As to the individual injuries:
1. Wounds in the intestinal area, except in certain directions, often traverse the abdomen without inflicting a perforating injury on the bowel.
2. If the alimentary canal is perforated, injuries in certain segments, even if perforating, may be followed by spontaneous recovery. I should say the prognosis from this point of view is best in the ascending colon, then in the rectum; after these most favourable segments, I should place the others in the following order: stomach, sigmoid flexure, descending colon. As to perforating wounds of the transverse colon and small intestine, I believe spontaneous recovery to be very rare.
3. Wounds of the solid viscera generally, usually heal spontaneously, and give no trouble unless one of the great vessels has been injured. I include in this category all organs except the pancreas, of wounds of which I had no experience.
4. Wounds of the bladder, if of the nature of pure perforations in the intra-peritoneal segment, often heal spontaneously.
5. As a rule, injuries to the organs in their intra-peritoneal course have a far better prognosis than those which implicate the organs in their uncovered portions.
6. The small calibre of the bullet is alone responsible for the favourable results observed.
7. The danger or otherwise of an intestinal injury depends mainly on mechanical conditions; for instance, the fixity of the ascending colon, and its comparative freedom from a covering of small intestine capable by movement of diffusing any infective material, account chiefly for such favourable results as are seen when that segment of the bowel is implicated.
WOUNDS OF THE EXTERNAL GENITAL ORGANS
Wounds of the _scrotum_ were not uncommon, especially in connection with perforations of the upper part of the thigh. They offered no special feature, beyond the common tendency of every-day experience to the development of extensive ecchymosis.
Wounds of the _testicles_ I saw on several occasions. I remember only one out of some half-dozen in which castration became necessary. I was told of one case, for the accuracy of which I cannot vouch, in which destruction of one testicle was followed by an attack of melancholia, culminating in the suicide of the patient.
Wounds of the _penis_ also occurred, but as a rule were unimportant. I append a case, however; in which the penile urethra was wounded, which is of some interest.
(209) Wounded at Heilbron. Range 1,500 yards. _Entry_, 2-1/2 inches below the right anterior superior iliac spine; the bullet traversed the groin superficially in the line of Poupart's ligament, emerged, and crossed both penis and scrotum. The trooper was in the saddle when struck, and the penis probably somewhat coiled up. Three wounds were found, one at the junction of the penis and scrotum which opened the urethra, a second one about 3/4 of an inch along the under surface of the penis, and a third on the left side of the base of the prepuce. A considerable amount of oedema and ecchymosis of the scrotum developed, but no extravasation of urine. A catheter was kept in the urethra for some days, and the opening eventually closed by granulation.
I only once saw a patient with an injury to the deep urethra; in this case concurrent injury to other pelvic organs led to death on the third day. As a good many of the patients with pelvic wounds died rapidly, the accident may have been more common than my experience would suggest.
FOOTNOTES:
[19] _British Med. Journal_, May 12, 1900, i. 1195.
[20] 'On Traumatic Rupture of the Colon.' _Annals of Surgery_, vol. xxx.
1899, p. 137.
[21] Two of these died.
[22] The cases of injury to the solid viscera are those only which happen to be quoted in the text, and give no idea of relative mortality.
[23] _British Medical Journal_, May 12, 1900, vol. i. p. 1194.
CHAPTER XII
ON SHELL WOUNDS
The title of this work hardly allows of its conclusion without a brief mention of the shell wounds observed during the campaign.
As already pointed out, these formed but a very small proportion of the injuries treated in the hospitals, and beyond this they possessed comparatively small surgical interest, since, as a rule, the features presented were those of mere lacerated wounds, while the more severe of the cases which survived only offered scope for operations of the mutilating class so uncongenial to modern surgical instincts.
The fatal wounds consisted in extensive lacerations resulting in the destruction of the head or limbs, the laying open of the abdominal or thoracic cavities, or the production of visceral injuries beyond the possibility of repair. Of such injuries no further mention will be made.
