by Dr. Edmond Delorme -- (Translated into English by Dr. H. Méric)
The book was in use during the second World War in 1940 as there is an inscription on the Title Page referring to "Boy Johnson - 1940".
The following chapters include a description of the different bullets used by the warring countries of WW1, ballistic data of bullets and shells and a chapter on the management of gunshot wounds of the soft tissues.
Modern surgical management of gunshot wounds of soft tissues, with the advantages of such technical advances in radiology as Computerised Axial Tomography and vastly improved anaesthesia, tends to be much more aggressive in its approach; surgical exploration of the track, or debridement, is now more likely to be used compared with the pre-antibiotic era of 1915.
Dr Geoffrey Miller, Editor
The weapons used in warfare are either defensive (helmets, cuirass) or offensive (cold steel, firearms). We will not stop to consider defensive ones, as projectiles from modern rifles go through them at whatever distance an action is engaged.
Amongst cold steel weapons we may include the bayonet, the sword-bayonet, the sabre-bayonet, the cavalry sword, the lance.
Bayonets have a straight styloid blade with a slender point, two sides (Lebel rifle), and sharp serrated edges. Some are merely a kind of hunting-knife (Germany, Austria, England, Italy).
Bayonets are employed as puncturing or stabbing weapons, the direction being specially towards the abdomen or the upper part of the lower limbs. The serious injuries thus inflicted are somewhat analogous to wounds made by pointed instruments, or by those that at the same time are pointed and cutting.
During the Balkan War bayonet injuries were very frequently observed. In certain battles they reached a pro- portion of 10 per cent. of the wounded. The injured regions were mainly the body, the abdomen, the upper part of the lower limbs. The sabre or sword, having a blade with hollow sides, straight or curved, is used for stabbing and thrusting in the same way as the bayonet, or as a cutting weapon. The wounds it inflicts are generally numerous (two, four, twenty). They are usually found on the head, the right elbow, the upper part of the left arm.
The lance is a pointed weapon that has considerable power behind it. The head of the French lance is 10 centimetres long (5.9 inches) and 2 centimetres (0.7 inch) in diameter; its section is quadrangular. The head of the German lance is 30 centimetres long (11.8 inches) and is 15 millimetres (0.6 inch) in diameter; its section is tri angular. In the attack the point of the lance is directed against the trunk.
Wounds by cold steel, rarely observed during relatively recent wars, now tend to increase in number. During the war of 1870 only 600 cases were recorded among 98,000 wounded. They now occur in the proportion of 5 per cent.
Weapons of Offence (Firearms).
These comprise rifles, mitrailleuses, guns. The projectiles from these arms are alone of interest to the military surgeon.
Projectiles of Firearms carried by the Soldier (Fig. 1).
They are projected by means of smokeless powder, which has increased their velocity. At the present time they are pointed instead of conical cylinders. Their calibre has been reduced from 11 to 8, and even to 6.5 millimetres (from 0.43 to 0.31, and even 0.25 inch) (D bullet). Their length, on the contrary, has increased: from 2 calibres it has risen to 3, 4, and even 5 (D bullet).
Their weight, on the other hand, has diminished from 25 grammes (386 grains) to 15 grammes (231 grains), to 12.50 grammes (193 grains) (bullet D), to10 grammes (154 grains) (bullet S).
Some bullets are of a uniform composition of soft or hardened lead, steel, or copper; others have a protective envelope. The central nucleus of hardened lead is covered by a casing of steel, copper, nickel, or nickel silver, which is either closed or open at the base. We shall only describe the smaller projectiles used by the belligerent Powers.
The German S Bullet. - The S bullet of the German Mauser is a pointed cylinder, ogival-shaped projectile of hardened lead, surrounded by an envelope of soft steel plated with nickel. Its cylindrical part hardly exceeds a fourth of its total length; its point, which measures 19 millimetres (0.75 inch), is very tapering, and ends in a very small flat apex, measuring about 1 millimetre (0.04 inch). Its calibre is 7 millimetres (0.28 inch), its length 28 millimetres (1.10 inches), its weight 10 grammes (154 grains). The S bullet is shorter and lighter than the D bullet.
The Austrian Bullet, of the Austrian Mannlicher rifle, is formed of hardened lead compressed in a steel wrapper. It weighs 15.8 grammes (244 grains); it is 31.8 millimetres long (1.25 inch), and 7.9 millimetres (0.31 inch) in diameter. It is conico-cylindrical, with a truncated extremity, which is rounded and not tapering.
The French Bullet.-The D bullet is of brass, without envelope; it is biogival, the point being very sharp in front, and the bullet truncated at its base. Its calibre is 8 millimetres (0.31 inch), its length 39 millimetres (1.53 inches), its weight 12.80 grammes (197 grains).
The M bullet consists of a nucleus of hardened lead surrounded by an envelope of brass and steel. Its calibre is 8 millimetres (0.31 inch), its length 30 millimetres (1.18 inches), its weight 15 grammes (231 grains).
The Russian Bullet is ogival in shape, with a blunt extremity. It has an envelope of nickel, surrounding a nucleus of hardened lead. Calibre, 7.6 millimetres (0.3 inch) ; length, 30.5 millimetres (1.2 inches); weight, 13.70 grammes (211 grains).
The English Bullet is ogival, with a blunt apex and a casing of nickel. Calibre, 7.70 millimetres (0.3 inch); length, 31 millimetres (1.2 inches); weight, 15.90 grammes (215 grains).
The Belgian Bullet. - Ogival, with blunt apex, nucleus of hardened lead, envelope of nickel. Calibre, 7.6 millimetres (0'3 inch); length, 30 millimetres (1.18 inches); weight, 14.10 grammes (213 grains).
The Mitrailleuse fires rifle bullets. Use is made of the infantry rifle cartridge. The multiplicity of the injuries inflicted, rather than their nature, distinguishes the mitrailleuse.
Ballistic Data (Bullets).
