These points of comparison having been made, it only remains to consider

one other point, that of the relative stability of the bullets. This is

a matter of the greatest importance as regards the regularity or

otherwise of the wounding power of the projectile, and, as far as my

experience went, I believe the Mauser to far exceed the Lee-Metford in

instability of structure.

The core of all four bullets is composed of lead hardened by a certain

admixture of tin or antimony, but the mantle differs in composition,

thickness both general and in different parts of the bullet, mode of

fixation, and consequently in its power of resistance to violence.

Fig. 15 gives an exact representation of the relative thickness of the

mantles, and shows the general tendency to a thickening of the mantle at

its upper extremity, designed to increase both the stability and

striking power of the projectile. It will be noted that in general

stoutness the Lee-Metford stands first, as the case increases gradually

in thickness from base to apex.

Beyond this it must be noted that the Lee-Metford is the only one of the

four that is ensheathed with a mantle composed of a definite alloy, this

consisting of 80 parts of nickel and 20 of copper. Two of the remaining

bullets, the Mauser and Krag-Jörgensen, are ensheathed with steel

covered with a thin coating of an alloy of copper or cupro-nickel, to

take the rifling of the barrel, while the third has a plain steel mantle

which is covered with a layer of wax to take the place of the nickel

used in the manufacture of the two others. It is interesting to mention

here that the Boers evidently found the copper alloy coating

insufficient for its purpose, or at any rate not satisfactory in

preserving the weapon from the ill-effects consequent on the friction

between the steel case and the rifling of the barrel, as at about the

middle of the campaign they began to use their bullets waxed, as in the

case of the Austrian Mannlicher; hence the legend of the poisoned

bullets which caused such a sensation for a short period amongst the

uninitiated. It is possible also that the additional layer of wax was

necessitated by the wearing of the barrel.

The wax employed for the Mauser bullets was not originally green. Mr.

Leslie B. Taylor informs me that it is probably paraffin wax, the green

colour depending on the formation of verdigris from the copper alloy

with which the steel envelopes are plated. This completely corresponds

with my own experience, since on the bullets in my possession the green

colour, originally pale, has steadily increased in depth. Many old

leaden bullets I found in the Boer arsenals were also waxed, but in this

case no alteration in colour had taken place. The Guedes bullets, which

are cased in mild steel, become somewhat brown with exposure from a

similar oxidation or rusting of the surface.

As far as my experience went, however, the steel casing has an important

surgical bearing beyond the mere question of wear and tear on the rifle

barrel. That it possesses elasticity and capability of bending is

obvious, and in a later chapter, devoted to irregular wounds, several

illustrations of such deformities are given; but when it strikes stone I

believe it splits and tears with very much greater freedom than the

cupro-nickel mantle of the Lee-Metford. At any rate, I never came across

Lee-Metford bullets deformed to the same degree as Mauser bullets,

either when removed from the body, or as ricochet projectiles on the

field of battle. For this reason, therefore, provided the fighting takes

place on stony ground, I believe the Mauser bullet and others ensheathed

in steel to be much more dangerous surgically than those encased in

cupro-nickel. I fancy this would be equally the case even if the mantles

were of exactly the same thickness.

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 passing 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-Jörgensen was

little used, and beyond pointing out its capacity to inflict very neat

individual injuries, in which it must surpass 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 illustrations of a number of sporting bullets of small calibre, as

well as of large calibres in lead, found in the Boer arsenals 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 classes:

1. Direct or immediate destruction of tissue.

2. Remote changes induced by the transmission of vibratory force from

the passing projectile to neighbouring tissues or organs.

Those of the first class 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

distinguishing 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.

[Illustration: FIG. 16.--Mauser Entry and Exit Wounds. A, entry in

buttock; 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]

[Illustration: 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 homogeneous

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 passed

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.

[Illustration: 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 pronounced

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 pronounced 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.

[Illustration: 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 circumstances: 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 distinguishing

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.

[Illustration: FIG. 20.--Circular Entry back of arm; exit (bird-like) in

anterior elbow crease]

[Illustration: 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 débris 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

buttock, crossed the limb behind the femur, and emerged at the inner

aspect by a vertical slit: the bullet then entered the scrotum 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.

[Illustration: FIG. 22.--Entry and Exit Wounds in both thighs and

scrotum. From right to left: 1. Circular entry in left buttock behind

trochanter. 2. Vertical slit exit in adductor region. 3. Slit entry in

scrotum (probably inverted before bullet broke the surface, and then a

slit occurred in a normal crease). 4. Circular exit in scrotum (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 illustrates 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.

[Illustration: 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 assume 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.

[Illustration: 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)]

2. _Direct course taken by the wound track._--This character primarily

depends on the velocity with which bullets of small calibre are made to

travel, and on the small area of the tissues upon which they operate. In

this relation the degree of velocity retained by the bullet is often of

minor importance, provided it be sufficient to penetrate the body. Fired

within a distance of 2,500 yards there is little doubt that a bullet of

the Lee-Metford, Mauser, or Krag-Jörgensen types, passes straight

between the apertures of entry and exit when these are of the type

outline, even when the bones are implicated. By reason of the small size

of the projectiles, their shape, and the spin and velocity transmitted

to them, there is no reason why at a sufficiently short range they

should not traverse the body from the crown of the head to the sole of

the foot. The necessary conditions of position and distance for such an

injury are obviously not often obtained, but it may be pointed out that

the Belgian Mauser rifle at a distance of five yards is capable of

driving a bullet 55 inches or nearly five feet into a log of pine-wood.

Many examples of long tracks will be referred to later, but the

following instances may be of interest in this relation. A bullet

entering at the occipital protuberance traversed the muscles of the

neck, passed through the thoracic cavity, fractured the bodies of the

third and fourth and grooved the seventh and eighth dorsal vertebræ,

grooved the seventh and eighth and fractured the ninth and tenth ribs,

traversed the muscles of the back and finally lodged against the ilium;

the whole length of this track measured some 25 inches. Again, at the

battle of Belmont a Mauser bullet entered the pelvis of a horse just

below the anus, and traversed the entire trunk before emerging from the

front of the chest: it may be of interest to mention that this animal

was alive and moving about the next day, but I am sorry I can give no

further information regarding his fate.

[Illustration: FIG. 25.--Superficial Track on external surface of Thigh.

Local discoloration of skin five weeks after reception of injury]

The possibility of contour tracks travelling around the walls of the

chest or abdomen has therefore rarely to be considered, except in

occasional instances where the bullet fired from a long range has

impinged against a bone and is retained in the body. The small volume of

the bullets, however, allows the production of very prolonged direct

subcutaneous tracks in the body wall, in positions where they would be

manifestly impossible with projectiles of larger calibre.

Figs. 24 and 25 illustrate wounds of this nature. In the case figured in

fig. 24 the bullet entered over the third rib in a vertical line above

the right nipple; it then coursed obliquely down, crossing the seventh

costal cartilage, and finally emerged 3 inches above the umbilicus.

Where the track crossed the prominence of the thoracic margin the skin

was so thinned as to undergo subsequent discoloration, while a distinct

groove was evident there on palpation. In some similar cases I have seen

the central part of the track secondarily laid open as a result of the

thinning of the skin and consequent sloughing due to the interference

with its vitality.

Short of sloughing, the skin may show signs of alteration of vitality

for a long period after the injury; thus fig. 25 depicts the condition

seen in a superficial wound of the thigh five weeks after the injury.

The line of passage of the bullet between the two openings was still

clearly visible as a dark red coloured streak. Grooves in such cases are

generally readily palpable in the early stages, while later the want of

resistance is replaced by the readily felt firm cord representing the

cicatrix. These points are of much importance in discriminating between

perforating and non-perforating wounds of the abdomen, and are again

referred to in that connection.

