. Philip Giddings, M. D.

Of the 3,154 abdominal injuries which make up this series, 3,052, or 96.8 percent of the total, were caused by missiles of war (fig. 17). High-explosive fragments of various types caused 2,123 of these 3,052 wounds (69.6 percent), 1,844 of this group being caused by artillery-shell fragments. The remaining 929 wounds were caused by missiles discharged from small arms. Probably many of the wounds listed in the records as caused by shell fragments were actually the result of mortar fire. The case fatality rate for bullet wounds was 24.7 percent and for high-explosive fragments 23.1 percent.

Wounds of entry and exit-The experience in this large series of injuries made it clear that the effects of a given type of missile are by no means uniform. It was generally true, for instance, that the wound of entry was smaller than the wound of exit, but cases were observed in which the wound of exit was the smaller. The wound of exit was always the smaller when a slender fragment which presented its greatest diameter at the site of entry made its exit along a path parallel to its long axis.

In the 2,586 abdominal injuries in which data concerning the site of entry and of exit of the wounding agent were accurately recorded (fig. 18), the missiles entered anteriorly in 1,228 cases (47.5 percent), posteriorly in 730 (28.2 percent), and laterally in 617 (23.9 percent). Three hundred and forty-one wounds of entry (13.2 percent) were in the buttocks or the region of the hips, and 11 (0.4 percent) were in the perineum.

The wounds were distributed almost equally between the right and left sides of the body. Excluding the 151 wounds in the midline and the 11 in-

FIGURE 17.-Distribution of causative missiles in 3,052 abdominal injuries.


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FIGURE 18.-Anatomic distribution of wounds of entry in 2,586 recorded abdominal injuries.


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stances in which the wound of entry was through the perineum, there were 1,209 wounds on the right side and 1,215 wounds on the left side.

The most significant discrepancy in the distribution of the wounds of entry is the much larger number of anterior than posterior wounds. For this there are two possible explanations, aside from the obvious reason that the casualties were part of an advancing army:

1. The greater thickness of the musculature of the back, combined with the presence of the bony spine, tended to afford more protection against injury than did the anterior abdominal wall.

2. Soldiers carrying field packs on their backs had some additional protection from them, especially against low-velocity missiles.

On the other hand, a certain number of posterior wounds are to be expected. Combat soldiers, while advancing, are often pinned to the ground, and many times lie prone, thus exposing posterior portions of the body and making them readily accessible to exploding agents of war.

Tracks of missiles-Clinical observations suggest that the possibility of tracks of missiles not following a straight line has been greatly overemphasized in the past. In practically every instance in this series, the course of the missile within the body was a straight line. Bizarre or circuitous tracks were extremely uncommon.1 A seemingly erratic course could almost invariably be explained by an accurate reconstruction of the position of the soldier when he was struck (fig. 19). Changes of posture caused significant displacement of viscera and altered their customary relationships.

In no instance in the series did a missile traverse a major diameter of the abdomen without causing visceral injury.

Effects of missiles-Clinically, effects of the missiles were of extraordinary variability, the results apparently being related to the size of the fragment, which was usually roughly proportional to the caliber of the shell; its shape; and the distance of the soldier from the site of the explosion. This distance served as a rough index of the velocity of the missile. Explosive, concussive effects were more frequently observed in casualties injured at close range than in those at a distance from the shell burst. Jagged, lacerated, irregular wounds were, in general, more frequently caused by shell fragments than by missiles from small arms, but there were many exceptions to this generalization. In some instances, large fragments or multiple smaller fragments produced by a shell burst close at hand destroyed large parts of the abdominal parietes or even carried away the entire flank; casualties with injuries of this kind seldom survived to reach the hospital.

