Chapter II: Part 2

=Internal wounds without external marks.=—Among the wide variety of injuries from gunshot, there have not unfrequently been noticed cases in which serious internal mischief has been inflicted, without any external marks of violence to indicate its having resulted from the stroke of a projectile. An important viscus of the abdomen has been ruptured, yet no bruising of the parietes observable; symptoms of cerebral concussion have shown themselves, yet no injury of the scalp to be detected. Even bones have been comminuted without any wound of the integuments or appearance of injury. The records of the Crimean campaign afforded not unfrequent examples of such wounds. Two cases occur, in the French records, of fracture of the forearm without any external apparent lesion; in one the internal structures were reduced to a mass of pulp. The difficulty of reconciling the several facts noticed in such instances, together with the vague descriptions by patients of their sensations, led surgeons to seek an explanation for them in the supposition that masses of metal projected with great velocity through the air might inflict such injuries indirectly by aerial percussion. Either the air might be forcibly driven against the part injured by the power and pressure of the ball in its flight, or a momentary vacuum might be created, and the forcible rush of air to refill this blank might be the origin of the hurt. Electricity has also been called into aid in explaining these injuries. All these hypotheses are now abandoned. So many observations have been made of cannon–balls passing close to various parts of the body, as near as conceivable without actual contact, without any such consequences as those attributed to windage, as to lead to the necessary conclusion that the theory must in all instances have been fallacious. Portions of uniform and accouterments have been torn away by cannon–balls without injury to the soldier himself. Even hair from the head has been shaved off, and cases are on record where the external ear and end of the nose have been carried away without further mischief.

The true explanation of the appearances presented in those cases which were formerly called “wind contusions,” appears to rest in the peculiar direction, the degree of obliquity, with which the missile impinges on the elastic skin, together with the situation of the structures injured beneath the surface, relatively to the weight and momentum of the ball on one side, and hard resisting substances on the other. Thus, in the case of a cannon–ball passing across the abdomen, as in two instances mentioned by Sir Gilbert Blane, where men were killed by the passage of balls across the epigastrium, the elasticity of the skin probably enabled that structure to yield to the strain to which it was exposed, while viscera were ruptured by the projectile forcing them against the vertebral column. So the weight of a ball passing obliquely over a forearm may possibly crush the bone between itself and some hard substance against which the arm may be accidentally resting, without lesion of the interposed skin. Baron Larrey, who examined many fatal cases of this kind, relates that he always found so much internal disorganization as to leave no doubt in his mind of its being the result of contact with the ball. He explained the absence of superficial lesion, by the surface having been struck by cannon–balls in the latter part of their flight, when they had undergone a change of direction from straight to curvilinear, and acquired a revolving motion, owing to atmospheric resistance and the effect of gravitation. In such a condition, he argued, they would turn round a part of the body, as a wheel passes over a limb, in place of forcing their way through it; and, while elastic structures would yield, bones and muscles, offering more opposition, would be bruised or broken.

In some recently published letters on the wounded in the late campaign in Italy, by M. Appia, this writer states that wounds from massive projectiles having been rare, he had not met with an example of internal destruction of parts with skin preserved intact, and that he had nowhere seen a wound which was attributed to _vent de boulet_. The hypothesis, he remarks, seems generally abandoned. It is presumed that, in stating wounds from _gros projectiles_ to have been rare, he refers only to the wounded in the hospitals, and that it is to be inferred that the injuries from cannon–shot proved generally fatal in the field.

=Seat of injury.=—A knowledge of the seat of injury from the passage of a ball involves diagnosis of its course, the depth of its penetration, the particular organs or structures injured, and the extent of the injuries to which they have severally been subjected. The course pursued by balls in wounds presents many features of interest. The depth of penetration, in connection with direction, becomes of great importance when there is question of one of the great visceral cavities being opened. This part of the subject, however, together with that of injuries to the viscera themselves, will be more conveniently considered when treating of gunshot wounds in their special relations to particular regions. In like manner, the diagnosis of the extent of injury in wounds complicated with fractures of the long bones will be best considered under gunshot wounds of the extremities.