The direction of the tracks obviously depends on the attitude assumed by

the patient at the moment of impact of the bullet and the direction

whence the firing has proceeded. The frequent assumption of the prone

position during the campaign led to the occurrence of a large proportion

of longitudinal tracks in the trunk, or trunk and head, which will be

referred to later. Certain battles were in fact strongly characterised

by the nature of the wounds sustained by the men. Thus at Belmont and

Graspan, where some rapid advances were made in the erect attitude,

fractured thighs were proportionately numerous, while at Modder River,

where many of the men lay for a great part of the day in the prone

position, glancing wounds of the uplifted head, of the occipital region,

or longitudinal tracks in the trunk and limbs were particularly

frequent. I very much regret that the material at my disposal does not

allow me to add some remarks as to variation in the nature of the

wounds according to whether they were received from an enemy firing from

a height or from below, but it is possible that some information on this

subject may be forthcoming when the returns of the Service are made up,

since it is naturally of great importance as to the effect of trajectory

in the proportionate occurrence of hits.

3. _Multiple character of the wounds._--The same conditions responsible

for the length and directness of the tracks, account for the frequently

multiple character of the wounds implicating either the limbs or

viscera--thus, lung, stomach, liver; neck, thorax, abdomen; abdomen,

pelvis, thigh. Also for the frequent infliction of two or more separate

tracks by the same bullet--thus, arm and forearm with the elbow in the

flexed position; both lower extremities; both lower extremities, penis

or scrotum; leg, thigh, and abdomen, with a flexed knee; upper extremity

and trunk, and more rarely one upper and one lower extremity. Again, it

was remarkable how often the same bullet would inflict injuries on two

or more separate men, not unfrequently dealing lightly with the first

and inflicting a fatal injury on the second, or vice versâ. The small

calibre of the bullet, moreover, allows of the neatest and most exact

multiple injuries. Thus in a patient who was crawling up a kopje on all

fours, the flexed middle digit of the hand was struck. The bullet

entered at the base of the nail, first emerged at the distal

interphalangeal flexor fold, re-entered the metacarpo-phalangeal fold,

and finally emerged from the back of the hand between the third and

fourth metacarpal bones.

4. _Small 'bore' of the tracks, and tendency of the injury to be

localised to individual structures of importance._--Here we meet with

the most striking characteristic of the injuries, and evidence that

reduction of calibre affects more strongly the nature of the lesion than

does any other element in the structure of the modern rifle. The

diameter of the track slightly exceeds that of the external apertures,

probably as a result of the more ready separability of the elements of

the structures perforated than exists in the skin. The calibre,

moreover, tends to be fairly even throughout when soft structures only

are implicated, though local enlargements result wherever increased

resistance is met with. Thus a strong fascia may offer such resistance

as to increase locally the bore of the track, and in this particular the

state of tension of the fascia when struck will affect the degree of the

enlargement. The most striking instances of local enlargement of the

track are of course seen when a bone lies in the course of the bullet,

but we must here bear in mind the introduction of a new element--the

propulsion of comminuted fragments together with the bullet itself. In

cases of fracture the distal portion of the track is in consequence many

times larger than the proximal. The most striking examples of small even

tracks are seen, on the other hand, in punctures of the elastic and

practically homogeneous lung tissue, where the wounds are extremely

small.

On transverse section of the track the gross amount of actual tissue

destruction occupies a lesser area than that corresponding to the

diameter of the bullet. The destructive action of the projectile is in

fact exerted mainly on the tissues directly lying in its course, the

track being opened up during the rush of the passage of the bullet,

partly as a result of its wedge-like shape and partly as a result of the

throwing off of the tissues forming the walls of the track by a

diversion of a portion of the force in the form of spiral vibrations

dependent on the revolution of the bullet. Again, the opening out of the

tissues may be aided by the direction taken by the first and strongest

as well as the simplest series of vibrations transmitted, which would

assume the shape of a cone of which the point of impact forms the apex.

The escape from actual destruction by structures lying in the immediate

neighbourhood of the track is indeed often surprising, but not perhaps

so astonishing as the perforation of long narrow structures such as the

peripheral nerves and vessels, without irreparable damage to the parts

remaining, and this although the structures themselves may be of a

diameter not exceeding that of the bullet itself. The capacity of these

projectiles to split such structures as tendons was already well known

before our experience in this campaign, but the injuries to the nerves

and vessels of the same character came as a surprise to most of us. The

lateral displacement of tissues seems to bear a strong resemblance to

what is seen on the passage of an express train, when solid bodies of

considerable weight are displaced by the draught created without ever

coming into contact with the train itself. The tendency to lateral

displacement is still more strongly exhibited when dense hard structures

such as bone are implicated. Here the fragments at the actual points of

impact on the proximal and distal surfaces of a shaft are driven

forwards, while the lateral walls of the track in the bone are simply

comminuted and pushed on one side without loss of continuity with their

covering periosteum.

The extension of this form of displacement to a degree amounting to a

so-called explosive character in the case of the soft tissues, even when

the bullet passed at the highest degrees of velocity, was, however,

never witnessed by me, and I very much doubt the existence of a

so-called 'explosive zone' so far as wounds of the soft parts are

concerned. On the contrary, I am inclined to believe that the highest

degrees of velocity are favourable to clean-cut neat injuries of the

soft tissues. I saw a large number of type wounds of entry and exit

inflicted at a range of under fifty yards.

5. _Clinical course of the wounds._--The tendency of simple wounds such

as are above described to run an aseptic course was very marked, and,

given satisfactory conditions, deep suppuration and cellulitis were

distinctly rare. It may also be confidently affirmed that when

suppuration did occur, with apertures of entry and exit of the normal

small type, this was always the result of infection from the skin, or

infection subsequent to the actual infliction of the wound. The

infrequency of suppuration depended on the aseptic nature of the injury,

the smallness of the openings, the small tendency of the track to weep

and furnish serous discharge in any abundance, the comparative rarity of

the inclusion of fragments of clothing or other foreign bodies, and

possibly in some degree on the purity and dryness of the atmosphere,

which favoured a firm dry clotting of the blood in the apertures of

entry and exit, and consequent safe 'sealing of the wound.'

As to the aseptic nature of the injury, it will be well to first

consider the question of the sterility of the bullet. Putting laboratory

experiments on one side, the large experience of this campaign seems to

prove to absolute demonstration that, bearing in mind the very large

proportion of instances of primary union in simple tracks, the surgeon

has nothing to fear on the part of the bullet itself. This is the more

striking when we remember that these bullets shortly before their

employment were carried in a dirty bandolier, and freely handled by men

whose opportunities of rendering either their hands or implements

aseptic were as bad as it is possible to conceive.

Several explanations are to hand, but none of them conclusive. Two must,

however, be shortly considered. First, the surface of the bullet, except

its tip and base, is practically renewed by passage through the barrel.

Secondly, there is the question of the heat to which it is subjected. As

far as cauterisation of the tissues is concerned, this question has been

practically settled in the negative, since actual determinations of the

heat immediately after the moment of impact have been made, and again it

has been shown that butter is not melted, and that neither gunpowder nor

dynamite is exploded, by firing bullets through small quantities of

those materials. Again, the absence of any sign of scorching of the

clothes of the wounded is strong evidence against the possibility of any

considerable heat being applied to the tissues of the body; while

another observation, although of less importance as affecting spent

bullets only, that bullets, which have perforated the body but lie

between the skin and the clothing, leave no sign of cauterising action

on either, may be mentioned. None the less, the sources of heating while

the bullet is passing from the barrel are many and obvious. Thus there

is the heat consequent on explosion of the powder, the warm state of the

barrel itself when the rifle has been fired a few times consecutively,

and the heat resulting from the force and friction essential to the

propulsion of the bullet through the barrel. Again, bullets covered with

wax before their introduction into the barrel retain no trace of this

when they have been fired, although at any rate the portion covering

the tip is not exposed to friction on the part of the rifle, and lastly

the base of the bullet has no other explicable reason for its

innocuousness than subjection to a certain degree of heat. While not

claiming any cauterising action on the tissues by the bullet, I should

therefore still be inclined to allow the probability of the heat to

which the surface of the bullet is exposed exerting a cleansing action

on the projectile. In regard to this point it is interesting to bear in

mind that shots from an ordinary gun seldom or never give rise to

infection.

