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                               LONGMORE

                                  ON

                            GUNSHOT WOUNDS.




                              A TREATISE

                                  ON

                            GUNSHOT WOUNDS.


                                  BY

                          T. LONGMORE, ESQ.,

     DEPUTY INSPECTOR–GENERAL OF HOSPITALS; PROFESSOR OF MILITARY
                    SURGERY AT FORT PITT, CHATHAM.


                             PHILADELPHIA:

                        J. B. LIPPINCOTT & CO.
                                 1862.




                               CONTENTS.


  GUNSHOT WOUNDS IN GENERAL.

                                                                PAGE
  Definition of the term                                           9
  History of the surgery of gunshot wounds                         9


  VARIETIES OF GUNSHOT WOUNDS.

  Form and nature of missile                                      14
  Grape–shot, canister, and spherical case                        16
  Musket–shot—Conical bullets                                     16
  Bullets of various weights and sizes                            17
  Double bullets                                                  18
  Stones, and splinters of iron or wood                           19

  Degree of velocity                                              20
  Increased by modern fire–arms                                   21
  Comparison of round and conical balls                           21
  The Enfield and Whitworth rifles                                22

  Number of wounds in battle                                      22
  Proportion to shots discharged                                  22

  Spent balls                                                     23

  Lodgment of balls                                               24
  Consequences of unextracted balls                               25
  Lodgment of an 8–pound ball                                     26
  Illustrative cases                                              27
  Fragments of shells                                             28
  Fragments of bullets                                            29
  Small foreign bodies                                            30

  Internal wounds without external marks                          32
  Hypotheses concerning                                           32
  Explanation concerning                                          33

  Seat of injury                                                  34

  Course of balls                                                 34

  SYMPTOMS OF GUNSHOT WOUNDS.

  Diagnostic symptoms                                             38
  Appearances from various kinds of projectile                    38
  Apertures of entrance and exit                                  41

  Pain of gunshot wounds                                          44

  Shock of gunshot wounds                                         45
  Primary hemorrhage                                              47

  Prognosis of gunshot wounds                                     50

  Treatment of gunshot wounds in general                          51
  Provisional dressing recommended                                51
  Surgeon’s first duty                                            52
  Position of patient for examination                             53
  Instruments for conducting examination                          54
  Views respecting enlargement of the external orifice            54
  Instruments for extracting balls                                56
  Means to be employed for readjusting lacerated wounds           59
  Constitutional treatment                                        61

  Progress of cure                                                62


  GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY.


  GUNSHOT WOUNDS OF THE HEAD.

  Observations on                                                 63

  Wounds of the scalp and pericranium                             65

  Wounds complicated with fracture, but without depression on
  the cerebrum                                                    67
  Fissured fracture                                               68

  Wounds complicated with fracture and depression on the
  cerebrum                                                        69

  Wounds with penetration of the cerebrum                         70

  Treatment                                                       71
  Use of the trephine                                             71
  Opinions concerning                                             72


  GUNSHOT WOUNDS OF THE SPINE.

  Statistics of                                                   75

  Vertebral column and spinal cord                                76


  GUNSHOT WOUNDS OF THE FACE.

  General observations on                                         77

  Treatment                                                       78

  GUNSHOT WOUNDS OF THE CHEST.

  Comparison with other wounds                                    80

  Non–penetrating                                                 81

  Penetrating                                                     82
  Signs indicating                                                83
  Hemorrhage from                                                 83
  Indications of the lung being penetrated                        84
  Treatment                                                       85

  Wounds of the heart                                             89


  GUNSHOT WOUNDS OF THE NECK.

  Abstract of                                                     90


  GUNSHOT WOUNDS OF THE ABDOMEN.

  Observations on                                                 93

  Non–penetrating                                                 94

  Penetrating                                                     94

  Of the diaphragm                                                99
  Fatality of                                                     99

  Treatment                                                      100


  GUNSHOT WOUNDS OF THE PERINEUM AND GENITOURINARY ORGANS.

  Statistics of in the Crimea                                    101


  GUNSHOT WOUNDS OF THE EXTREMITIES.

  Frequency of                                                   103

  Division of                                                    103

  Pyemia from                                                    104

  Upper extremity                                                105
  Percentage of recoveries from, without amputation              106

  Lower extremity                                                109
  When to amputate and when to be avoided                        109
  The femur                                                      110
  Statistics of cases of                                         110
  Proportions of recoveries in amputations in                    114
  Fractures in the middle and lower third of the femur           116
  Statistics in fractures of the leg, in the Crimean war         117


  AMPUTATION.

  Advantages of primary as compared with secondary               117

  SECONDARY HEMORRHAGE.

  Reasons for its occurrence                                     120
  Not uncommon in deeply–penetrating wounds of the face          121
  Rule of treatment                                              122


  WOUNDS OF NERVES.

  Temporary or complete paralysis caused by                      122
  Amputations sometimes necessary                                122


  TETANUS.

  Statistics of                                                  124
  Treatment                                                      125


  HOSPITAL GANGRENE                                              126

  PYEMIA                                                         126


  ANESTHESIA IN GUNSHOT WOUNDS.

  Chloroform                                                     126
  Views respecting its use in secondary operations               129
  Mode of administering                                          130


  AFTER–USEFULNESS OF WOUNDED SOLDIERS.

  Observations upon                                              131
  General summary                                                131




GUNSHOT WOUNDS.


Gunshot wounds consist of injuries from missiles projected by the force
of explosion. As the name implies, this class of wounds is ordinarily
restricted to injuries resulting from fire–arms; but it should be
remembered that wounds possessing the same leading characteristics
may result from objects impelled by any sudden expansive force of
sufficient violence. Injuries from stones, in the process of blasting
rocks, or from fragments of close vessels burst asunder by the elastic
power of steam, offer familiar examples of wounds of a like nature with
those from gunshot. In the following article, however, gunshot wounds
will be considered as they are met with in the operations of warfare.




HISTORY.


From the earliest time of the application of gunpowder to implements
of war, down to the present day, the wounds inflicted by its means
have excited the most marked interest among surgeons; nor can this
be wondered at, when the immensely superior energy of this agent
in comparison with all the mechanical powers previously in use for
hostile purposes, and the terrible nature of its effects on the human
frame, are remembered. By its introduction the whole aspect of war
was changed, in a great degree, by the distance at which opposing
forces were enabled to contend with each other; just as, in our
day, the nature of battle seems destined to undergo another change
from the increased range and precision of fire obtained through the
general use of rifled weapons. But though the alterations now being
made in the qualities of fire–arms are of the utmost importance to
those whose business and especial study is the art of war, to the army
surgeon the interest they excite is chiefly limited to the degree of
injury and destruction inflicted by them as compared with weapons of a
less perfect kind; while to the surgeons employed at the time of the
introduction of gunpowder, the wounds were wholly new in their nature
as well as degree. Recollecting the ignorance which then prevailed in
all departments of science and art, it can excite no surprise that
the new engines of war, with the flame and noise accompanying their
discharge, were regarded with superstitious terror; nor that surgeons
for a long time found an explanation of the sloughing severity of the
injuries they inflicted, and of their difficult cure, in the poisonous
nature of gunpowder, or of the projectiles which had been acted upon
by it, or in the burning effects of these latter from heat acquired
in their rapid flight through the air. Unfortunately, these erroneous
views did not end with the theories from which they started, but led to
treatment which only aggravated the evils inflicted by the new weapons,
and interrupted the progress of the healing action, which nature would
otherwise have established. The wound being regarded as a poisoned
wound, it was only by a long and tedious process of suppuration that
the poison could be hoped to be got rid of from the surface, and
prevented from entering the system of the patient. The irritative
fever, the wasting and emaciation, and all the other results of the
protracted cure of the injury were so many evidences of the indirect
effect of the poison working in the frame; just as the constitutional
shock at the time of the wound, the loss of vitality along the surface
in the track of a small projectile, or of the tissues laid bare by the
passage of the cannon–ball were regarded as evidences of its direct
influence. On looking back at the works of successive writers on
this class of injuries, the reader is surprised that the improvement
in their treatment has been so gradual and slow; and cannot fail to
observe that the chief impediment to a more rapid amelioration of
the system pursued has been the prevailing idea of the necessity of
delaying the tendency of nature to close the wound, in order that the
supposed poison might be eliminated from the constitution. The openings
of entrance and exit and track of the ball were incised; the wound
dilated by tents or other means, and terebinthinates, or even boiling
oil, poured into it; irritating compounds and ointments applied where
superficial dressings were practicable; and it was only after the wound
was considered to be fully purged of its venom and foul humors by the
extensive suppurative action thus kept up, that cicatrization was
permitted to be established.

It required long years of observation in many conflicts, and the
exercise of much industry, not to mention moral courage in opposing
authorized custom and prejudice, before a simpler and more rational
mode of practice was followed. It is satisfactory to know that though
Continental surgeons have written more voluminously on the subject of
gunshot wounds, the older English military surgeons and writers stand
forth conspicuously in leading the way to a more practical knowledge of
their nature and proper treatment.

Although, however, much that was erroneous was removed by the earlier
surgeons, the light of science can hardly be said to have penetrated
this important province of military surgery until the great and last
work of John Hunter, on the Blood, Inflammation, and Gunshot Wounds,
was published in 1794. This distinguished philosopher filled some of
the highest positions in the British service, having been appointed in
1776 Surgeon Extraordinary to the Army, in 1786 Deputy Surgeon–General,
and subsequently Surgeon–General; but he only served abroad about three
years, and then only had the opportunity of seeing active service as
staff–surgeon in the expedition to Belleisle. Had the field of his
practical observation been more extensive, there can be no doubt that
his zealous and scientific mind would have turned the advantage to
the most valuable results for humanity. The physiological principles
which he enunciated, based on extensive study and observation in civil
life, cannot be controverted; but their practical application, so far
as regards the treatment of gunshot wounds, has been greatly modified
since his treatise on the subject was published. There cannot be a
better illustration of the special position in which this department
of military surgery is placed, from the peculiar circumstances under
which it is practiced, than the fact that, though men of the highest
mental attainments have discussed the subject of gunshot wounds, we are
nevertheless indebted to practical experience in military campaigns for
every improvement, some few of recent date excepted, that has occurred
in their treatment. Thus John Hunter was led to advocate very strongly
the delay of amputation, after severe gunshot wounds, for weeks, that
the patient’s constitution might accommodate itself to the injury;
while more extended observation has demonstrated that such secondary
amputations are more fatal than those which are performed shortly
after the infliction of the wounds leading to them—the advantage of
the patient thus coinciding with what must very constantly happen to
be a practice of necessity in the field. Mr. Guthrie remarks, in his
Commentaries on the Surgery of the Peninsular War, between 1808 and
1815, that the surgical principles and the practice which prevailed at
the commencement of the war were superseded on almost all important
points at its conclusion; and he quotes a remark of Sir Astley Cooper
to the effect that the art of surgery received from the practical
experience of that war an impulse and improvement unknown to it before.

The still more recent military operations in Algeria, in
Sleswick–Holstein, in the Crimea, and in India have afforded the
opportunity of testing practically the applicability to army practice
of some of the great improvements which have been accomplished in the
civil practice of surgery in Europe since the termination of the war
in 1815. Among these may be particularly enumerated the avoidance of
amputation of limbs by recourse to excision of joints; resections of
injured portions of the shafts of long bones; mitigated amputations,
by removal only of those terminal portions of the extremities which
had been destroyed by the original injury; and the practice generally
of what has been styled conservative surgery. In these wars, too, the
value of chloroform as an anesthetic agent in military surgery has been
fully established. They have also especially illustrated the influence
of various states of health and climates on the results of gunshot
wounds. All the anticipations which were held out at the commencement
of some of these campaigns have not been realized, but still they have
added much valuable information and many improvements to military
surgery.

The alterations made during the last five or six years in the
arms of a great proportion of the troops of the leading powers of
Europe, and which will, no doubt, be extended to all soldiers in
regular armies—namely, the transformation of muskets into “_armes de
précision_,” with rifled barrels and graduated aims—have led to changes
in the severity and almost in the nature of gunshot wounds from small
balls; and the consideration of these changes requires the especial
attention of army surgeons. The effects of the new rifle–balls were
widely witnessed during a portion of the period of the Crimean war.
The campaign just concluded in Italy will probably produce additional
practical observations from the Continental surgeons engaged in it. The
fearful proportion of killed and wounded—greater than in any former
experience—will have shown the effects not only of rifled muskets, but
of rifled cannon also; and in the French forces engaged an opportunity
will have been afforded of instituting a comparison of the results
of their treatment under circumstances of bodily health and hospital
accommodation very different from those of the French army in the
Crimea. It may be hoped that the experience thus gained will advance
the knowledge of gunshot wounds and their treatment a still further
stride toward accuracy.

In England, one valuable result which emanated from the late war with
Russia was the regular collection and arrangement, under government
authority for the first time, of the observations and practice of the
medical officers employed in the campaign. The value to science of such
systematized historical records, if fairly and fully developed, can
scarcely be overrated; and it is to be hoped that henceforth a similar
course will be always adopted whenever the country may become involved
in war.




VARIETIES OF GUNSHOT WOUNDS.


Gunshot wounds are modified in their nature by the form and kind of
missile, by the degree of force with which it is propelled, and by the
seat of injury. They are, in addition, affected by the circumstances in
which the soldier happens to be placed, and by the state of his health
when the injury is received.

=Form and nature of missile.=—The projectiles used in warfare of the
present day are cannon and musket shot, shells of various kinds,
hand grenades of iron or thick glass, case–shot, slugs, and other
minor varieties of such missiles. These are the ordinary instruments
of _direct_ gunshot wounds in warfare; but, in addition, there are
numerous sources of _indirect_ wounds, resulting from the discharge
of cannon and musketry. These are stones, or other hard substances,
struck from parapets or from the surface of the ground by cannon–shot;
splinters of wood from platforms and framework, or of iron from
gun–carriages; fragments of bone from wounded comrades, or articles in
their possession; and any other miscellaneous objects which may happen
to come into contact with the solid ball or shell in its course.

The objects above enumerated present several varieties of forms. The
chief are—1st, spherical, as cannon–balls, grape, musket–shot, and
shells; 2d, cylindro–conoidal, as balls belonging to rifled cannon and
rifled muskets; 3d, irregular, but generally bounded by linear and
jagged edges, as fragments of shells and splinters.

A gunshot wound, whether received from a direct or indirect projectile,
may be complicated by the entrance of extraneous bodies of various
kinds, most commonly portions of the cloth or buttons of the dress
worn by the person wounded. Such foreign substances, though not of
themselves causing the wound, often have a special bearing on the
progress of its cure.