=Course of balls.=—Of the circuitous and unexpected directions pursued by bullets in their course through the human frame, which were formerly so common, we are not likely to see many instances in future warfare, when the rifle is the weapon chiefly employed. The conical shape of the ball and the force with which it is propelled have had the effect, among others already named, of changing this characteristic of the ball from the smooth–bored musket. The latter, bearing a force that scarcely carried it true to a mark at eighty yards, and usually receiving, as it left the firelock, an impulse which caused it to revolve on its axis at right angles with the line of flight, was deflected by the most trifling obliquity of surface, by the resisting obstacle of a bone, by tendons or the aponeuroses of muscles, or even by the elastic resilience of muscles themselves in a state of action, when the relative direction of their fibers was favorably placed to exert this influence. The Enfield cylindro–conoidal bullet, armed with a force that will carry it to a given spot distant one thousand yards or upwards, flies like an arrow, penetrates the softer tissues in a straight line, and on meeting bone, as before noticed, enters it like a wedge. When a bullet of this kind strikes an object point–blank, it is always the apex of the conical part which first meets the object struck; and, if sufficient resistance be met with, it is this apex which becomes first compressed and turned back. When it strikes a solid object lying nearly parallel with its line of flight, the ball is planed, as it were, from its apex toward its base. In a case before referred to—page 29—where a conical ball entered the loin of a soldier of the 19th Regiment, and was subsequently passed per anum, the apex of the bullet was found to be turned and bent round on itself, and the ball generally flattened. On examining carefully the convex surface of the convoluted apex, minute spiculæ of bone were observed to be impacted in its substance. It became evident, therefore, that the ball had struck, probably penetrated through, some portion of the lumbar vertebræ in its course from the loin to the intestine. There were no general symptoms to indicate spinal injury, but, four years afterward, the opportunity of a post–mortem examination being afforded, the track of the ball through some of the lumbar vertebræ was distinctly traced.[2]

It will often appear, at first examination, that the track of a wound by the cylindro–conoidal bullet, even at full speed, is widely removed from a straight line, especially when this class of injuries is new to the surgeon. It is not difficult to understand the apparent irregularity in the line of the wound, when the many varied positions in which the body and its parts are liable to be placed are called to mind, and if, when making the examination, the surgeon has omitted to place the patient in a similar posture to that he was in when struck. A certain allowance must also be made for the spasmodic actions of the various muscles among themselves, and momentary displacement of other structures, at the instant of receiving the injury.

Occasionally, though rarely, an accidental concurrence of circumstances may lead to the conical bullet pursuing a circuitous instead of a direct course, especially when, after traveling a certain distance, its speed has become diminished; and, as round musket–balls are not yet wholly discarded from warfare, it is necessary to call attention to the observations which have been made on this subject. Balls have been known to pass round the outer convex and the inner concave surfaces of the abdominal and thoracic cavities, sometimes forcing their exit at points nearly opposite to those of entrance, sometimes making a complete circuit. Thus, from simple observation of the line of direction of two wounds, a ball may be supposed to have passed through the thorax or abdomen, while really it may not have penetrated the cavity, but only made its way beneath the integument. In like manner, a lung may be supposed to have been traversed by a ball, not merely from the relative position of the wounds of entrance and exit, but also by some of the characteristic signs of such an injury, when really the ball, after entering the cavity of the chest, has rolled round the costal pleura, never penetrating the lung, but at the most bruising its surface. In the same way, balls have been known to travel round the cranium beneath the scalp, and to have found their way beneath the integuments of the neck, without injury to the deeper structures. Dr. Hennen saw a case where a ball was found lying in a wound by the thyroid cartilage. It had made a complete circuit of the neck, and returned to the spot where it had entered. Cases sometimes occur where two openings are found in a man’s shoulder, in such relation that a straight line between them would necessarily pass through the head of the humerus, yet the ball has only made a half circuit, outside the joint.

Many examples of such injuries will be found in the works of all writers on gunshot wounds until the recent introduction of rifled weapons, while those who have only seen the latter in use are almost inclined to doubt the accuracy of previous statements on this subject, from not meeting with similar instances in their own experience. In the early part of the late war with Russia, the musket wounds were nearly all inflicted by the round bullet; but during the year 1855 conical bullets of various shapes and sizes were brought into use by the Russians generally, as they had been for some time previously by nearly the whole of the English army, and a large proportion of the French army. As early as the battle of Inkerman, however, the Russians were partly armed with the Liège rifle, with its conical bullet. Among 3000 wounded from the recent battles of Palestro and Magenta, assembled in the hospitals at Turin, M. Appia, whose letters on the wounded in the late Italian campaign have been before quoted from, writes that he was astonished not to meet one case of a cylindrical ball having taken a curved direction in its passage. He mentions the case of an officer being wounded by a ball, which entered at the epigastrium and passed out by the side of one of the lumbar vertebræ, without penetration of the abdomen, a red mark or zone connecting the two wounds and indicating the circuit which the ball had made. In another case, a ball had traversed the chest from right to left, and still had sufficient force to wound the left arm. Both these injuries, however, were caused by spherical balls.

SYMPTOMS OF GUNSHOT WOUNDS.

The leading symptoms of gunshot wounds are the diagnostic marks of these injuries, and the constitutional disturbance, pain, hemorrhage, edema, and other circumstances with which they are attended. Some of these require to be noticed separately.

=Diagnosis.=—The external distinguishing signs of a penetrating gunshot wound are generally manifest enough, but exact diagnosis of the nature and extent of the wound is not always so simple as it might at first appear to be. It is necessary to describe, firstly, the external appearances. These, although possessing certain universal characteristics, vary to a wide extent, according to the different forms, already described, of the missiles causing the injuries, their velocity, the part of the body struck, and its position relative to the projectile at the time of injury.