Wounds caused by mortar fragments, especially at close range, were often characterized by the presence of multiple small fragments which were slight in mass but which had entered the body at high velocity. These fragments apparently decelerated rapidly on impact; though they penetrated the abdomen,

1One interesting case of this kind is personally known to the editor in chief. The surgical consultant, Office of the Surgeon, Headquarters, Third U. S. Army, was wounded by a sniper in France. The bullet struck the left anterior chest of this officer, fractured a rib, followed the rib path laterally and posteriorly, and lodged beneath the left scapula.


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FIGURE 19.-Possible effect of position on track of missiles and resulting visceral injuries.

they seldom caused perforating (through-and-through) wounds. Roentgenologic examination of casualties who were literally peppered with tiny holes showed the penetration of the skin by hundreds of small fragments. Tissue destruction of an almost unbelievable extent was sometimes found below the cutaneous wounds, because each fragment had imparted all of its kinetic energy to the tissue through which it had passed. It was impossible in such cases even to localize all the fragments accurately, let alone to remove them.

Wounds caused by rifle fire were usually single. Wounds from German machineguns or machine pistols were usually multiple, because these weapons fired at a very rapid rate. The destructive effect of small-arms missiles on the tissue was often similar to the effect of high-explosive fragments. When bullets struck perpendicularly, they often caused small, clean perforations. When their impact was tangential, they produced large lacerations and even concussive rupture of viscera. Their effects, which were frequently multiple, depended upon velocity as well as upon angle of impact, as the following case history shows:

Case history.-A German prisoner of war was wounded at a range of about 20 yards by a caliber .30 bullet from an American carbine, when the missile was in the initial phase


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of high velocity. The wound of entry was in the left midaxilla, and the wound of exit was through the symphysis pubis on the same side. The missile caused a 5-mm. perforation of the diaphragm, with only slight contusion, and a gutter wound of the lateral margin of the left kidney. Its concussive effect was such, however, that the entire kidney was split wide open to the uretero-pelvic junction. Two small through-and-through perforations of the jejunum resulted from the perpendicular impact of the bullet, while in other portions of the bowel its tangential impact produced mangled perforations and lacerations. The bullet also passed through the bladder, leaving a large, explosive wound of entry and a small, clean wound of exit.

In wounds caused by armor-piercing bullets of small caliber, the jacket, which was usually shed by the projectile, sometimes acted as a secondary missile. The trauma produced by the steel core was similar to that caused by a bullet with an ordinary lead core, but the jacket, because of its ragged contour, was often mistaken roentgenologically for a shell fragment. Bullets which ricocheted were usually distorted, and the jacket was usually partially separated at the base. The tearing effect of such missiles was often extremely destructive.

Mine fragments, nearly all from the German "S-mine" or "Bouncing Betty," caused a small number of abdominal wounds. The characteristic missiles from these mines were steel balls (shrapnel) and small, machine-cut steel cylinders. Their effects were essentially the same as those of shell fragments.

Dirt, stones, occasionally bits of impedimenta carried in the pocket, pieces of identification tags, and bone fragments were encountered as secondary missiles. Of these, bone fragments were the most destructive. In a large number of the 238 cases in this series in which fractures of the pelvis occurred in association with abdominal wounds, the forcible irruption of spicules of bone into the peritoneal cavity caused perforations of both the large and the small intestine, particularly the cecum. A similar effect was observed when missiles entered the peritoneal cavity through the spine.

Ruptures of the intraperitoneal viscera were occasionally associated with injuries in which the peritoneum was not penetrated. Injuries of this kind were apparently caused by missiles of extremely high velocity and great concussive power (p. 331).

The extent of tissue destruction caused by the various missiles used in World War II, particularly by artillery-shell fragments, at times almost passed belief. Intestines were often found shredded into ribbons, and solid viscera often seemed to have exploded, with completely detached pieces of liver, spleen, or kidney being observed free in the peritoneal cavity. The destructiveness of the missiles employed in World War II is impossible to overemphasize. Nothing seen in civilian surgery even remotely approaches the extent of the trauma associated with the wounds encountered in this war.

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