Not only the form of outline, but the weight, and in some instances
the matter of which the missile is composed, influence the nature of
gunshot wounds. In the largest kinds of balls, such as are projected
from field–pieces or guns of position, the form offers little subject
for consideration to the surgeon. So long as there is momentum enough
to carry forward the mass of iron of which these missiles are composed,
so long will their weight be the most important ingredient in the
production of the wounds inflicted by them. Whether the shot come as
a solid cone or bolt from one of the new guns or as a round ball from
an ordinary cannon, the injury will be equally destructive to life or
limb. The same remark is applicable to the heavier forms of shell,
before explosion. The only difference surgeons may look for from the
use of cylindro–conoidal balls, or Whitworth bolts applied to cannon,
should they become general, independent of increase in the number of
direct wounds from greater power and precision of fire, will be the
less number of indirect injuries likely to result from their action,
as they neither ricochet nor roll as “spent balls” in the manner that
spherical shot are accustomed to do.

Grape–shot, canister, and spherical case, on striking collectively—that
is, before they have spread—as sometimes happens in assaulting or in
accidental close proximity to guns in the field, produce the same kinds
of injuries as cannon–shot, but individually resemble musket–shot in
their effects. Wounds from grape–shot are always of a grave character,
not only from the extent of the flesh wound, but also because, from
their large diameter and weight, the nerves and vessels of the part
struck are less likely to escape injury, if not destruction, than in
wounds from the smaller shot projected in canister or spherical case.

With regard to musket–shot, the form presents several features for
the consideration of the military surgeon. In discussing the subject,
however, it must not be omitted to be borne in mind that we have no
experience of the effects of round musket–balls propelled with the
same amount of force as recent improvements in fire–arms have given
to balls furnished with a conical vertex; although, in the old,
two–grooved rifle, with its belted round ball, a momentum was procured
far exceeding that of the common smooth–bore musket. The change in
form from the round to the prolonged cylindro–conoidal ball seems to
derive its chief importance in surgery from the conical end possessing
the mechanical characteristic of a wedge, while the former acted
simply as an obtuse body. From this quality the power of penetration
of conical bullets is greater, independent of the increased momentum
communicated to them by the construction of the weapons from which they
are discharged. Thus, supposing one of the old musket–bullets to strike
a limb at 80 yards, and an Enfield rifle conical bullet of the same
weight at 800 yards, the rate of velocity being similar in each case,
the injury from the latter may be expected to be considerably greater
than that from the former, on account of its shape. The wedge–like
quality of the conical bullet is rendered particularly obvious on its
being driven into the shafts of the long bones of the extremities.
The solid, osseous texture of which the cylindrical portion of these
bones is composed is split up into fragments, having mainly a direction
parallel with the central cavity; and fissures not unfrequently extend
from the seat of injury to their terminations in the joints, of which
they form component parts. Such results were scarcely ever noticed
from the impulse of round balls. The bone might be comminuted, but
the fragments were of a more cuboid shape, and the long fissuring did
not occur. It has been stated that the screw motion impressed on the
ball by the rifling of the musket contributes to its increased power
of injury on bone; but its shape, combined with its momentum, seem
sufficient to explain the severity of its effects above those of the
round bullet. Another result of the tapering form of the conical bullet
is that it is less exposed, in its course through soft parts of the
body, to opposition from tendons and other long and elastic structures,
so frequently noticed to stay the progress of spherical shot. If not
dividing them by direct impingement, it readily turns them aside;
and it is partly due to this pointed shape, therefore, as well as to
increased force, that, as will be noticed hereafter, the lodgment of
balls is now so rare in comparison with the experience of former wars.

Much has been written on the comparative surgical effects of
bullets of various weights and sizes; but these qualities do not,
on consideration, excite so much practical interest in the mind
of the surgeon as it might at first appear they are calculated
to do. Some very heavy bullets were used by the Russians in the
defense of Sebastopol, nearly one–third heavier than any employed
by the troops opposed to them. Such bullets, if of like form and
density, and propelled with equal velocity, would obviously inflict
injuries—especially against osseous structures, which offer great
resistance—wider in proportion to their greater size and momentum; but,
in respect to simple flesh wounds, the increased size of the wound
left by the larger ball would make little difference in the gravity
of the wound, or the time required for its cure, while the escape of
foreign substances, which it might happen to carry with it, would be
facilitated by the freer means of exit and increased discharge from
the surface. Mr. Guthrie mentions that, having had a wide field for
observation in the effects of the heavy British musket–ball, sixteen
to the pound, on the French wounded, he did not think them more
mischievous in their results than the French musket–balls, twenty to
the pound, on the English soldiers; while the advantages of carrying a
lighter musket and greater number of rounds of ammunition were on the
side of our adversaries. It is understood that in warfare the object
is not so much to destroy life as to disable antagonists, and the
smaller size has been supposed to be fully equal to this object by the
British military authorities of the present day; for in the weapon most
recently given to the troops, the Enfield rifle, the weight of the ball
has been reduced two drachms and a half below that of the ball with the
Minié, previously in use. After all, within the moderate limits which
must be preserved to suit the circumstances of infantry soldiers, the
form and velocity of musket–balls must be the qualities of interest to
the surgeon in connection with the wounds inflicted by them, rather
than their weight or size, as with projectiles from guns of large
caliber.

Double bullets, linked together by a spiral coil of wire, something
after the manner of chain cannot–shot, were introduced by the Russians
during the war in the Crimea. Specimens of these bullets were found
about the works around Sebastopol, but no injuries received from them
have been recorded; although, after the discovery, peculiarities in the
characters of some wounds, which had not previously been satisfactorily
accounted for, were supposed to have probably resulted from them. It
seems likely, however, that, when discharged, the divergent forces
impressed on the two bullets were sufficiently great to break apart
the connecting wire, which was of very slender diameter, before they
came into contact with the troops against whom they were directed.
Dr. Scrive, in his History of the Eastern Campaign, mentions also that
incendiary balls were employed by the Russians. They consisted of a
small cylinder of copper containing a detonating composition, and made
up into the form of an ordinary cartridge, so as to be discharged from
a musket. On hitting its object, the projectile burst with violence.
These balls were not known till after the conclusion of the siege;
and it was only then, M. Scrive remarks, that a key was obtained to
some wounds of a frightful character which could not be accounted for
by the action of ordinary bullets or fragments of shell. No similar
observation is recorded in the British surgical history of the war.

Wounds caused indirectly by stones from parapets, splinters of iron
or wood, and by fragments of shells are very varied in character and
severity. They derive their importance chiefly from the extent of
surface usually lacerated and destroyed. Unless they happen to have
penetrated or torn away largely the coverings of vital parts of the
body, they are often less grave, though to the sight more fearful,
than injuries of less alarming appearance from direct projectiles. In
missiles of this secondary kind, the amount of resistance offered to
their displacement proportionably diminishes the impetus with which
they strike. In like manner, the powerful opposition of the hollow
iron shell to the force of the bursting charge within, as well as the
shape of the portions into which it is usually rent asunder, combine to
cause the momentum of each fragment at starting to be much less, and
this momentum to be more rapidly retarded during its flight through
the air, than happens in ordinary missiles of direct explosion.
The constitutional shock, in these injuries, is consequently, as a
general rule, less than in direct gunshot wounds. Occasionally simple
fractures happen from indirect missiles; from direct, they are almost
necessarily compound. Although there may be no communication with an
external wound, however, there is often great comminution of the bone
in these accidents. The laceration and bruising of the soft parts
are frequently rendered more dangerous from indirect projectiles
in consequence of large vessels or nerves being implicated in the
injuries, leading more often to primary hemorrhage and subsequent
sloughing of wider tracts than in wounds from direct projectiles of
corresponding size. Such sloughing may lead to a fracture of bone
becoming compound which was at first simple. Fragments of shells
sometimes wound by falling, after having been projected upward in the
air. These do not generally produce such serious injuries as fragments
striking at once from the exploded shell; not that the force is
different, but because the parts chiefly exposed—the shoulders, back,
etc.—are more protected from injury, and offer less resistance, from
relative form and position, than do the abdomen, loins, and other parts
of the body, which usually meet the fragments shot upward when the
shell explodes on the ground.

=Degree of velocity.=—The velocity of motion of different projectiles
is an important ingredient in the consideration of the several
wounds produced by them. The rates of motion imparted to missiles
by the fire–arms of early times were probably, from the imperfect
construction of the weapons, defective quality of gunpowder, and other
circumstances, as inferior to those of the musket lately in use as the
velocity of musket–balls was to that of the conical bullets of the
rifles in present use. In a table showing the velocities of certain
moving bodies, published in 1851, the common musket–bullet is set down
as moving at the rate of 850 miles per hour, the rifle–ball of that
time at 1000, the 24–lb. cannon–ball at 1600 miles per hour. But the
musket–ball then could not be depended on to hit an object beyond 80
yards, the rifle 200 to 250 yards; while the present Enfield rifle is
sighted to 900 yards, and the short Enfield to 1100 yards. The effects
of different rates of velocity on wounds are seen in the variations
which occur in proportion to the distance which the missile has
traveled before inflicting the injury. A cannon–ball which, with but
slight velocity of motion added to its weight, would knock a man over,
at ordinary speed will carry away a limb without disturbing the general
equilibrium of the body. A musket–ball that would be arrested half way
through a limb is now replaced by a ball which, at like distance from
the point of discharge, will pass through several bodies in succession.

The increased velocity, or, in other words, greater force, of modern
projectiles exhibits its effects in two directions—locally, by the
greater destruction of the tissues in the track of the projectile; and
constitutionally, by greater disturbance in the nerve–force of the
whole system. The component parts of that portion of the organized
fabric through which a bullet, traveling at the rate of several miles
per minute, cleaves its way are inevitably deprived of their vitality.
Instances are quoted by authors, of gunshot wounds having healed by
simple adhesion; but such examples are not met with from rifle–bullets
retaining their original form. Moreover, when considering the course
taken by balls in the body, it will have to be shown that the velocity
imparted to projectiles from modern weapons has led to another change
in gunshot wounds. The great power of resistance so often before
exhibited by the yielding elastic tissue of the skin, by tendinous and
other structures, is no longer of avail against projectiles from modern
fire–arms at their usual rates of speed.

The splitting and destructive effects of conical balls on the shafts
of the long bones of the extremities have already been mentioned when
referring to the peculiarities of their shape. But, together with form,
the amount of momentum is a necessary ingredient in estimating this
result. The old round balls—partly from their form, but also from the
imperfect mechanism of the firelocks from which they were discharged,
and consequent minor degree of velocity imparted to them—on striking
bones, would simply be turned away from the direct line, or, failing
this, would knock out a portion of the shaft without further fracture,
or, having perforated on one side, remain in the cancellated structure,
or be simply flattened without penetrating. It seems not unlikely,
also, that the modern conical bullets are denser, from the circumstance
of their manufacture by mechanical pressure, than bullets, such as are
still used in some places, cast in moulds. The influence of density
with respect to power of penetration is very great. In the two most
perfect of modern English rifles, the Enfield and the Whitworth, the
projectiles and charges being of the same weight, when lead is used,
the penetration at 800 yards is one–third greater with the Whitworth
than the Enfield; but if a less yielding projectile is used, (as when
the lead is mixed with tin,) its penetration is as 17 to 4 at 800
yards. Whether this cause operates or not, the fact is certain that
conical balls in action exhibit almost invariably an overpowering force
over all the structures, bone included, with which they come into
contact in the human body, and are rarely met with flattened, or so
much altered in form as bullets not unfrequently were formerly under
like circumstances.

=Number of wounds in battle.=—The increased velocity of modern
projectiles, together with the more rectilinear path in which they
move, causes a greater number of wounds in modern warfare. The
difference which has existed in the proportion of wounded to shots
discharged in recent engagements, compared with the experience of
former wars, is most marked. It is well known that from expansion
of the bore of the musket in use a few years since, and consequent
increase in the difference between its diameter and that of the
bullet, after a few rounds of fire musket–balls rolled out in numerous
instances in the act of elevation of the musket previous to discharge.
Now every shot is propelled to a great distance, and with force
sufficient, if brought into collision early in its flight, to penetrate
and wound several persons. Colonel Wilford, Chief Instructor at the
Government School of Musketry, stated publicly in a recent lecture
the fact that 80,000 rounds of ball–cartridge were fired from the old
musket in one day in Caffraria, and only 25 Caffres were known to
be hit; while at Cawnpore, one company of soldiers, armed with the
Enfield rifle, brought down 69 out of a body of horsemen by whom they
were attacked, at one discharge. At the battle of Salamanca, only one
ball in 3000 fired by the British took effect. Another result is, that
we may now expect to meet more frequently the occurrence of several
bullet wounds in the same individual. It is mentioned that, among the
wounded from Solferino, it was not uncommon to see several wounds
of different origins in one body; and M. Appia mentions a case, in
one of the hospitals at Brescia, where a soldier had been struck at
the same time by four balls. These circumstances become important in
estimating the amount of surgical attendance that is required in modern
engagements. At the battle of Solferino, just referred to, some returns
show that, in twenty–four hours, 11,500 French, 5300 Sardinians, and
21,000 Austrians were laid _hors de combat_. The surgeons had no
time to attend to the first necessities of a great proportion of the
wounded. A multitude of those unfortunates were hastily conveyed to the
little village of Castiglione, and had to wait hours, many even days,
before their wounds could be dressed. To relieve thirst, and apply wet
compresses of linen to ease the pain of the wounds, by calling into
service the people of the neighborhood, was as much as could be done to
a great number for the first day or two, on account of the vast number
of wounds inflicted by the new weapons. At Brescia, within a short time
after this battle, 15,000 wounded were congregated in thirty–eight
fixed and temporary hospitals. From the actions in Flanders on the
16th, 17th, and 18th of June, 1815, including the battles of Quatre
Bras and Waterloo, the returns show the number of wounded, not
including those killed in action, in the Duke of Wellington’s army, to
have been rather more than 8000. In the whole Crimean campaign, the
total number of British wounded amounted to 11,361, exclusive of men
killed in action.

=Spent balls.=—In connection with degree of velocity, the subject of
what are called “spent balls” naturally occurs. After a cannon–ball has
ceased to pursue its course through the air or to proceed by ricochet,
it not unfrequently travels to a considerable distance, rolling along
the surface of the ground. When its rate of movement is not much faster
than that at which a man can walk, and when to all appearance it might
be stopped by the pressure of the foot as readily as a cricket–ball, it
yet possesses the power of inflicting serious injury on such an attempt
being put into execution. This power is easily understood if the amount
of force is remembered which must still be inherent in the cannon–ball
for it to overcome the inertia of its own mass, and the resistance to
which it is exposed in passing over the ground on which it is rolling.
It is this force, multiplied by the weight of the ball, which gives it
the destructive power. If this ball is brought into collision with the
foot of a person, such destruction ensues as generally to necessitate
amputation. Should it impinge on other parts of the body, as in the
instance of a man lying on the ground, it may cause mortal injury to
internal organs, and that without exhibiting external evidence of the
amount of injury it has inflicted. So, also, though powerless to carry
away a limb, it may cause comminuted fractures of bones and extensive
contusions of the softer structures.