When a cannon–ball at full speed strikes in direct line a part of the body, it carries away all before it. If the head, chest, or abdomen are exposed to the shot, an opening corresponding with the size of the ball is effected, the contiguous viscera are scattered, and life is at once extinguished. If it be part of one of the extremities which is thus removed, the end remaining attached to the body presents a stump with nearly a level surface of darkly contused, almost pulpified, tissues. The skin and muscles do not retract, as they would had they been divided by incision. Minute particles of bone will be found among the soft tissues on one side, but the portion of the shaft of the bone remaining _in situ_ is probably entire.

In ricochet firing, or in any case where the force of the cannon–shot is partly expended, the extremity, or portion of the trunk, may be equally carried away, but the laceration of the remaining parts of the body will be greater. The surface of the wound will be less even. Muscles will be separated from each other, and hang loosely, offering at their divided ends little appearance of vitality; spiculæ of bone of larger size will probably be found among them; and the shaft may be found shattered and split far above the line of its transverse division. The injury to nerves and vessels may be proportionally higher and greater. Occasionally it happens, even where the limb seems to have been struck in direct line, that it is nevertheless not completely detached, but remains connected by shreds of the skin and parts of the tissues, on which the bone, reduced to minute fragments, is mixed with the contused muscles and other soft parts in a shapeless mass.

If the speed be still further diminished, so that the projectile becomes what is termed a “spent ball,” there will not be removal of the part of the body struck, but the external appearances will be limited usually to ecchymosis and tumefaction, without division of surface; or even these may be wanting, notwithstanding the existence of serious internal disorganization. The rationale of such phenomena has been previously described.

Should the cannon–ball strike in a slanting direction, the external appearances of the wound will be similar to those just described, according to its velocity, modified only in extent by the degree of obliquity with which the shot is carried into contact with the trunk or extremity wounded.

Large fragments of heavy shells generally produce immense laceration and separation of the parts against which they strike, but do not carry away or grind, as round shot. Ordinarily, the line of direction in which they move forms an obtuse angle with the part of the body wounded. When they happen to strike in a more direct line, so as to penetrate, the external wound, as alluded to under the head of lodgment of projectiles, is mostly much smaller than the fragment itself, from the projectile not having had force enough to destroy the vitality and elasticity of the soft parts through which it entered.

Small projectiles, with force enough to penetrate the body, leave one or more openings, the external appearances of which also vary according to their form and velocity. The appearance of a wound from a rifle–ball, at its highest rate of speed, may be sometimes witnessed in cases of suicide. A soldier, in thus destroying himself, mostly stoops over the muzzle of his firelock, pressing it against the upper part of his body, and springing the trigger by means of his foot. The muzzle is usually applied beneath the chin. In such a case, a circular hole, without any puckering or inversion of the marginal skin, together with dark discoloration of the integument for several inches round, is observed at the wound of entrance. The vertex of the head is shattered; fragments of the parietal and occipital bones, together with small portions of brain, are carried away and scattered about; the bones not broken are loosened from their sutures; the mass of brain is torn to pieces, but held by its membranes; the superficial vessels of the face are distended with blood. These effects are not wholly due to the passage of the ball, but partly to the flame from the ignited gunpowder jetting out at the mouth of the musket, and in part also to the expansive force exerted within the cavity of the cranium, by the gases resulting from the explosion.

When the musket–ball strikes at a distance from the weapon by which it was propelled, but still preserves great velocity, the appearances of the wound are changed. An opening is observed, irregularly circular, with edges generally a little torn; and the whole wound is slightly inverted. There may be darkening of the margin, of a livid purple tinge, from the effects of contusion, or it may be simply deadlike and pale. Should the ball have passed out, the wound of exit will be probably larger, more torn, with slight eversion of its edges and protrusion of the subcutaneous fat, which is thus rendered visible. These appearances are the more easily recognized, the earlier the wound is examined. They are more obvious if a round musket–ball has caused the injury than when it has been inflicted by a cylindro–conoidal bullet. Indeed, with the latter, where it has simply passed through the soft tissues of an extremity of the body at full speed, it is usually very difficult to distinguish by its appearance the wound of entrance from that of exit. In medico–legal investigations concerning gunshot wounds, it must be often a matter of great importance to decide this point; but to the military surgeon, more especially from the circumstances connected with the new projectiles, it has become a subject of little practical interest. When the indirect and tortuous penetration of balls was the rule rather than the exception, a knowledge of the spot at which the ball entered was often useful in diagnosing the mischief it had probably committed in its passage, and in determining the part of the wound where foreign bodies might be supposed to be carried and to be lodging. When the track of the ball is nearly in a straight line, as now usually happens, such information cannot be looked for from knowing the relation of either opening to the entrance or passage of the missile.

