Surgical Experiences in South Africa, 1899-1900 Part 7

_Pari pa.s.su_ with the closure of the external openings, healing of the track takes place, but this is not always so rapid a process as is apparently the case. In many instances the closure, and even definite healing, of the external wounds is complete long before the track has actually healed, even though it be contracted up to complete closure as far as any cavity is concerned. This is well seen in many cases in which the exit opening is large as a result of deformation of the bullet, or the pa.s.sage of bone splinters in conjunction with it; here, in spite of absence of all suppuration, the track may remain patent for many weeks.

This may point to infection, but the tardiness in actual consolidation corresponds with what we are well acquainted with in the case of all aseptic wounds when a slough has to separate or become absorbed, and it is therefore only what might be reasonably expected when we remember that every such bullet track is lined by a thin layer of damaged tissue.

[Ill.u.s.tration: FIG. 25 (_b_).--Great Omentum carried by the bullet into an exit track leading from the abdominal cavity. A. Outline of opening in the peritoneum]

When fully healed, the points of entry and exit are so insignificant as to be less obvious than ordinary acne scars, and later are often hardly visible, but for a considerable period they are often more palpable than apparent. This depends upon the induration of the line of cicatrix corresponding to the course of the original track which is adherent to the two points. The induration is indeed so marked as to occasionally give rise to the suspicion that a foreign body such as a fragment of lead or of the mantle of the bullet has been enclosed during the healing of the wound.

In the deeper portions of the tracks the extreme density of the cicatrix is a factor of great prognostic importance, since if it implicates muscles, tendons, vessels, or nerves, impairment of movement, circulatory disturbance, or signs of neuritis or nerve pressure are often witnessed. Thus, for instance, a track traversing the calf, will more or less tie the whole thickness of the structures perforated at one spot, and the apertures of entry and exit may be visibly retracted when the muscles are put in action with consequent pain and stiffness to the patient. Such pain and stiffness form some of the most troublesome after-consequences of many simple wounds. It is remarkable for how long a period after the healing of the wound and resumption of active duty the patients suffer from pain in and radiating from the locality of the wound, when fatigued or suffering from stiffness from the prolonged retention of one att.i.tude or exposure to cold. The cords, however, eventually completely disappear, and the cicatrices become moveable. The effects of secondary pressure on the vessels and nerves are considered under the headings devoted to those structures.

_Suppuration._--While the occurrence of deep suppuration or septic phlegmon was rare, local suppuration of the apertures of entry and exit was seen in a considerable proportion of the wounds. This was referable to infection from the skin itself, or to infection from without subsequent to the infliction of the injury. Infection from the skin, difficult to obviate at all times, is especially likely to occur in wounds the first dressing of which is often delayed, and which happen to men sweating freely into clothes the condition of which is at least undesirable for contact with a recent wound. Beyond this, the first dressing materials, removed from a soiled tunic by possibly a comrade or a stretcher-bearer, are scarcely above reproach of the probability of containing septic organisms themselves. Again, once applied, the exigencies of the situation often necessitate an amount of movement fatal to the retention of the dressing over the wound, and a second opportunity of infection arises before the patient comes into the hands of the surgeon in the Field hospital.

The general tendency of such suppurations when they occurred in uncomplicated flesh wounds was to remain superficial, either involving the contused margin of the cutaneous opening and the plug of blood-clot occupying it, and resulting in a slight enlargement of the wound only, or at most involving the subcutaneous tissue and not extending into the deep planes of the trunk or limbs. In either case a slight delay in healing was the most serious result, while const.i.tutional signs of infection were either absent or of the slightest nature. The same indisposition to spread by the track was equally noted when a deep portion became infected from, for instance, the intestine in a belly wound.

Wounds of irregular type, however, such as those caused by ricochet bullets, or accompanying severe fractures, or those caused by fragments of larger projectiles, often suppurated freely in spite of exposure to no more unsatisfactory surrounding conditions than the wounds of small bore. This appears to show conclusively that the first element in the general slight consequences of small-bore wounds is their calibre, and, secondly, that increase of velocity on the part of the bullet, while it in some measure compensates for the loss of volume in the projectile, on the other hand reacts in favour of the wounded in so far as the injuries it effects on the soft tissues are ill suited to the development of septic organisms in the parts.

_Retained bullets._--These were met with more frequently than might have been expected, but I can give no idea as to their proportional occurrence, since so many of the slighter injuries never came under my observation. Experience, however, showed that the bullets of large calibre and low velocity employed during the campaign were far more commonly lodged in proportion to the frequency of their use. Thus I saw a considerable number of Martini-Henry, Snider, large leaden sporting bullets, and shrapnel retained. Again, among the bullets of smaller calibre, the Guedes 8-mm. bullet, which travels at a comparatively low rate of velocity and with moderate spin, was far more frequently lodged than the Lee-Metford or Mauser in comparison with the number of Guedes rifles in use.