=Lodgment of balls.=—Low rate of velocity leads to musket and other
balls lodging in various parts of the body. When the smooth–bore musket
was in common use, lodgment of balls was of frequent occurrence. In
the first place, from absence of sufficient initial velocity to effect
its passage out of the body, and, secondly, from its liability to be
diverted from a direct line, a round ball might be arrested in its
progress at any distance from its point of entrance. Conical balls
lodge when their velocity has become nearly expended before entering
the body; or, from peculiarity in the posture of the person wounded, a
ball, having had force enough to traverse a limb, may afterward enter
into another part of the body and lodge. A ball may reach a part so
deep in the muscles of the back, for example, or be so far removed
from the aperture of entrance, as to elude all attempts on the part of
the surgeon, at the time of examination of the wound, to discover its
retreat. Or it may have reached some position from which the surgeon
fears to take the necessary steps for its extrication, judging the
additional injury that would thus be inflicted more mischievous than
the probable effects of allowing the ball to remain lodged.

Unextracted balls lead to consequences varying according to the site
of lodgment and state of constitution of the patient. If the ball have
become fixed in the body of a muscle, or in its cellular connections,
adhesive inflammation may be established around it, and in time a dense
sac be thus formed, in which the ball may remain without causing any,
or but very slight, inconvenience. M. Baudens asserts that a cellular
envelope is of very early formation around balls lodged in muscular
tissues. Although thus encysted, a ball may press upon nerves, and
give rise to pain and much uneasiness, or may be so situated as to
embarrass the person in certain movements of the body. Foreign bodies
not unfrequently change the position of their first lodgment, under the
effect of gravitation or the impulse of muscular actions. The following
instance, which occurred to Staff–Surgeon Dr. Daniell, illustrates the
distance to which a lodged ball may travel before finding its exit:
In the disastrous affair of Malageah, on the west coast of Africa,
fought in May, 1855, between detachments of the West India regiments
and the Moriah chiefs, a man was wounded just below the spine of the
scapula by a shot fired down from an elevation. The aperture was small,
no ball could be traced, and the wound healed up rapidly. Six months
afterward the man attended hospital, complaining of inability to march
and pain about one of his ankles. A red, painful swelling and abscess
formed over the inner malleolus, disease of bone was suspected, when
examination led to the discovery of a small iron ball, of irregular
shape, which was removed. No pain or irritation had existed between
the shoulder and the foot. When lodged in the lower extremities, balls
sometimes form for themselves canal–shaped cysts, along which they
can be moved freely on pressure. When, however, the health or other
circumstances of the patient are not favorable, the lodgment of a ball
with a smooth surface, like missiles of a more angular and irregular
shape, may excite inflammation and constitutional disturbance of a
very troublesome kind, and keep up a profuse suppurating discharge
along the track of the wound, or perhaps lead to abscesses burrowing
in other directions. Balls have been known to lodge in bones, without
their positions having been suspected or inconvenience excited by their
presence. On the other hand, balls similarly impacted have given rise
to disease, and in some bones, as those of the pelvis, have produced
such constitutional irritation as to lead to a fatal termination. Balls
lodging in the circumscribed cavities of the body or their contained
viscera require notice elsewhere.

Grape–shot, and even balls of larger size from field guns, occasionally
lodge. The large, gaping wounds inflicted by such missiles usually
render the detection of their lodgment and position very easy; but
still remarkable instances have occurred where the presence of bodies
of this nature of very large size has been overlooked. Mr. Guthrie’s
experience of the war in the Peninsula led him to record that “it
was by no means uncommon for such missiles as a grape–shot to lodge
wholly unknown to the patient, and to be discovered by the surgeon at
a subsequent period, when much time had been lost and misery endured.”
The same distinguished surgeon mentions a case where a ball weighing
eight pounds was not discovered till the operation of amputating
the thigh in which it had lodged was being performed. Baron Larrey
describes a similar case: An artilleryman had his femur fractured by a
ball, which, according to the man’s description, had afterward struck
another artilleryman by his side. On being brought to hospital, no
one doubted that the ball, after fracturing the limb, had glanced
off; but on amputating, the ball, weighing five pounds, was found in
the hollow of the thigh toward the groin. The wound of entrance was
on the outside of the thigh; and the ball had not only fractured, but
had turned round, the bone. M. Armand, surgeon attached to the French
Imperial Guard, has related the case of a soldier who was brought to
the ambulance, after the taking of the Mamelon Vert, in the Crimea,
with his left thigh wounded; one opening, such as might be made by a
large musket–ball, was found on the outside of the thigh. There was
no second opening. On examination, a swelling was detected in the
popliteal space, without any external mark of injury nor much pain
on pressure. It was concluded to be the ball; and, on incising, an
enormous grape–shot was found. It had turned round the femur without
breaking it. M. Armand writes that the appearance of the wound alone
would have led to the supposition that the ball had not lodged, and no
one would have suspected that such a thing as a grape–shot had been the
cause of it. In the British Surgical History of the Crimean War the
case of a soldier of the 1st Royals, who was wounded in the face by a
grape–shot weighing 1 lb. 2 oz. is recorded. The ball lodged at the
back of the pharynx, and escaped observation for three weeks. Were it
not for experience of many such instances, it would be deemed almost
impossible that foreign substances of such size and weight could remain
in the body without the knowledge of the patient, if not discovered by
the surgeon. Even with so large a missile as a grape–shot, a surgeon
should not be contented with examining merely by the wound, wide as it
usually is, in case lodgment is suspected; it may travel in a direction
which may cause its discovery to be very difficult by that track. An
officer of the 19th Regiment was struck during the assault on the
Redan, on September the 8th, by two grape–shot, at the back of the
chest. They entered close to the spine. One of these balls lodged in
the inner part of the right arm, below the axilla, whence the writer
excised it.

Penetrating fragments of shells, if projected edgeways, almost
invariably lodge. In these cases, the appearance of the wound seldom
indicates to the observer the true size of the body which has caused
the injury. At an early period of the battle of the Alma, a piece of
shell, about four pounds in weight, lodged in the buttock of a soldier
of the 19th Regiment; and, to extract it, an incision had to be made
nearly equal in extent to the length of the original wound. In this
instance the concave aspect of the fragment—evidently, by the nature of
the curve and thickness, a portion of a very large shell—had adapted
itself to the parts lying beneath, while its convex surface so agreed
with the natural roundness of the parts above, that it would have been
impossible to have arrived at a knowledge of its lodgment, from any
change in the external appearance of the parts. Examination by the
wound alone gave decided information on the question. Such fragments
become very firmly impacted among the fibers of the tissues in which
they lodge, and the effused blood fills up inequalities, and rounds
off edges that might otherwise show themselves prominently; so that,
without due care, their presence is not unlikely to be overlooked at
first examination. Dr. Macleod, of Glasgow, mentions that he saw a case
at Scutari, in which a piece of shell weighing nearly three pounds was
extracted from the hip of a man wounded at the Alma, which had been
overlooked for a couple of months, and to which but a small opening
led.[1] But bodies of still more irregular form may lodge in this
region, and escape notice. A soldier in a battery in the Crimea was
wounded, during a heavy artillery fire, in the left hip. A twelvemonth
afterward he was in the General Hospital at Chichester, with a narrow
sinus, which allowed a probe to pass deeply among the gluteal
muscles. On cutting down in the direction indicated, a piece of stone
was extracted, upwards of four ounces in weight. This man had passed
through several hospitals before his arrival at Chichester.

Bullets scattered from canister or spherical case not unfrequently
lodge; apparently in consequence of the direct velocity received from
the primary discharge being disturbed, and lessened by the force of the
secondary explosion of the case in which they were contained.

A small layer of metal, like a portion of one of the coats of an
onion, occasionally becomes detached from a leaden bullet, and lodges.
The writer was once applied to by a discharged soldier, suffering
from some troublesome granulations at the bottom of the left orbit.
The globe of the eye had been destroyed nearly two years before by
a musket–ball shot from above, which, after traversing the orbit,
had descended, and was excised from the right side of the neck. On
examining the granulations by a probe, the point came into contact
with a hard substance, which further examination showed to be a small
projecting point of lead. It proved to be a scale from the bullet
which had caused the original wound, being equal in length to half
its circumference, and in width, at the broadest part, about a third
of the same dimension. It retained the curved form of the bullet from
which it had been detached. The following case shows that similar
sections may be separated from cylindro–conical as well as from round
bullets. An officer of the 41st Regiment was struck in the Crimea by
a conical bullet, which destroyed the forearm in such a manner as to
necessitate amputation below the elbow. Secondary hemorrhage occurred
on the eleventh day, and on the following day the stump was opened and
examined. “While searching for the bleeding vessel, a slice of the
bullet, about the size of a worn sixpence, was found deeply imbedded
in the muscle.” In the case of a soldier of the 19th Regiment, who was
wounded before Sebastopol in the loin by a conical bullet, which was
discharged per anum, and who died in Guy’s Hospital of albuminuria,
nearly four years afterward, a small scale of lead from the bullet was
found at the post–mortem examination fixed in the spleen. Strange to
say, in this instance the lodgment did not appear to have excited any
inflammatory action or mischief.

Lodgment of small foreign bodies, angular pieces of metal, as slugs,
nails, and others, and of soft textures, as shreds of linen or
woolen cloth, often give rise to much inconvenience. The track of a
musket–ball may be prevented from healing, and a troublesome sinus
formed, by such small fibers of cloth as would hardly attract notice if
within means of observation. Although a wound be closed, and apparently
healed, if any shreds of cloth remain, it will probably open from time
to time, when small fibers may be noticed in the discharge; and this
will continue until the whole is thus got rid of. The probability of
cloth entering a wound with the conical ball is not so great as it was
with the spherical ball, which not unfrequently tore out a little cap,
as it were, of cloth in its passage. This is another result of its
shape and velocity. John Hunter and others make mention of circular
pieces of the skin being cut out by bullets, and then lodging, and
acting as foreign bodies in the wounds.

When the Minié–ball, with the iron cup at its base, was first brought
into use, surgeons anticipated that the addition of the iron cup would
complicate the ill effects of the wounds inflicted by it. It does not
appear that this has proved to be the case. The iron is usually so
far driven into the lead by the force of the exploded gunpowder, and
so firmly fixed by the alteration in shape and pressure of the lower
part of the ball, that it but rarely becomes detached so as to form a
separate lodgment.

Gravel and small stones struck up by shells at the time of their
explosion, or by shot ricochetting against the ground, often lodge, and
give much trouble in their extraction, especially about the face. In
the assault of Sebastopol, at the Great Redan, the attacking parties
in their approach, the ground being rocky and having been much broken
up by shell explosions, were particularly exposed to such injuries; and
in several instances men were placed _hors de combat_ by dust and small
fragments of stone thus projected, though the injuries were not of a
permanently serious character. One case is recorded where both eyes
were penetrated and totally destroyed by gravel thrown up by a shell
explosion.

Foreign substances derived from persons standing near a wounded man,
sometimes fragments of the bodies of other wounded men, have been
already named as occasionally lodging. In a severe injury to the face,
which occurred in a man of the 1st brigade of the Light Division,
in the Crimea, the surgeon was at first puzzled by the strange
displacement of a part of the upper jaw. After closer examination, and
obtaining a clearer view by the removal of clot, it was found that a
piece of the jaw of another man, whose head had been smashed by a round
shot by his side in the battery, had been driven into the palate, and
was there impacted. Among other cases recorded in the Surgical History
of the Crimean War, is one of a double tooth of a comrade having been
found imbedded in the globe of the eye; and another, where a portion of
a comrade’s skull was removed from between the eyelids of a soldier. In
such injuries as these, where one of two men standing side by side is
wounded by a portion of the body of his neighbor, the fragment striking
is usually detached from a corresponding region with that struck. The
late Mr. Guthrie extracted from the thigh of a Hanoverian soldier, on
the third day after his admission into hospital, two five–franc pieces
and a copper coin. The man had had no money about him previously to
the injury, nor pocket to contain any. The coins had been carried from
the pocket of a neighbor, who stood before him in the ranks, and who
had been hit by the same grape–shot. These coins, flattened out and
jammed together by the force of the shot, are in the museum at Fort
Pitt. Similar examples might be multiplied; but sufficient have been
mentioned to show the necessity of careful examination in warfare, not
only for direct missiles which may effect lodgment in the body, but for
many other foreign substances which may be forced in by their agency.

=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.

Should there be reason for concluding that a ball or other foreign body
has lodged, but after manual examination, and observation as well by
varied posture of the part of the body supposed to be implicated as by
indications derived from the patient’s sensations, effects of pressure
or injury to nerves, and all other circumstances which may lead to
information, should the site of the lodgment not be ascertained, the
search should not be persevered in to the distress of the patient.
Neither, although the site of lodgment be ascertained, if extensive
incisions are required, or if there is danger of wounding important
organs, should the attempts at extraction be continued. Either during
the process of suppuration, by some accidental muscular contraction, or
by gradual approach toward the surface, its escape may be eventually
effected; or, if of a favorable form, and if not in contact with nerve,
bone, or other important organ, it may become encysted, and remain
without causing pain or mischief. When John Hunter wrote on gunshot
wounds, he remarks, the practice of searching after a ball, broken
bones, or any other extraneous bodies, had been in a great measure
given up, from experience of the little harm caused by them when at
rest, and not in a vital part; and he himself advises, even when a
ball can be felt beneath skin that is sound, that it should be let
alone, chiefly on the ground that two wounds are more objectionable
than one, and that the extent of inflamed surface is proportionably
increased by incision. More extensive experience has, however, shown
that not only is the risk of subsequent ill results greater in those
cases where foreign bodies remain lodged than when they have been cut
out, but also that the advantages of a second opening for the escape
of the necessary sloughs and discharges greatly preponderate over the
disadvantages connected with it, as regards the additional extent of
injured surface. The advantage also of the satisfaction to the mind of
a patient from whom a ball has been removed must not be overlooked; for
men suffering from gunshot wounds are invariably rendered uneasy by a
vague apprehension of danger, for some time after the injury, if the
missile has remained undiscovered.

When a gunshot wound has been accompanied with much laceration and
disturbance of the parts involved in the injury, it is necessary, after
the removal of all foreign substances that can be detected, to readjust
and secure the disjointed structures as nearly as possible in their
normal relations to each other. The simplest means—strips of adhesive
plaster, light pledgets of moist lint, a linen roller, favorable
position of the limb or part of the body wounded—should be adopted for
this purpose. Pressure, weight, and warmth should be avoided as much
as possible in these applications, consistent with the end in view. It
must not be forgotten, in thus bringing the parts together, that the
purpose is not to obtain union by adhesion, which cannot be looked for,
but simply to prevent avoidable irritation and malposition of parts,
during the subsequent stages of cure by granulation and cicatrization.
In all gunshot wounds, much discomfort to the patient is prevented by
carefully sponging away all blood and clot from the surface adjoining
the wound, and by adopting measures to prevent its spreading again
in consequence of oozing. This can be readily done with the aid of a
little warm water, and arrangement when the wound is first dressed, but
can only be accomplished with considerable inconvenience after the thin
clots have become hard and firmly adherent to the skin.