A musket–ball ordinarily causes either one wound, as when after entering it lodges, or, as sometimes happens, from its escaping again by the wound of entrance; or two wounds, from making its exit at some point remote from the spot where it entered; but occasionally leads to a greater number of openings. This last result may happen from the ball splitting into two or more portions within the body, and causing so many wounds of exit. A case occurred to M. Dupuytren, where a ball split against the spine of the tibia; and after traversing the calf of the leg in two directions, entered the other leg at two points,—one ball thus causing five orifices. A case occurred to the writer, in the Crimea, where a cylindro–conoidal rifle–ball with three canalures, after fracturing the cranium, was cut in two by the upper edge of bone at the seat of fracture, smoothly as if by a sharp instrument. One part glanced off, the other entered the cranium. A strange feature in this case was, that the depressed portion, after admitting the ball, closed up again; so that no aperture, but only a slight depressed line of fracture, was visible.[3] A somewhat similar case occurred in the 38th Regiment, but the ball appears to have been a round one. M. Huguier has collected some curious cases of splitting of balls, from the records of the French revolution: among others, the division of a ball into two parts, of another into three parts, against the supra–orbital ridge, and of another into three parts against the clavicle. A case is recorded, where a grenadier in Algeria was wounded in five places, all wounds of entrance, by one ball. It was divided into five portions by first striking against a rock at five or six paces from the soldier, the fragments rebounding at various angles. John Hunter mentions the case of a young gentleman who was shot through the abdomen by means of a musket loaded with three balls. In this instance there were only two orifices of entrance and two of exit, one ball having followed in the track of one of the others; “that there were three that went through him was evident, for they afterward made three holes in the wainscot behind him, but two very near each other.” Had it not been for this proof, it being known that three balls were discharged, a suspicion might have existed that one of the three balls had lodged. The recollection that such accidents may occur will sometimes assist in the diagnosis of doubtful cases.

The number of wounds made by one ball may be increased by its traversing two adjoining extremities of the same person, or even distant parts of the body from accidental relative position at the time of the injury. On the 18th of June, 1848, at Paris, a man received a ball in his right arm, above the elbow, which caused a comminuted fracture of the humerus. It then passed across and entered the left arm below the elbow, fracturing the upper part of the radius. Dr. Hennen mentions the case of a man on a scaling–ladder, in which a ball passed from the middle of the upper arm on one side to the middle of the thigh on the opposite side. It is evident, when the ball traverses with sufficient velocity, that these accidents will not unfrequently occur, especially between the upper extremity and trunk. They correspond with such events as more than one person being wounded by the same ball, examples of which were not unfrequently noticed in the trenches before Sebastopol, from enfilading shots, especially prior to the capture of the Mamelon Vert and other outworks; and are said to have been very common in the late campaign in Italy. Should the Whitworth rifle ever be brought into general use, the proportionate number of wounds thus caused from the greater density of the ball, its immensely superior force, and low trajectory, must be still further increased.

The two openings made by one ball may hold such a relative situation as to lead to the mistake of their being supposed to be caused by two distinct balls. A case is recorded where a ball entered the scrotum, and made its exit from the right thigh, without any intermediate mark of its passage; such a wound might lead to an erroneous diagnosis of this sort. Length of traverse, and consequent distance between the two openings, parts of the body brought into unusual relations from peculiarities of posture, and peculiar deflections of the ball, may all be sources of this error.

The appearances of wounds resulting from penetrating missiles of irregular forms, as small pieces of shells, musket–balls flattened against stones, and others, differ from those caused by ordinary bullets in being accompanied with more laceration, according to their length and form. Being usually projected with considerably less force than direct missiles, such projectiles ordinarily lead only to one aperture, that of entrance.

=Pain.=—A gunshot wound by musket–shot is attended with an amount of pain which varies very much in degree according to the kind of wound, condition of mind, and state of constitution of the soldier at the time of its infliction. It will sometimes happen in simple flesh wounds, that patients will tell the surgeon they were not aware when they were struck; and examples attesting the truth of such statements occur, of soldiers continuing in action for some time without knowing they had been wounded. Sometimes the pain from the shot is described as a sudden smart stroke of a cane; in other instances as the shock of a heavy intense blow. Occasionally the pain will be referred to a part not involved in the track of the wound. Lieutenant M. of the 19th Regiment was wounded by a musket–ball at the assault of the Redan, on the 8th of September, 1855. His sensations led him to imagine that the upper part of his left arm was smashed, and he ran across the open space in front of the works, supporting the arm which he supposed to be broken. On arriving at the advanced trench, he asked for water; on trying to drink, he found that his mouth contained blood, and that he was unable to swallow. The arm, on examination, was found to be uninjured, but a ball had passed from right to left through his neck, and from its direction had no doubt struck some portion of the lower cervical or brachial plexus of nerves. Immediately after the transit of a ball, the sensibility of the track and parts adjoining is found to be partially numbed, so that examination is borne more readily for a short time after the accident than at any later period. Of course, after reaction sets in, or when inflammation has become established, the pain of the wound is proportionably increased. When a ball does not penetrate, but simply inflicts a contusion, the pain is described to be more severe than where an opening has been made by it.

