Surgical Experiences in South Africa, 1899-1900 Part 5

The layer of copper alloy on the steel mantles is also a physical characteristic worthy of mention. This very readily chips off in a manner similar to that we are accustomed to see with nickel-plated instruments. This may be due to the compression into the grooving of the rifle, or as the result of pa.s.sing impact of the bullet with an obstacle previous to entering the body or contact with a bone within it. Small scales of metal set free in one of these ways are seen in a very large proportion of Mauser wounds, and although they are so small as usually to be of little importance, the presence of such in, for instance, the substance of one of the peripheral nerves which has been perforated cannot be considered a desirable complication.

To recapitulate, it would appear that at mean ranges, both in striking force and as regards the area of the tissues affected, the Lee-Metford is a superior projectile to the Mauser, in spite of the greater initial velocity possessed by the latter. On the other hand the comparative ease with which the Mauser bullet undergoes deformation either without or within the body, so ensuring more extensive injury and laceration, renders it the less desirable bullet to receive a wound from when not in its normal shape and condition.

I can say little about the remaining two rifles. The Krag-Jorgensen was little used, and beyond pointing out its capacity to inflict very neat individual injuries, in which it must surpa.s.s even the Mauser, I can only add that I had no opportunity of forming an opinion as to the danger dependent on the great initial velocity imparted to the bullet.

The Guedes rifle has been included in the table because it approximates in bore to the other three. Its bullet is of the same calibre as the Austrian Mannlicher, one of the most powerful military rifles in use, and it was used to a considerable extent during the war by the Boers.[8]

As to its capabilities, it appeared an inferior weapon, since want of velocity and striking power of the bullets was indicated by the number of these which were retained in the body, and by the fact that I never saw one extracted that had undergone any more serious deformation than some flattening on one side of the tip. On the other hand wounds of the soft parts occasioned by it were only to be distinguished from Mauser wounds by their slightly greater size, and at a short range of fire the weight and volume of the bullet made it a dangerous projectile.

The question of deformed bullets will be again referred to at length in the section on wounds of irregular type, and a number of type specimens are there figured and described (p. 76). In the same chapter will be found ill.u.s.trations of a number of sporting bullets of small calibre, as well as of large calibres in lead, found in the Boer a.r.s.enals and camps.

I have placed them in that position as mainly of interest in connection with the occurrence of large and irregular wounds (see figs. 42 and 43, pp. 95 and 98).

The small sporting bullets were mostly of the Mauser (.276), Lee-Metford (.303), or Mannlicher (.315) calibre.

FOOTNOTES:

[5] See tables, pp. 12, 13, 15, Chapter I.

[6] The weights are from cartridges brought home. The charge of powder was small and variable.

[7] H. Nimier and E. Laval, _Les Projectiles des Armes de Guerre_, p.

20. F. Alcan. 1899.

[8] Mr. Leslie B. Taylor informs me that this rifle is a discarded Portuguese regulation pattern, with which a copper-ensheathed soft-nosed bullet was originally employed. For the purposes of the present campaign a modified cartridge was constructed. Examination of some specimens in my possession showed the charge of powder to be very small. (Table I. p.

48.)

CHAPTER III

GENERAL CHARACTERS OF WOUNDS PRODUCED BY BULLETS OF SMALL CALIBRE

The effects of injuries inflicted by bullets of small calibre may be divided into two cla.s.ses:

1. Direct or immediate destruction of tissue.

2. Remote changes induced by the transmission of vibratory force from the pa.s.sing projectile to neighbouring tissues or organs.

Those of the first cla.s.s will be mainly considered in this chapter; the remote effects will be dealt with under the headings devoted to special regions.

In dealing with the wounds as a whole I shall first describe those of uncomplicated character as type injuries, and deal with those possessing special or irregular characters separately.

TYPE WOUNDS

1. _Nature of the external apertures._--The apertures of entry and exit in uncomplicated cases are very insignificant, but the size naturally varies slightly with that of the special form of bullet concerned. As will be shown moreover, the difference in size is the only real distinguis.h.i.+ng characteristic in many cases between wounds produced by the modern bullet of small calibre and those resulting from the use of the older and larger projectiles of conical form. I have been very much struck on looking over my diagrams of entry, and especially exit, wounds to find that they reproduce in miniature most of those figured in the History of the War of the Rebellion; some of these diagrams are reproduced in this chapter.

_Aperture of entry._--The typical wound of entry with a normal undeformed bullet varies in appearance according to whether the projectile has impinged at a right angle or at increasing degrees of obliquity, or again, to whether the skin is supported by soft tissues alone, or on those of a more resistent nature such as bone or cartilage.

