if the wound of entrance, and the line which the bullet was following when it struck the body, are known, the path in the body cannot be predicted with any certainty. Many instances of this fact are given by all authors on military surgery. The following is a singular illustration of it: In a duel with pistols between two students of Strasburg, one fell, apparently mortally wounded in the neck, but almost immediately got up, without feeling any inconvenience from his wound. It was found that the bullet had struck the larynx obliquely, and, glancing from the cartilage, had gone completely around the neck, and stopped on the opposite side of the larynx from where it had entered. It was taken out by simply making an incision over it. Other examples might be cited in which balls have made a circuit around the cavities of the body without entering them. In a wound of the head, thorax, or abdomen, the ball may make a half circuit of the body, and lodge or emerge at a point opposite that at which it entered, thus leading one to suppose that it must have passed directly through. In the battle of Suddozam, a soldier was struck by a bullet just above the right haunch bone. The ball passed around the trunk, entered the abdominal parietes on the left side, then passed downward through the sciatic notch, and "at length contented itself with remaining in the left nates." 10 The bullets may even be deflected by the skin or some subcutaneous bone, leaving a slit-like wound, more like that expected from an edged instrument than like an ordinary perforating bullet wound. So, too, wounds by bullets that are deflected after penetrating the skin may so weaken the deeper tissues just below the skin that if, for instance, the wound be of the abdominal wall, after the wound has apparently healed the weakness of the wall may lead to a hernia. The slower velocity of the lead bullet, and the ease with which it is deformed leads to much more laceration of the tissues than in the case of the more rapidly moving jacketed bullets. Infectious material, also, is more frequently introduced with the ball, so that the dangers of the wound are greater. The wound of exit of these bullets is often distinctly different from that of entrance. It is larger, more irregular in shape, and often protruding. The edges of the wound are usually distinctly lacerated. While the wound of exit is larger than the wound of entrance, it may still be smaller than the bullet, as Matthysens has shown11 by experiment on the dead body, 10 Cole's Military Surgery. Quest. Méd. Lég. surles Plaies par les "See Gaz. des Hôpitaux, No. 145, Armes à Feu. with a pistol fired at 12 paces from the body. With a ball 15 mm. in diameter he obtained a wound in the breast 8.5 mm. in diameter, and at the point of exit on the back, a wound 10 mm. in diameter. Similar relations were obtained from wounds in other parts of the body. Bullets from these low velocity weapons lodge in the body much more frequently than those from the modern small caliber rifles. The appearance of the wound of entrance changes as the time after the infliction lengthens. The description just given is that of the fresh wound. Within a few hours there are evidences of contusion in the reddening of the edges of the wound, and this may proceed to necrosis of the tissues to such an extent that the wound of entrance after a few days becomes larger than that of exit. Moreover, the wound of exit tends to heal more rapidly than the wound of entrance, so that after a few days the original condition may be reversed, and the wound of entrance becomes larger than the wound of exit. If the firearm be exploded in immediate contact with the body, the wound is large and circular, the skin denuded, blackened, and burned and the point where the ball has entered livid and depressed. The blackening and burning of the skin is often associated with the embedding of grains of powder. If a pistol be held tightly against the skin, so that no air may escape around the end of the barrel, the compressed air may act as a cushion, and force the explosive gases to escape through the joints of the gun. Here there would be no injury from the bullet. In the celebrated case of Peytel, tried in 1839, for the murder of his wife, it was found that she had been killed by two balls which entered near the nose. The eyebrows, lashes, and lids were completely burned, and a large number of grains of powder had imbedded themselves in the cheek. Experiments being made in order to determine the distance required to produce these effects, it was found that the weapon must have been held within a foot's distance. 216. Wadding wounds. According to some experiments made by Dr. Swift, it was found that a pistol loaded with powder and wadding alone, at 12 inches distance, tore the clothes and abraded the skin, without penetrating it; at half this distance, the wadding penetrated to the depth of half an inch; at 2 inches, a ragged and blackened wound was made, and the wadding was embedded at the depth of 2 inches; at 11⁄2 inches from the chest, the wadding passed between the ribs into the thorax, and, in a second experiment, carried away a portion of the rib.12 M. Lachèse found in his experiment that the distance at which the wadding of a gun would enter the body in one mass did not exceed 6 inches from the muzzle, but that even at this distance it only occurred when a double charge of fine powder was used, and with an army cartridge. 18 Hence, it is probable that an ordinary wadding, such as loosely wrapped paper, rag, or similar material, used in a fowling-piece, or in a musket by those not accustomed to the military use of the weapon, would not produce a rounded opening which would resemble that made by a bullet. Even if held at a less distance than 6 inches from the body, it is doubtful whether such a wound could be produced. Yet, although the opening may not be mistaken for that made by a bullet, it is certain that dangerous and fatal wounds are often made with wadding at short distances, by its penetrating the body and lacerating some important blood-vessel. Shotgun wads may mark the skin up to a distance of 5 yards. The distance which a gun will ignite a person's dress or cloth or paper of any sort must be determined for each style of gun; in general, for small arms, it may be said to be less than 1 foot. The wounds from toy pistols, made by wadding without any bullet, seem especially