Foreign bodies were rarely carried into the wounds with the bullet. I

saw several instances in which portions of the metal of cigarette cases

and of cartridge cases when the bullet had perforated cartridges in the

wounded man's bandolier, and in one instance small pieces of glass from

a pocket mirror, must have been carried in without any obvious ill

effect. Fragments of clothing, on the other hand, in every case caused

suppuration: clothing was not often carried in, the khaki linen was

perforated with a clean aperture, most commonly a slit; but the thick

woollen kilts of the Highlanders, and thick flannel shirts, occasionally

furnished fragments. The introduction of large pieces of clothing is a

sure proof of irregularity of impact on the part of the bullet. The

frequency with which portions of cloth were introduced from the kilt was

one of the strongest surgical objections to its retention as a part of

the uniform on active service.

Retained bullets themselves remained as foreign bodies in a certain

number of cases. I cannot say that suppuration never followed the

retention of a bullet, since in two of the instances where I saw such

removed they lay in a small cavity containing at any rate a 'purulent

fluid.' In one of these the bullet was a Martini-Henry, and in both the

bullet had been imbedded for some weeks, and had certainly not

occasioned a primary suppuration of the wound.

The favourable influence of the pure and dry nature of the atmosphere in

this campaign must certainly not be underrated, and in support of this

influence I think I may say, from the experience of cases that I saw

coming from Natal where the climate and surroundings were not so

favourable as on the western side, that suppuration was more common and

more severe in the moister atmosphere.

Putting aside all the above remarks, however, I am inclined to think

that a general tendency to primary union and the absence of suppuration

will always be a feature of wounds from bullets of small calibre, and

that this favourable tendency is attributable to certain inherent

characters of the injuries. Of these the nature and small size of the

openings, the dry character of the lining of the track due to

superficial destruction and condensation of the tissue forming its wall,

the small disposition to prolonged primary hæmorrhage, and the absence

of any great amount of serous exudation during the early stages of

healing are the most important.

A mechanical factor of great importance also exists in the spontaneous

collapse and automatic apposition of the walls of the track. This

closure is rendered additionally effective in many cases by the

interruption of the continuous line in the wounded tissues consequent on

alteration in the position of the parts traversed when an attitude of

rest is assumed by the injured part. The indisposition to suppuration

and the apparent unsuitability of the tissue lining the track for the

development and spread of infecting organisms are well illustrated by

several observations. Thus, even if the bullet be thoroughly aseptic,

the fragments of destroyed skin driven into the track by the bullet can

scarcely be free from organisms; yet these seldom give rise to trouble.

Again, if for any reason a deep portion of a track becomes infected and

suppurates, there is no tendency for the spread of infection along the

line of wounded tissue, but rather for the development of a local

abscess, pointing in the ordinary direction of least resistance,

irrespective of the course originally taken by the bullet.

[Illustration: PLATE I.

Engraved and Printed by Bale and Danielsson, Ltd.

G. L. CHEATLE.

Mauser Wound of Entrance, a little more than 48 hours after infliction.

About 12/1.

Section of the entry segment of an aseptic Mauser wound removed a little

over forty-eight hours after its infliction. Magnified twelve diameters.

The margins of the opening are still sloping and depressed, indicating

the originally 'punched-in' nature of the aperture. A thin stratified

layer of epidermis completely closes it. No scab remains.

The wound track is occluded by an effusion of lymph, commencing

organisation of which is shown under a higher magnifying power by the

presence of leucocytes near the margin of the bounding tissue, and some

giant cells. The effusion of lymph occupies a slightly wider area

immediately beneath the papillary layer of the skin, then narrows, and

broadens again as the subcutaneous fascia is reached, indicating the

effect of resistance in widening the area of damage.

The subcutaneous connective tissue bounding the track shows little sign

of alteration beyond a general slight tendency of the lines of structure

to deviate in the direction of the passage of the bullet.

No hæmorrhage is apparent beyond a small collection of blood situated

immediately beneath the new layer of epidermis at the left-hand corner

of the opening.

Range probably within 800 yards. Seat of wound, abdominal wall a highest

point of iliac crest.]

Fig. 25 (_a_), A (plate I.) represents a section carried across an

aseptic aperture of entry. The specimen was removed by Mr. Cheatle from

a patient who died forty-eight hours after reception of the injury. It

shows well the small amount of gross destruction suffered by the

subcutaneous tissue, and the rapid repair which follows, since

macroscopically the track is scarcely discernible. Reference to plate I.

shows the remarkable fact that even at this early date considerable

progress towards definite healing has occurred, and a thin layer of

stratified epidermis covers the original opening. The question may be

raised whether the origin of this epidermal layer is not in part a

floating up of the margins of the main aperture.

During the course of healing some variation takes place in the

appearance of the apertures, especially that of entry. This, at first

contracted, later becomes somewhat relaxed, while in many cases a small

halo of ecchymosis develops around it. The blood-clot occupying its

centre now contracts, the margins rapidly become approximated

centripetally, and a small circular dark spot only remains, which is

later replaced by a small red cicatrix. The dark central spot under

these circumstances consists of the contused margin of the wound in the

skin, and a small proportion of blood-clot which finally comes away as a

small dry scab. When slight local infection occurs in place of simple

contraction and dry scabbing, the process is prolonged, the contused

margin separates by granulation, the clot in the opening breaks down,

and a small ulcer of somewhat larger proportions than the original wound

remains and takes some days to heal.

[Illustration: FIG. 25 (_a_).--_A._ Wound of entry 48 hours after

reception. _B._ Wound of exit, 7-1/2 days after reception. 1. Skin. 2.

Subcutaneous fat carried into the lips of the wound by the bullet. 3.

Infected blood extravasation in subcutaneous tissue. Exact size. (See

plates I. and II.)]

The aperture of exit in simple wounds of the soft parts sometimes heals

even more rapidly than that of entry, and if of the slit form may be

almost invisible at the end of ten days or a fortnight, actual primary

union having taken place as after a simple small incision. Larger or

irregular exit apertures, however, take a longer period to close than

entry wounds, and this is most often observed when the bullet has

undergone deformation within the body, or bone fragments have been

driven out with the bullet.

Fig. 25 (_a_), B (plate II.) represents a section of an infected exit

aperture from a patient who died seven and a half days after its

infliction. Two main points of interest are at once apparent: 1. The

carrying forwards of the subcutaneous fat into the lips of the skin

wound by the bullet. This illustrates the manner in which lightly

supported structures are carried forward by the bullet, and throws some

light on the mode by which vessels and nerves may escape by a process of

displacement. This figure may be compared with fig. 25 (_b_) which shows

a tag of omentum similarly carried forward by a bullet crossing the

abdominal cavity and plugging the exit wound. 2. The second feature of

interest is the amount of hæmorrhage into the subcutaneous tissue. In

this respect the contrast between the exit and entry apertures is

marked, since in the latter hæmorrhage is scarcely apparent. The

presence of such hæmorrhages is explained by the same dragging action as

the extrusion of the fat, and is of course dependent on consequent

rupture of small vessels. It is of importance as predisposing the exit

wound to more easy infection, and it accounts for the persisting

subcutaneous induration more often detected beneath healed exit than

entry apertures. Again, it suggests that the presence of blood in the

deeper parts of the tracks may be the determining cause of the indurated

cords often replacing them.

[Illustration: PLATE II.

Engraved and Printed by Bale and Danielsson, Ltd.

G. L. CHEATLE.

Mauser Wound of Exit, 7-1/2 days after infliction. Healing delayed by

Infection. About 12/1.

Section of the exit segment of a Mauser wound, removed seven and a half

days after infliction. Magnified twelve diameters.

The healing process has been delayed by infection.

There is no attempt at closure by a layer of epidermis, and the margins

are not depressed.

The wound track is narrower than that seen in the entry wound plate I.,

and completely occluded by a plug of the subcutaneous fat which has been

carried forward by the bullet in its passage. A small wedge-shaped plug

of lymph indicates the position of the actual track at its termination.

Dragging on the surrounding tissue consequent on the extrusion of the

plug of fat has ruptured some capillaries, and given rise to

considerable extravasation of blood, which is seen as a darker layer in

the deepest portion of the wound.

Comparison of this plate with the exit wound depicted in fig. 16, p. 56,

explains the nature of the tags of tissue there seen to protrude from

the convex opening.

Range 800 yards. Seat of wound, abdominal wall below 9th costal

cartilage.]

_Pari passu_ 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 passage 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.