The military surgeon must be familiar with a certain number of ballistic data in order to understand, from a scientific and practical point of view, the effects of bullets. We shall content ourselves by recalling, and we hope without dryness, the essential data; but it is quite indispensable for him to thoroughly know what we are now going to set forth.
Velocity Transit. - A bullet has two kinds of velocity: a velocity of transit, by which the bullet passes through space; and a velocity of rotation, which sustains it during its trajectory. The velocity of transit of a bullet is one of the principal factors of its active force (vis viva), or, in other words, of its power and of its effects.
The initial velocity of a bullet is expressed by the number of metres over which it would travel during the first second after leaving the muzzle, were it not subjected to gravity.
The remaining velocity, which is of far greater importance for us to know, is the velocity the bullet still has at the different distances of its trajectory. The "remaining" velocity decreases with the distance of the bullet from the muzzle of the rifle, owing to the force of gravity and the resistance of the air.
The initial velocity of the bullets now in use is considerable. The German bullet S has the greatest initial velocity, amounting to 860 metres, or 940.5 yards, which is 160 metres (165.0 yards) superior to that of the French bullet D; but the latter, being heavier, retains its velocity better during the remainder of its course; it is thus still very dangerous at distances at which the S bullet is harmless.
The French bullet D possesses an initial velocity of 701 metres (767 yards); the M, or the bullet of the Lebel rifle, 651 metres (712 yards); the Russian, 643 metres ,(703 yards); the Austrian, 626 metres (684 yards); the English, 574 metre's (628 yards, etc.).
The remaining velocity is inversely proportional to the square, of the diameter of the bullet and proportional to its length and its weight.
Velocity of Rotation. -To maintain the bullet on its trajectory, the grooves of the rifle impart to it a rotatory movement. The longer the projectile, the greater its movement of rotation; the latter, however, has but little influence the projectile; it remains constant for the same projectile.
Bascule Movements.-The S and D bullets are subject to movements of oscillation and of deflection, to which other projectiles are also subject, but in a slighter degree. Bullets may turn crosswise or with their base in front; this may occur when they encounter a small obstacle in their course, or when they strike the human body. With bullet M, and also with the old German bullet, at 400 metres a fourth of such direction has been noticed; at 600 metres one-third. These overturnings occur more frequently with the bullets S and D, a fact that the military surgeon must bear in mind, as well as the frequency of ricochets.
Trajectory. - The course followed by the bullet, its trajectory, was formerly represented by a long curve; the trajectory of modern bullets is straighter, and so increases the vulnerability of the object fired at, and also the extent of the dangerous space. The effect of the tension imparted to the bullet insures a more direct trajectory. Up to 500 metres the trajectory of modern bullets is almost a straight line.
Range.-The great speed of the bullets now in use enables them to attain a range of 3 kilometres, or more (3,500 metres - 2.36 miles) in the case of bullet D.
Active Power (Vis Viva). - The damaging effects of bullets are dependent on their active power (vis viva). This is expressed by the formula P = WV2
W being the weight and V the velocity of the projectile.
The following table represents in kilogrammetres the initial active power (vis viva) and the remaining velocity of the S bullet, of the Mannlicher, and of the French D bullet: This table shows that the acting or damaging power is practically the same for the three projectiles; it is tremendous at 100 metres, considerable up to 500 metres.
From 500 to 1,000 metres the damaging power decreases rapidly; it is very small between 1,000 and 2,000 metres.
We thus understand why the classical works on army surgery, when dealing with the effects of bullets, are always careful to bring these effects within touch of the question of the distance at which the firing has taken place, and to speak of very short distances from 0 to100 metres, short distances up to500 metres, middle distances from500 to 800 and1,000 metres, great distances from1,000 metres upwards. The greater the active power (vis viva), the more extensive are the injuries inflicted.
The Power of Penetration of a bullet is dependent on its active power (vis viva), on the extent of the surface on which it strikes, on its density of section-i.e., the weight that prolongs backwards each unit of surface that is opposing resistance. This is the reserve of active molecules. A last condition that influences the penetrating force is the state of its surface of peripheral friction.
It follows from the above that the pointed S and D bullets have more power of penetration than the cylindro-ogival bullet with a flat apex; that the D bullet, being longer, has more power of penetration than the shorter S bullet; that a projectile that has ricochetted and struck sideways is less penetrating than one fired point-blank. The resistance, opposed by the tissues to penetration, of projectiles of equal speed, is inversely proportional to the square of the diameters. The bullet exercises on any obstacle it meets a more or less great pressure. The coefficient of pressure depends on the active power (vis viva) and on the calibre of the projectile. The smaller the calibre, the greater the pressure.
Ricochets. - Injuries inflicted by ricochetting bullets are very frequent. They are observed in the proportion of 1 in 3 of all cases.
A projectile ricochetting from the ground is deflected, and strikes the body obliquely or transversely. It is put out of shape, flattened, turned out of its course, broken up, separated from its envelope, and so the number of injuries to which it gives rise is multiplied. To be put out of shape a leaden projectile must have a velocity of 450 metres, a bullet with an envelope a remaining velocity of 750 metres.
The S bullet, formed of hardened lead and covered by its envelope, is more easily put out of shape, flattened, and broken up on striking the ground, than the D bullet, which is made of brass.
Injuries inflicted by ricochetting projectiles are more serious than those caused by bullets fired point-blank.
Modus Operandi of Bullets.
Pointed bullets such as the S and D bullets make a puncture-like opening in the tissues when they reach them from a Point-blank discharge. After penetrating, they push the tissues aside, but without greatly bruising them, thus creating very favourable conditions for spontaneous healing. Moreover, they do not carry with them to any great extent foreign bodies derived from the, clothes of the wounded man. These are essential points to bear in mind.
When the S and D bullets have tipped over - when they have ricochetted in their course - they strike the body with a much enlarged irregular surface, and so exert strong pressure upon the tissues. Their mechanism then becomes Punch-like, with a tearing and bruising action. Moreover, they carry with them foreign bodies derived from the clothes, and may be soiled by contact with the earth. These are points of paramount importance.