[Ill.u.s.tration: FIG. 16.--Mauser Entry and Exit Wounds. A, entry in b.u.t.tock; circular opening filled with clot and crossed by a tag of tissue. B, exit in epigastrium near mid-line; irregular slit form, with well-marked prominence. Specimens hardened in formalin immediately after death; the resulting contraction has slightly exaggerated the irregularity of outline of the entry wound]

[Ill.u.s.tration: FIG. 17.--Gutter Wound of outer aspect of shoulder, caused by a normal Mauser, which subsequently perforated a man's leg. At the central part the gutter was 3/4 in. deep a few days after the injury]

When the bullet impinges at a right angle the wound is circular, with more or less depressed margins, and of a diameter, corresponding to the size of the bullet occasioning it, from a quarter to a third of an inch.

The description 'punched out' has been sometimes applied to it, but it would be more correct to reverse the term to 'punched in,' since the appearance is really most nearly simulated by a hole resulting from the driving of a solid punch into a soft structure enveloped in a denser covering. The loss of substance, moreover, in the primary stage is not actually so great as appears to be the case, fragments of contused tissue from the margin being turned into the opening of the wound track.

The true margin therefore is not sharp cut, and the nature of the line differs somewhat according to the structure of the skin in the locality impinged upon. Thus the granular scalp and the comparatively h.o.m.ogeneous skin of the anterior abdominal wall will furnish good examples of the nature of the slight difference in appearance. From the first the margin is also often somewhat discoloured by a metallic stain, similar to that seen when a bullet is fired through a paper book. This ring is, however, narrow, and not likely to be noticeable when the bullet has pa.s.sed through the clothing. In any case it is subsequently obscured by the development of a narrow ring of discoloration due to the contusion. This latter varies in width, and still later a halo of ecchymosis half an inch or more in diameter surrounds the original wound.

[Ill.u.s.tration: FIG. 18.--Oblique Exit Gutter. Diagram enlarged to actual size from case shown in fig. 24, p. 64.]

With increasing degrees of obliquity of impact more and more p.r.o.nounced oval openings of entry result, culminating in an actual gutter such as is seen in fig. 17.

In all oval openings the loss of substance is more p.r.o.nounced at the proximal margin, while the wound is liable to undergo secondary enlargement at the distal margin, since in the former the epidermis is mainly affected, while in the latter the epidermis is spared as an ill-nourished bridge, the deeper layers of the skin suffering the more severely. When the wound occurs in regions, such as the chest-wall or over the sacrum, where the skin is firmly supported, the oval openings are often very considerable in size, reaching a diameter at least double that of the circular ones. In the case of the oval openings the depression of the margins is not such a well-marked feature as in wounds resulting from rectangular impact of the bullet, since the distal margin is really lifted.

[Ill.u.s.tration: FIG. 19.--Oval Entry Wound over third sacral vertebra.

Exit wound, anterior abdominal wall. Slightly starred variety. Diagram made on second day]

_Aperture of exit._--The wound of exit in normal cases offers far more variation in appearance than that of entry, this variation depending on several circ.u.mstances: first, the want of support to the skin from without, and such other factors as the degree of velocity retained by the travelling bullet, the locality of the opening, and the density, tension, and resistance offered by the particular area of skin implicated.

When the range has been short and the velocity high, it is often difficult to discriminate between the two apertures. Both may be circular and of approximately the same size, and the only distinguis.h.i.+ng characteristic, the slight depression of the margin of the wound of entrance, may be absent if any time has elapsed between the infliction of the injury and examination by the surgeon. One very strong characteristic if present is the general tendency of the margins, and even the area surrounding the exit wound itself, to be somewhat prominent. Fig. 16 shows this point, although the wound from which it was drawn had been produced thirty-six hours before death. The specimen was then hardened in formalin and still preserves its original aspect.

This character is, however, more frequently displayed in wounds received at mean, or longer, ranges. In wounds produced by bullets travelling at the highest degrees of velocity it is often absent.

[Ill.u.s.tration: FIG. 20.--Circular Entry back of arm; exit (bird-like) in anterior elbow crease]

[Ill.u.s.tration: FIG. 21.--Circular Entry over patella. Starred exit of elongated form in popliteal crease]

When the range of fire has been greater and the velocity retained by the bullet lower, slit wounds are common, or some of the slighter degrees of starring. Actual starring I never saw, but reference to figs. 20 and 21 will show a tendency in this direction, also a close resemblance to the starred wounds resulting from perforations by large leaden bullets.

Such wounds, I believe, are usually the result of a somewhat low degree of velocity.

