Surgical Experiences in South Africa, 1899-1900. George Henry Makins
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.
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.
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