When the parts of a lacerated gunshot wound have been brought into
apposition, as in simple penetrating wounds, the only dressing
necessary is moistened lint. It should be kept moist either by the
renewed application of water dropped upon it, or by preventing
evaporation by covering it with oiled silk. The sensations of the
patient may be consulted in the selection of either of these, and
climate and temperature will be often found to determine the choice. In
hot climates cold applications are the more grateful, and by checking
the amount of inflammatory action and circumscribing its extent are
usually the more advantageous. M. Velpeau and other French surgeons
have strongly recommended the use of linseed–meal poultices, above
all wet linen applications. Charpie is still extensively employed
in French military hospitals.[5] M. Baudens and Dr. Stromeyer have
strongly recommended the topical application of ice placed in bladders;
others, the continued irrigation of the wound with tepid water. The
means of applying such remedies are rarely available in the military
hospitals where gunshot wounds are ordinarily treated in their early
stages. When much local inflammation has set in, and when there is
much constitutional fever even without unusual local irritation, the
non–evaporating or warm applications will be found to be the most
advantageous.

When suppurative action has been fully established, the surgeon
must be guided by the general rules applicable to all other such
cases. Care must be taken to prevent the accumulation of pus, lest
it burrow, and sinuses become established—not an unfrequent result
of want of sufficient caution in this regard. If much tumefaction of
muscular tissues beneath fasciæ occurs, or abscesses form in them,
free incisions should be at once made for their relief. In wounds
where the communication between the apertures of entrance and exit is
tolerably direct, occasional syringing with tepid water may be useful,
by removing discharges and any fibers of cloth which may be lying in
the course of the wound. Weak astringent solutions are occasionally
employed in a similar way, with a view to improving the tone of the
exhalents and exciting a more vigorous action in the process of
granulation. The strictest attention to cleanliness and the complete
removal of all foul dressings are essentially necessary, not merely for
the comfort of the patient, but to prevent the accumulation of noxious
effluvia, and also to obviate the access of flies to the wounds. In
tropical climates, and in field–hospitals in mild weather, where many
wounded are congregated, flies propagate with wonderful rapidity,
and the utmost care is necessary to prevent the deposit of ova and
generation of larvæ in the openings of gunshot wounds, especially while
sloughs are in process of separation. Cloths dipped in weak solutions
of creasote or disinfecting fluids, laid over the wound, are found
necessary for this purpose when the insects abound in great numbers.

The constitutional treatment in an ordinary gunshot wound,
uncomplicated with injury to bone or structures of first importance,
should be very simple. The avoidance of all irregularity in habits
tending to excite febrile symptoms or to aggravate local inflammation,
attention to the due performance of the excretory functions, and
support of the general strength, are chiefly to be considered.
Bleeding, with a view to prevent the access of inflammation in such
cases, is now never practiced, as formerly, by English surgeons.
The diet should be nutritious, but not stimulating. A pure fresh
atmosphere is a very important ingredient in the means of recovery.
If from previous habits of the patient, or from circumstances to
which he is unavoidably exposed, the local inflammation has become
aggravated,—indicated by pain, increased swelling, and redness about
the wound,—topical depletion by leeches or cupping, bleeding from
the arm, saline and antimonial medicines, and strict rest in the
recumbent position, must be had recourse to, the extent being regulated
by the circumstances of each case. In instances such as these, when
the inflammation has become diffused, the purulent secretion is not
confined to the track of the wound, but is liable to extend among the
areolar connections of the muscles; and if the cure be protracted,
attention will be necessary to prevent the formation of sinuses. If
stiffness or contractions result, attempts must be made to counteract
them by passive motion and friction, with appropriate liniments; if
a tendency to edema and debility remain in a limb after the wound is
healed, the cold–water douche will be found to be one of the most
efficient topical remedies. In French practice, the administration of
a chalybeate tincture,[6] as a tonic, or diluted as an injection, in
wounds threatening to assume an unhealthy character, is very highly
praised. It is stated that under the conjoined employment of this
remedy internally and externally, in wounds of a pallid, unhealthy
aspect, accompanied by nervous irritability and symptoms of approaching
pyemia, the granulations have resumed a red and healthy appearance, and
the general state of health become rapidly favorable.

=Progress of cure.=—Simple flesh wounds from gunshot usually heal in
five or six weeks. In the course of the first day the part wounded
becomes stiff, slightly swelled, tender, a slight inflammatory blush
surrounds the apertures through which the missile has passed, and a
slight serous exudation escapes from them. Suppuration commences on the
third or fourth day, and in about ten days or a fortnight the sloughs
are thrown off. Granulation now progresses, more or less quickly
according to the health and vigor of the patient’s constitution.
The opening of exit is usually the first closed. When the wound is
complicated with unfavorable circumstances, whether inducing in the
patient a condition of asthenia or leading to excess of inflammatory
action, the progress of the cure may be extended over as many months
as, under favorable circumstances, weeks are occupied in the process.




GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY.


The circumstances connected with wounds in particular situations of the
body, or in particular organs, are in many respects common to injuries
from other causes than gunshot; and in the following remarks the
attention is chiefly drawn only to those leading peculiarities which
constantly demand the consideration of the army surgeon, and which
spring either from the nature of gun projectiles, or the circumstances
under which this branch of military practice has for the most part to
be pursued.




GUNSHOT WOUNDS OF THE HEAD.


No injuries met with in war require more earnest observation and
caution in their treatment than wounds of the head. The vital
importance of the brain; the varied symptoms which accompany
the injuries to which this organ may be subjected, directly or
indirectly; the difficulty in tracing out their exact causes; the
many complications which may arise in consequence of them; the sudden
changes in condition which not unfrequently occur without any previous
warning,—all these circumstances will keep a prudent surgeon who has
charge of such wounds continually on the alert. Injuries of this class,
the most slight in appearance at their onset, not unfrequently prove
most grave as they proceed, from encephalitis and its consequences, or
from plugging of the sinuses by coagula, leading to coma, paralysis,
or pyemia; and the converse sometimes holds good with injuries
presenting at first the most threatening aspects, where care is taken
to avert these serious results. Much will depend on the part of the
head struck, both as regards the thicker and stronger processes or
portions of the skull, and the situation of the sinuses and parts of
the cerebrum within; on the force and shape of the projectile; the
angle at which it strikes; the age and condition of the patient; and
other matters already referred to in the general remarks on gunshot
wounds. Mr. Guthrie has laid down as a rule that injuries of the head,
of apparently equal extent, are more dangerous on the forehead than on
the side or middle portion, and still more so than those on the back
part; and that a fracture of the vertex is infinitely less important
than one at the base of the cranium. When the injuries are caused by
rifle–balls, however, these considerations are rarely of much avail,
for the power of injury is such that it can scarcely ever be confined
to the immediate neighborhood of the part directly struck.

Wounds of the head may be divided, for convenience of description,
into wounds of the scalp and pericranium, without fracture of bone;
similar wounds complicated with fracture of the outer or of both
tables, without pressure on the encephalon; wounds with fracture and
depression; and lastly, wounds in which the encephalon itself has been
penetrated. Severe contusion of the bones of the cranium, followed by
necrosis, and even fracture, with or without depression, may occur
without an open wound of the superficial investments. The case of
an officer is mentioned in Dr. Macleod’s Notes of the Crimean War,
who was thus killed by a round shot. The scalp was not cut, almost
uninjured, but the skull was most extensively comminuted.

=Wounds of the scalp and pericranium.=—These wounds are usually
inflicted by projectiles which are brought into contact at a very acute
angle, so that little direct injury to the brain or its membranes is
inflicted, and the surgeon’s attention need only be directed to the
same considerations as must occur in any contused wounds of the scalp
from other causes than gunshot. But even in these accidents, though
appearing to be simple flesh wounds, serious cerebral concussion and
other lesions are occasionally met with. The usual stupor and other
signs of concussion may be very evanescent, or may last for several
days, disappearing gradually and wholly, or entailing subsequent
evils at more or less remote periods. It must not be forgotten that
when the pericranium is removed by a musket–ball, however superficial
the injury may seem, there is always a certain degree of injury and
bruising to the bone from which it is torn, and necessary laceration
of the vessels which inosculate with the nutritive capillaries of
the diploë, and through them of the vessels of the meninges with
which they are connected. The injury to this vascular system almost
invariably leads to necrosis of the portion of the skull from which the
coverings are carried away; and sometimes, even when the pericranium
is not torn off, sufficient injury is inflicted to lead to a like
result. The death of bone is generally limited to a thin layer of
the outer table, which in due time exfoliates. The injury to the
vessels ramifying between the inner surface of the cranium and dura
mater may lead to serious results. There may be rupture of a sinus,
leading to compression, or fatal results may ensue from inflammation
and suppuration. The case of a young soldier in whom the longitudinal
sinus was thus ruptured occurred to the writer. In this instance a
rifle–ball had divided the scalp and pericranium about four inches
in length obliquely across the skull, just anterior to the angle of
the lambdoidal suture, the posterior end of the sagittal suture being
exposed midway in the line of the wound. The patient vomited at the
instant of the blow, and symptoms of compression, mixed with some of
concussion, soon followed. He died eleven hours after the injury. At a
post–mortem examination, the superior longitudinal sinus was found to
be ruptured, and about four ounces of coagulated blood were lying on
the brain. Two darkly–congested spots were observed in the cerebrum,
one on each hemisphere, corresponding with the line of direction in
which the ball had passed, and these, when cut into, presented the
usual characters of ecchymoses. There was no fracture of bone. The case
may be found detailed at some length in the _Lancet_, vol. i., 1855.
When inflammation follows the passage of a ball, whether terminating in
resolution or leading to abscess, the symptoms and treatment required
will be the same as in similar affections from other causes. In like
manner, the occurrence of erysipelas, or other complications to which
these wounds of the scalp are liable, will be found treated elsewhere.
(See INJURIES OF THE HEAD.)

The treatment of an ordinary gunshot wound of the scalp should be
very simple. Cleansing the surface of the wound, removing the hair
from its neighborhood for the easier application of dressings, lint
moistened with clean water, very spare diet, and careful regulation of
the excretions are the only requirements in most cases. The patient
must be closely watched, so that measures may be taken to counteract
inflammatory symptoms in their earliest stages. Even after one of
these wounds has healed, and the patient to all appearance has quite
recovered, it is necessary to enjoin continued abstinence from excesses
of all kinds. Instances are frequently quoted where intoxication, a
long time after the date of injury, has induced symptoms of apoplexy
and death. In the Surgical History of the Crimean Campaign, the case of
a soldier of the 31st Regiment, thirty–eight years old, who received a
contused wound at the back of the head from a piece of shell, without
section of the scalp and without lesion of the bone, is related.
In this instance a small abscess formed under the scalp, and was
evacuated. After the wound was healed the man suffered from constant
headaches, and was invalided to England. Soon after landing he drank
freely, coma followed, and he died shortly afterward. The post–mortem
examination showed traces of inflammatory action in the dura mater, and
“just anterior and superior to the corpora quadrigemina was a tumor the
size of a walnut, composed of organized fibrin and some clotted blood.”

=Wounds complicated with fracture, but without depression on the
cerebrum.=—These are very uncertain in their effects, and often apt to
mislead the surgeon, from the absence of urgent symptoms in their early
stages. The occurrence of fracture is, however, sufficient to show the
force with which the projectile has struck the head, and to indicate
the mischief which the brain and its immediate coverings have not
improbably sustained.

In these injuries there may be a simple furrowing of the outer table,
without injury to the inner; or there may be fissure extending to a
greater or less degree of length, or radiating in several lines; or
both tables may be comminuted in the direction the ball has traversed
in such small portions that they lie loosely on the dura mater without
much alteration in the general outline of the cranial curve. The chief
and only means, in many cases, of concluding that no depression upon
the cerebrum has taken place is the absence of the usual symptoms
of compression; for it is well known that simple observation of the
injury to the outer table, whether by sight or touch, will by no means
necessarily lead to a knowledge of the amount of injury or change of
position in the inner table.

When simple removal of a portion of the outer surface of the skull
has been caused by the passage of the ball or other missile, the
wound will sometimes heal, under judicious treatment, without any
untoward symptom. A layer of the exposed surface of bone will probably
exfoliate, and the wound granulate and become closed without further
trouble. But such injuries, for reasons before named, are very likely
to be followed by inflammation, and not improbably abscess, between the
internal table and dura mater; and further, as a consequence of the
vascular supply being stopped, and perhaps also partly from the effects
of the original contusion by necrosis of the inner table itself. Care
must be taken not to mistake one of these injuries for a depressed
fracture, as is not unlikely to happen when the excavation effected by
the projectile is rather deep and the edges of the bone bordering the
excavation are sharp.

Fissured fractures, when the fissure extends through the skull, usually
result from injuries by shell. The passage of a ball may fracture and
very slightly depress a portion of the outer table of the cranium, and
then the line of fracture will very closely simulate fissured fracture
extending through both tables, and the diagnosis between them be
excessively doubtful. When fissured fracture exists, the distance to
which it may be prolonged is often quite unindicated by symptoms, and
its extent is very uncertain. Fissures often extend to long distances.
They may occur at a part remote from the spot directly injured. In the
case of a lieutenant of the 11th Hussars, who was apparently slightly
wounded at Balaklava in the middle of the forehead by a piece of
shell, a fissured fracture was found, after death, across the base of
the skull, quite unconnected with the primary wound, and seemingly
from _contre–coup_. Death resulted from inflammation and suppuration
set up near this indirectly–injured part. Fissured fracture of the
inner table may also occur from the action of a ball without external
evidence of the fracture. Such a case occurred in the 55th Regiment, in
the Crimea. The soldier had a wound of the scalp along the upper edge
of the right parietal bone. The ball in passing had denuded the bone;
but there was no depression. The man walked to camp from the trenches
without assistance, and there were no cerebral symptoms on his arrival
at hospital; but five days afterward there was general edema of the
scalp and right side of face, the wound became unhealthy, and slight
paralysis appeared on the left side. The next day hemiphlegia was more
marked, convulsion and coma followed, and he died on the thirteenth day
after the injury. Pressure from a large clot of coagulum and extensive
inflammatory action were the immediate causes of death; but a fissure,
confined to the inner table, running in line with the course of the
ball, was also discovered. A preparation of the calvarium in this case
was presented by Dr. Cowan, 55th Regiment, to the museum at Fort Pitt.

The cases where comminution has resulted from the track of a ball
across the skull generally present less unfavorable results than those
where a single fissured fracture, extending through both tables,
exists. The small, loose fragments can be removed; and if the dura
mater be intact, the case, with proper care to prevent inflammatory
action, may not improbably be attended with a favorable recovery.