[Illustration: 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 attitude 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 constitutional 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 circumstances 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 passing 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]

[Illustration: 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-Jörgensen; 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 illustrates the relative thickness of the

mantles in the Krag-Jörgensen, 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 assumption is justifiable that the thinner

mantles would tear or burst more readily in direct ratio to their

relative thinness. I believe this assumption 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.

[Illustration: 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-Jörgensen 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.

[Illustration: 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 pronounced 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 'flange.']

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 pronounced degrees of the same

type of deformity, accompanied by more or less extensive fissuring of

the mantle. No. 4 illustrates the turning out of the longitudinally

fissured mantle in such a way as to make a cutting flange. 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.

[Illustration: 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 illustrates 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.

[Illustration: FIG. 30.--Ruptured Mauser Mantle, to illustrate the

tendency to complete longitudinal fissuring]

Fig. 31 represents bullets removed from the body and illustrates 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.

[Illustration: 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.

[Illustration: 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 hæmatoma

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

hæmorrhages, the patient's temperature rose high, and on the third day

the hæmatoma 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-Jörgensen, 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.

[Illustration: 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 illustrated 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 penis. A case in which larger fragments

perforated and simulated type wounds has already been referred to on p.

44.

[Illustration: 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 illustrations 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 illustrations, 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.

[Illustration: 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]

[Illustration: 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 pass 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.

[Illustration: FIG. 37.--Four Soft-nosed Bullets from Boer trenches.

From left to right: 1. Mauser (.275); small amount of core exposed. 2.

Lee-Metford (.303). 3. Lee-Metford, with larger amount of exposed core,

also cupped apex. This is probably the most effective of these forms. 4.

Mannlicher (.315)]

These consisted in soft-nosed bullets of the Mauser and Lee-Metford

patterns, Tweedie and Jeffreys modifications of the Lee-Metford and

Mauser, several soft-nosed bullets of a slightly larger calibre, mostly

old Mauser or Mannlicher types, and a large variety of sporting leaden

bullets of larger calibre and volume. Figs. 37 and 43.

With regard to the various soft-nosed bullets of small calibre, I will

first advert to a feature common to all, which consists in a solid base

to the mantle. In the regulation whole-cased bullets the leaden core is

inserted from the base, and the edge of the mantle is then so turned

over for fixation purposes as to leave the central portion of the lead

exposed. The position of the exposed portion of the core is therefore

reversed in the two varieties. The small experience I had the

opportunity of obtaining was all to the effect that the solid base

considerably increases the stability of the mantle, and I never saw the

latter seriously torn in any specimen either collected on the field or

removed from the body.

[Illustration: FIG. 38.--Two Soft-nosed Lee-Metford Bullets (see text).

1. Removed from forearm. 2. Removed from beneath skin of back after it

had perforated the scapula. In both the velocity retained was no doubt

low, and neither encountered great resistance]

Fig. 38, 1, represents a soft-nosed Lee-Metford removed from just below

the lesser sigmoid cavity of the ulna, after it had perforated the

elbow-joint. The soft nose appears to have been torn, and separated by

impact with the bone, but the mantle is little altered. There can be

little doubt, however, that the bullet was travelling at a comparatively

low rate of velocity, since it was retained in the forearm, whence its

various parts were removed by Major Lougheed, R.A.M.C. I picked up a

number of similarly deformed bullets on the field. No. 2 represents a

soft-nosed Lee-Metford which perforated the scapula from the front; the

bullet was retained, hence again velocity cannot have been very high,

and the comminution was slight. If it had passed out, a large exit wound

would, however, have resulted.

[Illustration: FIG. 39. Soft-nosed Lee-Metford Mantle. Lateral ricochet.

Illustrating effect of solid base in maintaining the stability of the

mantle]

Fig. 39 represents a type of ricochet sometimes found on the field. In

spite of a considerable amount of violence which has caused the escape

of the core, the fissuring of the mantle is comparatively slight. In

point of fact, the casing is, as a rule, preserved from the severe

violence it suffers when complete, by the flattening and turning over of

the soft nose. I am sorry I cannot append an illustration of a damaged

soft-nosed Mauser, but I am of opinion that those used during the

campaign were not of a very dangerous nature on account of the small

amount of lead exposed. To gain the full advantage of the soft nose at

least a third of the core should be exposed. No. 3, fig. 37, of a

Lee-Metford, probably represents the most effective form of such

bullets. I am inclined to think these bullets as a class, however, are

not more dangerous to the wounded man than the regulation Mauser fired

at short range, if the latter either comes into contact with bone or

suffers ricochet.

The Tweedie and Jeffreys bullets come under a somewhat different

category. In the Tweedie the top of the bullet is sawn off in such a

manner as to flatten the tip and widen the surface of direct impact, and

to expose the leaden core over a small area. The general principle of

the flat tip resembles that of the French Lebel bullet. In the Jeffreys

modification the mantle is sawn down for about half the length of the

whole mantle, the slits neither reaching tip nor base. I seldom saw

these bullets removed, but they were used to a considerable extent. Fig.

40 illustrates one of Mauser calibre in the possession of Mr. Cuthbert

S. Wallace. It perforated the abdomen, producing fatal injuries, but the

only alteration in outline consists in slight bulging and shortening.

This specimen, however, manifestly suffered but slight resistance. A

somewhat general impression existed that a number of severe injuries had

been produced by the Jeffreys bullets, but it was a matter of

conjecture, as few of them were removed. A weekly illustration appears

in the advertisement sheet of the 'Field,' showing the deformity of some

of them shot into animals, which bear a strong resemblance to the Mauser

figured earlier (fig. 31), and which we have seen can be produced in the

human body by contact of a regulation fully cased bullet with a bone

like the malar. A tendency on the part of the longitudinal slits to

become caught in the rifling of the barrel militates against the use of

this bullet.

[Illustration: FIG. 40.--Jeffreys modification of Mauser. The bullet is

in the possession of Mr. C. S. Wallace. It perforated the abdomen and

caused death. The bullet is only slightly shortened by bulging at the

shoulder]

[Illustration: FIG. 41.--1. Section of Mark IV. Lee-Metford. Note

thickness of mantle and exposed core at base. 2. Soft-nosed Mauser. Note

solid base. Short pattern]

Fig. 41 represents sections of the soft-nosed Mauser, and the British

Mark IV. bullet, and shows the different method of closure of the base.

If the former remarks on the influence of the closed base in maintaining

the stability of the bullet be correct, Mark IV. should be a very

destructive bullet. I have no experience of its use, but I am inclined

to think that here, as elsewhere, the thickness and resistance of the

cupro-nickel mantle would endow it with considerable stability, unless

it met with very great resistance.

[Illustration: FIG. 42.--Types of Bullets tampered with by the Boers in

the trenches. 1 and 3. Cross-cut tips, Martini-Henry and Lee-Metford. 2.

Groove cut at base of exposed tip of Lee-Metford. Another modification

of the Martini-Henry consisted in boring it longitudinally and inserting

a wooden plug]

In connection with the subject of soft-nosed bullets, I should mention

that the Boers occasionally extemporised various modifications of them,

such as are shown in fig. 42, with intent to increase the wounding power

of the projectiles. I am unable, however, to give any information as to

the effects produced by these, and I do not think they were often

employed. The illustrations are from cartridges found in trenches which

had been occupied for some time by the Boers, who had no doubt used

their spare time in exercising their ingenuity on the bullets.

'Explosive' bullets of small calibre were also said to have been

employed; with regard to these I can only say that I never met with any

example of a hollow bullet containing explosive material.

One officer in a Colonial corps who spoke freely about them, told me he

had 'sawn' them in half and found the cavities, but the method of

investigation he had employed seemed against the presence of any

fulminant in the body of the bullets. Others based their statements on

the fact that they had frequently heard the bullets burst in the air;

but this is probably to be explained by the breaking up of regulation

bullets on impact with stones, which makes a smart crack like a small

explosion.

A clip of soft-nosed Mauser cartridges, in which a copper centre to the

bullet suggested a percussion-cap, was sent home to the War Office.

Colonel Montgomery has kindly furnished me with the following report on

the bullet:

'The bullet contains no explosive matter, it is fitted with a hollow

copper tube in the nose, similar to the ordinary "Express" bullet. The

envelope is made with a solid base, which is possible in this bullet

owing to the core being inserted from the front.'