A very great variety of shells was employed during the campaign, especially on the part of the Boers, and the frontispiece gives some idea of these. The photograph was taken by Mr. Kisch after the relief of Ladysmith. For the want of more extended knowledge I shall confine myself to the description of a few injuries caused by two classes of large shell, those of the Vickers-Maxim or 'Pom-pom,' and two varieties of shrapnel.
The large shells employed may be divided into classes according to the metal used in their construction, and the nature of the explosive with which they were filled. These details are of some surgical import, because they affect the nature of the fragments into which the shells are broken up.
Fragments of shells constructed with cast iron and burst with powder, and also of forged steel exploded with lyddite, are depicted in fig. 90.
[Illustration: FIG. 90.--A, B, D. Fragments of 200 lb. forged Steel Howitzer Shell exploded by lyddite. C. Fragment of Cast-iron Shell exploded by powder. B exhibits transverse markings which might be mistaken for the lines seen in the Boer segment shells, but which really correspond to the area of fixation of the copper driving band]
Examination of fragment C of a cast-iron shell exploded by powder shows the characteristic granular fracture, and edges, although sharp, yet of a comparatively rounded nature. The fragment is also heavier for its surface measurement, as the metal is thicker than that seen in the remaining fragments, although the cast-iron shell was of a much smaller calibre than the steel one. The lesser degree of penetrative power, and increased capacity to contuse, possessed by such fragments are obvious.
A B and D are fragments of a large forged steel howitzer shell exploded by lyddite, such as were cast by our guns. The photograph well shows the more tenacious structure of the metal in the incomplete longitudinal fissuring exhibited, while the margins are of a sharp knifelike character, well calculated to penetrate or, in the case of superficial injuries, to produce wounds of a more sharply incised character than the cast-iron shell. Fragments A and B also show an appearance suggestive of partial fusion, characteristic of high explosive action, in the turning of the prominent margins.
The larger fragments of such shells were responsible for the most serious mutilating injuries, while small fragments sometimes caused comparatively simple perforating wounds. I remember a fragment of the fused character not larger than a small nut which had perforated the front of the thigh of a Boer, and lodged near the inner surface of the femur. Removal of the fragment was followed by a free gush of haemorrhage. When the wound was opened up an opening was found in the external circumflex artery, haemorrhage from which had been controlled by the impaction of the piece of shell. As an example of the cutting power of sharp fragments of shell I might instance the case of another Boer in whom light passing contact had been made by the missile. A gaping incised wound extended from above the angle of the scapula down to the outer surface of the buttock. The wound involved the latissimus dorsi, and the external and internal oblique muscles of the abdomen. The separate muscular layers were sharply defined in the lateral parts of the floor of the wound, and remained so for some time during the gradual contraction of the large granulating surface produced. The degree of contusion was in fact slight, while the incised character was strongly marked.
In some cases the fragments merely struck the soldiers on the flat without producing any wound. In one such case a blow upon the epigastrium was, according to the patient, followed by the vomiting of a considerable amount of blood. A fluid diet was ordered, and no further ill effects were noted. The following case illustrates an oblique blow of a perforating character, which was nevertheless recovered from.
[Illustration: FIG. 91.--Various portions of Brass Percussion and Time Fuses]
(210) _Shell-wound of abdomen. Injury to liver._--Wounded at Paardeberg by a fragment of shell. Aperture of entry, a ragged opening in the median line. The fragment of shell was retained over the ninth costal cartilage in the nipple line. The wound bled freely, but the man was taken into camp, and then four miles on to the hospital, where he was anaesthetised and the fragment extracted. The wound of entry was at the same time enlarged, cleansed, and partly sutured. The patient vomited once after the anaesthetic, and the bowels remained confined for three or four days after the injury. The extraction wound healed readily, but a considerable amount of slimy, bile-stained discharge was still escaping from the ragged entrance wound on the man's arrival at the Base on the fourteenth day. The abdomen was then normal in appearance, and as to physical signs, except for a tympanitic note over the hepatic area to the right of the wound. The temperature was normal, the pulse 90, the tongue clean, and the bowels were acting. At the end of four weeks pleurisy, with effusion, developed on the right side; the chest was aspirated and [Symbol: ounce]xx of clear serum drawn off. The man then rapidly improved; the bile-stained discharge ceased at the end of five weeks, and a small granulating wound eventually closed at the end of two months, when the man returned to England.
