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 96.8percent of the total, were caused by missiles of war (fig. 17). High-explosivefragments 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 929wounds were caused by missiles discharged from small arms. Probably many of thewounds listed in the records as caused by shell fragments were actually theresult of mortar fire. The case fatality rate for bullet wounds was 24.7 percentand for high-explosive fragments 23.1 percent.
Wounds of entry and exit-The experience in this largeseries of injuries made it clear that the effects of agiven type of missile are by no means uniform. It was generally true, forinstance, that the wound of entry was smaller than the wound of exit, but caseswere observed in which the wound of exit was the smaller. The wound of exit wasalways the smaller when a slender fragment which presented its greatest diameterat 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 thesite 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), posteriorlyin 730 (28.2 percent), and laterally in 617 (23.9 percent). Three hundred andforty-one wounds of entry (13.2 percent) were in the buttocks or the region ofthe hips, and 11 (0.4 percent) were in the perineum.
The wounds were distributed almost equally between the right and left sidesof the body. Excluding the 151 wounds in the midline and the 11 in-
FIGURE 17.-Distribution of causative missilesin 3,052 abdominal injuries.
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FIGURE 18.-Anatomic distribution of wounds of entry in 2,586 recordedabdominal injuries.
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stances in which the wound of entry was through the perineum, there were 1,209wounds on the right side and 1,215 wounds on the left side.
The most significant discrepancy in the distribution of thewounds of entry is the much larger number of anterior than posterior wounds. Forthis there are two possible explanations, aside from the obvious reason that thecasualties 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 protectionagainst injury than did the anterior abdominal wall.
2. Soldiers carrying field packs on their backs had some additionalprotection from them, especially against low-velocity missiles.
On the other hand, a certain number of posterior wounds areto be expected. Combat soldiers, while advancing, are often pinned to theground, and many times lie prone, thus exposing posterior portions of the bodyand making them readily accessible to exploding agents of war.
Tracks of missiles-Clinical observations suggest that the possibility oftracks of missiles not following a straight line has been greatlyoveremphasized in the past. In practically every instance in this series, thecourse of the missile within the body was a straight line. Bizarre or circuitoustracks were extremely uncommon.1 A seemingly erratic course could almostinvariably be explained by an accurate reconstruction of the position of thesoldier when he was struck (fig. 19). Changes of posture caused significantdisplacement of viscera and altered their customary relationships.
In no instance in the series did a missile traverse a major diameter of theabdomen without causing visceral injury.
Effects of missiles-Clinically,effects of the missiles were ofextraordinary variability, the results apparently being related to the size ofthe fragment, which was usually roughly proportional to the caliber of theshell; its shape; and the distance of the soldier from the site of theexplosion. This distance served as a rough index of the velocity of the missile.Explosive, concussive effects were more frequently observed in casualtiesinjured at close range than in those at a distance from the shell burst. Jagged,lacerated, irregular wounds were, in general, more frequently caused by shellfragments than by missiles from small arms, but there were many exceptions tothis generalization. In some instances, large fragments or multiple smallerfragments produced by a shell burst close at hand destroyed large parts of theabdominal parietes or even carried away the entire flank; casualties withinjuries of this kind seldom survived to reach the hospital.
Wounds caused by mortar fragments, especially at close range, were oftencharacterized by the presence of multiple small fragments which were slight inmass but which had entered the body at high velocity. These fragments apparentlydecelerated rapidly on impact; though they penetrated the abdomen,
1One interesting case of thiskind is personally known to the editor in chief. The surgical consultant, Officeof the Surgeon, Headquarters, Third U. S. Army, was wounded by a sniper inFrance. The bullet struck the left anterior chest of this officer, fractured arib, followed the rib path laterally and posteriorly, and lodged beneath theleft scapula.
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FIGURE 19.-Possible effect of position on track of missilesand resulting visceral injuries.
they seldom caused perforating (through-and-through) wounds.Roentgenologic examination of casualties who were literally peppered with tinyholes showed the penetration of the skin by hundreds of small fragments. Tissuedestruction of an almost unbelievable extent was sometimes found below thecutaneous wounds, because each fragment had imparted all of its kinetic energyto the tissue through which it had passed. It was impossible in such cases evento localize all the fragments accurately, let alone to remove them.
Wounds caused by rifle fire were usually single. Wounds from Germanmachineguns or machine pistols were usually multiple, because these weaponsfired at a very rapid rate. The destructive effect of small-arms missiles on thetissue was often similar to the effect of high-explosive fragments. When bulletsstruck perpendicularly, they often caused small, clean perforations. When theirimpact was tangential, they produced large lacerations and even concussiverupture of viscera. Their effects, which were frequently multiple, depended uponvelocity 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 20yards by a caliber .30 bullet from an American carbine, when the missile was inthe 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 missilecaused a 5-mm. perforation of the diaphragm, with only slight contusion, and agutter wound of the lateral margin of the left kidney. Its concussive effect wassuch, however, that the entire kidney was split wide open to the uretero-pelvicjunction. Two small through-and-through perforations of the jejunum resultedfrom the perpendicular impact of the bullet, while in other portions of thebowel its tangential impact produced mangled perforations and lacerations. Thebullet also passed through the bladder, leaving a large, explosive wound ofentry 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 secondarymissile. The trauma produced by the steel core was similar to that caused by abullet with an ordinary lead core, but the jacket, because of its raggedcontour, was often mistaken roentgenologically for a shell fragment. Bulletswhich ricocheted were usually distorted, and the jacket was usually partiallyseparated at the base. The tearing effect of such missiles was often extremelydestructive.
Mine fragments, nearly all from the German "S-mine" or"Bouncing Betty," caused a small number of abdominal wounds. Thecharacteristic missiles from these mines were steel balls (shrapnel) and small,machine-cut steel cylinders. Their effects were essentially the same as those ofshell fragments.
Dirt, stones, occasionally bits of impedimenta carried in thepocket, pieces of identification tags, and bone fragments were encountered assecondary missiles. Of these, bone fragments were the most destructive. In alarge number of the 238 cases in this series in which fractures of the pelvisoccurred in association with abdominal wounds, the forcible irruption ofspicules of bone into the peritoneal cavity caused perforations of both thelarge and the small intestine, particularly the cecum. A similar effect wasobserved when missiles entered the peritoneal cavity through the spine.
Ruptures of the intraperitoneal viscera were occasionallyassociated with injuries in which the peritoneum was not penetrated. Injuries ofthis kind were apparently caused by missiles of extremely high velocity andgreat concussive power (p. 331).
The extent of tissue destruction caused by the variousmissiles used in World War II, particularly by artillery-shell fragments, attimes almost passed belief. Intestines were often found shredded into ribbons,and solid viscera often seemed to have exploded, with completely detached piecesof liver, spleen, or kidney being observed free in the peritoneal cavity. Thedestructiveness of the missiles employed in World War II is impossible tooveremphasize. Nothing seen in civilian surgery even remotely approaches theextent of the trauma associated with the wounds encountered in this war.