Bullets of small calibre were, however, also retained with some degree of frequency, either as the result of striking at a long range, or in such a direction as to need to traverse a large segment of the body before escaping, or as striking large or several bones, or making some irregular form of impact: the last was a not infrequent explanation of lodgment, especially when a bone lay in the course of the track.

Ricochet bullets naturally were especially likely to be retained, both on account of the low velocity with which they often travel and the irregularity of their surface with consequent loss of penetrating power.

WOUNDS OF IRREGULAR TYPE

Many of the wounds met with deviated so greatly in appearance and general characters from what has been described above as to afford little or no evidence of having been inflicted by small-calibre bullets, and before describing these it is necessary to give a short account of the circ.u.mstances which are responsible for such departures from the common type. In the case of the wound of entry, the simplest explanations are lateral impact on the part of the cylindro-conoidal projectile, due to the position of the part struck or the direction in which the bullet has been fired, wobbling on the part of the bullet due simply to loss of velocity and force in flight, or to turning of the bullet by impact with an obstacle to its course (ricochet) which may amount to actual reversal of the striking end. As a rule, in such cases the size of the aperture of entry exceeds that of exit, and in a large proportion the bullet is retained within the body.

Of these explanations that of the 'wobble' needs some pa.s.sing notice. In its simplest form it depends merely on loss of velocity of flight on the part of the bullet, the centre of gravity of which lies behind its middle; hence a tendency to turn over and over is acquired. As a result of this, either the side of the tip, the side of the bullet, the side of the base, or the base itself may form the portion of the projectile which comes into contact with the body. The tendency to wobble is naturally greatly increased in ricochet bullets, since the contact, if lateral, serves to check the spin on which the bullet depends for its flight on an axis parallel to its long diameter. The first effect of wobbling is to increase the size and interfere with the regularity of outline of the wound of entry; but it also acts in a more serious manner, since the increase of the area of impact augments the resistance offered by the body; therefore the degree of damage to the tissues is accentuated and becomes greater than it would be from a bullet travelling at the same rate on its normal axis. Hence the wounds are both large and severe, or if the velocity is very low, the projectile is especially likely to be retained.

Actual reversal of the bullet usually only slightly enlarges the aperture of entry, but injuries to cancellous bone are apt to be more severe when the bullet enters in this manner, or again it is often retained. I saw several such cases during the campaign.

Another form of wobble is suggested by Nimier and Laval,[9] of which I can offer no experience. They suggest that, as rotation slows, the bullet may on impact wobble like a top before it ceases to spin.

Probably the power of penetration possessed by a bullet wobbling in this manner would not be very great, but its effect would mainly be altered in the direction of an abnormal increase in the size of the aperture of entry, or possibly in the degree of comminution in fractures.

It is probable that some of the more serious wounds observed were merely the result of unusual forms of impact with normal flight on the part of the bullet. The majority, however, depended, in the case of the wound of exit, on deformation of the bullet within the body, or the propulsion of bone fragments with it, and, when both apertures were affected, to previous ricochet on the part of the projectile.

It is here necessary to give a short account of the more common deformities met with, and to refer to the special characters possessed by different types of bullet of small calibre which may affect the ease with which deformity is produced, and the degree to which it is commonly carried. The effect of ricochet is to lower the velocity of flight, and at the same time to effect certain alterations of form in the bullet.

These with rectangular impact in the case of bullets travelling at a low degree of velocity consist in a bending and deformation of the tip; in the higher degrees, of bending, shortening, extensive destruction, or complete fragmentation. If the bullet makes lateral impact, only widening and flattening result, often with the escape of the lead core from the mantle. That a ricochet bullet may travel a considerable distance is shown by the following observations quoted from Nimier and Laval.[10]

[Ill.u.s.tration: FIG. 26.--Sections of four Bullets to show relative shape and thickness of mantles.

From left to right: 1. Guedes; regular dome-shaped tip; mild steel mantle; thickness at tip 0.8 mm.; at sides of body 0.3 mm. 2.

Lee-Metford; ogival tip; cupro-nickel mantle; thickness at tip 0.8 mm.; gradual decrease at sides to 0.4 mm. 3. Mauser; pointed dome tip, steel mantle plated with copper alloy; thickness at tip 0.8 mm.; gradual decrease at sides to 0.4 mm. 4. Krag-Jorgensen; ogival tip as in Lee-Metford; steel mantle plated with cupro-nickel; thickness at tip 0.6 mm.; gradual decrease at sides to 0.4 mm. The measurements of the sides are taken 2.5 cm. from the tip. Note the more gradual thinning in the Lee-Metford mantle.]