prone to carry the infection of lockjaw. A curious and interesting case, which led to experiments confirmatory of the above, occurred in Paris, in 1858. In the circus a cannon was fired in the direction of the boxes, at a distance of about 150 feet. The cannon was about 4 feet long, 4 inches in caliber, and loaded with 3 ounces of powder, retained by a wad made of old the ater bills torn from the street walls, loosely rolled together and rammed home with moderate force. On one occasion a man was seated in a box opposite the muzzle of the gun, and at the distance already mentioned; he was leaning forward, with his arms crossed upon the handle of his umbrella, and, as the explosion took place, he fell violently backward, and was afterwards found to have his arm broken above the elbow. Several portions of wadding were found upon the ground underneath the place where the man had sat; but no marks existed upon his clothing, and none upon the anterior part of the arm, which, indeed, must have been inaccessible to any projectile that did not at first strike the forearm. It was concluded that the fracture had been caused by the sudden and violent starting of the man backwards, which must have brought his arm against the 12 Phil. Med. Exam., March, 1846. hard edge of partition; and various experiments tried with the cannon proved that any wadding which could be made of paper was dispersed in pieces, or lost all power of mischief, at a much less distance than 120 feet.14 217. Powder wounds.- Gunpowder alone is capable of producing wounds which may prove fatal. When a pistol or gun charged with gunpowder alone is fired at an uncovered portion of the body at a distance of a few inches, a blackened, burned, and slightly lacerated wound will be produced, or, if the grains of powder be large, the skin may present the appearance of having been struck with small shot. The burnt appearance of the skin, the singeing of the hair in the neighborhood, or the burning of a portion of the clothing, will all indicate that the charge has been fired close to the body. The introduction of smokeless powder with these new rifles has modified also the character of the powder burns. Major Blankensop records three cases of suicide with Lee-Metford rifles, small caliber bullets, and cordite powder at short range. In none of them was there any blackening, charring, or tattooing from the powder.15 218. Multiple wounds. Multiple wounds from a gun may be found not merely from the shotguns, which are ordinarily loaded with several bullets, but also from a rifle or revolver, loaded with a single bullet. Such instances are evidently possible when, for example, a bullet traverses a limb and then enters the trunk or head. Similar multiple wounds are caused by the splitting of the bullet either just before or after it enters the body, the two fragments each making its own path. At the same time it should be remembered that the gun may have been charged with more than one bullet. In cases where the gun has been known to be charged with more than one bullet, only a single wound may be found, one of the bullets having passed by outside of the body. The appearance of the gunshot wound is usually so characteristic that it is not liable to be mistaken for one inflicted by any other method. But in instances where there has been only the wound of entrance and no wound of exit it may be desirable to confirm the diagnosis by an X-ray examination, which will show the presence of the bullet in the body. Gunshot wounds are usually associated with considerable shock to the nervous system, so that wounds which, at the moment of infliction, seem to be trivial, may, in the course of a few hours, develop most alarming symptoms of shock. "Annales d'Hyg., Avril, 1859, p. 420. 15 See Brit. Med. Jour., Vol. I., 1900, p. 434. II. DEGREE OF INJURY. 219. Mortal versus nonmortal wounds, in general.-In considering the extent of injury done, account must be taken of the injury to the function of the yarious organs, and also the danger to life. A division into mortal and nonmortal wounds, if it could be made, would be very desirable; but the unexpected complications and the various extraneous causes which give gravity to the simplest cases. and, on the other hand, the favorable termination of some injuries apparently the most dangerous, render any such classification impracticable. The general classification into slight, severe, dangerous, and mortal wounds may be used, but the possibility of the slight wound terminating with the loss of the person's life, and the apparently mortal ending with only a slight impairment of some function, must always be kept in mind. The interference with the function of any part of the body, due to the wound, will be considered later, in connection with the wounds of the various parts of the body. The danger to life of any wound is dependent upon a number of factors: the extent of the injury, the form of the wound, the region of the body affected, the blood vessels, nerves, or organs involved, the entrance of disease-producing bacteria or other organisms into the wound, the age and constitution of the person injured, and the opportunities for administering proper surgical treatment. No one should be willing, on theoretical grounds alone, to give an opinion as to the agency of the wound in producing death. A careful postmortem examination will usually show the violent cause of death, and it is the duty of the physician whose opinion is desired, to make that examination most carefully, and to base his opinion entirely upon the findings of this examination; not upon previous notions of the probable nature and effects of the wound. Moreover, it is necessary not merely to make an examination of the regions apparently involved in the injury, but also a thorough examination of the entire body; for, notwithstanding the immediate cause of death may be evident, it is still advisable to be sure that there was no cause of death in any other part. Although there may be no suspicion of poisoning, the stomach should be opened. In a case often referred to, a girl died while her father was chastising her for stealing; and, on account of the marks of violent treatment upon her body, it was supposed that this had caused her death. On opening the stomach, however, it was found to be inflamed, and contained a white powder, which was proved to be arsenic. The girl had taken the arsenic in |