=Shock.=—When a bone is shattered, a cavity penetrated, an important viscus wounded, a limb carried away by a round shot, pain is not so prominent a symptom as the general perturbation and alarm which supervene on the injury. This is generally described as the “shock” of a gunshot wound. The patient trembles and totters, is pale, complains of being faint, perhaps vomits. His features express anxiety and distress. This emotion is in great measure instinctive; it is witnessed in the horse hit mortally in action, no less than in his rider; it is sympathy of the whole frame with a part subjected to serious injury, expressed through the nervous system. Examples seem to show that it may occasionally be overpowered for a time, even in most severe injuries, by mental and nervous action of another kind; but this can rarely happen when the injury is a vital one. Panic may lead to similar results when the wound is of a less serious nature. A soldier, having his thoughts carried away from himself—his whole frame stimulated to the utmost height of excitement by the continued scenes and circumstances of the fight—when he feels himself wounded, is suddenly recalled to a sense of personal danger; and if he be seized with doubt whether his wound is mortal, depression as low as his excitement was high may immediately follow. This will happen according to individual character and intelligence, state of health, and other circumstances. For while, on the one hand, numerous examples occur in every action of men walking to the field hospital for assistance almost unsupported, and with comparatively little signs of distress, after the loss of an arm or other such severe injury; on the other, men whose wounds are slight in proportion are quite overcome, and require to be carried.

As a general rule, however, the graver the injury, the greater and more persistent is the amount of “shock.” A rifle–bullet which splits up a long bone into many longitudinal fragments, inflicts a very much more serious injury than the ordinary fracture effected by the ball from a smooth–bore musket, and the constitutional shock bears like proportion. When a portion of one or of both lower extremities is carried away by a cannon–ball, the higher toward the trunk the injury is inflicted, the greater the shock, independent of the loss of blood. Some writers, in accounting for “shock,” lay stress on the concussion, and general mechanical effects on the whole body, of the momentum of the iron shot.[4] To a certain extent this may be true, but, judging from analogy in physics, the greater the velocity, and consequently the momentum, of a ball carrying away a limb, the less would the concussion of the trunk and distal parts of the body be. A pistol–ball at full speed will take a circular portion out of a pane of glass without disturbing the remainder; if the speed be much slackened, as when fired from a distance, it will shake the whole pane to pieces.

That true “shock,” (_ébranlement_ of French writers,) as distinguished from shock resulting from mental depression after unusual excitement, or the effects of groundless alarm on the part of a patient, is a phenomenon the essential relations of which are connected with vital force, and with that endowment of the organization only, may be judged from observation of cases in which the direct result of the wound is inevitably fatal, including many where no physical effects on neighboring parts from concussion could possibly be produced. In such injuries the “shock” remains, from the time of first production of the fatal impression till life is extinguished. And the practical experience of every army surgeon teaches him that where a ball has entered the body, though its course be not otherwise indicated, the continuance of shock is a sufficient evidence that some organ essential to life has been implicated in the injury. That the shock of a severe gunshot wound may be complicated with other symptoms, or that some of its own symptoms may be exaggerated from other causes,—hopes disappointed, the approach of death, and all the attendant mental emotions,—scarcely affects the question at issue; for its existence, independent of these complications, in all such cases is undoubted.

=Primary hemorrhage.=—Primary hemorrhage of a serious nature from gunshot wounds does not often come within the sphere of the surgeon’s observation. If hemorrhage occur from one of the main arteries, it probably proves rapidly fatal; and surgeons, after an action, are usually too much occupied with the urgent necessities of the living wounded to spare time for examining the wounds of the dead, who are mostly buried on the field where they fall. Thus most surgeons speak of primary hemorrhage being exceedingly rare, more rare, perhaps, than it actually is. M. Baudens, referring to his service in Algeria, has remarked that he has often found on the field of battle wounded soldiers who had died of primary hemorrhage.

In those wounds to which the surgeon’s care is called, the primary hemorrhage is ordinarily small in quantity and of short duration—a sudden flow at the moment of injury, and nothing more. When a part of the body is carried away by round shot or shell, the arteries are observed to be nearly in the same state as they are found to be in when a limb is torn off by machinery. The lacerated ends of the middle and inner coats are retracted within the outer cellular coat; the caliber of the vessel is diminished, and tapers to a point near the line of division; it becomes plugged within by coagulum; and the cellulo–fibrous investing sheath, and the clot which combines with it, form on the outside an additional support and restraint against hemorrhage. When large arteries are torn across, and their hemorrhage thus spontaneously prevented, they are seldom withdrawn so far but that their ends may be seen protruding and pulsating among the mass of injured structures; yet, though the impulse may appear very powerful, further hemorrhage is rarely met with from such wounds. There is more danger of continued hemorrhage from wounds by pieces of shell, as the arteries are liable to be wounded without complete transverse section of their coats. The sharp edges, less velocity, and oblique direction in which the fragments usually impinge sufficiently explain this difference.