Up to a distance of 1,700 to 1,800 metres the bullet may make several ricochet bounds. When the bullet strikes first at short distances (as 600 metres), it may make several bounds of from 300 to 400 metres: at moderate distances (as from 600 to 1,200 metres), bounds of 200 to 300 metres; and at distances above 1,200 metres, bounds of 100 to 200 metres. The length of the ricochet bounds depends on the angle of impact of the bullet with the ground, the nature of the slope of the latter, and the velocity of the bullet.

Putting aside the question of calibre and volume of the bullets we are concerned with, I believe the most important variations as serious effects of ricochet depend on the relative thickness and the composition of the mantles. Fig. 26 ill.u.s.trates the relative thickness of the mantles in the Krag-Jorgensen, Mauser, Lee-Metford, and Guedes bullets.

Given an equal degree of force and velocity on the part of the bullet at the moment of impact, the a.s.sumption is justifiable that the thinner mantles would tear or burst more readily in direct ratio to their relative thinness. I believe this a.s.sumption to be borne out by my own experience of the common deformities that occurred; but the great relative frequency with which Mauser bullets came under my observation, and the difficulty of forming any estimate of the velocity and force retained by any particular bullet at the moment of impact, make it impossible for me to express myself with the confidence which I should wish.

[Ill.u.s.tration: FIG. 27.--Normal Mauser Bullet]

The second condition which influences the nature and degree of the deformities depends on the relative tenacity or brittleness peculiar to the metal employed in the manufacture of the mantles. In the case of the Lee-Metford this consists of an alloy of 80 parts of nickel with 20 of copper. The Krag-Jorgensen and Mauser are ensheathed in steel plated with cupro-nickel, and the Guedes has a plain steel envelope coated with wax.

Both as a result of experience in the field gained from ricochet bullets, and in the hospitals from bullets which had undergone deformation within the body, I am under the firm impression that the thin nickel-plated steel envelope of the Mauser bullet splits more readily than the thicker and more tenacious cupro-nickel envelope of the Lee-Metford, that the direction of the ruptures is more purely longitudinal, and the fissuring itself more extensive and complete.

I append below a series of deformities observed in Mauser bullets, some of which were collected on the field of battle, but all of which were familiar to me in bullets removed from the bodies of patients, except the complete disc shape shown in fig. 29. They correspond with specimens of which I made sketches at the time of removal from the body, but which I had not the heart to retain in view of the natural wish of the patients to keep them as mementoes of their wounds.

[Ill.u.s.tration: FIG. 28.--Four common types of lateral Mauser Ricochet Bullets.

From left to right: 1. Slipper form; slight broadening and turning of tip. 2. More p.r.o.nounced degree of form 1, with laceration of the mantle opposite the shoulder of the bullet. This is the weakest spot, for two reasons: the alteration in curve at this position, and the junction of the thickened point of the mantle with the thinner sides. 3. Lateral ricochet involving nearly whole length of bullet. Rupture of mantle from broadening of core opposite shoulder. 4. Similar lateral ricochet with extensive longitudinal rupture of mantle, the latter being turned out and forming a cutting 'f.l.a.n.g.e.']

Slight indentations and deviations from strict symmetry of form of such degree as not seriously to influence the outline and nature of the apertures were very common. Beyond these one of the most frequent primary deformities was that we familiarly spoke of as the 'slipper form' (No. 1, fig. 28). This results from light glancing contact of the tip with a hard body: in it the mantle of the bullet is rarely fractured, and the deformity itself is of slight importance, except in so far as it may influence the direction of the wound track, which acquires a tendency to be curved. The tip of the bullet is slightly flattened and turned up, down, or to one side, according to the point struck. I saw this deformity frequently, both with Lee-Metford and Mauser bullets. Nos. 2, 3, and 4 are more p.r.o.nounced degrees of the same type of deformity, accompanied by more or less extensive fissuring of the mantle. No. 4 ill.u.s.trates the turning out of the longitudinally fissured mantle in such a way as to make a cutting f.l.a.n.g.e. I have seen such bullets removed, and the variety is of some importance as materially increasing the cutting capabilities of the bullet, and augmenting its area of destructive action. No. 5, fig. 29, is the only form I have not seen removed, but such a bullet would account for some of the long irregular gutter wounds observed, if it retained sufficient velocity to strike with any force.