Slit exit wounds may be vertical or transverse (fig. 20) in direction, and the production of these is dependent on the locality in which they are situated, the thickness, density, and tension of the skin, and the nature of the connection of the latter with the subcutaneous fascia in the locality. Thus in wounds of different parts of the hairy scalp, so little variation exists in the relative density and structure of the skin, that, in spite of the want of external support at the aperture of exit, it is often difficult to discriminate offhand the two apertures, if neither bone nor brain debris occupies that of exit.

If, however, a wound crosses from side to side a region such as the thigh where well-marked differences exist in the subjacent support, thickness, and elasticity of the skin implicated in the apertures, the wound of entry, if in the thick skin of the outer aspect, was usually circular, while the exit in the thin elastic skin of the inner aspect was either slit-like or starred. The difficulty in laying down any general rule as to the occurrence of circular or slit apertures of exit in any definite region is, however, great, as may be seen by reference to the accompanying diagrams taken from two patients wounded at Paardeberg (figs. 22 and 23).

In fig. 22 the bullet entered the outer and posterior aspect of the left b.u.t.tock, crossed the limb behind the femur, and emerged at the inner aspect by a vertical slit: the bullet then entered the s.c.r.o.t.u.m by a vertical slit, and emerged by a typical circular aperture; re-entered the right thigh by a transverse slit aperture, and, striking the femur in its further course, underwent deformation, and finally escaped by an irregular aperture 3/4 of an inch in diameter. The occurrence of exit slits in the adductor region is common, and to be explained by the tendency of the comparatively thin elastic skin to be carried before the bullet; the slit entry in this position must, I suppose, be explained by the comparatively slight support afforded by the underlying structures, which are often in a condition of hollow tension. The scrotal wounds are perhaps more difficult to account for, but in this case the fact of the distal aperture being directly supported by the right thigh is a ready explanation of the circular exit, while the skin corresponding to the slit entry was no doubt carried before the bullet, and finally gave way in the line of a normal crease.

[Ill.u.s.tration: FIG. 22.--Entry and Exit Wounds in both thighs and s.c.r.o.t.u.m. From right to left: 1. Circular entry in left b.u.t.tock behind trochanter. 2. Vertical slit exit in adductor region. 3. Slit entry in s.c.r.o.t.u.m (probably inverted before bullet broke the surface, and then a slit occurred in a normal crease). 4. Circular exit in s.c.r.o.t.u.m (here supported by surface of right thigh). 5. Transverse slit entry in right adductor region. 6. Irregular 'explosive' exit, the bullet having set up on contact with the front surface of the femur, but without having caused solution of continuity of the bone.]

In fig. 23 all the wounds are circular except the final exit, which was irregular as a result of the bullet in this case also having struck the femur in the second thigh. Considerable variation also exists in the size of the circular apertures; this ill.u.s.trates the secondary enlargement often occurring in such wounds, and most marked at the apertures of entry, as the more contused. Both diagrams were made from patients eight days after the reception of the wounds.

[Ill.u.s.tration: FIG. 23.--Wound of both Thighs. First and second entry typical circular wounds. First exit a small circular wound; the bullet 'set up' on contact with the femur without causing solution of continuity of the bone, and second exit is irregular and large.

This diagram is of considerable interest when compared with fig. 22. I believe the comparative regularity in the wounds to have been due to a higher degree of velocity of flight on the part of the bullet]

Lastly, vertical or transverse slits may be looked for with considerable confidence in situations in which transverse oblique or vertical folds or creases normally exist in the skin, and depend on the lines of tension maintained by the connection of the skin in these situations to the underlying fascia. Thus I saw well-marked transverse and vertical slits in the forehead corresponding with the creases normally found there, and in this situation I noted some slit entries. Transverse slits were common in the folds of the neck, the flexures of the joints (fig. 20), and the anterior abdominal wall either in the mid line or in creases like those stretching across from the anterior superior iliac spines. Again they were seen in the palms and soles, but here more readily tended to a.s.sume the stellate forms. Vertical slits are less common; they occurred with the greatest frequency in the posterior axillary folds.

Oval apertures of exit are far less common than those of entry, since the most common factor for the production of an oval opening, bony support, is never present. In long subcutaneous tracks, or very superficial wounds, they are however sometimes met with and may terminate in a pointed gutter (see figs. 18 and 24).

The greatest modifications in the appearance and nature of the apertures of entry are dependent on previous deformation of the bullet, when all special characteristics are lost, and it becomes impossible to form any opinion as to the type of bullet concerned. These modifications are naturally far more common in the aperture of exit, since the bullet so often acquires deformity in the body as the result of impact with the bones. Further remarks on this subject will be found with the description and comparison of the various bullets on p. 81.

[Ill.u.s.tration: FIG. 24. Superficial Thoracico-abdominal Track. Small entry: discoloration of surface over costal margin from deep injury to skin; well-marked 'flame' gutter exit (see fig. 18)]