The greater the remaining velocity of the bullet and the more tearing its effects (bullets that have tipped or lost their shape), the greater the amount of active force it imparts to particles of tissue it separates. The fragments of tissue torn off play the part of secondary projectiles, which, at first propelled in front of the bullet, whose track they prepare by slipping over its sides, transversely enlarge the track of the wound, giving rise to more or less bruising and disturbance.
The intensity of the action of the so-called secondary projectiles varies with the velocity of the bullet, its shape, the nature of the tissues with which it has come into contact, and with the easy dissociation of these last, and their mobility.
An intense action is chiefly observed with projectiles possessing very great or great velocities - that is to say, at short distances, varying from 0 to 100 up to 500 metres (from 0 to 109 and to 547 yards (zone of so-called explosive effects).(Fig 2)
Fig. 2 Effects of Explosive fire (S Bullet)
With pointed projectiles, discharged at point-blank range, it is possible that the abovementioned effects may no longer be seen. At all events, they occur more rarely than with conico-cylindrical bullets having a flat apex, or with bullets having a calibre of more than 8 millimetres (0.31 inch, Gras bullets). On the other hand, they are produced by the S and D bullets when these projectiles become deviated whilst proceeding at a high velocity. This has been observed over and over again in the present war.
Intense divulsive and propulsive action is exercised with greater facility the more the tissues are capable of dissociation, the less they show elasticity (muscles), and the freer the molecules (parenchymatous organs, brain). Incompressibility and their frequent projection explain the awful extension of the havoc that at times is wrought by bullets upon organic receptacles (bladder, intestines, stomach, gall-bladder). Not only may these receptacles present enormously enlarged apertures of exit, but they may also burst, and show large openings at some distance from the track pursued by the bullet.
The most elastic tissues of the body (tendons, fasciae, aponeurosis), especially when they are movable (tendons of the wrist, of the instep), can transmit for some distance the active force (vis viva) imparted by a bullet. Thus they bruise and split up the neighbouring and less resistant tissues (integuments, muscles). Fragments of bone detached by a bullet act like fragments of the projectile or like the bullet itself, forming a shower of secondary projectiles, which, from the centre of the injured limb, are propelled outwards through the soft tissues.
When the active Power (vis viva) is of average strength (beyond the 500 metres, and up to the 1,000 metres range), the action of the bullet remains localized. The injury is of the nature of a Puncture or an abrasion, with a weak projection, and more rarely with hard or soft secondary projectiles. Such is the usual normal type of the lesions.
When the active power (vis viva) is weak (beyond the range of 1,000 metres), the lesions are still more circumscribed; again, the bullet acts by puncture, and especially separates the fibres of the tissues.
The zones of the action of a bullet have been classed as follows -
1. Explosive zones (up to 500 metres).
2. Perforation zones (regular course, from 500 to 2,000 metres) -
3. Contusion zones (beyond 2,000 metres).
Although the above classification has been criticized, it deserves to be maintained for bullets such as those of the Lebel rifle. Projectiles of a calibre greater than 8 millimetres (0.31 inch), in addition to their divulsive effect, have a vibratory action which may be transmitted over a more or less considerable distance from the bullet's course, this vibratory action showing itself by phenomena of inhibition and of local or general shock. With pointed bullets fired point-blank, these phenomena are no longer observed. It may even happen that the wounded, even when their attention has not been taken off by the excitement of the battle, are unaware of the very serious injuries inflicted on them. The S and D bullets pass through the flame of a candle without causing it to flicker. On the contrary, when deflected, the S and D bullets frequently produce this shock.
The considerable active power (vis viva) possessed by the bullets now in use enables them to pass through several bodies, and a fortiori through more than one limb. The S bullet fired from a distance of 2,000 metres can still go through two men. The damage extends from the first to the last body or limb traversed by the projectile, if they are near to one another.
An active power (vis viva) of 8 kilogrammetres is sufficient to disable the combatant.
Contour wounds no longer occur with point-blank firing.
The So-called Humanitarian Bullets. - The modern S and D bullets cause a considerable immediate mortality, a fact often too little remembered by the surgeon who treats the wounded in the rear. The fortunate influence exercised by their pointed form and their small diameter is counter- balanced by the frequency of their turning over; this widens the bullet's track from its aperture of entry to its deep resting-place, and gives rise to contamination of the wound by the foreign bodies carried. in by the bullet.
Therefore S and D Projectiles are not humanitarian.
According to Journée, fatal injuries are in the ratio of 25 per cent., serious injuries 15 per cent., slight injuries 60 per cent. Generally, the same ratio is observable throughout.
If, in a certain measure, owing to their small calibre, to their pointed shape, and, as in the case of the D bullet, to their composition in a single piece, the present bullets give rise to a long series of slight traumatisms, whose very mildness, when the wounded are taken to the rear, strikes not only the surgeons, but also the general public, there is no reason for bestowing upon them, and on some of those that have been used previously, the so abusively eulogistic German appellation of humanitarian bullets. The average of wounds, other than very small ones of the soft parts, remains grave; therefore we may repeat in regard to these bullets what we have said in speaking of the others: it is truly pushing the love for paradox very far to call humanitarian a bullet that goes through several men when fired from a short distance, and that is capable of causing great slaughter in a zone of more than 3,000 metres.
Other things being equal, the extent and severity of the injuries caused by rifle-fire depend on the active power (vis viva) of the bullet. But, far from the distance between the combatants being increased, it has remained unchanged; even it was noticed during the Balkan War, and has already been observed in the present war, the distance tends to decrease, and firing is carried on in zones in which the bullets acquire an excessive active power (vis viva), and the wounds they inflict are amongst the most dangerous known. In short-distance rifle-firing the mortality is appalling. The kind of madness soldiers feel in a charge (furie française) is heavily paid for, and charging would be most criminal were it useless.