=Wounds complicated with fracture and depression on the cerebrum.=—Such
wounds are most serious, and the prognosis must be very unfavorable.
They must not be judged of by comparison with cases of fracture with
depression caused by such injuries as are usually met with in civil
practice. The severe concussion of the whole osseous sphere by the
stroke of the projectile, the bruising and injury to the bony texture
immediately surrounding the spot against which it has directly
impinged, as well as the contusion of the external soft parts, so
that the wound cannot close by the adhesive process, constitute very
important differences between gunshot injuries on the one side, and
others caused by instruments impelled solely by muscular force on the
other. So, also, the injury to the brain within, and its investments,
is proportionably greater in such injuries from gunshot. The experience
of the Crimean campaign shows that, when these injuries occurred in
a severe form, they invariably proved fatal. Of seventy–six cases
treated, where depression only, without penetration or perforation,
existed, fifty–five proved fatal, twelve were invalided, and nine
only were discharged to duty. In the twenty–one survivors, the amount
of depression is stated in the history of the campaign to have been
slight, though unmistakable, and all except one recovered without any
bad symptom. Of eighty–six other cases where perforation or penetration
of the cranium occurred, all died.

=With penetration of the cerebrum.=—It is obvious that, where a
projectile has power not only to fracture, but also to penetrate the
cranium, it will rarely be arrested in its progress near the wound of
entrance. Either splinters of bone, or the ball, or a portion of it
will be carried through the membranes into the cerebral mass. Sometimes
a ball, if not making its exit by a second opening in the cranium, will
lodge at the point of the cerebral substance opposite to that of its
place of entrance; but the course a projectile may follow within the
cranium is very uncertain.

Instances have occurred where balls have lodged in the cerebrum without
giving rise to serious symptoms of danger for a long time. Such cases
might lead to throwing surgeons off their guard in making a prognosis,
from supposition that the ball by some accident had not lodged. The
case of a soldier wounded by a ball in the posterior part of the side
of the head is mentioned by Mr. Guthrie. The wound healed, and the man
returned to duty; a year afterward he got drunk, and died suddenly.
The ball was found in a sac lying in the corpus callosum. Another
soldier wounded at Waterloo had a similar recovery, and also died
after intoxication. The ball was found deeply lodged in a cyst in the
posterior part of the brain. An artillery soldier was wounded, in the
Crimea, by a rifle–ball, which entered near the inner angle of the left
superciliary ridge. The wound progressed without a bad symptom until a
month afterward, when coma came on, and death shortly followed. The
ball was found in a sac, in which pus also was contained, at the base
of the left anterior lobe of the brain.

=Treatment.=—The treatment of the various kinds of fractures from
gunshot, and their complications, may be considered together. Formerly,
a gunshot wound of the head was supposed to be in itself a sufficient
indication for the use of the trephine; indeed, even where no fracture
was caused, an opening was recommended by comparatively recent surgeons
to be made in the cranium, to meet symptoms which might be expected
to result. Modern surgeons, however, generally have made use of the
trephine only when there was reason for concluding that depressed bone
was leading to _permanent_ interruption of cerebral function, or that
an abscess had formed within reach, and was capable of evacuation.
Preventive trephining has been proved to be useless, as well as
dangerous, and is no longer an admissible operation. The tendency
of the most recent experience has been to limit the practice of
trephining to the narrowest sphere; and when the very great difficulty
of making accurate diagnosis in these cases is considered,—whether
as to the distinguishing signs of compression; the precise seat of
its cause, if the compression exist; the space over which this cause,
when ascertained, may extend; its persistent or temporary character;
its complications; and certain dangers connected with the operation
itself,—no wonder need be excited that this tendency should exist.
Besides, the numerous cases which have now been noted where bone
has evidently been depressed, but the brain has accommodated itself
to the pressure without serious disability being caused, or where
compression from effusion has been removed by absorption under proper
constitutional treatment, are further causes of hesitation in respect
to trephining. In the Surgical Report of the Crimean Campaign, it
is stated that the trephine was only successfully applied in four
cases (and none of these were from rifle–balls) during the whole war;
and that in these instances the patients were subsequently subject
to occasional headache and vertigo; and in the French report, by Dr
Scrive, it is stated that trephining was for the most part fatal in
its results in the French army. In siege operations, the experience as
regards wounds of the head is always very extensive, the lower parts
of the body being so much more protected in the trenches. According to
Dr. Scrive’s returns, one of every three men killed in the trenches
before Sebastopol, and one in every 3·4 wounded, was injured in this
region. In the English returns, wounds of the head and face in the men
are shown as 19·3 per cent.; in the officers, as 15 per cent.; but this
is of the total wounded in the field as well as in the trenches. There
was, therefore, as extensive a range for observation of the effects of
trephining in the siege of Sebastopol as is likely to happen in any
war. Dr. Stromeyer, who in the early part of his professional career
resorted to trephining in complicated fractures of the skull, records,
in his Principles of Military Surgery, that he has abandoned the
practice. After the battle of Kolding, in Sleswick, in 1849, there were
eight gunshot fractures of the skull, with depression, and more or less
cerebral symptoms. In all these, with one exception, the detachment
of the fractures was left to nature, and all recovered. One patient,
from whom some fragments were removed on the seventh day, was placed in
considerable danger by the treatment, and Dr. Stromeyer resolved never
to adopt it again. In 1850, in Sleswick, two young surgeons came under
Dr. Stromeyer’s care with gunshot wounds of the head, accompanied by
deep depression; they were both treated without trephining, and both
recovered. Throughout the three campaigns of the Sleswick–Holstein war,
there was only one case of trephining which gave a favorable result.
Military experience makes it difficult to understand the frequent
and successful performance of trepanning by the older surgeons for
such slight causes as they performed it, excepting that the patients
labored under little else than the effects of the operation itself,
while very fatal mischief has existed in addition in those instances in
which the operation has been resorted to for accidents from gunshot. A
circumstance quoted by Sir G. Ballinghall particularly illustrates the
favorable results of abstaining from trephining in some cases. After
the battle of Talavera, a hospital which had been established in the
town had to be suddenly abandoned, and an order was given for all the
wounded who could march to leave it. There was no time for selection,
and among those who marched were twelve or fourteen men with wounds
of the head, in which the cranium was implicated, four or five having
both tables fractured, and two having the globe of one eye destroyed
along with fracture of the os frontis. All these men recovered, though
they were sixteen days on the march, harassed and exposed to a burning
sun, and had no other application than water–dressing. Of eight cases
of contusion or fracture of the cranium, with displacement of both
tables, recorded by Dr. Williamson, among men who were sent from India
to Chatham, during the late mutiny, none had been trephined. In all
these there was a depressed cicatrix, the wound having contracted and
become closed by a strong fibrous investment. In one case—a wound by
a musket–ball, in the center of the forehead—the ball was supposed to
be still lodged within the skull. In the Fort Pitt museum are several
preparations, showing depressed fracture of the inner table of the
skull from gunshot, taken from patients who had recovered without
trephining, and died years afterward from other causes. The edges of
the depressed portions of bone had become smooth, and united by new
osseous matter, and the cerebrum must have accommodated itself to the
new form of the inner cranial surface. Two or three instances are
known in which the course of a ball has been traced from the sight
of entrance across the brain, and trephining resorted to for its
extraction, with success; but there are also many others in which the
mere operation of the extraction of a foreign body has apparently led
to the immediate occurrence of fatal results. Moreover, splinters of
bone are not unfrequently carried into the brain by balls, and these
may elude observation; or the ball itself may be divided and enter the
brain in different directions, as was observed in the Crimea; when
the operation of trephining can only be an additional complication to
the original injury, without any probable advantage. Where irregular
edges, points, or pieces of bone are forced down and penetrate—not
merely press upon—the cerebral substance, or where abscess manifestly
exists in any known site, or a foreign substance has lodged near the
surface, and relief cannot be afforded by the wound, trephining may be
resorted to for the purpose; but the application of the operation, even
in these cases, will be very much limited if certainty of diagnosis
be insisted upon. In all other cases, it seems now generally admitted
that much harm will be avoided, and benefit more probably effected,
by employing long–continued constitutional treatment, viz., all the
means necessary for controlling and preventing the diffusion of
inflammation over the surface of the brain and its membranes,—the most
careful regimen, very spare diet, strict rest, calomel and antimonials,
occasional purgatives, cold application locally, so applied as to
exclude the air from the wound, and free depletion by venesection, in
case of inflammatory symptoms arising. Similar remarks will apply in
case of lodgment of a projectile within the brain; if the site of its
lodgment is obvious, it should be removed with as little disturbance
as possible, but trephining for its extraction on simple inference is
unwarrantable.




GUNSHOT WOUNDS OF THE SPINE.


Gunshot wounds of the spine are closely associated with similar
injuries of the head. In both classes corresponding considerations
must be entertained by the surgeon in reference to the important
nerve–structures, with their membranes, which are likely to be
involved in the injury to their osseous envelope; in both, the effects
of concussion, compression, laceration of substance, or subsequent
inflammatory action, chiefly attract attention. In the Surgical History
of the Crimean Campaign, twenty–seven cases are noted in which vertebræ
were fractured, eight being without apparent lesion of the spinal
cord, and nineteen with evident lesion. Of these, twenty–five died;
and two, in which the fractures were confined to the processes of the
vertebræ, survived to be invalided. The gunshot wounds affecting the
spinal column have not been separated from injuries in other regions
in the French returns. Six men only wounded in the spine, during the
late mutiny in India, arrived in Chatham. In all, they were the results
of musket–balls. Two were wounds of the sacrum; in the remainder,
the portions of the vertebræ fractured were the spinous processes.
Concussion of the spinal column, leading to paralysis more or less
persistent, is usually occasioned by fragments of shell, or stones
from parapets; and in these cases the accidents are mostly accompanied
by extensive lesions of the neighboring structures. In one fatal
case in the Crimea, the ball passed through the spine rather below
the first dorsal vertebra, leading to complete loss of sensation and
voluntary motion below the seat of injury, and death on the sixteenth
day afterward; in another, a rifle–bullet entered the right side of
the second lumbar vertebra, traversed the spinal canal at that part,
and lodged in the body of the bone. In this latter case, violent pain
was complained of in the lower extremities, shooting along the groins.
The patient was paraplegic, and death ensued thirty–three hours
after admission. In another fatal case, a rifle–bullet passed through
the right cheek, and lodged near the base of the skull. There was no
paralysis, but delirium and coma supervened, and the patient died five
days after receiving the wound. The bullet was found after death,
lying just below the basilar process, and a large piece of the atlas
was broken off and almost detached. The spinal cord did not appear to
have been primarily injured, but acute inflammation had been set up,
and had extended to the membranes of the brain. There is a preparation
in the museum at Fort Pitt which shows fracture both of the atlas and
axis, without lodgment of the ball. The patient survived thirty days.
It is curious that, in a case under the care of the writer, before
referred to, where a rifle–ball passed through the right loin, entered
the spinal canal between the third and fourth lumbar vertebræ, breaking
the laminæ, passed upward within the column, between it and the cord,
and made its exit through the left intervertebral foramen between the
second and third vertebræ, as shown after death, no paralysis occurred
at the time of the injury, nor subsequently, nor was any evidence
afforded post mortem of thecal inflammation having been excited. (See
Guy’s Reports, vol. v., 1859.)

In injuries of the vertebral column and spinal cord occurring in
military practice, the mischief is usually so complicated and
extensive, and the medulla itself so bruised, that the cases must be
very rare indeed in which the operation of trephining, if justifiable
in any case, can offer the slightest prospect of benefit. M. Baudens
extracted, with an elevator supplied with a canula, a ball which had
lodged in the eleventh dorsal vertebra and was causing compression with
complete paraplegia. The paralysis disappeared immediately after the
extraction of the bullet; but tetanus came on four days afterward, and
proved speedily fatal. Balls have been known to pass through the bodies
of vertebræ, and apparent cure follow; but as such patients in military
practice are usually invalided out of the service as soon as they are
fit to leave hospital, no opportunity is afforded of observing the
consequences which ulteriorly ensue.




GUNSHOT WOUNDS OF THE FACE.


Wounds of the face from musket–shot, grape, and small fragments of
shell are usually more distressing from the deformity they occasion
than dangerous to life. The absence of vital organs, the natural
divisions among the bones, and their comparatively soft structure,
rendering them less liable to extensive splitting; the copious vascular
reticulation and supply rendering necrosis so much less likely and
repair so much easier than in other bones; the limited amount of space
occupied by the osseous structure between their respective periosteal
investments, and the opportunities from the number of cavities and
passages connected with this region for the escape of discharges, lead
to this result. On the other hand, the vascularity of this region
leads to danger both of primary and especially secondary hemorrhage—a
circumstance which, in all deep wounds of this region, must be looked
for as a not improbable complication. The other complications of these
gunshot wounds are lesions of the organs of special sense, injury to
the base of the skull, paralysis from injury to nerves, wounds of
glands, their ducts, and of the lachrymal apparatus; but it is scarcely
necessary to do more than allude to them, as the considerations
connected with their treatment will be found elsewhere.

Wounds from cannon–shot occasionally illustrate what terrible injuries
may be borne in this region without life being at once extinguished.
They are the more distressing because the patient lives conscious of
his sufferings without possibility of surgical alleviation. The case of
an officer of Zouaves, wounded in the Crimea, is recorded, who had his
whole face and lower jaw carried away by a ball, the eyes and tongue
included, so that there remained only the cranium, supported by the
spine and neck. This unfortunate being lived twenty hours after the
injury, breathing by the laryngeal opening at the pharynx, while his
gestures left no doubt that he was conscious of his condition. Mr.
Guthrie has recorded a similar case which occurred in an officer during
the assault of Badajos. This patient suffered distressingly from want
of water to moisten his throat, but could not swallow when some was
brought. One eye was left hanging in the orbit, the floor of which was
destroyed, and this enabled him to write thanks for attention paid him.
He did not die till the second night after the injury.

