Surgical Experiences in South Africa, 1899-1900 Part 47

In a second case the fuse, together with a fragment of the iron case, entered the b.u.t.tock by a ragged opening. The fragment of iron escaped by an exit aperture of about the same size. When the patient arrived at the Base some days after the injury, a hard body was felt in the wound, and on exploration the fuse was found and removed.

In a third case the fuse struck the side of the foot below the outer malleolus and comminuted the astragalus, and then pa.s.sing forwards lodged beneath the extensor tendons of the toes. The wound was explored at the time of the injury and some fragments of bone removed; considerable cellulitis supervened, and the fuse was only discovered some days later when the patient came under the care of Sir W. Thomson in the Irish Hospital in Pretoria. It was there removed, together with some more fragments of bone, and the wound slowly granulated. The patient then returned to England, when the wound rapidly healed after the removal of some further necrosed fragments of cancellous tissue. The astragalus had been reduced to a mere sh.e.l.l of compact tissue, and the convexity of the articular surface was altogether lost. The deformity, together with the formation of adhesions in the ankle-joint, led to the development of a firm anchylosis.

[Ill.u.s.tration: FIG. 94.--Pom-pom Percussion Fuse, exact size]

My friend Mr. Abbott removed a similar fuse from the substance of the lung after the lapse of nine months, the patient having developed an empyema, and a chronic fistula, which rapidly closed after the removal of the foreign body.

[Ill.u.s.tration: PLATE XXV

OBLIQUE FRACTURE OF THE HUMERUS CAUSED BY A FRAGMENT OF A VICKERS-MAXIM OR POM-POM Sh.e.l.l

The entire absence of comminution is very striking]

I will add one further case, that ill.u.s.trated by plate XXV. In this a fragment of a pom-pom sh.e.l.l entered the outer aspect of the right shoulder to escape on the inner aspect of the arm, just below the confines of the axilla. An oblique, non-comminuted fracture of the humerus resulted, which in spite of moderate suppuration united well in the course of six weeks. The case is of particular interest as ill.u.s.trating the nature of the fracture to be expected when the velocity retained by the missile is low.

The above instances show that such peculiarities as belong to wounds produced by pom-pom sh.e.l.ls depend on the comparatively small size and weight of the fragments, and on the small degree of impetus with which they are propelled.

[Ill.u.s.tration: FIG. 95.--Boer Segment Sh.e.l.l, or Shrapnel. The large fragment is a piece of the case, the smaller are two of the pieces of iron packed within]

Fig. 95 ill.u.s.trates a form of shrapnel employed by the Boers, the case of which is of cast metal arranged in definite segments, while the interior is filled with small fragments of iron so shaped as to pack in concentric layers. As to the wounds produced by the contained fragments I have no experience, since I never saw one of the pieces of iron removed. This no doubt depended in part on the very unsatisfactory practice made by the Boers with shrapnel generally. Even when they fired English shrapnel, the sh.e.l.ls were, as a rule, exploded far too high to cause any serious danger to the men beneath. I saw on one occasion a large number of shrapnel sh.e.l.ls exploded over a body of Imperial Yeomanry, but as a result of the great height at which all the sh.e.l.ls were exploded, not a single casualty resulted.

The segment casing of the sh.e.l.l, however, I several times saw removed from the body. The fragment shown in fig. 95 was removed from the b.u.t.tock of a man after one of Lord Methuen's early battles. It may be remarked that the b.u.t.tock is rather a common, and also a favourable, seat for sh.e.l.l wounds with retention of the fragment. This no doubt depends on the fact that the b.u.t.tock is one of the few superficial regions in which sufficient depth of tissue exists for the retention or the pa.s.sage of so large an object as a fragment of sh.e.l.l.

Fig. 96 is of a number of leaden shrapnel bullets from our own sh.e.l.ls. A normal undeformed bullet, such as was the usual cause of wounds, is shown at the left-hand upper corner. The remainder show common forms of deformity caused by striking on the ground or against rocks. I attribute small importance to the deformed bullets, as I never saw one removed, and it is probable that a ricochet shrapnel bullet would rarely retain sufficient force to penetrate. The lower fragments are inserted to ill.u.s.trate a fact that would scarcely have been a.s.sumed, that these bullets on impact occasionally suffer a fracture of a somewhat crystalline nature. The occurrence of this gross form of fracture is of some interest in relation to the extreme fragmentation sometimes undergone by the hardened leaden cores of the small-calibre bullets.

A considerable number of wounds from leaden shrapnel bullets were met with among our own men, as well as among the Boers. The wounds possessed little special interest, except from the fact that the bullets were often retained. I saw bullets in the chest on several occasions, also in the abdomen, pelvis, the neighbourhood of joints, and in the limbs.

I saw one patient who had suffered no less than six perforating wounds as the result of the bursting of one shrapnel sh.e.l.l.

I will here quote one case of interest as completing the various forms of perforating wound of the abdomen met with during the campaign.

[Ill.u.s.tration: FIG. 96.--Normal, Deformed, and Fractured Leaden Shrapnel Bullets]

(212) _Perforating shrapnel-wound of abdomen._--Boer wounded at Graspan. Aperture of _entry_ (shrapnel), opposite eighth left costal cartilage, 1 inch external to nipple line. The opening was circular, and surrounded by an area of ecchymosis 4 inches in diameter; _exit_, 4-1/2 inches above and to the right of the umbilicus. Patient was at first in a Boer ambulance, and only seen by me on the ninth day. At that date he was dressed and walking with a gauze pad and bandage over the wounds. From the exit wound, which was 1 inch in diameter, protruded a piece of sloughing omentum, the margin of the wound being everted and raised over a circular indurated area.

It was thought best to allow the sloughing omentum, which was very foul, to separate spontaneously, and then to return the stump. At the end of three weeks, however, the slough had not only separated, but the stump had retracted, and only a small granulating surface was left, which healed spontaneously.

I have little to say regarding the treatment of sh.e.l.l wounds. The mutilating injuries, if not of a fatal character, necessitated treatment of a corresponding nature to the damage. In all such cases the general rules of surgery indicate the lines to be followed.

In the case of shrapnel wounds the bullets were often better removed; but when in dangerous positions, as sunk deeply in the chest, abdomen, or pelvis, they were best left, unless some very special indication for removal existed. Large fragments of sh.e.l.l always demanded removal.

In conclusion I will only make the further remark, that sh.e.l.l wounds, with the exception of clean leaden shrapnel tracks, always suppurated.

I make this closing statement with the view of emphasising the influence exerted on the aseptic course of modern rifle wounds by the small calibre of the bullet, since both bullet and sh.e.l.l wounds were exposed to the same surrounding conditions.