To appreciate as a whole the gravity of the injuries inflicted by bullets, we must take into account not only those injuries the surgeon sees in patients brought to the rear, but also the wounds that are treated at the front, the patients being subsequently removed to hospital, and the injuries seen on the battlefield in soldiers that have been killed. When all these data are united, instead of one only being kept in view, the impression with regard to the small bullets now in use, far from being favourable, becomes, on the contrary, unfavourable.
If all these injuries be taken as a whole, the pointed bullets now in use do not present any essential differences from the projectiles used in former times.
Explosive Bullets or Dum-Dum Bullets.
At the outbreak of every war there are always questions raised with regard to the employment of dum-dum bullets. It is so to-day. We have seen wounded men in the present campaign concerning whom this old error has been brought forward. The terrible injuries that have given rise to this mistake differ so greatly in character from those usually observed that it seems impossible to attribute them to the action of a bullet which causes but very small apertures of entry and of exit. This, however, is not so. In such cases it is a question of explosive shots due to projectiles of very high velocity becoming more or less broken up in their course through the tissues. The fury with which our soldiers have many times fallen on the enemy, and the fact of their being hit by bullets from very short distances, sufficiently account for these wounds that need no further explanation.
Systematic use of explosive bullets would show a want of common sense, because we rely on the effects of ricochetted bullets, a ricochet occurring in the proportion of 1 in 3 of bullets discharged; besides, an explosive bullet can no longer hit a man if it has touched the ground, however slightly.
PROJECTILES FROM FIREARMS NOT CARRIED BY INFANTRY (GUNS)
These projectiles are those of field, mountain, garrison, siege, naval, and coast guns. Projectiles from garrison, siege, naval, and coast guns, being chiefly directed against armoured objects in defence or attack, are distinguished from the first by their massiveness and by the small tendency they have to divide. We will not stop to consider them. On the other hand, the two first-mentioned guns, mainly destined to be used against troops, will be minutely studied from the point of view of their construction, their ballistic qualities, and, lastly, of their effects.
Shells of Field Artillery. As a general rule, shells from field guns are metallic cylinders of cast iron or steel, cylindro-conoidal in shape, with thick walls; the shell is subdivided into cavities which contain the bursting charge, and usually the projectiles.
The shell's anterior extremity, which is well strengthened, and is called the ogive, contains the fuse, which is separable, and is formed by an irregular mass of copper.
The shell's posterior extremity, which is also strengthened, and can often be separated, is called the rear-piece.
On the outer surface of the shell are the forcing bands, which can be detached; they are formed of copper rings, of girdles of lead, of side-pieces, of nuts. Some howitzer shells are provided with discs.
The shell, when acted upon by the time fuse, explodes in the air; when acted upon by a percussion fuse it explodes on striking the ground. Some fuses have a double action, and are both time and percussion fuses.
Shells are designated according to their calibre: shell of 75, of 77 mm., etc., or according to their mode of bursting: shells having a systematic mode of bursting, shells containing grape-shot (mitraille), shrapnel, explosive shells.
I. Shells whose bursting is systematic are projectiles with double-lined sides, showing lines of rupture, and breaking up into large fragments; others of the same kind have in the interior of their thick external envelope a number of piled up cast-iron rings, which break up into large and sharp fragments. These shells are but little employed.
2. Shells containing Mitraille have an outer shell containing metallic discs hollowed out into alveoli, for round bullets from 12 to 15 millimetres (0.47 to 0.59 inch). Segmentation, which takes place at the level of the alveoli, sets free fragments of cast iron irregularly cubic in shape and with sharp angles. Such is the present French mitraille shell.
3. Shrapnel.--The outer shell in this instance is thin; it rests in front upon a heavy ogive, at the back, upon a thick rear-piece. The interior of the shell is filled with free spherical bullets (10 to 16 millimetres, 0.39 to 0.63 inches) of hardened lead. In some shrapnel the charge of powder is placed behind, by the rear-piece (Austria); great force is thus imparted to the bullets. In other cases the charge is placed in front; it then lessens the speed of the bullets, but facilitates their scattering. Lastly, the charge may be mixed with the bullets; this facilitates their scattering, and increases their power (French shells).
With this shell the ignition of the charge is secured by a central tube. The French shrapnel of 75 centimetres contains 290 bullets of grammes each 12 grains); the German shrapnel of 77 centimetres has 300 bullets of 10 grammes (134 grains) each. The shrapnel of the German field-howitzer contains 500 bullets of 10 grammes each.(Fig. 4)
4. Explosive Shells.--Their moderately thick steel walls are hollowed out into a large cavity filled with an explosive material (gun-cotton,, melinite, cresylite, etc.) The explosive shells are generally fired in the proportion of 1 to 3 by all artillery. The variable quantity of explosive material contained in a shell has a very great influence on the effects produced. The German shell containing but 150 grammes (2,315 grains) of melinite is far less destructive than the French grape shot shell, which contains 800 grammes (176 pounds) of the same material. From the outset of the war considerable difference has been observed between the injuries inflicted by German and French shells.
5. Mixed Universal Shells unite the characteristics of shrapnel and of explosive shells. --
A universal shell with a double effect has been adopted by Germany for her field-gun 98 and for her howitzer 105. In its posterior part there is a powder-charge to project the bullets; in the centre are the bullets mixed up with a charge of powder. This central part of the shell is crossed by a tube which secures the ignition of the charge in the posterior portion of the shell. Finally, the ogive in front contains a strong charge of an explosive. The shell may be used as shrapnel with time fuse, causing deflagration of the charge behind, or as an explosive shell with percussion fuse, with or without delay in the explosion after the contact shock, through detonation of the charge in front. Thus it may be easily understood that mixed shells which project shrapnel and sharp fragments of steel in the same way as an explosive shell may give rise to traumatisms of a special nature (Ferraton).