[Ill.u.s.tration: FIG. 29.--'Disc'-shaped Lateral Ricochet. This form is of little practical importance, as the velocity retained by the bullet is low, and no perforating power would be retained. It is inserted separately in order to complete the series, shown in fig. 28.]

Fig. 30 ill.u.s.trates complete longitudinal fissuring of the mantle. Such mantles are common, and still more so are the opened-out sheets such as is shown still attached in fig. 29. Free mantles are often very numerous on stony ground, but are of little importance, since I never saw fragments of them removed or impacted. They probably travel a very short distance after their formation, and if they did strike would possess little power of penetration. The freed leaden cores do, however, sometimes enter the body, and some of the specimens removed have been referred to the use of expanding bullets. In all the Mauser specimens the longitudinal direction of the fissuring of the mantle is striking.

[Ill.u.s.tration: FIG. 30.--Ruptured Mauser Mantle, to ill.u.s.trate the tendency to complete longitudinal fissuring]

Fig. 31 represents bullets removed from the body and ill.u.s.trates types of deformity due to impact with the bones. The deformity resembles in some degree that of the mushroomed lead cores, and also indicates that the shoulder of the cased bullet is its weakest point. Each specimen exhibits shortening and widening without fracture of the mantle, the latter being simply thrown into folds; both bullets were lodged in the thigh after fracturing the femur. The localisation of injury to the fore part of the bullet, and the fact of expansion, allow us to infer that the degree of velocity retained on impact with the bone was comparatively low, and that neither bullet had been exposed to very severe strain.

[Ill.u.s.tration: FIG. 31.--Two retained Mauser Bullets which had produced comminuted fractures of the femur of moderate severity. Each has given way at the shoulder, but the mantle has developed creases without rupture, and the bullets are correspondingly bent. Both bullets were travelling at a moderate if not low degree of velocity]

Fig. 32 is also of a retained bullet in which the fore part of the mantle is very extensively fissured and the core set free. In this the mantle has suffered severely and the leaden core to a less extent. As an apical ricochet it corresponds with the Lee-Metford shown in fig. 36.

[Ill.u.s.tration: FIG. 32.--Apical Ricochet Mauser Bullet (see text). The 'mushrooming' of the core is moderate, but the destruction of the anterior part of the mantle very considerable]

The deformity found in fig. 32 I met with both in retained bullets and also in those which had been fired into sand or anthills. The particular specimen figured was removed from the thigh of a patient wounded at the battle of Belmont. An irregular entry wound was situated over the internal tuberosity of the tibia, while a large fluctuating haematoma existed in the lower third of the thigh, at the upper part of which a hard elongated body was palpable. As was so often the case with internal haemorrhages, the patient's temperature rose high, and on the third day the haematoma was incised by Major Coutts, R.A.M.C. The core of the bullet was then found in the blood cavity near the surface, but on introduction of the finger a second body was discovered entangled in the quadriceps muscle, and this proved to be the tattered mantle. I saw similar deformity produced within the body by a bullet, which, entering by a small type aperture in the left ala of the nose, struck the margin of the right malar bone, and lodged beneath the latter. The similarity of this bullet to that seen in the ricochet in fig. 32 was exact. The form is of great importance both on account of the degree of laceration it effects in the track, the presence of two foreign bodies in the wound, and from the fact that it can be produced by making the bullet travel through sand or antheaps, since both the former in the shape of sandbags and the latter in their natural state so often formed the cover to men during the campaign. Bullets of 6.5 mm., such as the Krag-Jorgensen, with steel envelopes apparently break up with great ease in sand.

Fig. 33 shows a form not uncommon when the bullet comes into contact with the ribs. It is produced in bullets travelling at a low rate of velocity and striking by their side. I several times met with it when the bullet was retained, and also without fracture of the rib. In some variety it might occur after impact with any narrow margin of bone, and some importance attaches to the form, since it affords evidence as to the ease with which alterations in symmetry can be produced in Mauser bullets. Again its bent outline favours deviation in the further course of the bullet subsequent to impact with the bone, a result which I observed on more than one occasion.

[Ill.u.s.tration: FIG. 33.--Grooved Mauser removed from anterior abdominal wall after crossing the ribs. I saw several such removed from the thoracic wall, and am inclined to attribute the grooving to impact with the margin of the ribs]

Lastly, the question of actual spluttering or breaking up of the bullets must be considered. It is extraordinary into how many fragments either a Lee-Metford or a Mauser bullet may break up if it strike a hard body while travelling at a high rate of velocity. Fragmentation is exhibited in the skiagram forming the subject of plate XI. p. 194. It is somewhat remarkable how often this occurred when the short hard bones of the metacarpus were struck. With regard to the casing, the separation of small scales of the nickel plating has already been referred to; reference to the skiagrams, plates IX. and XVI., shows how readily the whole thickness of the mantle breaks up into small fragments, even when the bullet is travelling at moderately low degrees of velocity, and this I believe to be a special characteristic of the thin cupro-nickel-plated steel mantles.