In the treatment of gunshot wounds of the face where the bones are
splintered and torn, the surgeon should always retain and replace
as many of the broken portions as possible. It is often surprising
how small connections with neighboring soft parts will suffice to
maintain vitality and lead to restored union in this region. A case
which occurred to the writer in August, 1855, in a private of the
19th Regiment, is detailed in the _Lancet_, p. 436, of that year. The
wound was caused by a fragment of shell. The right half of the arch of
the palate was jammed in and fixed at right angles to the other half,
and the upper maxillary bone was so comminuted that it was scarcely
possible to note the directions of the lines of fracture. The lower
maxilla was broken in three places, and there was extensive laceration
of the soft parts. Great difficulty was met with at first in unlocking
the parts of the palate which had been driven into each other, and,
when they were separated, the right half hung down loosely in the
mouth; yet favorable union was obtained between all these fractures,
the broken portions being adjusted so that the man recovered with both
the upper and lower maxillæ consolidated in their normal relations to
each other. No teeth had been driven out of their sockets, and they
were very useful as points of support in the steps taken to procure
coaptation of the disunited fragments. In the _Lancet_ of February
24th, 1855, may be found the description of a series of wounds of
the face, from the Crimea, which were examined by Mr. Samuel Solly,
and described by him, some of them illustrating how wonderfully the
larger arteries often escape in these injuries. In one, loss of the
sense of taste on one side of the tongue had resulted; in two, there
was partial paralysis of the portio dura; in another, impaired action
of the jaw. In one, where a ball entered at the junction of the malar
bone and os frontis on the left side, and descended and escaped at
the posterior border of the sterno–mastoid muscle, the sight of the
left eye was destroyed, and that of the right weakened; and constant
headache, dullness of intellect, and incapacity for mental application
remained. The injury had originally been followed by symptoms of
cerebral concussion. In another case, the man came home with an
iron shot firmly wedged and lodged in the center of the vomer. When
extracted, at Chatham, by Staff–Surgeon Parry, it was found to weigh
nearly four ounces. The returns of the Crimean campaign, from the 1st
of April, 1855, to the end of the war, show 533 wounds of the face,
of which number 445 returned to duty, 74 were invalided, and 14 died.
Bones were penetrated in 107 of these cases, one eye was injured in
42, and both eyes in 2 cases. Mr. Guthrie has recorded that he several
times saw both eyes destroyed by one ball, without much other mischief,
and one, and even both, rendered amaurotic by balls which had passed
behind the eyes. Of 21 cases of wounds of the face, with injuries to
bones, returned to England from the late Indian mutiny, and recorded by
Dr. Williamson, 11 had lost the sight of one eye, and 1 of both eyes;
6 cases were complicated with fracture of the lower jaw, and in 3 of
these the fracture remained ununited.




GUNSHOT WOUNDS OF THE CHEST.


These always form a large proportion of the injuries from warfare,
both in the open field and more especially in sieges, where the upper
part of the body is chiefly exposed. Dr. Scrive’s returns show that
the proportion of chest to other wounds was 1 in 12 in the trenches,
and 1 in 20 in ordinary engagements. In the British forces they are
returned as 1 in 10 among the officers during the whole war, and nearly
1 in 17 among the men, from 1st April, 1855, to the end of the war.
The ample space of this region, and the exposed surface it offers as a
target toward the enemy, would lead to an anticipation of such results.
The serious complications which ensue when the cavity of the chest is
penetrated, and the dangerous consequences of wounds of its viscera,
cause the proportionate mortality to be very great. The British returns
show that among the officers treated for these wounds 31–1/2 per cent.
and among the men 28–1/10 per cent. died. Out of 603 wounded men who
returned to England from the late Indian mutiny, the number who had
received wounds of the chest was only 19. In many instances men thus
wounded do not live long enough to come under treatment, but die on the
field of action from penetration of the heart, hemorrhage, suffocation,
or shock; and the proportion of chest wounds returned as “killed in
action,” or as “died under treatment,” will constantly vary according
to circumstances connected with the nature of the military operations,
and the opportunities of early removal from the field to hospital.

Gunshot wounds of the chest may conveniently be divided for study into
two classes, viz., _non–penetrating_ and _penetrating_. NON–PENETRATING
wounds become subdivided into simple contused wounds of the soft
parietes; contused and lacerated wounds; the same accompanied with
injury to bones or cartilage; and, lastly, those complicated with
lesion of some of the contents of the chest, the pleura remaining
unopened, or, if opened, without a superficial wound. PENETRATING
wounds may exist without wound, or with wounds of one or more of the
viscera of this cavity. Among the more serious complications with which
the latter may be accompanied is the lodgment of the projectile or
other foreign bodies, as of fragments of bone, within the chest. As
wounds of the heart and great vessels are almost invariably at once
fatal, and as the organs of respiration occupy the greater part of
the cavity of this region, it is in reference to the latter that the
treatment of chest wounds is chiefly concerned.

=Non–penetrating wounds.=—Of the simpler wounds in which the soft
parietes only are involved little need be observed, excepting that the
healing process is often prolonged by the natural movements of the
ribs to which the wounded structures are attached, especially when
the ball has taken a circuitous course beneath the skin, and that
the surgeon must be on his guard to watch for pleuritis arising as
an occasional consequence of these injuries. In two deaths recorded
in the Director–General’s History of the Crimean War, under simple
flesh wounds, without fracture or pleural opening, from bullets, the
fatal termination arose from pleuro–pneumonia. When the force has been
great, as when fragments of shell or rifle–balls strike at full speed
against a man’s breast–plate, not only may troublesome superficial
abscesses and sinuses follow, but the lungs may have been compressed
and ecchymosed at the time of the injury, and hemoptysis be one of the
symptoms presented.

When the projectile has been of large size, although no opening of the
parietes or fracture exists, death sometimes ensues by suffocation as
the direct result of pulmonary engorgement. The danger of pleuritis
or pneumonia will be greater when the injury has been so severe as to
cause division of bone or cartilage, and the subsequent suppuration and
process of exfoliation will not unfrequently prove very tedious and
troublesome. Although the pleura has not been opened, the lung may be
lacerated either by the force of contusion or, as in a case recorded by
Dr. Macleod, by the edges of the fractured ribs, which may afterward
return to their normal relative positions, so as to leave no indication
during life of the means by which the lung had been wounded. Such an
injury would be rendered much more probable by the existence of old
adhesions, connecting the pulmonary and costal pleuræ opposite to the
site of injury.

Notwithstanding a projectile has not penetrated the parietes of the
chest, a pleural cavity may be opened, as in injuries from other
causes, and the lung wounded by the sharp edges of fractured ribs. This
will be indicated by emphysema, pneumothorax, hemoptysis, probably
signs of internal hemorrhage, and inflammation. Such wounds will
generally be the result of injuries from fragments of shell.

=Penetrating wounds.=—These wounds, especially when the lung is
perforated or the projectile lodges, are necessarily exceedingly
dangerous. Fatal consequences are to be feared, either from hemorrhage,
leading to exhaustion or suffocation; from inflammation of the
pulmonary structure or pleuræ; from irritative fever accompanying
profuse discharges; or from fluid accumulations in one or both of the
pleural sacs.

In gunshot injuries a penetrating wound of the chest is in most
instances readily obvious to the sense of sight or touch; but it will
be found by no means easy always to decide whether a lung has been
penetrated or otherwise. The train of symptoms usually described as
characterizing wounds of the lung must not be expected to be all
constantly present; they are each liable to be modified by a great
variety of circumstances, and may each severally exist in penetrating
wounds of the chest where the lung has escaped perforation. Nor is
it always easy to determine whether the ball has lodged or not; or,
the ball having passed through, whether fragments of bone, or other
substances, have remained behind.

When the chest has been opened by a projectile, the following signs
may be expected in addition to the external physical evidences of
the injury: a certain amount of constitutional shock; collapse from
loss of blood; and, if the lung be wounded, effusion into the pleural
cavity, hemoptysis, dyspnœa, and an exsanguine appearance. These will
generally, but not invariably, be followed, after twenty–four hours or
later, by the usual signs of inflammation in some of the structures
injured.

The shock of penetrating wounds of the chest, apart from the collapse
consequent on hemorrhage, is not generally so great as happens in
extensive injuries to the extremities or in penetrating wounds of
the abdomen. There is often much more “shock” when a ball has not
penetrated; but, having met with something to oppose its course, has
nevertheless inflicted a violent percussion of the whole chest and its
contents.

When loss of blood occurs without the lung being wounded, the
hemorrhage is probably proceeding from a wound of one of the
intercostal arteries, which has been torn by the sharp ends of
fractured bone. Serious hemorrhage, however, is exceedingly rare from
vessels external to the cavity of the chest.

When blood is effused in any large quantity into the pleural sac—as
indicated by the exsanguine appearance of the patient, increasing
dyspnœa, occasional hemoptysis, and the stethoscopic signs on
auscultation,—the inference is, that the lung has been opened, and
that it is from its structure the blood is flowing. The amount of
hemorrhage in wounds of the lungs will greatly vary according to the
direction of the track of the ball; for the large vessels cannot here
glide away from the action of the projectile, as they may in the neck
or extremities of the body. Wounds, therefore, near the root of each
lung, where the pulmonary arteries and veins are largest, are attended
with the greatest amount of hemorrhage; and as coagula can hardly form
sufficiently to suppress the flow of blood, are generally fatal.

Hemoptysis indicates injury to the lung, but does not give assurance
that this organ has been penetrated. It generally accompanies gunshot
wounds of the lung in a greater or less degree, no doubt always when a
bronchial tube of large size is penetrated; but, as may be ascertained
by careful perusal of recorded cases, is sometimes wholly absent, even
though the patient may be troubled by cough. Dr. Fraser, in a recent
monograph on Wounds of the Chest, states that out of nine fatal cases
observed by him in the Crimea in which the lungs were wounded, only
one had hemoptysis; and out of seven in which the lungs were found not
to be wounded, two had hemoptysis. This, however, from the writer’s
observation, would appear to be an unusual proportion of cases in which
hemoptysis was not present after wounds of the lungs.

Dyspnœa is a frequent accompaniment of wounds penetrating the lung,
but not a constant symptom before inflammatory action has set in.
When dyspnœa is great in the early period, it will often be found to
depend upon the injuries to the parietes, and to the pain caused on
taking a full inspiration; as a sign of subsequent mischief in the
progress of the case, it is, of course, very constantly present. It is
now known that the opening of the pleura does not necessarily induce
collapse of the lung, even though unfettered by adhesions, during life.
It was formerly supposed that the escape of air by the wound was a
sufficient proof that the lung had been opened by the projectile; but
it is evident that it is not so, as the air may enter by the wound
and be forced out again by the expansion of the lung in inspiration,
or by the action of the chest on expiration. If air and frothy mucus
with blood, as noticed in one of the cases recorded in the Crimean
campaign, escape by the wound, there can be no doubt of the nature of
the injury. Emphysema is not common in penetrating gunshot wounds,
but occasionally happens. The free opening generally made by the
projectile sufficiently explains this fact.

It is not necessary to refer at any length in this place to the
inflammations which may supervene. Diffused inflammation of the
lung after wounds is not so common as might perhaps be expected. In
unfavorable cases, the pleural cavity is generally found to be the seat
of extensive inflammatory action or unhealthy accumulations, especially
where irritation has been kept up by the presence of foreign bodies or
the patient’s constitution has become from any cause debilitated.

=Treatment.=—The object of the surgeon’s care must be in the first
place to arrest hemorrhage; afterward, to remove pieces or jagged
projections of bone, or any other sources of local irritation; and to
adopt means to prevent interference with the natural process of cure,
which takes place by adhesion of the opposite pleural surfaces near
the wound in the first instance, and subsequently by cicatrization of
the wound itself, or, as shown in an interesting preparation in the
museum of the Army Medical Department at Fort Pitt, by contraction
into a narrow sinus lined with a distinct adventitious membrane into
which the small bronchial tubes open. Although the shock may happen
to be considerable, attempts to rally the patient, if any be made,
should be conducted very cautiously; the prolongation of the depressed
condition may be valuable in enabling the injured structures to assume
the necessary state for preventing hemorrhage. Hemorrhage from vessels
belonging to the costal parietes should be arrested by ligature, as in
other parts, if the source from which it proceeds can be ascertained,
and if the flow of blood be so free as not to be controlled by the
ordinary styptics. Operative interference of this kind is chiefly
called for on account of secondary, not primary, hemorrhage. Hemorrhage
from the lung itself must be treated on the general principles adopted
in all such cases; the application of cold to the chest, perfect quiet,
the administration of opium, and, if the patient be sufficiently
strong, bleeding from a large opening until syncope supervenes. When
blood has accumulated in any large quantity, and the patient is much
oppressed, the wound should be enlarged, if necessary, so as, with the
assistance of proper position, to facilitate its escape. If the effused
blood, from the situation of the wound, cannot be thus evacuated,
and the patient be in danger of suffocation, then the performance of
paracentesis, as directed for the relief of empyema, must be resorted
to.

The extensive bleedings formerly recommended in all penetrating
gunshot wounds of the chest are now practiced with much greater
limitations—indeed, should never be employed simply with a view to
prevent mischief from arising. Venesection carried to a great extent
does harm by lessening the restorative powers of the frame. It appears
to interrupt the process of adhesion between the pleural surfaces and
the steps taken by nature to repair the existing mischief, while it
leads the injured structures into a condition favorable for gangrene,
or encourages the formation of ill–conditioned purulent effusions. When
inflammation has arisen, venesection may be joined with other means to
control its excessive action, and to give relief, which it certainly
does, to the patient; and where hemorrhage is manifestly going on
internally, it may be practiced with a view of draining the blood from
the system and more speedily inducing faintness, to give an opportunity
to the pulmonic vessels to become closed; but, even when thus applied,
the general state of the patient will not be unconsidered by a
judicious surgeon, nor caution neglected, lest the venesection cause
him to sink more rapidly from the additional shock to the system and
abstraction of restorative force. Taking away blood certainly does not
prevent pneumonia from supervening, but occasionally seems to give the
inflammation, when it arises, more power over the weakened structures,
or even to cause it to be accompanied with typhoid symptoms. Many
cases will be found in the various published records derived from the
Crimean campaign, where favorable recovery has taken place after wounds
of the lung without venesection being at all resorted to as part of the
treatment.

The case of an officer of the 19th Regiment, who was shot at the
assault of the Great Redan, and under the care of the writer, will
serve to illustrate some of the points before named. In this instance,
a rifle–ball passed through the upper part of the left scapula near
its superior posterior angle, comminuting the bone and entering the
chest. The ball, together with a piece of cloth, was excised in
front, two inches above and internal to the fold of the axilla. The
mouth was filled with blood immediately after the injury; bloody
expectoration continued for three days; there was hacking cough on
increased inspiration; the respiratory murmur was accompanied with
slight crepitating _ráles_ in the upper part of the lung; there was
weakness, but not much shock. The small degree of the latter symptom,
and the absence of evidence of effusion of blood into the pleural
cavity, led at the time to a suspicion that the ball had glanced round
the costal pleura and had only contused the lung; but the fact of the
absence of vessels of large size at this part of the lung, especially
if there were pleural adhesions, may have been the cause of these
results. This officer had been much weakened in frame by scorbutic
diarrhœa in the winter of 1854–55, and though the cure was protracted
by occasional attacks of diarrhoea subsequently to the injury, by
profuse discharge from the wounds, and separation from time to time
of spiculæ of bone, he left for England two months afterward with his
recovery nearly completed, and no inconvenience has been experienced in
the discharge of his duties since. No venesection was practiced in this
case; but tonics, nourishing diet, and port wine were given as soon as
suppurative action had been established.

