Surgical Experiences in South Africa, 1899-1900 Part 8

[Ill.u.s.tration: 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.

[Ill.u.s.tration: 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 pa.s.sed out, a large exit wound would, however, have resulted.

[Ill.u.s.tration: FIG. 39. Soft-nosed Lee-Metford Mantle. Lateral ricochet.

Ill.u.s.trating 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 ill.u.s.tration 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 cla.s.s, 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 ill.u.s.trates 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 ill.u.s.tration appears in the advertis.e.m.e.nt 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.

[Ill.u.s.tration: 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]

[Ill.u.s.tration: 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.

[Ill.u.s.tration: 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 ill.u.s.trations 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 pa.s.s 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 a.s.sume 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.

[Ill.u.s.tration: 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 a.r.s.enals. 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 a.r.s.enal 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 pa.s.sed between the bones. Secondary haemorrhage from the anterior tibial artery necessitated exploration of the wound and ligature of the vessel (Mr. Carre). 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 b.u.t.tock in which very large exit apertures were present with small entry openings; in these again it was impossible to exclude pa.s.sing 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 ill.u.s.tration 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 spinae 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 a.s.sume that impact with the margin of the erector spinae 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 vertebrae 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 a.s.sume that the bullet pa.s.sed 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.

[Ill.u.s.tration: 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 a.s.signed 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 ill.u.s.trated 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 p.r.o.nounced, 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.

[Ill.u.s.tration: 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 const.i.tutional 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 circ.u.mstances 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 b.u.t.tock, 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 b.l.o.o.d.y 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 circ.u.mstances were that they felt as if they had been struck by 'a brick,' 'a ton of lead,' or 'a sledge-hammer.'

3. _Haemorrhage._--This question is fully treated under the heading of injuries to the blood-vessels. It will suffice here to say that haemorrhage 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 haemorrhage. 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 haemorrhage 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.