One cannot help feeling some astonishment at the strong feeling that has

been exhibited regarding the use of expanding bullets of small calibre,

both at the Hague Conference and during this campaign, when the

Martini-Henry, a far more dangerous and destructive missile in its

effects at moderate ranges, is allowed to pass muster without notice.

Lastly, we come to bullets of large calibre unprovided with a mantle.

The Martini-Henry is practically representative of all these, but I

append a photograph of some twenty out of thirty varieties which came

into my possession during searches amongst captured ammunition. Some of

these were provided with a copper core to facilitate 'setting up,'

others were cupped at the top, and others flattened, to increase the

resistance on impact. I can say little about them except that I believe

some of the forms were responsible for a considerable proportion of the

most severe injuries we met with, in some of which a large and regular

entry made their use certain, while a considerable proportion of them

were retained. In the case of the viscera their power of doing serious

damage was very striking compared with that of the bullets of small

calibre. As with the small sporting bullets I think their use was often

due to the fact that the sporting Boer preferred to use the weapon he

was accustomed to rather than his military weapon.

A considerable number of the Boers were armed with Martini-Henry rifles,

and this was particularly the case with small bodies of men, rather than

with the larger commandos fighting regular engagements. The Transvaal

Government, moreover, had Martini-Henry rifles made as late as 1898. The

Martini-Henry bullet was responsible for some of the worst fractures

that came under my notice, but it is of interest to remark that its

capability to do damage did not satisfy some of the Boers, who cut them

as is shown in fig. 43. I cannot say what the effect of this manoeuvre

was, although it may have accounted for some of the wounds of the calf

such as are mentioned below.

Some odd missiles were met with during the campaign; thus, at Ladysmith,

I was told ball bicycle bearings were at one time in use amongst the

Boers.

_Anatomical characters of wounds of irregular type._--It will be seen

from the above that in dealing with wounds of irregular type we have to

consider those due to irregular impact of normal regulation bullets, to

bullets deformed by contact with bone, to ricochet bullets, and lastly

to bullets of the expanding type.

No further mention of those due to irregular impact is needful beyond

what has already been said under the heading of wobbling, except to

point out that, given a fair degree of velocity, these injuries may

assume an actual explosive character, especially in the case of skull

fractures. The description of extensive wounds accompanying comminuted

fractures finds its most appropriate place under the heading of injuries

to the bones, and will be there considered (Chapter V. p. 155).

'Explosive' exit apertures are, however, described as occasionally

occurring in injuries involving the soft parts only. I saw no cases

substantiating this belief, but several were described to me as having

been met with in abdominal injuries, which terminated fatally at an

early date.

[Illustration: FIG. 43.--Four Soft-nosed Bullets of small calibre shown

in fig. 37. Twenty large-calibre leaden carbine and rifle bullets from

cartridges found in Boer arsenals. These were not very extensively used,

but specimens of most varieties were at times removed from our wounded

men. It will be noted that some are of great weight, and a large

proportion either cupped or flattened at the apex to increase area of

impact and consequent resistance. The 'express' bullet with a copper

core is included in this series. It is worth remarking that all the

bullets of this nature in the Pretoria Arsenal were waxed, and that the

wax retained its white colour on the lead.]

I still, however, incline to the opinion that the bullet in these cases

had come into contact with some bone, or was one of the larger varieties

of projectile. A few cases of wound of the calf did, however, come under

my observation which presented fairly typical 'explosive' characters

without evidence of solution of continuity of the bones. I will shortly

recount two of them. In the first the exit opening was very large and on

the outer aspect of the limb in the upper third. The bullet had

apparently passed between the bones. Secondary hæmorrhage from the

anterior tibial artery necessitated exploration of the wound and

ligature of the vessel (Mr. Carré). When the wound was thus laid open no

injury to the bones could be detected, but I do not consider that it

could be actually excluded. In the second case a wound traversed the

calf transversely, just above the centre; the exit aperture was large

and ragged. Deep suppuration occurred, and the wound had to be laid

open, when a fracture of the tibia without solution of continuity was

discovered. I also saw one or two wounds of the buttock in which very

large exit apertures were present with small entry openings; in these

again it was impossible to exclude passing contact of the bullet with a

part of the pelvic wall. Unfortunately in all these cases it is

impossible to obtain the bullet responsible for the injury. In this

relation I append a diagrammatic illustration of a peculiar wound shown

to me by Mr. Hanwell. In this case a typical small entry wound was

situated at the outer margin of the left erector spinæ muscle in the

loin. The bullet had taken a subcutaneous course of not more than

three-quarters of an inch, while the exit opening was a long shallow

wound measuring 4-1/2 in. in length by 1-1/2 in. width. (Fig. 44.)

The wound was stated to have been received at a distance of from fifty

to a hundred yards. I think we can scarcely assume that impact with the

margin of the erector spinæ could have resulted in 'setting up' of the

bullet, while an irregular tongue of skin at the point where the wound

crossed the spines of the lumbar vertebræ did suggest possible bony

contact. That the latter must have been of the slightest nature is

evident, as no signs of concussion of the spinal cord were noted. I

should rather be inclined to compare this case to one of gutter wound

quoted on p. 56, and to assume that the bullet passed so closely

beneath the surface as either to entirely sever the skin, or at any rate

to allow it to give way on flexion of the back on movement.

[Illustration: FIG. 44.--Small Circular Entry, large 'explosive' skin

wound of back. Track only an inch or less in length (see text)]

On the ground of the observations made in the foregoing pages it will be

gathered that the opinion I formed was against either the very free use

or the great wounding power of so-called expanding bullets of small

calibre. I believe that a great number of the injuries which were

attributed to the employment of these missiles were produced either by

ricochet regulation bullets of small calibre, or by large leaden bullets

of the Martini-Henry type.

_Symptoms._--I very much doubt whether the general symptoms observed as

the result of wounds from bullets of small calibre differ in more than

slight degree from those described when larger bullets were regularly

employed. Great variation was met with, but I do not think a diminution

in serious results in this direction corresponding to the comparatively

limited nature of the direct injury to the organs or tissues can be

affirmed. It is true that the immediate symptoms in many patients were

amazingly slight, but after all, this has always been a feature of

gunshot injuries on the field of battle and cannot be assigned a

position of distinctive importance.

1. _Psychical disturbance and shock._--Some remarkable instances of

psychical disturbance were observed, and although perhaps in no way

influenced by the calibre of the projectile, they seem worthy of note in

this place. Thus a patient wounded over the cervical spine and who

suffered later with a slight degree of spinal concussion emitted an

involuntary shriek like that of a wounded hare on being struck; another

(Martini wound), after receiving a wound of the chest, lost all sense of

his surroundings for a considerable period, and occupied himself in

attempts to write on a white stone lying near him on the veldt; then

suddenly realising his position he was greatly bewildered in trying to

account for his own action. A similar instance of preoccupation is

probably offered by the dead man in the accompanying photograph (fig.

45), whose arms, forearms, and hands had evidently been in play until

the actual moment of death. Again the influence of the psychical state

on the actual occurrence of shock was often illustrated by the mental

condition of the wounded after a battle; thus after the battles of

Belmont and Graspan the patients came into hospital in excellent

spirits, and minimised their injuries in the wish of rapidly regaining

the front; while after the battle of Magersfontein the men were

depressed and miserable, shock was more pronounced, and their sufferings

were undoubtedly greater.

On the whole, however, shock was by no means a prominent symptom in the

small-bore injuries of soft parts, and was possibly less than when

larger bullets were the rule, and again it was often remarkably slight

after the infliction of serious visceral injury. Still shock was

observed in a considerable proportion of the patients, and its

occurrence appeared to vary under very much the same conditions as

obtain in civil practice. Grades of severity depended on individual

idiosyncrasy, on the degree of excitement or preoccupation at the moment

of injury, and to a certain degree on the range of fire at which the

injury was received.