But in discountenancing great bleeding, mention should not at the same
time be omitted that, in many cases, recorded by numerous authors,
and judging _post factum_, the successful issues appear to have been
owing to copious venesection. A remarkable case occurred in a young
soldier of the 33d Regiment, private Thomas Monaghan, under the care
of Deputy Inspector–General Dr. Muir, then surgeon of the regiment.
This man was wounded in August, 1855, through the left shoulder–joint
and chest, the glenoid cavity and head of the humerus being injured
and the lung implicated. In this instance complete recovery as to the
chest, and recovery with partial anchylosis of the shoulder, without
operative interference, followed, and appeared attributable chiefly
to inflammatory action being subdued by repeated depletion, the use
of antimonial medicines, and enforced abstinence. In two other cases,
hitherto unrecorded, which occurred during the same month in the same
regiment, successful terminations appeared to be attributable to
similar means. In one of these the ball entered the front of the chest,
between the third and fourth ribs, and passed out between the seventh
and eighth ribs below; in the other, after passing through the right
arm, it entered the chest at the posterior border of the axilla, and
emerged near the apex of the scapula.

To remove splinters of bone, and readjust indented portions of the
ribs, the finger should be introduced into the wound, and care taken
that in doing so no pieces of cloth or fragments be separated and
projected into the pleural sac. Notice must at the same time be taken
of any bleeding vessel requiring to be secured. A pledget of lint
should be laid over the wound, and a broad bandage placed round the
chest, just tight enough to support the ribs and in some degree to
restrain their movements, but with an opening over each wound large
enough to permit the ready access of the surgeon to it if necessary. If
the patient’s comfort admits of it, he should be laid with the wound
downward, with a view to prevent accumulation of fluid in the pleura;
and if there be two openings, as will be most frequently the case in
rifle–ball wounds, one wound should be thus placed, and the upper one
kept covered. In gunshot wounds, closure of the parietes by adhesion is
of course not to be looked for. The diet, beverages, and medicines must
constantly have reference to the avoidance of inflammatory action; and
should this occur it must be combated on general principles. It is by
such means we shall best assist the natural efforts toward recovery.

If the presence of a ball within the cavity be ascertained, efforts
should be made for its removal. But any attempt to determine where the
ball has lodged should be made very cautiously, as more harm may result
from the interference than from the lodgment of the foreign body. The
existence of old adhesions will modify the effects of a penetrating
wound, by excluding the track of the ball from the general pleural
cavity, and may influence the result of the injury, especially if there
be hemorrhage, or lodgment of foreign bodies, which may thus be brought
within the sphere of removal more readily.

=Wounds of the heart= seldom come to the military surgeon’s notice,
as they ordinarily prove fatal on the battlefield. Still it is right
to mention, that examples occur in which musket–balls are lodged in
the heart without immediately fatal results; and one case is recorded,
where a ball was found imbedded in its substance six years after the
injury was received, and death then ensued from causes unconnected
with the wound.[7] Cicatrices have also been discovered, showing that
a portion of this organ had been wounded with recovery. A private of
the 2d Foot, wounded in the chest, came to England in a transport,
and died sixteen days afterward in the military hospital at Plymouth.
On removing the heart, a ball was found in the pericardium. There was
a transverse opening in the right ventricle, near the origin of the
pulmonary artery, and the appearances led to the supposition that the
ball had, previous to death, been lying in the right auricle. There
was general inflammation of the heart and left side of the chest, but
no signs of inflammation on the right side. A preparation of this heart
is preserved.[8] These are only referred to as indications of what
cases may occur among chest injuries; such accidents are so rare as to
lead to little practical result.




GUNSHOT WOUNDS OF THE NECK.


Gunshot wounds of this region do not appear to be so fatal as might be
anticipated from the large vessels and important canals leading to the
thorax and abdomen, which at first sight appear to be so exposed and
unprotected. In no region are so many examples offered of large vessels
meeting but escaping from balls in their passage as in this; because
the cause which operates elsewhere—ready mobility among long and
yielding structures—exists in a greater degree in the neck than in any
other part. Where the large vessels happen to be divided, death must
follow almost immediately.

Superficial wounds of the neck offer no peculiarities. The larynx and
trachea being the organs most prominent, and most frequently injured,
are those which chiefly attract the surgeon’s notice in warfare; but
a consideration of the anatomical structure will at once show what
numerous other complications, whether from direct injury or consequent
inflammation, projectiles are likely to cause when driven deeply into
or perforating this region.

A brief abstract of some wounds of the neck, which occurred during the
Crimean campaign, will serve to exhibit the leading symptoms connected
with them when the larynx, or larynx and œsophagus, are involved.
Four cases may be found in the _Lancet_ of January 19th, 1856, to
which journal they were communicated by the late Mr. Guthrie, as
“very interesting.” In the Surgical History of the War it is stated
that only three wounds of the neck, other than simple flesh wounds,
occurred among the officers, from the commencement to the end of the
war; of which two proved fatal, and one led to invaliding. The case
of an officer of the 19th Regiment, however, fell under the care of
the writer, which is not included in that number; and in this instance
the neck was completely traversed, the œsophagus perforated from side
to side, and the larynx injured. It is detailed among the cases by
Mr. Guthrie. After the shock had subsided, the leading symptoms were
aphonia, dysphagia, numbness of one arm, edema and stiffness of the
neck, distressing accumulation of mucus about the fauces, and slight
pyrexia. Recovery progressed favorably, and on the twenty–second day
after the injury both external wounds in the neck were healed, and the
two in the œsophagus appeared to be closed also. The patient referred
to still suffers from a certain amount of aphonia, but not enough
to prevent him from performing his duties as a captain, though want
of sufficient power of voice would probably disable him for a more
extensive command. Another of these cases, in which emphysema of the
neck, edema of the glottis, great dyspnœa, and threatened suffocation
gradually supervened in a superficial gunshot wound of the neck, with
fracture of the thyroid cartilage, is related by Assistant–Surgeon
Cowan, 55th Regiment, who performed tracheotomy, and thereby saved the
patient’s life. In another, the ball passed through the thyro–hyoid
membrane, fractured the thyroid cartilage, and tore the lining membrane
of the glottis. Tracheotomy was performed on the day after the injury,
without benefit. Liquids could not be prevented from passing into the
trachea through the wound made by the projectile. The fourth case above
referred to was in a private of the 97th Regiment. The ball entered
at the pomum Adami, and passed out by the anterior edge of the right
sterno–mastoid muscle. Loss of voice, frequent cough, bloody sputa,
slight emphysema at the wound of entrance, and nausea, were the leading
symptoms. When the man attempted to drink, some of the fluid escaped by
the wound of exit. After five days this occurrence ceased; and after
the twelfth day, air no longer passed out of the wound of entrance.
Both wounds gradually healed; but aphonia—the voice being reduced to a
whisper—existed when the man left the regimental hospital. A soldier of
the Rifle Brigade, under the care of Deputy Inspector–General Fraser,
C.B., then surgeon of the battalion, was shot through the trachea, and
respiration was for some time carried on by the wound; it, however,
gradually and completely healed, and a favorable recovery ensued.
Another interesting case, hitherto unrecorded, occurred in a soldier
of the same battalion, at the last assault of the Redan. A rifle–ball
entered this man’s neck at the lower part of the left sterno–mastoid
muscle, passed across under the skin, wounding the anterior surface
of the trachea, severed some fibers of the right sterno–mastoid, and
effected its exit. The man was wounded at the same time by two other
rifle–balls, both flesh wounds, one through the left forearm, the other
through the upper part of the right thigh; while a shell exploding
near him, caused his left eye to be penetrated with particles of stone
and earth. Vision was lost; but in other respects, excepting a little
lameness from the wound in the thigh, he was discharged cured, after
fifty–six days’ hospital treatment.

Seven cases of gunshot wounds of the neck returned to England from the
late mutiny in India. They were all simple flesh wounds. In one the
musket–ball had not been discovered, and its position remained unknown.
The man was wounded at Lucknow, and the ball entered the left side of
the neck, close to the thyroid cartilage. Baron Percy reports a similar
wound and case of lodgment in his _Army Surgeon’s Manual_; in this
instance, the ball was known to pass away by the bowels, a fortnight
after the injury was received.

The liability to concussion of the cervical portion of the vertebral
column, and to injury of the deep cervical and other nerves, must not
be overlooked. Wounds of the neck are often accompanied by more or
less loss of power in one of the upper extremities; and more extensive
paralysis occasionally succeeds, although there was no primary evidence
of the spine being implicated in the injury.




GUNSHOT WOUNDS OF THE ABDOMEN.


Gunshot wounds of the abdomen, like those of the chest, are, for the
sake of convenience, divided into _non–penetrating_ and _penetrating_.
The NON–PENETRATING may be either simple flesh wounds, or may be
accompanied with fracture of some of the pelvic bones, or with injury
to some of the contained viscera. In PENETRATING wounds, the peritoneum
only, or, together with it, one or more of the abdominal viscera, may
be wounded; or, in comparatively rare cases, a viscus may be penetrated
without the peritoneum being involved. It is in the regional cavity
of the abdomen that the proportion of penetrating wounds is the
greatest. The cranium, from its form, structure, and coverings, serves
as a strong defense even against gunshot; the osseous yet elastic and
movable ribs, the sternum, and muscular parietes greatly protect the
contents of the cavity which they inclose; but the extensively exposed
surface of the abdomen, anteriorly and laterally, has no power of
resistance to offer against a projectile directly impinging it; and
when this important cavity is once penetrated by these means, death
is the almost inevitable result. Even the chances of a favorable
termination which may exist in wounds from other causes are generally
wanting; and much of their treatment, such as the use of sutures, and
other means to insure the apposition of cut edges, is inapplicable,
from the parts to a certain distance being almost necessarily deprived
of their vitality, to injuries from gunshot.

=Non–penetrating= wounds require but few remarks in this place. The
fatal injuries which occasionally occur from masses of shell or round
shot, in which the liver, spleen, or other viscera are ruptured without
penetration of parietes, and where death ensues from shock, hemorrhage,
or peritonitis, have already been alluded to. If, although the viscera
have been contused, the injury does not amount to being mortal, the
patient should be subjected to perfect quiet, extreme abstinence,
and, only when inflammation arises, to the necessary treatment for
its control. If the parietes have been much contused, abscess or
sloughing may be expected; and a tendency to visceral protrusion must
be afterward guarded against.

When portions of the pelvic parietes are fractured by heavy
projectiles, very protracted abscesses generally arise, connected with
necrosed bone; and the vital powers of the patient are greatly tried
by the necessary restraint and long confinement. The great force by
which these wounds must be produced, and the general contusion of the
surrounding structures, cause a large proportion sooner or later to
prove fatal, notwithstanding the peritoneal cavity may have escaped.
Of twenty–nine such cases which came under treatment in the Crimea,
sixteen died. Even apparently slight cases, as where a portion of the
crest of the ilium is carried away by shell, or ball lodged in one of
the pelvic bones, often prove very tedious, from the long–continued
exfoliations and abscesses which result.

=Penetrating wounds.=—A penetrating wound of the abdomen, whether
viscera be wounded or not, is usually attended with a great amount
of “shock.” The prognosis will be extremely unfavorable, if there
is reason to fear the projectile has lodged in the cavity of the
peritoneum; and in all cases the danger will be very great from
inflammation of this serous investment. The liability to accumulation
of blood in the cavity, from some vessel of the abdominal wall being
involved in the wound, must not be forgotten.

When, in addition to the cavity being opened, viscera are penetrated,
and death does not directly ensue from rupture of some of the larger
arteries, the shock is not only very severe, but the collapse attending
it is seldom recovered from up to the time of the fatal termination
of the case. This is sometimes the only symptom which will enable the
surgeon to diagnose that viscera are perforated. The mind remains
clear; but the prostration, oppressive anxiety, and restlessness are
intense; and, as peritonitis supervenes, pain, dyspnœa, diffused
tenderness, irritability of the stomach, distention, and the other
signs of this inflammation are superadded. In ordinary wounds from
musket–shot, scarcely any matter will escape from the opening of the
parietes, the margin of which becomes quickly tumefied; but if any
escape, it will probably indicate what viscus has been wounded. If
the stomach has been penetrated, there will probably be vomiting of
blood from the first. If the spleen or liver be wounded, death from
hemorrhage is likely to follow quickly. In some instances patients,
however, recover after gunshot wounds involving these viscera, and
examples in illustration may be found in various works on military
surgery. Two particularly manifest instances, where officers were shot
through the liver by musket–balls, occurred lately in India, one at
Lucknow, the other at the siege of Delhi: both recovered. The cases are
described in the _Indian Annals of Medical Science_ for January, 1859.
If the small intestines have been perforated, and death follows soon
after from peritonitis, the bowels usually remain unmoved, so that no
evidence is offered of the nature of the wound from evacuations; but
in any case of penetrating wound of the abdomen, when the opportunity
is offered, steps should be taken—a matter not unlikely to be omitted
under the circumstances of camp hospitals full of patients—to isolate
and examine all evacuations which may follow. By attending to this
direction, the writer had the satisfaction of ascertaining the passage
of a ball and piece of cloth, after a wound in the loin, in a case
already alluded to. If the kidneys or bladder are penetrated, the
escape of urine into the abdomen is almost a certain cause of fatal
result. The latter viscus may, however, be penetrated without the
peritoneal cavity being opened; and, as experience proves, the wound
is then by no means of a fatal character. Musket–balls sometimes lodge
in the bladder. This was ascertained to have happened in a soldier
of the 20th Regiment, in the Crimea; but the patient died from other
injuries, so that the information could not be turned to account. Mr.
Guthrie performed the usual operation of lithotomy, with success, to
remove a musket–ball which had struck a soldier just above the pubes,
at Waterloo, and lodged. He also records a similarly successful case
in a man wounded at the battle of Chillianwallah: this ball formed
the nucleus of a calculus. Baron Percy removed a ball and a portion
of shirt from the bladder. In all such cases, it is probable that the
bladder has been penetrated at some part uncovered by peritoneum,
so that the cavity of the abdomen has not been opened; or, if
otherwise, the foreign body has found its way in by ulceration, after
adhesions had been established, and thus circumscribed the openings of
communication. Small foreign bodies may also pass into the bladder by
the ureter. A case in which the kidney was wounded came under the care
of the writer, after the 8th of September, 1855. The patient survived
twelve days, and then died from pyemia. He had been taken prisoner, but
was found in Sebastopol, and brought to his regimental hospital on the
second day after the assault. There was only one wound in the right
loin, and the ball had lodged. Extensive abscesses formed among the
gluteal muscles on the left side, and down the left thigh; and though
free incisions were made, great constitutional irritation supervened,
and he sank. The substance of the right kidney had been perforated,
but the ureter had escaped. The ball had passed across the abdomen,
and lodged in the left buttock. Mr. Guthrie mentions some wounds of
the kidney where recovery took place; in one, seven months after the
wound, after an attack of retention of urine, a piece of cloth was
forced out by the urethra, which must have come down from the pelvis
of the kidney. When the abdominal parietes have been opened by shell
or passage of large shot, protrusion of omentum and intestines will
probably be one of the results. This does not always happen. In Dr.
Macleod’s Notes, p. 237, is detailed a remarkable case of recovery,
which was witnessed by the writer, after the wall of the abdomen,
including the peritoneum, had been destroyed to the extent of five
inches long by three broad; and a coil of intestine laid bare without
protrusion, in the right iliac region. This patient had also a fracture
of the ileum, another of the great trochanter on the same side, and his
right forearm smashed. This case was treated in the general hospital
before Sebastopol, by Mr. Hooke. Sometimes a wound caused by a large
projectile, which was at first not penetrating, will indirectly become
so, from the severe contusion and consequent sloughing to such an
extent as to denude the viscera; and if, as is not unlikely, adhesion
has taken place in the mean time between a portion of the viscera and
peritoneal lining of the abdominal paries, the sloughing action may
extend more deeply and the bowel itself become opened.