It comparatively rarely happens that arteries are cut across by musket–bullets, either round or conical. The lax cellular connections of these vessels, the smallness of their diameters in comparison with their length, the elasticity as well as toughness of the tissues forming their coats, the fluidity of their contents, and, in consequence of all these conditions, the extreme readiness with which they slip aside under pressure, act as means of preservation when these important structures are subjected to such danger as the passage of a musket–ball in their direction. Endless examples occur where the ball appears to have passed through in the direct line of the artery, so that it must have been pushed aside by it to have escaped division. Mr. Guthrie mentions a case where a ball even opened the sheath of the femoral vessels, and passed between the artery and vein, in a soldier at Toulouse, without destroying the substance of either vessel. So close was the ball, and such contusion was produced, together with, doubtless, injury to the vasa vasorum, that the artery became plugged with coagulum, and obliterated. A preparation of these vessels is in the museum at Fort Pitt. Another case is mentioned by Mr. Guthrie, where the direction of a ball between the left clavicle and first rib, and permanent diminution of the pulse in the arm on the same side, led to the conclusion that the subclavian had escaped direct destruction by the missile in a similar way.

Vessels do not always thus happily elude division by the ball. Captain V., of the 97th Regiment, whose death led to so much interest in England, was struck by a ball which divided the axillary artery on the right side. The arm had apparently been extended when he received the injury, as if in the act of holding up his sword. The night was very dark, the distance from the place where the sortie took place in which he was wounded to the camp hospital was more than a mile and a half, and he sunk from hemorrhage while being carried up. The death of an officer from division of the femoral artery is recorded in the Surgical History of the Crimean War, where also cases are mentioned, though not immediately fatal, of a wound of the femoral vein and profunda artery in the same subject from a conical bullet; and another, of the popliteal artery and vein, also from a rifle–ball. Mr. Guthrie mentions the cases of two officers who were killed, almost instantaneously, one by direct division of the common iliac artery, the other of the carotid. Primary but indirect hemorrhage, in consequence of a gunshot injury, usually occurs as a complication of fractured long bones, the sharp points and edges of which, extensively torn up as they now are by conical bullets, are well calculated to cause such injuries. They are not as frequent as might be expected, from the limits within which the dispersion of the fragments is restricted by their periosteal and other connections, and the yielding mobility, before mentioned, of the vessels themselves. We have no data, however, to guide us in determining the proportionate frequency of fatal results from primary hemorrhage after wounds; nor can we have them until proper examination and classification of the particular causes of death on the field of battle are instituted.

PROGNOSIS.

Gunshot wounds vary in gravity from the simplest laceration of cuticle to the instantaneous destruction of life. Death may take place primarily from direct causes already alluded to, viz.: from the destruction of vital organs, from extreme shock to the vital forces through the nervous system, or from hemorrhage; or it may ensue indirectly from secondary hemorrhage, gangrene, erysipelas, hectic fever, pyemia, or from the results of operations necessarily required in consequence of the original injury. In estimating the probable issue of a particular wound, not only the state of health at the time, but, if a soldier, the previous service, and diseases under which he has labored during it, must be taken into account, and the circumstances in which he is placed with respect to opportunity of proper care and treatment must also be carefully weighed. The time which has elapsed after the receipt of the injury is another important matter in forming a prognosis. The difficulties which have been already enumerated in the way of arriving at a safe diagnosis of the true nature and extent of the injury, and the liabilities above mentioned to which a patient with a gunshot wound is exposed, should put a surgeon on his guard against giving a hasty judgment in any case that is not very plain and simple. Military surgery abounds with examples of wounds of such extent and gravity as apparently to warrant the most unfavorable prognosis, which have nevertheless terminated in cure; while others, regarded as proportionably trifling, have led to fatal results. Tables may be found in works showing statistically the nature and relative numbers of wounds and injuries received in various actions, with their immediate and remote consequences, as well as the results of the surgical operations they have led to; but these afford little aid toward the prognosis of particular cases, each of which must be estimated in its own individual circumstances. Such tables are chiefly of value where they afford indications of the effects of different modes of treatment in wounds of a corresponding nature, and then only in patients under like circumstances of age and condition. Even moral circumstances must not be disregarded. The probable issue in any given case will be very different in one soldier, who is supported by the stimulating reflection that he has received his wound in a combat which has been attended with victory, from what it will be in another, who labors under the depression consequent upon the circumstances of defeat.

TREATMENT OF GUNSHOT WOUNDS IN GENERAL.