Case-shot are cylinders of sheet-zinc containing round leaden bullets held together by sulphur. When fired at a short range, these cylinders burst at once and scatter the leaden bullets; these are analogous to shrapnel bullets, although heavier (40 grammes, or 617 grains, France). Great use was made of these projectiles during the attack on Liege.
Grenades are explosive bombs thrown by hand; they are spherical in shape and loaded with explosives. The grenade is often an improvised bomb containing projectiles of every shape and weight. The effect produced by its fragments varies greatly, terrible in general at a short distance. Its action is quickly exhausted. The explosive action of the gases is exerted over only a small area, in which, however, it produces great havoc.
Following the method adopted in describing bullets, we shall now only consider the data that are of interest to the military surgeon. It may be said that shells only act through their splinters or their bullets. In the case of the ordinary shell with cast-iron walls, the large fragments are almost exclusively supplied by the rear-piece, the ogive, and the fuse. Fragments of average size weigh from 100 to 300 grammes (1543 to 4,630 grains); small splinters are about the size of a walnut. The present steel shells eject from their entire periphery small elongated splinters, not very thick, about I or 1.5 centimetres (0.39 or 0.59 inch), sometimes they are as large as a pea; their dimension however, may even be that of a small fragment.
Fragments of these shells rapidly lose their velocity. The slightest obstacle--a clod of earth, a helmet, a haversack, etc.--may serve as a protection from them. The Serbians use the shovels with which entrenchments are being made; the Bulgarians use earth; the French soldier his knapsack, which protects his head and shoulders, whilst leaving his hands perfectly free.
The French mitraille shell discharges 416 bullets of 25 grammes (386 grains), besides 288 disc fragments, weighing on an average 40 grammes (617 grains).
The larger fragments of shrapnel are supplied by the ogive and the rear-part.
The principal projectiles of shrapnel are round bullets, from 10 to 15 millimetres (0.9 to 0.59 inch) in diameter, of small weight, and low velocity; they may be compared to the old smooth-bore bullets.
They inflict, in general, slight injuries, such as contusions or incomplete perforations, the projectile remaining in the wound, rather than through-and-through perforations, and their "cul-de sac " wounds are often complicated by the presence of foreign bodies derived from the soldier's clothes, which favour suppuration.
Fragments from the much sub-divided wall of an explosive shell are usually broken up into small, thin, striated and sharp lamellae; nevertheless, some of them spread out and act like a badly sharpened knife. These fragments are very small, and sometimes become localized in the body as if they had been sown like seed.
Most frequently the shell explodes in the air (time fuse) at more or less distance above the combatants. The distance separating the shell from the ground is called bursting height. When this height is small, the shower of fragments or bullets is dense, that is to say, closely charged with projectiles, and the velocity of these secondary projectiles is increased; the shell then is very deadly. It would appear that it is of very little use when the bursting height is great, the shower of projectiles is then more spread out, less dense, more apt to produce wounds, but dangerous effects upon the human body are less conspicuous.
The shell with percussion fuse, which is rarely used, must strike the ground before exploding. When it falls perpendicularly, it either buries itself in the earth or forms a funnel-like excavation, in which its fragments are retained. If it strikes the ground obliquely, it rebounds, gives off a shower of projectiles, the marks of which are shown on the ground as an elongated ellipse. The splinters and the bullets close to the bursting-point have a greater penetrating force than those from a greater distance. In general, these last are the ones that cause wounds.
The velocity of the fragments and of the bullets at the point of explosion is that of the shell at the time of falling. The velocity is--
At 1000 metres: 422 metres, French shell; 369 metres, German shell.
At 2000 metres: 346 metres, French shell; 310 metres, German shell.
At 3000 metres: 300 metres, French shell; 279 metres, German shell.
In the case of the time-fuse shell, this velocity is increased by the active power (vis viva), communicated by the charge in the interior. With the percussion-fuse shell, the bullet has to travel over several hundred metres before reaching the body; and during its course in the air, owing to its shape and size, it undergoes great loss of velocity.
Whether the bullets or splinters proceed from a shell with a percussion fuse or from a shell with a time fuse, when they penetrate into the tissues the large rounded shape of the former, the spread out and irregular shape of the latter, considerably limit the power of penetration, as the resistance of the tissues is proportional to the square of the diameters of the projectiles.
Consequently, one may say that these bullets or splinters do not possess half the penetrating power of rifle bullets.
Explosive shells directed against obstacles, but which reach the defending troops, are commonly and deliberately used at the present time against the enemy. These explosion shells, as well as the ordinary percussion shells, under certain circumstances, may loosen and hurl about stones and debris that play the part of accessory projectiles.
Explosive shells are often productive of multiple wounds. Six, seven, ten, and more, have been observed in one wounded man.
The injuries inflicted by bullets on the soft parts are very frequent. This frequency is a factor of great importance to the army surgeon, who has to take it into consideration in the preparation and distribution of dressings when arranging for transport, and making a computation of invalided men and of those who return to duty.
The percentage of the injuries of the soft parts is estimated at about 45 or so. The percentage even rose to 80 during the American War. Fischer stops at 65 per cent.
We will first study the injuries caused by rifle bullets. The division here adopted should be maintained in statistics.
CONTUSIONS -- These are produced by spent bullets or tangential firing, frequently also caused by bullets from a shell. Contusions may be very slight, or they may end in sloughing.
EROSIONS, FURROWS, result from tangential rifle fire-- small scratches at the level of which the skin dries up and becomes covered with a brownish pellicle; no cicatricial trace is then present. Sometimes these are cutaneous abrasions more or less extensive, occasionally 5, 6, or 7 centimetres long and 2 or 3 centimetres wide, owing to the retraction of the skin, showing regular or contused perpendicular edges. Their deeper part is formed of cellular or muscular tissue; they leave cicatrices.
CUL-DE-SAC WOUNDS are due to the action of bullets of low velocity which have frequently ricochetted. They leave a blind track more or less deep, generally containing the projectile that has caused the wound. When the track is short, the bullet may have been displaced by some movement or by the removal of the clothes.