[Illustration: FIG. 45.--Note position of head, neck, and forearms in

upper figure]

The last is the only special factor, and as far as my observation went

it was one of considerable importance. When the soft parts only were

affected, even high velocity did not produce much effect; but when to a

flesh wound a severe bone fracture or injury to any part of the nervous

system was added, shock might be severe or profound. The question of

shock dependent on visceral injury will be considered in succeeding

chapters, but it may be well to state here that the most severe shock

appeared to follow injuries to the central nervous system especially to

the spinal cord, fracture of the larger bones, and wounds of the

abdominal and thoracic viscera, the latter especially when the cardiac

neighbourhood was encroached upon: hence the severity depended almost

solely on the importance of the part injured and the degree of damage

inflicted. I never observed instances of entire absence of shock in

visceral injuries, unless the range of fire had been an especially long

one.

To these remarks on constitutional shock I should add a few on the

'local shock' exhibited by the actual part of the body struck. The

phenomena were of a severity I was quite unacquainted with in civil

practice, and apparently were attributable to the local vibration

transmitted to the whole structure of a limb or part of the trunk. In

many fractures, and in some wounds of the soft parts alone, without the

direct implication of any large nerve trunk, the loss of functional

capacity of the limb was complete, and this condition persisted for

hours or even days.

2. _Pain._--As an initial symptom the occurrence of pain varied greatly

with the idiosyncrasy of the patient, and according to the circumstances

under which the wound was received. Some individuals are remarkably

insensitive, and in these the fact of a wound being a gunshot injury in

no way altered their habitual insensibility, but in persons of what may

be termed the normal type in this particular great differences were

observed.

When a wound was received in the full excitement of battle during a

rapid advance, pain was often slight, or so trifling in degree that it

was almost unnoticed; many patients did not realise that they had been

struck until a second wound, possibly implicating a bone or some

specially sensitive structure, was superadded. In such instances the

pain was often described as 'burning' in character, or even likened to a

'sting from an insect.' Occasionally the pain was referred to a distant

part; thus a man struck in the head first felt pain in the great toe,

and another struck in the abdomen also felt pain in his foot only. Again

in some multiple injuries, pain was only felt in the more sensitive of

the regions implicated; thus a patient in whom a bullet (Martini)

traversed the arm and chest emerging in the neck to again enter the chin

and comminute the mandible, only felt pain in the chin and first

realised that he had been wounded elsewhere when he undressed. A

striking instance of the entire absence of initial pain was afforded by

a man shot through the buttock, the bullet then traversing the abdomen:

this patient remained unaware that he had been hit until on undressing

he found blood in his trousers and exclaimed: 'Why I have got this

bloody dysentery!' None the less his internal injuries were sufficiently

severe to lead to death during the next thirty-six hours.

Although initial pain might be slight or absent, practically all the

patients complained of some of varying severity at the end of an hour

after reception of the wound.

In a large proportion of the wounded, however, pain was more or less

severe from the first, and this was especially the case when the men had

been exposed to fire for some hours behind inadequate 'cover.' The most

common descriptions under these circumstances were that they felt as if

they had been struck by 'a brick,' 'a ton of lead,' or 'a

sledge-hammer.'

3. _Hæmorrhage._--This question is fully treated under the heading of

injuries to the blood-vessels. It will suffice here to say that

hæmorrhage was rarely of a dangerous nature so far as life was

concerned, unless the large visceral vessels or those in the walls of

serous cavities were concerned, when death was often rapid. From limb

wounds, even when the largest trunks were implicated, the general

tendency was to spontaneous cessation of the hæmorrhage. Consequently,

except these patients were seen on the field, one seldom had to deal

with serious bleeding. None the less, the condition of the patients'

clothes bore testimony to a free rush immediately after the injury, and

pools of blood were occasionally found where patients had lain. In

nearly all cases the rush of the bullet determined the initial flow of

the blood from the exit wound, and this aperture usually furnished any

hæmorrhage of importance.

_Diagnosis._--The only diagnostic point which it is necessary to

consider in this chapter is the determination of the nature of the

bullet which has caused the particular injury under observation, and

this is more a matter of interest than importance.

The primary indication lies in the size of the aperture of entry, which

naturally varies with the calibre of the bullet employed, and the

difference, except in the case of large projectiles, is not always

easily determined, unless we can be sure that the impact of the bullet

was at right angles. In the latter case it is possible to distinguish

even between, for instance, a Lee-Metford and a Mauser wound, if the

resistance likely to be offered by the part struck is kept in mind. A

ricochet bullet, on the other hand, may upset all our calculations, if

size alone be taken as an indication; but here the irregularity of the

wound often serves to exclude one of the larger varieties as the cause.

The appearances of the exit wound are less useful in determining the

nature of the bullet employed, as irregularities of outline are so much

more common whatever projectile may have emerged; but examination of

this wound often gives us useful information as to the existence of an

injury to the bones not involving loss of continuity.

[Illustration: FIG. 46.--Two flattened Leaden Cores to illustrate means

of determination of nature of bullet. Note ring at base. The right-hand

bullet is probably a 'man-stopping' revolver bullet; it flattened

against bone]

Other information beyond that furnished by the external wounds may be

gleaned from the presence of fragments of lead in the wound; these, if

unaccompanied by portions of casing, afford some presumptive evidence of

the use of an unsheathen bullet, especially if found on the fractured

surface of the bones; but it must be borne in mind that in the case of

ricochet bullets the leaden core often perforates when entirely freed

from its mantle. Pieces of the mantle again may give useful information

both from examination of their thickness and composition. Lastly a naked

core nearly always retains the marking on its base corresponding to the

turning over of the mantle, this not being likely to suffer impact

calculated to efface the groove. When this groove existed the employment

of any of the soft-nosed bullets used in this campaign might be safely

excluded (fig. 46).

_Prognosis._--The question of general mortality amongst the wounded has

already been considered (Chapter I. p. 11), and it has been shown,

putting aside those dying at once on the field, or during the first

twenty-four hours, that the mortality was a low one. Some other points

specially dependent on the nature of the injury are, however, worthy of

mention in this place. First, it has been shown, with a slight

reservation as to when a wound can be considered definitely sound, that

if suppuration did not occur, healing was rapid, and that many men with

slight wounds were back with their regiments in the course of a very few

days. Again, that suppuration when it did occur tended to be local in

character; none the less, if it was at all extensive, it often proved

very prolonged and difficult of treatment, while residual abscesses

after apparent healing were not uncommon. In connection with this

subject I may quote from Colonel Stevenson[12] an observation that limbs

the subject of marked local shock are especially liable to furnish

septic discharges. Parts the subject of local shock when infected show a

lesser degree of vitality and power of resistance to the spread of

infection than do normal ones, and if infected do badly. I think I

convinced myself of this on many occasions, and also of the fact that

cases of fracture in which this condition was marked were slow in

consolidating. Again I am inclined to think that the bad results which

sometimes followed the tying of the limb arteries were also consequent

on lowered vitality, and possibly vaso-motor disturbance due to the

effects of the exquisite vibratory force to which the nerves had been

subjected. On this account I was never anxious to hurry operations in

such cases, unless obviously necessary at the moment.

The larger question of general nervous breakdown as the result of

injuries from bullets of small calibre is at present hardly capable of

an answer, and is so complicated by the co-existence of concurrent

mental anxiety, exposure, &c., that a definite answer will always be

difficult. I think there is already sufficient evidence, however, to

suggest that the remote effects of many of these injuries may be far

more serious than we expected at the moment, especially in the direction

of sclerotic changes in the nervous system.

_Treatment_.--In view of the remarks on the treatment of special

injuries contained in succeeding chapters, I shall confine myself here

to the question of the treatment of wounds of the soft parts alone.

This consisted during the campaign in the primary application of the

regulation first field dressing by one of the wounded man's comrades, an

orderly, or less commonly an officer or a medical man. This dressing is

composed of a piece of gauze, a pad of flax charpie between layers of

gauze, a gauze bandage 4-1/2 yards long, a piece of mackintosh

water-proof, and two safety pins, enclosed in an air-tight cover. Mr.

Cheatle,[13] in insisting on the importance of an immediate antiseptic

dressing in the field, recommends the following. A paste contained in a

collapsible tube, made up in the following proportions: Mercury and zinc

cyanide grs. 400, tragacanth in powder gr. 1, carbolic acid grs. 40,

sterilised water grs. 800; sufficient bicyanide gauze and wool for the

dressing of two wounds, a bandage, and four safety pins; the whole

enclosed in a mackintosh bag. The paste possesses the advantage over any

liquid or powder, that it can be applied in any position of the body to

severe wounds, and its application in the open air is not interfered

with by draughts of wind. Mr. Cheatle used a similar preparation with

success during the campaign.