Any variety of cased bullet, however, when it strikes against a stone, hard ground, or a bone, may be broken into innumerable fragments. The leaden fragments occasionally show a simple fractured surface, such as is ill.u.s.trated on a larger scale by the broken shrapnel bullets shown in fig. 96, p. 485. More commonly, however, the fragments, if of any size, appear torn, and if small, are mere spicules. These if of lancet shape often bury themselves in the skin only, while larger ones may penetrate deeply or even perforate. Thus, of a group of three officers standing near a stone on which a bullet struck, all were spattered about the face; most of the fragments lodged in the skin, but one perforated the concha of the ear and bruised the mastoid area, while others caused small jagged cuts. In another instance, both thighs of the patient were spattered after perforation of the clothes, and a large fragment lodged beneath the skin of the p.e.n.i.s. A case in which larger fragments perforated and simulated type wounds has already been referred to on p.

44.

[Ill.u.s.tration: FIG. 34.--Normal Lee-Metford Bullet]

The above remarks apply, for the most part, to Mauser bullets only, because my experience of that projectile was far wider than of the Lee-Metford. The only deformed Lee-Metford bullets that I saw removed from the body were of the 'slipper' variety, exactly corresponding to the similarly altered Mausers, and with no fissuring of the mantle. I saw none so freely deformed as the Mausers depicted in figs. 28, 29, 31, and 32.

In spite of diligent search on several battlefields, I was unable to collect many forms of Lee-Metford ricochet, although I found many undeformed bullets. I insert here, therefore, some ill.u.s.trations I obtained through the kindness of Colonel Hopton, Director of the School of Musketry at Hythe, which are of interest, and in some degree substantiate the impression I formed in South Africa as to the greater stability of the Mark II. Lee-Metford bullet (fig. 34). I am aware that, as meeting a smooth target at right angles, some of these are not strictly comparable to the Mauser bullets forming the subjects of the preceding ill.u.s.trations, which struck stones, and these mainly by their sides (if we except figs. 31 and 32), but they sufficiently exhibit the characters on which I wish to insist. That they support my opinion is the more probable as, with the exception of the type included above, I am under the impression that the large majority, if not all, of the Mauser bullets which struck stones fairly with their tips were broken to pieces, otherwise I must have met with some among the immense number which I saw. On the top of Tabanyama, for instance, the whole ground was littered at the time of my visit with shattered mantles and leaden cores, deformed almost past recognition.

[Ill.u.s.tration: FIG. 35.--Apical Lee-Metford Ricochets. From Hythe targets. Tendency of cupro-nickel envelope to tear in transverse direction]

The specimens depicted in figs. 35 and 36 indicate--(1) a greater malleability on the part of the mantle; thus in fig. 35 the cupro-nickel is obviously hammered and flattened out, while the fissures are neither numerous nor extensive. (2) Both bullets exhibit transverse tearing of the mantle, a common feature in Lee-Metford ricochets, of which I could offer other examples, but which I less often observed in Mauser bullets. (3) Tear is the term best expressing the nature of the fissures, while fracture more nearly expresses the nature of the fissures in the Mauser mantles. (4) Fig. 36 shows a mushroomed core and split mantle, which may be compared with the similarly deformed Mauser depicted in fig. 31. I think the variation in appearance is characteristic, the fissuring of the mantle being much less extreme, while the leaden core is normal at its base in consequence of the support afforded by the more tenacious cupro-nickel mantle. With regard to complete splitting of the mantles, however, I must add that free Lee-Metford mantles are often found from bullets fired at the target or elsewhere, and Nimier and Laval figure numerous forms.[11]

[Ill.u.s.tration: FIG. 36.--Apical Lee-Metford Target Ricochet. Well-marked 'mushrooming' of core. 'Torn' nature of the fissures in the mantle and limited extent. Compare with fig. 32]

_Expanding bullets._--The wounds resulting from perforation with deformed regulation bullets, such as are described above, differ for the most part by deviation from the type appearances, and a tendency to take a less favourable course on account of their increased size and of the greater degree of laceration of the tissues accompanying them. I must now pa.s.s on to the consideration of the forms of bullet especially likely to occasion those wounds spoken of as 'explosive' in character, and my remarks on these must be prefaced by a short description of the varieties which were in use during the campaign.