When the circumstances of a battle admit of the arrangement, the wounded should receive surgical attention preliminary to their being transported to the regimental or general field hospitals in rear. A slight provisional dressing, a few judicious directions to the bearers, may occasionally prevent the occurrence of fatal hemorrhage, or avert serious aggravation of the original injury from malposition, shaking, and spasmodic muscular action, in the course of conveyance from the neighborhood of the scene of conflict to the hospital. In the siege operations before Sebastopol, this was accomplished by assistant surgeons in the trenches, or, according to the French system, by regular ambulance hospitals in the ravines leading to them. The provisional treatment should be of the simplest kind, and chiefly directed to the prevention of additional injury during the passage to the hospital, where complete and accurate examination of the nature of the wound can alone be made, and where the patient can remain at rest after being subjected to the required treatment. The removal of any missiles or foreign bodies which may be readily obvious; the application of a piece of lint to the wound; the arrangement of any available support for a broken limb; protection against dust, cold, or other objectionable circumstances likely to occur in the transit; if “shock” exist, the administration of a little wine, aromatic ammonia, or other restorative, in water,—need little time in their execution, and may prove of great service to the patient. If hemorrhage exist from injury to a large vessel, it must of course receive the surgeon’s first and most earnest care. He should not trust to the pressure of a tourniquet, but secure it at once by ligature. Without this safeguard during the transport, and while in the hands of uneducated attendants, the life of the wounded man might be endangered, either from debility consequent upon gradual loss of blood or from sudden fatal hemorrhage. It has been recommended by some surgeons that all attendants whose duties consist in carrying the wounded from a field of battle should be directed, when bleeding is observed, to place a finger in the wound, and keep it there during the transport until the aid of a surgeon is obtained. The precise spot where compression by the finger is wanted, and the degree of pressure necessary, will be quickly made manifest to the sight by the effects on the flow of blood. Such a practice seems to offer less objection than the use of tourniquets by men whose knowledge of their proper application must be exceedingly limited.

On arrival at the hospital, where comparative leisure and absence of exposure afford means of careful diagnosis and definitive treatment, the following are the points to be attended to by the surgeon: firstly, examination of the wound with a view to obtaining a correct knowledge of its nature and extent; secondly, removal of any foreign bodies which may have lodged; thirdly, adjustment of lacerated structures; and fourthly, the application of the primary dressings.

The diagnosis should be established as early as possible after the arrival at hospital. An examination can then be made with more ease to the patient and more satisfactorily to the surgeon than at a later period. Not only is the sensibility of the parts adjoining the track of the ball numbed, but there is less swelling to interfere with the examination, so that the amount of disturbance effected among the several structures is more obviously apparent.

One of the earliest rules for examining a gunshot wound is to place the patient, as nearly as can be ascertained, in a position similar to that in which he was, in relation to the missile, at the time of being struck by it. In almost every instance the examination will be facilitated by attention to this precept. Occasionally it will at once indicate the probable injury to vessels or other important structures, in cases where the mutual relations of the wounds of entrance and exit, in the erect or horizontal posture of the body, would lead to no such information. Even in the direct course taken by a rifle–ball in a simple flesh wound, an erroneous opinion of the line in which the ball has moved may be formed from the first view, in consequence of the ready mobility of the several structures among themselves and their varying degrees of elasticity. Injury to nerves inducing paralysis, contusions of blood–vessels leading to secondary hemorrhage or gangrene, may thus, without sufficient circumspection, be overlooked on the first admission to hospital.

When only one opening has been made by a ball, it is to be presumed that it is lodged somewhere in the wound, and search must be made for it accordingly. But even where two openings exist, and evidence is afforded that these are the apertures of entrance and exit of one projectile, examination should still be made to detect the presence of foreign bodies. Portions of clothing, and, as has already been shown, other harder substances, are not unfrequently carried into a wound by a ball; and, though it itself may pass out, these may remain behind either from being diverted from the straight line of the wound or from becoming caught and impacted in the fibrous tissue through which the ball has passed. The inspection of the garments worn over the part wounded may often serve as a guide in determining whether foreign bodies have entered or not, and, if so, their kind, and thus save time and trouble in the examination of the wound itself.

Of all instruments for conducting an examination of a gunshot wound, the finger of the surgeon is the most appropriate. By its means the direction of the wound can be ascertained with least disturbance of the several structures through which it takes its course. If bones are fractured, the number, shape, length, position, and degree of looseness of the fragments may be more readily observed. In case of lodgment of foreign bodies, not only is their presence more obvious to the finger direct than through the agency of a probe or other metallic instrument, but by its means intelligence of their qualities is also communicated. A piece of cloth lying in a wound is recognized at once by a finger, while, saturated with clot as it is under such circumstances, it would probably be confounded among the other soft parts by any other mode of examination. The index finger naturally occurs as the most convenient for this employment; but the opening through the skin is sometimes too contracted to admit its entrance, and in this case the substitution of the little finger will usually answer all the purposes intended. When the finger fails to reach sufficiently far, owing to the depth of the wound, the examination is often facilitated by pressing the soft parts from an opposite direction toward the finger–end.