On arrival at the Field hospital, or in some cases at the station of the

bearer company, the wounds were then commonly dressed as follows: The

parts around the wound were cleansed with an antiseptic lotion, either

solution of perchloride of mercury 1 in 1,000, or 2-1/2 per cent.

solution of carbolic acid. The wound itself was then cleansed, and a

dressing of double cyanide of mercury and zinc applied. This was covered

with a pad of wool and secured with a bandage. The gauze was usually

wrung out in the lotion before application as a precaution against

previous contamination, and the moistening was also useful as helping to

ensure the dressing from subsequent displacement. It was early

recognised that the drier the dressing the better, and hence anything

like a mackintosh layer was carefully avoided. In some instances,

antiseptic powders were employed, but they did not find much favour, and

because they tended to favour slipping of the dressing, and to prevent

the adhesion of the gauze dressing to the wound, they were certainly not

desirable when there was any necessity for the patient to travel. In the

absence of reliable water the use of antiseptic lotions was obligatory,

and such is likely to be the case in most campaigns; in the present one,

filtration of the thick muddy water was impossible, without a

considerable expenditure of time, which could only be obtained when the

hospitals were fairly stationary. I very much preferred carbolic acid

lotions.

The wound having been once cleansed, or rather the surroundings of the

wound, the drier the surface was kept the better; hence a too heavy or

impervious dressing was not satisfactory; in point of fact, I think some

of the slighter wounds in which all the dressings slipped off, and in

which there was less consequent chance of the dressing being moistened

with the sweat of the patient, did as well as any.

I do not think the bicyanide gauze, absorbent wool, and common open-wove

bandages, together with a good supply of nail brushes, soap, and

carbolic acid for the primary disinfection of the skin and the external

wound, are to be greatly bettered at the present day as materials for

the first permanent dressing of cases in the field. The wound itself

should be carefully shielded during the preliminary cleansing of the

skin by a firmly applied antiseptic pad, and then the dressing applied

as above described. The one desirable improvement is some mode of

ensuring the dressing being kept in good position, and for this some

form of adhesive covering for the gauze and wool should be devised. When

the atmosphere is such as to allow of rapid drying, thin moistened

book-muslin bandages would be preferable to the plain open-wove ones.

The one period of danger is that of transport, and when that is over,

the dressing in Stationary or Base hospitals should give no trouble.

As a rule the wounds themselves need no interference, but in some

instances either the exit or entrance wounds may be in undesirable

positions for purposes of asepsis, when a large opening may seem safer

closed and actually sealed. I saw this method tried in a few cases, but

without much success. It is one which might be of much use in Base

hospitals if the patients were brought directly into them, but in the

Field hospitals, in face of the rush with which the first dressings have

to be done, I think it is seldom applicable, and consider the

interference with the wound as rather likely to increase the danger of

infection than to decrease it.

Dressings should not be too frequent; two should suffice for simple

wounds with type forms of entry and exit; there is little discharge and

usually no bleeding: hence the more the dry scab form of healing can be

simulated the better. When a dressing needs changing from fouling of its

outer parts, it is preferable to cut round the adherent part of the deep

layers and apply some fresh gauze over the central scab rather than to

remove it. One point should be kept in mind: the first dressing in the

Field hospital seals the fate of the wound as to the chances of primary

union, and hence too much care is impossible with it.

Operations in the Field hospitals were proportionately not numerous, and

they should be kept down in number, as far as possible. At the same time

such operations as are necessary are mostly of capital importance, such

as the treatment of fractures of the skull, abdominal section, the

ligature of arteries, and amputations. Of these only the first and last

classes occur with any degree of frequency. In order to be prepared for

these a stock of filtered water which has been boiled, and some special

sterilised sponges, should be at hand if possible, also some small

towels which can be wrung out in antiseptic lotion. If sterilised

sponges are not to be had, wool pads wrung out in carbolic lotion must

be substituted.

Primary amputations bore transport badly. I saw few sent down from the

front within a few days of their performance in which the flaps did not

slough, or worse consequences ensue. On the other hand, if the first

fortnight could be tided over at the front, they did well enough. The

head cases on the other hand bore movement fairly well, provided only

that asepsis was ensured.

Retained bullets are rarely suitable for removal in the rush of the

first work of a Field hospital after an engagement. A short delay is of

no importance, and ensures their being removed safely if necessary. With

regard to the broad question of the advisability of removing them at

all, it may be laid down that they should not be interfered with unless

some obvious reason exists. Those most commonly calling for removal are

as follows: 1. Bullets lying immediately beneath the skin or quite

superficially in any region, or those which, although they have produced

an exit opening, yet lie within the body. 2. Those which lie at the

bottom of an infected track, or cause secondary suppuration. 3. Those

causing pressure on important structures, particularly nerves. 4. Those

which interfere with the movements of joints when lodged in the bones or

soft tissues in close proximity, or those which lie within the articular

cavity itself. Bullets sunk in the great body cavities or in positions

difficult of access should never be interfered with. Retained bullets

sometimes give rise to unexpected surprises; thus in a man with a

retained bullet in the pelvis no steps for its removal were taken.

During the man's voyage home on a transport he had an attack of

retention of urine. As a catheter would not pass, he was placed in a

warm bath, and shortly after passed a Mauser bullet per urethram, and

thus saved himself a cystotomy.

One word may be added as to the treatment of shock when severe. Quiet in

the supine position, and the administration of a small amount of

stimulant, was usually all that was required. Hypodermic injections of

strychnine sulph. grs. 1/30 to 1/10 were useful, and in some severe

cases, especially where operations were needed, saline infusions with a

small amount of stimulant were made into the veins, either at the elbow,

or in amputation cases into one of the large veins exposed.

The treatment of hæmorrhage is dealt with in Chapter IV.

The after treatment of simple wounds needs little comment, but bearing

in mind what has been said as to the definite healing of the internal

portion of the tracks, it will be obvious that in parts such as the

thigh or calf, care was needed as to not commencing active work at too

early a date. On the other hand, a too long period of absolute rest is

also to be deprecated. The best results were obtained by careful

movement and massage, commenced after the first week or ten days,

according to the appearance presented by the external wound, followed by

a gradual resumption of active movement. It was a striking fact that

some of the patients suffering from such wounds took longer to become

apparently well than many of those who had suffered visceral injuries.

FOOTNOTES:

[9] _Loc. cit._ p. 31.

[10] _Loc. cit._ p. 100.

[11] _Loc. cit._ pp. 54, 55.

[12] _Wounds in War_, p. 83. Longmans & Co. 1897.

[13] A First Field Dressing, _Brit. Med. Jour._ 1900, vol. ii. p. 668.

CHAPTER IV

INJURIES TO THE BLOOD VESSELS

The small calibre of the modern bullet, and its tendency to take a

direct course, naturally favour the occurrence of more or less

uncomplicated wounds of the large vascular trunks, and both the nature

of these wounds and the results which follow them are in some respects

most characteristic.

NATURE OF THE LESIONS

1. _Contusion or laceration without perforation._--(_a_)The vessel may

be struck laterally, the injured portion then forming a part of the

bounding wall of the wound track, or (_b_) one or more layers of the

vessel wall may be destroyed over a limited area. Given primary union,

these conditions are only of importance in so far as subsequent

contraction of the lumen of the vessel may result from implication in

the neighbouring cicatrix. One of the most striking features of the

wounds as a whole was seen in the hair-breadth escapes of the large limb

vessels with no subsequent ill effects, and such injuries were seen in

every situation.

In a certain proportion of wounds in close proximity to large vessels,

however, a diminution of the normal calibre of the arteries was

observed, either shortly after the injury or later in the advanced

stages of cicatrisation. As an example of early obstruction, the

following may be related. A Mauser bullet passed from the inner side of

the thigh across the neck and great trochanter of the femur beneath the

femoral vessels, and probably struck and grooved the bone, since the

aperture of exit was large and irregular, some 3/4 of an inch in

diameter. One week later no pulse was palpable in either anterior or

posterior tibial arteries at the ankle, and pulsation which was strong

in the common femoral artery was very weak in the superficial femoral.