The cutaneous aperture of entry is generally of less dimensions than the diameter of the projectile - it is perfectly round or oblique; on the contrary, it is large and irregular when caused by a bullet that has been deflected before striking the body.
SETONS are perforations that go through and through. We will now study their apertures and track.
The aperture of entry varies in aspect: sometimes it is rounded, circular (in point-blank fire); with an apparent diameter much smaller than that of the projectile; there is loss of substance. On other occasions, especially with pointed bullets, it is punctiform, and so narrow that it is difficult to identify it. It has been compared to a flea-bite. More often than not it is soiled by the projectile that in passing has rubbed off against it the impurities gathered during its course; the epidermis has been destroyed, and the derma bruised around the apertures. At times it is contaminated by shreds of clothing that have penetrated farther than its edges. As to its dimensions, they vary, in general, with the velocity of the bullet. They are a little larger with short distances, a little smaller with middle, and insignificant with long ranges. They are also larger when the integument lies on a resistant plane, and smaller when the skin can be depressed. When the bullet strikes obliquely, the aperture of entry is increased in size, oval or elliptical in shape, with bruised edges.
The tension of the tissues, the position of the limb, the direction of the cutaneous folds, may modify its shape.
THE APERTURE OF EXIT is nearly always irregular, and shows in the form of a cleft, which may be either simple or radiated, and is sometimes circular and punctiform. It appears larger than the aperture of entry, but in reality it is smaller, as it is probable that the skin has been much distended before being perforated. Now and then its edges are everted, and not bruised like those of the aperture of entry. The dimensions are commonly, although not regularly, proportional to the velocity of the bullet--that is to say, inversely proportional to the distance of the firing.
Under the loosened integument a little pouch filled with blood sometimes forms Pirogoff's pouch.
TRACK -- ln the great majority of cases the track may be represented by a straight line uniting the apertures of entry and of exit, always supposing the limb or the trunk to be in the same position as at the time when hit by the bullet.
The laminae or accumulations of cellular tissue that the bullet meets with are, according to the velocity of the projectile and to their nature, freely perforated (laminae), or only dissociated (accumulations); the particulate masses of adjoining adipose tissue then fill up where there has been a loss of substance, thus forming an aseptic occlusion.
Superficial fascia are wounded, and present circular or oblique apertures, when the velocity of the bullet is great; but with average or low rates of velocity, only the transversal or uniting fibres are dissociated. The longitudinal fibres become forced apart, and, as we have before demonstrated (and the fact carries very great interest), the wound is no longer represented by a loss of substance, but by what resembles an incision, a sort of button-hole like slit with reunited edges. These aponeurotic button-holes secure the occlusion of the track.
In muscles the track is always cylindrical, widened in the living by muscular contraction, filled up with blood, exudation, and inflammatory swelling. The track is larger than the diameter of the projectile. Its size varies with the velocity of the bullet, as is the case with other tissues. In close-range firing the track is much larger than in middle ranges, and still more than in long ranges. Tracks in muscles are narrower when the bullet is pointed than when its apex is flattened; the fissures they cause are typical when the firing is point-blank.
When the track follows the direction of the muscular fibres, it is not an easy matter to find its course on the dead body (Ferraton).
By reason of their mobility, their elasticity, their shape, and of their being made up of linear fibres, tendons are, of all tissues, the ones that offer the most successful resistance to the action of the bullets. Being loose in their sheath, they are displaced and eroded; if they are more or less fixed, they are indented and lineally perforated.
Exceptionally they are completely divided, but it is doubtful whether this can occur with pointed bullets. This question must be further studied at autopsies. To sum up, the track modern bullets make in the soft parts, as it was with the old bullets, is irregularly cylindrical. It shows constrictions at the level of the linear aponeurotic slits, and even irregularities at the level of the thick cellular layers, and of the tendons that have only been displaced. It is filled with a magma of broken-down soft tissues and with blood. Infiltrations of blood and histological fissuration have been noticed a few millimetres, even a few centimetres, from the course followed by the bullet.
Theoretically, when the velocity of the bullet is very great, the dimensions of the track should increase as it approaches the aperture of exit; but the layers of aponeurosis generally resist the divulsive and progressive action of the projected particles of tissue by arresting them on their passage.
The track is more especially enlarged in the case of bullets that have tipped up and have remained in the tissues. It is still more enlarged, but in this case from one end to the other, when the bullet has ricochetted on the ground before reaching the injured part, or when it strikes obliquely or sideways. When deflected in the midst of the tissues its track is irregular.
ENFILADE WOUNDS - Certain tracks are greatly extended when the firing is from above downwards or from below upwards, as in cases in which hills, buildings, or houses are attacked. One frequently sees that a bullet under these circumstances has pierced for itself a course from the neck to the buttocks, from the hip-joint to the lower part of the leg, etc. Under normal conditions of firing one finds that the bullet may have traveled a considerable distance through different segments of the same upper limb, fore arm, axilla, etc. The prone horizontal position that is frequently assumed by the infantry soldier in the intervals during the rapid advances that bring him nearer to the enemy renders his body liable to be wounded over a lengthy extent, and explains why, even under ordinary conditions, enfilade wounds have become very frequent.
A great many tracks are multiple, either caused by several projectiles, by fragments of bullets broken up by having ricochetted near the wounded man, or by the same bullet having successively perforated two different parts of the body - arm and thorax, arm and forearm, both right and left thigh, etc. We must bear in mind when the velocity of the bullet is very great, the second track is often larger than the first.
When the soft tissues are the only ones involved, no explosive lesions are observed from pointed bullets fired at short range. Nevertheless they may occur, especially in tendinous regions.
Wounds of the soft tissues, inflicted by projectiles from modern rifles, are not painful; many of them bleed sufficiently to stain the clothing.