It was formerly the custom to enlarge the external orifice of all gunshot wounds by incision, and not merely the opening, but the walls of the wound itself, as soon after the injury as possible. This was not done as a means of rendering the examination easier, but as a prophylactic measure. Dilatation was also employed by tents and various other means with a view to secure the escape of sloughs and discharges. The opinions held by the older surgeons respecting the nature of these injuries, already briefly adverted to in the historical remarks on the subject, sufficiently explain their object in making incisions—namely, to convert what they regarded as a poisoned into a simple wound, and to obviate tension, and prevent strangulation of neighboring tissues by tumefaction or inflammation arising in its track. Even so late as 1792, Baron Percy, in his Manuel du Chirurgien d’Armée, writes: “The first indication of cure is to change the nature of the wound as nearly as possible into an incised one.” English surgeons have, however, generally discarded the practice since the arguments used by John Hunter against it, just about the same date as Baron Percy wrote, excepting only in cases where it is required to allow of the extraction of some extraneous body to secure a wounded artery, to replace parts in their natural situation, as in protrusion of viscera in wounds of the abdomen, or, “in short, when anything can be done to the part wounded after the opening is made for the present relief of the patient or the future good arising from it.” It does not often happen that it is necessary to enlarge the openings of wounds to remove balls, although a certain amount of constriction of the skin may be expected from the addition of the instrument employed in the extraction; but if much resistance is offered to their passage out, it is better to divide the edges of the fascia and skin to the amount of enlargement required than to use force. In removing fragments of shells or detached pieces of bone, the fascia and skin have almost invariably to be divided to a considerable extent.

Where the finger is not sufficiently long to reach the bottom of the wound, even when the soft parts have been approximated by pressure from an opposite direction, and when the lodgment of a projectile is suspected, a long silver probe, that admits of being bent by the hand if required, is the best substitute. Elastic bougies or catheters are apt to become curled among the soft parts, and do not convey to the sense of touch the same amount of information as metallic instruments do. The probe should be employed with great nicety and care, for it may inflict injury on vessels or other structures which have escaped from direct contact with the ball, but have returned, by their elasticity, to the situations from which they had been pushed or drawn aside during its passage. The above directions for examining wounds apply more particularly to such as penetrate the extremities, or extend superficially in other parts of the body; where a missile has entered any of the important cavities, search for it is not to be made, but the surgeon’s attention is to be directed to matters of more vital importance to be hereafter noticed.

As soon as the presence of a ball or other foreign body is ascertained it should be removed. If it be lying within reach from the wound of entrance, it should be extracted through this opening by means of some of the various instruments devised for the purpose. In case of a leaden bullet, Coxeter’s Extractor, corresponding with Baron Percy’s instrument for the same purpose, and consisting of a scoop for holding and central pin for fixing the bullet, has been found a very convenient appliance, from the comparatively limited space required for its action. Instruments of two blades, or scoops, with ordinary hinge action, dilate the track of the wound injuriously before the ball can be grasped by them. The way to the removal of a bullet may often be smoothed by judiciously clearing away the fibers, among which it is lodged, during the examination, by the finger; and sometimes, by means of the finger in the wound, and external pressure of the surrounding parts, the projectile may be brought near to the aperture of entrance, so that its extraction is still further facilitated. Such foreign substances as pieces of cloth can usually be brought out by the finger alone, or by pressing them between the finger and a silver probe inserted for the purpose. Sometimes a long pair of dressing forceps, guided by the finger, is found necessary for effecting this object. Caution must be used in employing forceps, where the foreign substance is out of sight and of such a quality that the soft tissues may be mistaken for it.

In instances where the foreign body has not completely penetrated, but is found lying beneath the skin away from the wound of entrance, an incision must be made for its extraction. Before using the knife, the substance to be removed should be fixed _in situ_, by pressure on the surrounding parts. In the instance of a round ball, the incision should be carried beyond the length of its diameter; an addition of half a diameter is usually sufficient to admit of the easy extraction of the ball. In removing conical balls, slugs, fragments of shells, stones, and other irregularly–shaped bodies, the surgeon cannot be too guarded in arranging that the fragment is drawn away with its long axis in line with the track of the wound. By proper care in this respect, much injury to adjoining structures may be avoided.

If balls are impacted in bone, as happens in the spongy heads of bones, in bones of the pelvis, and occasionally, though rarely, in other parts of long bones, they should be removed. This can be effected by means of a steel elevator, of convenient size; or, should this fail from the ball being too firmly impacted, a thin layer of the bone on one side of the ball may be gouged away, so that a better purchase may be obtained for the elevator, in effecting its removal. The fact is now fully established that, although in a few isolated cases balls remain lodged in bones without sensible inconvenience, in the majority the lodgment leads to such disease of the bony structure as often to entail troublesome abscesses, and in some instances eventually to necessitate amputation. The lodgment of balls will not often occur without extensive fracture in warfare where rifled arms of such force as the Minié or Enfield are the chief weapons employed, but will not unfrequently be met with in such campaigns as have lately happened in India.