Fig. 91 is inserted to illustrate the multifarious nature of the fragments into which the component parts of shells may break up. The pieces are for the most part of brass, and formed parts of either time or percussion fuses.
Fig. 92 represents the one-pound Vickers-Maxim shell in its actual size.
The wounds produced by this shell are of some interest, since the Vickers-Maxim may be said to have been on trial during this campaign.
The general opinion seems to have been to the effect that the moral influence produced by the continuous rapid firing of the gun and the attendant unpleasant noise were its chief virtues. A considerable number of wounds must, however, have been produced by it, which, if not of great magnitude and severity, were, at any rate, calculated to put the recipients out of action, and these wounds, moreover, were slower in healing than many of the rifle-bullet injuries.
The shell is so small that it was said to occasionally strike the body as a whole, and perforate. I was shown a case in which a wounded officer was confident that an entire shell had perforated his arm. The entry wound was at the outer part of the front of the forearm, the exit at the inner aspect of the arm, just above the elbow. Two ragged contused wounds existed, which healed slowly, but no serious nervous or vascular injury had been produced. Although it is probable that only a fragment perforated in this case, it is of interest in connection with the following.
In a case shown to me by Sir William Thomson in the Irish Hospital at Bloemfontein, an entire shell had passed between the left arm and body of a trooper, perforating the haversack, as also a non-commissioned officer's notebook contained within it, without exploding. The only injury sustained by the trooper was a contusion on the inner aspect of the elbow-joint, with slight signs of contusion of the ulnar nerve. The case is of some importance, as showing that a comparatively resistent body can be perforated without necessary explosion on the part of the shell; hence the possibility of a similar perforation of the soft parts of the body.
[Illustration: FIG. 92.--Unexploded 1-lb. Vickers-Maxim Shell. (Actual size)]
Fig. 93 is of a number of fragments of Vickers-Maxim shells, and it was by such that the great majority of the wounds were produced.
Wounds from fragments of these shells were, indeed, not at all rare.
They were met with on any position; but, as far as my experience went, they were more common on the lower extremities than in other parts of the body, if the sufferers were in the erect position when wounded. I saw a good many wounds in the neighbourhood of the knee, some of which implicated the joint. When the injuries were received by patients in the lying or crouching positions, any part of the body was equally likely to be affected, or, again, the presence of large stones or rocks in the vicinity might determine the scattering of the flying fragments at a more dangerous height than when the shells burst from contact with the actual ground.
The relation of one or two examples of wounds from pom-pom fragments may not be without interest, the more so as they illustrate the favourable influence of a low degree of velocity on the part of a projectile. I saw three wounds produced by the percussion fuses of these shells, an experience which shows that they were not very uncommon.
[Illustration: FIG. 93.--Fragments of Vickers-Maxim 1-lb. Shells. The centre fragment of the lower row is the point of a steel armour-piercing shell; although unsuitable for the purpose, they were occasionally employed in the field by the Boers]
(211) _Perforating shell-wound of abdomen._--Wounded at Magersfontein by the fuse screw of a small shell (Vickers-Maxim). Aperture of entry ragged, roughly circular, and 2 inches in diameter, with much-contused margins situated in the median line, nearly midway between the ensiform cartilage and umbilicus. The screw was lodged in the abdominal wall at the margin of the thorax, just outside the left nipple line. The aperture of entry was cleansed by Major Harris, R.A.M.C., who determined the fact that penetration of the peritoneal cavity had occurred, and removed the fuse (see fig.
94) by a separate incision. The patient made an uneventful and uninterrupted recovery, the wound healing by granulation and leaving little weakness of the abdominal wall. He returned to England at the end of five weeks.