Slight fulness existed in the hollow of Scarpa's triangle, but not

sufficient to make any serious difference in the contour of the two

limbs. No thrill or abnormal murmur was discoverable. There was no

oedema of the limb, which was also normal in temperature. The patient

was kept at rest in the supine position for three weeks, during which

time the tibial pulses gradually returned. Three weeks later he was

invalided home, the pulses, however, still remaining considerably

smaller than normal.

In the advanced stages of cicatrisation narrowing of the lumen of the

trunk vessels was far from uncommon, especially in cases of wounds of

the arm crossing the course of the brachial artery; in many of these the

radial pulse was diminished almost to imperceptibility. How far this

condition may prove permanent there has been little opportunity of

judging; nor as to the possible ultimate weakening of the vessel wall

and the development of a secondary aneurism has time allowed the

acquisition of experience. In the light of the observation of so many

cases in which large vessels were wounded without the occurrence of

severe hæmorrhage, either primary or secondary, it is impossible to be

certain whether some of the cases of arterial obstruction were not

secondary to perforating lesions of the vessels.

Pressure on, or minor lesion of the vessel was sometimes evidenced by

the development of a murmur, as in the following case. A Mauser bullet

entered immediately within and below the left coracoid process, and

emerged at the back of the arm at its inner margin, 2-1/2 inches above

the junction of the right posterior axillary fold. During the first week

dysphagia and some pain and soreness in the episternal notch, with pain

and difficulty of respiration, were noticed. Eight weeks later no

trouble with the pharynx or oesophagus remained, but a short sharp

systolic murmur was audible over the first part of the left axillary

artery, which could be extinguished by pressure on the subclavian; the

radial pulse was normal.[14]

When primary union failed or was prevented by infection and

suppuration, lesions, although incomplete, of the vessel coat naturally

frequently gave rise to secondary hæmorrhage.

2. _Perforation of the vessels._--(_a_) This may be oblique or

transverse to the long axis of a trunk; when the vessel is impinged upon

laterally, an oval or circular notch, as the case may be, is produced;

or (_b_) the bullet may strike more or less in the centre of the vessel,

perforating both in front and behind, while lateral continuity is

maintained; (_c_) beyond these degrees a vessel may, of course, be

completely divided. Cases of notching of the vessel will be referred to

under the heading of traumatic aneurism; those of perforation under that

of aneurismal varix and varicose aneurism, the perforations in these

cases affecting a parallel artery and vein.

RESULTS OF INJURY TO THE VESSELS

1. _Hæmorrhage._--The fact that hæmorrhage was not a prominent feature

in the wounds received during this campaign can scarcely be regarded as

an experience confined to injuries caused by bullets of small calibre.

The same observation was often made in the case of larger bullets in old

days, and the absence of severe hæmorrhage has previously been regarded

as a special characteristic of gunshot wounds. None the less, as high a

proportion as 50 per cent. of deaths occurring on the field in earlier

days has been ascribed to this cause.

Unfortunately no new facts can be furnished on this point, although a

few cases of rapid death from primary hæmorrhage will be found recounted

under the heading of visceral injuries. Beyond these the general

evidence offered by observations on men brought in from the field with

vascular injuries, was opposed to the frequent occurrence of death from

hæmorrhage, at any rate of an external nature. This subject will be

dealt with under the classical three headings of primary, recurrent, and

secondary hæmorrhage.

_Primary hæmorrhage._--A marked distinction needs to be drawn between

external and internal hæmorrhage. External hæmorrhage from the great

vessels of the limbs, or even of the neck, proved responsible for a

remarkably small proportion of the deaths on the battlefield. This

statement may be made with confidence, since it is not only my own

experience, but coincides with what I was able to glean from many

medical officers with the Field bearer companies. It is, moreover,

supported by the facts that cases in which primary ligature had been

resorted to were extremely rare at the Base hospitals, while, on the

other hand, traumatic aneurisms and aneurismal varices of any one of the

great trunks of the neck and limbs were comparatively common. Again,

primary amputation for small-calibre bullet wounds, except when

complicated by severe injury to the bones, was so rare as to render more

than doubtful the frequent occurrence of severe primary hæmorrhage on

the field. Only one case of rapid death due to bleeding from a limb

artery was recounted to me. In this a wound of the first part of the

axillary artery proved fatal in the twenty minutes occupied by the

removal of the patient to the dressing station. The amount of hæmorrhage

in many instances was no doubt checked by the application of pressure at

the time of the first field dressing; but it can scarcely be argued that

such dressings as were applied were of sufficient firmness to control

bleeding from such trunks as the brachial, femoral, or carotid arteries.

The spontaneous cessation of hæmorrhage is rather to be ascribed to the

special method of production and the consequent nature of the wound. The

lesions were the result of immense force strictly localised in its

application, which might well induce very complete and rapid contraction

of the vessel wall; while the track in the soft parts was not only

narrow, but also lined by a thin layer of tissue possibly so devitalised

superficially as to specially favour rapid coagulation of the blood.

Beyond this the tracks were often sinuous when the position of the limb

at the time of reception of the injury was replaced by one of rest. The

influence of mere narrowness of the track is illustrated by classical

experience in the development of aneurismal varices after stabs by

knives or bayonets; and in the injuries under consideration the frequent

development of large interstitial hæmorrhages into the tissues of the

limbs indicated that blood does not readily travel along the wound

track. It was noteworthy that when hæmorrhage did occur it was most free

from, or often limited to, the wound of exit. This is due to the

direction of the active current set up by the rush of the bullet through

the tissues. The mechanical factor is, no doubt, the most important.

Control of primary hæmorrhage from a wounded vessel by the impaction of

a foreign body was of much less frequent occurrence than appears to have

been the case with the older bullets. I saw a case in which, on removal

of a fragment of shell (Mr. S. W. F. Richardson), very free hæmorrhage

occurred from a wound of one of the circumflex arteries of the thigh,

but not a single one in which a similar result followed the extraction

of a bullet of small calibre. The comparative infrequency of retention

of modern bullets is probably one of the main elements in this relation.

A very curious instance of provisional plugging of a wound in the upper

part of the brachial artery by an inserted loop of the musculo-spiral

nerve was related to me by Mr. Clinton Dent. This instance must, I

think, be regarded as an accident definitely dependent on the size and

outline of the bullet and on the nature of the force transmitted by it

to neighbouring structures.

While, however, deaths from external primary hæmorrhage were rare, a

considerable number resulted from primary internal hæmorrhage. In some

of these, injury to the largest trunks in the thorax or abdomen led to

an immediately fatal issue; in others wounds of the large visceral

arteries, as of the lungs, liver, or mesentery, were scarcely less rapid

in their results. In such cases the potential space offered by the

peritoneal or pleural cavities favours the ready escape of blood from

the wounded vessel, while the tendency of the blood effused into serous

cavities to rapid coagulation is notably slight. Beyond this the

comparative deficiency in direct support afforded by surrounding

structures to vessels running in the large body cavities is also an

important element in their behaviour when wounded.

These remarks receive support from the observation that few, if any,

patients survived an injury to the external iliac vessels within the

abdomen, while the remarkable instances of escape from fatal hæmorrhage

from large vessels recorded below (cases 1-19) indicate that the mere

size of a wounded vessel is not to be regarded as the sole factor in

prognosis.

_Recurrent hæmorrhage_ was occasionally met with both in the case of the

limb and trunk vessels. In the limbs it often necessitated ligature of

the artery. I saw several cases in the lower extremity where recurrent

hæmorrhage on the second or third day was treated by ligature of the

femoral or popliteal artery, and it also occurred during the course of

development of one of the carotid aneurisms recounted below. On two

occasions I saw rapid death follow recurrent abdominal hæmorrhage; in

one I was standing in a tent when a man who had been wounded the day

before suddenly exclaimed: 'Why, I am going to die after all.' The

appearance of the man was ghastly, and on examining the abdomen it was

found greatly distended, and with dulness in the flanks; the patient

expired a few minutes later. Another example of recurrent abdominal

hæmorrhage is related in case 169, p. 432.