WOUNDS FROM REVOLVER SHOTS. They are analogous to the injuries of rifle bullets. The apertures and tracks are narrow; no explosive effects are noticed in their case. The projectile often remains in the wound.
INJURIES INFLICTED BY BULLETS FROM SHELLS AND BY SMALL SHELL SPLINTERS. The round balls from shrapnel, like rifle bullets, cause simple contusions, cul-de-sac wounds and setons, which may be compared with tbe wounds from rifle bullets; the description of the former, therefore, may refer also to the latter. Contusions are very frequent, as also cul-de-sac wounds, in which the bullet and foreign bodies derived from the clothes remain in the wound.
Cul-de-sac wounds are usually pretty superficial; their apertures and track, like those of the setons, are larger and more gaping than is the case with rifle bullets. They resemble the bullet wounds of old times. The wide gaping of these wounds and the presence of foreign bodies, chiefly derived from the clothes, tend to facilitate their infection.
EVOLUTION AND PROGRESS OF WOUNDS OF THE SOFT TISSUES. Most wounds of the soft tissues by rifle bullets heal by first intention, without a trace of suppuration, or else with a slight and passing secretion from the contused cutaneous aperture of entry. These wounds are quickly covered by a small protecting darkish scab, due to the drying up of the blood-clot, under which cicatrization takes place. Our modern methods of dressing powerfully contribute to this healing; but as it was observed to take place even before the adoption of modern methods of treatment, and as at present it is frequently noticed in patients in whose case treatment by a surgeon has been impossible, or who have even been badly dressed, we are forced to admit that other reasons must be brought forward to explain so favourable a result. At one time it might be considered due to surgeons having abandoned septic and frequent explorations of the wound; but to-day it is attributed to the ever-increasing narrowness of the wounds, in consequence of the small diameter and of the shape of the bullet, to the extremely slight gaping of the wound, to the much less frequent presence of foreign bodies, and, above all, to a fact upon which we have dwelt again and again--the occlusion of the track at the level of the aponeurotic septa.
Long discussions have taken place on the primary and direct contamination of the wound by the bullet and the dirt with which the projectile may be coated, by the shreds and pieces of clothing which it may carry with it; also on indirect contamination by contact with the wearing apparel, with the patient's fingers, or with the fingers of those of his comrades who may have administered first aid. To-day the problem is solved. To sum up, the germs carried along by a bullet are not pathogenic, and the bullet itself does not infect; the contamination brought by the clothing is annihilated by the defence set up by the tissues. Besides, a wound infected by a bullet, especially by a pointed bullet, having an average velocity, fired point-blank, carrying with it no large foreign bodies derived from clothing, is in the very best condition for spontaneous healing. Dressing but affords a fresh guarantee to a natural tendency towards cicatrization.
Aseptic evolution is frequent, especially in cases of narrow wounds; but large wounds, such as those resulting from a bullet that has been deflected by touching the ground, wounds soiled or contaminated by large pieces of clothing, wounds that have remained a long time in contact with clothing, or that have been badly dressed and badly looked after, are all subject to suppuration, and therefore must be carefully watched. The evolution of such wounds will then be either relatively aseptic or decidedly septic.
In the first case there will be slight suppuration of the cutaneous apertures and of the track. Slight, but not painful, swelling of the soft tissues will be noticed at first; next, a slightly indurated cord-like feeling will be found along the track, after which the natural condition will be re-established; the muscles will recover their suppleness, healing will take place without consecutive disturbance. Such is an ordinary course of wounds resulting from infected bullets, but these wounds must have been watched and treated by capable surgeons, haying a good armamentarium, in good sanitary quarters, and provided the wounded men present normal organic resistance in the second case--and the condition is customary in wounds due to shrapnel bullets, to shell splinters, to bullets deflected by contact with the ground, or in wounds badly dressed, and whose apertures are plugged by some foreign body -- suppuration takes place. It is more or less abundant, sometimes foetid; it is accompanied by tension and redness of the limb; the pus extends and burrows. Certain cases develop a diffuse phlegmon.
Wounds inflicted by shrapnel or by small shell splinters, generally show rapid formation of pus, with more or less intense local reaction, which usually quickly yields to antisepsis at the seat of the mischief, to free incision, and to removal of foreign bodies, either metallic, or composed of pieces of clothing.
To recapitulate: From a general and practical point of view, the wound by a rifle bullet may be considered as aseptic.
Many of these wounds become infected and threaten suppuration. The greater number heal naturally.
Healing takes place in a few days or weeks.
Wounds by shrapnel or by small shell splinters USUALLY SUPPURATE.
Very large and extensive wounds that are lacerated, bruised, and frequently very dirty, and result from large fragments of shell, the lesion containing or not containing the body that has caused the mischief, ARE HOPELESSLY DOOMED TO SUPPURATION. Healing is obtained after elimination of the scabs and when the wound has granulated. Local and general phenomena of reaction, sometimes very intense, subside rapidly if the wound is dressed with a solution of hydrogen peroxide. When the wound has been cleaned, its size may be reduced by means of careful bandaging, or by means of U-shaped mediate sutures.
TREATMENT. The first treatment of bullet wounds in the soft tissues consists in carrying out the indications that Ferraton has so well recapitulated:
1. Do not touch the apertures.
2. Do not explore the wound.
3. Carry out the dry toilet of the skin by means of an aseptic swab which may be wrung out in alcohol or in tincture of iodine.
4. Apply the ordinary dressings. Occlusion of the apertures, suturing, occlusion of the apertures, suturing, incisions to relieve constriction in the wound, must all be avoided.
For first aid to bullet wounds the dressings contained in the packet each soldier carries will suffice. As a rule the first dressing should be applied at the part of the field where the man has been wounded, or at the first aid station.
INDIVIDUAL DRESSING - PACKET CARRIED BY THE FRENCH SOLDIER. These packets are of various patterns. The old pattern has two wrappers of ordinary canvas, then a waterproof covering, partly tacked together, partly stuck together, which protects the contents from external impurities and from humidity. Each packet contains
(1) a square piece of gauze;
(2) a square piece of purified tow surrounded by gauze;
(3) a cotton bandage;
(4) two safety-pins.
The gauze and the tow are antiseptic; they are impregnated with bichloride of mercury.
Events have not allowed us to completely replace the old packets by the new model, which differs from the former one:
1. In the solidarity of the different pieces.
2. It guarantees the dressing of two wounds at a distance from one another.
3. It is aseptic.
The contents of the new model are wrapped in Japanese paper, which is strong, waterproof, and at the same time very light. The packet is opened by pulling on a small linen tape which projects from one of its corners. It contains two dressing; each consists of a pad of hydrophyllous cotton-wool enveloped in gauze. One of these dressings is fixed, being sewn to the linen bandage destined to bind up the wounded limb; the other is movable, and slides along the bandage by means of two tapes.
The materials forming this second dressing have been sterilized in the autoclave, and render unnecessary the use of an antiseptic.
The solidarity of the various parts forming the dressing facilitates its application and diminishes its risks of being contaminated. In order to better insure it against contamination, two distinct signs (a red cross and a black cross, surrounded by a circle) mark the places where the dressing should be taken up, one sign for the right hand and one for the left. To displace the movable dressing without soiling it, a little red tag will be found sewn on one of its corners by which it should be held.
It is impossible for us to lay too much stress on the fact that the individual dressing is "a reserve supply of material for ready use carried by the wounded." As a general rule the dressing should not be applied by the wounded man himself, nor by his comrades, nor by a N.C.O.; it should be applied by a medical man, or by a trained member of the Army Medical Service. This is undisputable; better not to dress a wound at all than to dress it badly, and it is as well to look upon with suspicion, and as necessitating a fresh application, any dressing that has not been carried out by a competent person (H. Billet). The necessity of a preliminary disinfection of the skin renders a new dressing imperative.
Dressings must be directly applied to the skin, the clothes having been unstitched or cut open into strips so as to expose the wound and its surrounding parts; this should be the exclusive duty of a surgical attendant. Another attendant should open the packets containing the dressings. The man who dresses the wound should first carefully disinfect his hands; washing the hands with soap is less practical than immersing them during three minutes in alcohol at go, or, if necessary, in methylated spirit, containing per litre 5 cc. of 1 in 10 tincture of iodine (the whole solution being 1 in 2000).
When we wish to disinfect the circumference of the wound with iodine--an excellent plan, and one which is held in high esteem in the surgical practice of all armies-- the above application should be made dry, without previous cleansing with soap, water, alcohol, or ether, etc. One single coating with iodine will suffice. More than one layer would be useless, or might even be injurious. Friction of any kind should be avoided.
For the cheeks, the eyelids, or the genital organs, diluted tincture of iodine should be used; for all other regions of the body the pure tincture should be employed. Accidents, brought about occasionally by tincture of iodine, such as erythema, vesication, excoriation, or ulceration, chiefly due to the applications having been made over too extensive a surface or too plentifully, to frictions having been carried out, or to antiseptic reaction, but also to the use of tincture of iodine that age has rendered stale. The medical staff is now provided with unalterable tincture of iodine (Courtot), of easy transport, thanks to its having been compressed (Pellerin). The compressed tincture is instantly dissolved in alcohol at 950, each block being made up so as to give a solution of 1 in 20, which is not caustic.
Robert and Carriere have enclosed sublimated iodine in glass ampullae. When required, the ampulla is broken, its contents poured into an accompanying tube containing alcohol at 950 in sufficient quantity to obtain tincture of iodine.
Tincture of iodine is at present the best and safest disinfectant to make use of in the practice of war surgery, both in the fighting line and in the rear.
Bichloride of mercury and carbolic acid, with which the individual packets of the old pattern were impregnated, like most of the individual dressings in use in different armies, render the patient liable, when tincture of iodine is used as an antiseptic to which preference is given nowadays for first aid treatment of a wound - to symptoms of irritation, which are but rarely observed with a simple aseptic dressing.
In the Manchurian campaign these symptoms of irritation were so pronounced that the Russians and the Japanese who made use of bichloride of mercury dressings were obliged to give up tincture of iodine for the disinfection of wounds.
We have been able to verify on wounded men in the present war the cutaneous irritation pointed out by the Russian surgeons. The difficulty might be overcome and these untoward incidents avoided by first of all applying under the dressing a little square of folded gauze; this should be done at the collecting and first aid stations.
The first dressing of the wound will generally be held in place by the bandage contained in the packet. An extra bandage will make the dressing more secure. In the ambulances in the rear, where the dressing has lost lost the fixity it had at the front, the use of adhesive rubber sparadrap, of the leucoplastic or vulvoplastic type, has been advised. Personally, we have not been satisfied with the results we have seen of this method. There are counter-indications to repeated dressing of wounds of the soft parts produced by bullets; these lesions are very slight, and already present conditions most favourable for spontaneous healing. We have already seen that wounds by ricochetted bullets are subject to symptoms of suppuration coming on very rapidly. After incisions have been made dressings will be applied of the usual topical remedies. Hydrogen peroxide here is particularly worthy of recommendation for the first consecutive dressing. Strong carbolic acid solutions, touching the wound with a 1 in 10 solution of chloride of zinc, iodine by instillation, or by simple application, instillations of ether, etc., are all of great use. We must not forget that these wounds are often complicated by foreign bodies derived from the clothes, or by the presence of the bullet itself; in such cases the only topic to be employed is hydrogen peroxide. The wounds we are now considering are among those in which there is always a danger of tetanus and of emphysematous gangrene; hydrogen peroxide is known to be a toxic for anaerobic microbes, which are the provocative agents of these complications.
The same principles should be followed and the same methods applied in dressing extensive wounds of the soft tissues resulting from shrapnel or shell fragments. We will not dwell upon this subject at present, as we shall have to consider it again in dealing with complications.