Curious instances are recorded in which balls have passed directly
through the abdomen without perforating any important viscus, as proved
by examination after death. As an example, on the other hand, of the
number of wounds which may thus be inflicted, a soldier of the 19th
Regiment, on duty in the trenches before Sebastopol, who was shot
through the abdomen in the act of defecation, was found by the writer,
on post–mortem examination, to have had as many as sixteen openings
made in the small intestine. He survived the wound nineteen hours.

Gunshot wounds of the colon, especially of the sigmoid flexure,
appear to be less fatal, probably from structural causes as well as
circumstances of position, than wounds of the small intestine. In the
Museum of Fort Pitt, however, is a preparation of jejunum exhibiting
three constrictions, and supposed to have been perforated in three
places, from a private of the 80th Regiment, who was shot through the
abdomen at Ferozeshah, in 1845, and who died from cholera in 1851.
Inspector–General Taylor, C.B., then surgeon of the regiment, who
made the examination post mortem, thus described the injured part
of the intestine: “The intestines neither there nor elsewhere were
morbidly adherent; but the fold of intestines immediately opposed to
the cicatrix presented a line of contraction as if a ligature had been
tied round the gut. The same appearance existed in two other places.”
It seems more likely that the gut was contused than perforated, and
that contraction gradually supervened, especially as no adhesions were
found; and, when wounded, the symptoms were so slight as to have led to
the supposition that the ball had gone round the abdominal wall.

A gunshot wound of the intestine, more especially the colon, may lead
to fecal fistula, and life be thus saved for a time. One such case only
occurred in the Crimea, in the 19th Regiment, of which the writer was
then the surgeon; this case, which has been before casually mentioned,
subsequently passed under the care of his friend Mr. Birkett, of Guy’s
Hospital, in which institution the patient died, from the effects of
albuminuria, four years after the receipt of the wound referred to. The
surgical history of this case has been already published at some length
in the _Lancet_;[9] the medical history, together with the results
of the post–mortem inspection, have been detailed by Dr. Habershon,
in vol. v., Ser. III., of the _Guy’s Hospital Reports_. The fistula
became closed at intervals, and occasionally, before other disease
supervened, hopes were entertained that recovery might result. The
direction and depth of the wound precluded any of the usual operations
for attempting to effect a radical cure. Two cases of abnormal anus by
gunshot perforation are recorded by Dr. Williamson among the wounded
who have recently returned from India; in both instances the descending
colon was the part of the bowel implicated. A similar result is
recorded in a private of the 13th Regiment wounded at Cabul in 1840.

=Wounds of the diaphragm.=—Musket–balls occasionally pass through
the diaphragm; and Mr. Guthrie has remarked that these wounds, in
instances where the patients survive, only become closed under rare
and particular circumstances. Hence the danger of portions of some
of the viscera of the abdomen, as the stomach or colon, passing into
the chest, and thus forming diaphragmatic herniæ, and of these,
eventually, from some cause becoming strangulated. Two very interesting
preparations of these accidents from gunshot exist in the museum at
Fort Pitt. In both instances, the stomach, colon, and omentum form the
hernial protrusions. In one, death occurred, a year after the wound,
from strangulation induced suddenly after a full meal; in the other,
the soldier continued at duty twenty–two years after, and died from
other causes. All the cases which occurred in the Crimea in which
openings had thus been established between the cavities of the chest
and abdomen proved fatal. A case is detailed in the Surgical History
of the War where the patient survived a double perforation of the
diaphragm, together with a wound of the liver, six days; in another
instance, where the lung, diaphragm, liver, and spleen were wounded,
the soldier lived sixteen hours. The direction of the ball, hiccough,
dyspnœa accompanied with spasmodic inspiration, and inflammatory
signs more particularly connected with the chest will be the usual
indications of such a wound; and in case of recovery, the risk of
hernial protrusion and strangulation must be explained to the patient.
Should strangulation occur, it can hardly be expected that division of
the stricture could be performed without the operation itself leading
to equally certain fatal results.

=Treatment.=—In the general treatment of penetrating wounds of the
abdomen by gunshot, the surgeon can do little more than to soothe and
relieve the patient by the administration of opiates, and to treat
symptoms of inflammation when they arise on the same principles as in
all other cases. The usual directions to attempt agglutination of the
opposite portions of peritoneum by favorable posture cannot generally
be carried out, the attempts being defeated by the restlessness of
the patient. The collapse which attends such injuries may be useful
in checking hemorrhage; and the exhibition of stimulants is further
contra–indicated by the risk of exciting too much reaction, should the
wound not prove directly fatal. If the wound be caused by grape–shot
or a piece of shell, and intestine protrudes, it must be returned; if
the intestine be wounded, sutures are inapplicable, as in an incised
wound, without previously removing the contused edges. When the bladder
is penetrated, care must be taken to provide for the removal of the
urine, either by an elastic catheter, or, if this cannot be retained,
by perineal incision. A freely communicating external wound prevents
the employment of the catheter from being essential. A soldier of the
57th Regiment was wounded, on the 18th June, 1855, by a musket–ball,
which entered the left buttock, fractured the pelvis, and came out
about three inches above the os pubis and one inch to the right of
the median line. The bladder was perforated; urine escaped by both
openings, chiefly by the one in front. Here the catheter caused so much
irritation that it was withdrawn; but the posterior wound soon ceased
to discharge urine, and in eighteen days the anterior wound was free
from discharge also. Seven weeks after the date of injury symptoms
resembling those of stone in the bladder came on; these were relieved
on three spiculæ of bone making their escape by the urethra. About
the same time the anterior wound became again open, and some pieces of
bone were discharged. After ninety–seven days’ treatment in the Crimea,
the man was sent home—the anterior wound being still so far open that
distention of the bladder, as from accumulation at night–time, led to
a little oozing from it. This subsequently healed; and he was sent to
duty on the 22d of November, nearly six months after the date of injury.




GUNSHOT WOUNDS OF THE PERINEUM AND GENITOURINARY ORGANS.


From the position of these parts of the body, uncomplicated gunshot
wounds of them are comparatively rare. Throughout the whole of the
Crimean war, the number of cases treated amounted, among the men, to
70; among the officers, only to 4. The number of deaths which resulted
were 21 among the men, chiefly cases of extensive laceration involving
the urinary apparatus; among the officers, none. Three men only, out
of 603 who returned from the late mutiny in India to Chatham, are
recorded under this class. In one, the injury was from a spent shot,
which caused a bruise without laceration over the symphysis pubis, and
produced persistent incontinence of urine; in each of the other two,
a musket–ball wounded the left testicle, injured the urethra, and led
to urinary fistula, which was, however, afterward healed. In one, the
testicle was so much injured that it was removed on the day the wound
was received; in the other, it sloughed away shortly after. A corporal
of the 19th Regiment, wounded in this region on the 8th September,
1855, was under the care of the writer. A portion of the ascending
ramus of the ischium on the right side was driven into the perineum,
the soft parts were much injured, and the right testicle was destroyed.
The viscera of the pelvis escaped. He was doing well until nearly a
fortnight after the injury, when nervous irritation and trismus set in,
and he sank.

Perineal wounds are not unfrequently caused by shells bursting and
projecting fragments upward; but they are generally mixed with lesions
of viscera of the pelvis, or fracture of its structure, or injuries
about the upper parts of the thighs or buttocks. In one such case, a
portion of the scrotum, the whole of one testicle, and the greater
part of the other were carried away. This wound healed without fungous
growth from the remaining portion of the testis. Separate wounds of
the external organs of generation are usually caused by bullets. In
two cases in the Crimea, a bullet entered between the glans penis
and prepuce, and traversed upward without penetrating the erectile
tissue. M. Appia records a case where the ball entered the summit of
the glans, traversed the whole length of the corpus cavernosum, passed
under the pubic arch, and went out by the right buttock. The urethra
was not opened. Double orchitis and scrotal abscesses followed; but
favorable cure took place. In another case, a ball carried away the
inferior part of the glans but did not wound the urethra. A soldier of
the Rifle Brigade was wounded in the Crimea by a musket–ball, which
entered the right buttock and came out by the body of the penis, just
below the glans, having ruptured the urethra about four inches from
the meatus. The wound of the penis closed favorably. Mr. C. Hutchinson
has recorded the case of a soldier of the 42d Regiment, treated at the
Deal Naval Hospital, who was wounded in the upper part of the thigh by
a musket–ball, which lodged. Three weeks afterward, the ball was found
imbedded in the pubes, the urethra being stretched around the convex
surface; and this explained the cause of a distressing distention of
the penis and dribbling of urine which had existed without intermission
from the time of the injury, but ceased at once on the removal of the
bullet.




GUNSHOT WOUNDS OF THE EXTREMITIES.


These injuries, always very numerous in warfare, offer many subjects
of consideration for the military surgeon. No class of wounds includes
so many cases that fall under his prolonged care as this. A large
proportion of wounds of the head and trunk are immediately fatal, or
from the commencement contain the elements of fatal results; while
wounds of the extremities, if those of the thigh be excepted, are free
from this extremely serious character. The treatment to be pursued,
including questions of conservation, resection, amputation, and the
proper time for the adoption of these latter if determined upon, often
demands the closest attention of the surgeon. These subjects will
be considered in their general bearing in other parts of this work,
and only those points especially connected with the circumstances of
warfare will be here referred to.

Gunshot wounds of the extremities divide themselves into flesh wounds
and contusions, and those complicated with fracture of one or more
bones. Flesh wounds may be simple, and these offer few peculiarities,
whatever their site; or they may be accompanied with lesion to nerves,
or blood–vessels, or both, and these usually increase in gravity in
proportion as they approach the trunk.

When complicated with fracture, the lesion is usually rendered compound
by the direct contact of the projectile with the bone injured; but the
fracture is sometimes simple, when caused by indirect projectiles,
such as stones or splinters, or by spent balls. These injuries are
liable to become further aggravated by the fracture extending into or
being complicated with an opening of one of the joints. Joints may
be contused or opened by projectiles, without apparent lesion of any
portion of the bones entering into their composition; but these are
exceptions to the usual order of such cases from gunshot.

Simple flesh wounds have already been referred to both in respect to
their nature and treatment in the commencement of this essay. It is
in connection with fractures of bones and their proper treatment that
the interest of surgeons is chiefly attracted in gunshot wounds of the
extremities. From the nature of the injuries, already described, to
which bones are subjected by the modern weapons of war, together with
the irreparable nature of the wound in the softer structures, except
after a long process of suppuration and granulation, as well as from
the usual circumstances of military life, it might be anticipated that
difficulty would often arise in determining which of the double set of
risks and evils—those attending amputation, and those connected with
attempts to preserve the limb with a profitable result—would be least
likely to prove disadvantageous to the patient. Experience in such
injuries has established certain rules which are now generally acted
upon; some still remain _sub judice_.

Although the subject of pyemia is considered in its general bearings
elsewhere, it is right to mention here that this serious complication,
as met with in gunshot wounds, appears to be especially induced
by injuries of bones, particularly those of long bones in which
the medullary canal has been laid open and extensively splintered.
Several circumstances probably conduce to this result: the prolonged
suppurative action during the removal of sequestra, the irritation
caused by sharp points and edges, sometimes increased by transport
from primary to secondary hospitals, the patulous condition of veins
in bones leading to thrombosis, being its chief local sources; while
depressed vital power from any cause, and continued exposure to an
impure atmosphere from the congregation of numerous patients with
suppurating wounds, are the principal agents in producing the state
of constitution favorable to its development and progress. Unless
the hospital miasmata engendered in this way are constantly removed
as they arise, or very greatly diluted by proper ventilation, it is
almost impossible that patients laboring under severe wounds of the
extremities with comminuted bony fractures can be long saved from
septicemia and pyemia; and these, when they supervene, rarely lead
to any but a fatal termination. The different conditions of hospital
air, which in one set of cases lead to the appearance of hospital
gangrene, in another set of pyemia, are not properly understood; but
from the frequency with which the latter complication follows wounds
of bones, it would seem that an especial influence is exerted by the
local peculiarities of these injuries already mentioned. However,
observation would also lead to the belief that certain individuals are
much more predisposed to pyemic action than others placed under similar
circumstances. Occasionally, in gunshot injuries of bones, where no
splintering has occurred, but only a small portion of the periosteum
has been torn off and the shaft contused by the stroke of a bullet,
severe inflammation will follow, the medullary canal become filled with
pus, and death ensue from pyemia. The attention of surgeons has been
particularly called to the various circumstances producing inflammation
and suppuration of the medullary tissues—osteo–myelitis—in long bones
after gunshot injuries by M. Jules Roux of Toulon.[10]

=Upper Extremity.=—Fractures of the bones of the arm are well known to
be very much less dangerous than like injuries in the corresponding
bones of the lower extremity. Unless extremely injured by a massive
projectile, or longitudinal comminution exist to a great extent,
especially if also involving a joint, or the state of the patient’s
health be very unfavorable, attempts should always be made to preserve
the upper extremity after a gunshot wound. In the Director–General’s
History of the Crimean Campaign, the recoveries without amputation
are shown to be, in the humerus, 26·6; radius and ulna, 35·0; radius
only, 70·0; ulna only, 70·0 per cent. of cases treated. The proportion
of deaths in these cases was only 2·3 per cent. Although not the
result of gunshot, a remarkable case, published by Staff–Surgeon Dr.
Williamson, by whom the operation was performed, serves to illustrate
how extensively bone may be removed from the upper arm, and a useful
member be still retained. The details will be found in his Notes on
the Wounded from the Mutiny in India. The whole of the ulna, (not
merely sequestra, but also the new bone which had formed around them,
the object of which proceeding is not stated,) two inches of the
humerus, and the head and neck of the radius were removed; and, four
months after the operation, the man could “bend his forearm, raise his
hand behind his head, lift a 28–lb. weight from the ground, pronate
and supinate the hand, and use his fingers well.” Of 194 wounds and
injuries of the upper extremity among men returned from the late mutiny
in India, 100 are recorded by Dr. Williamson to have been sent to duty
regular or modified, 67 invalided from the service, 1 died, and 26 were
still under treatment.

In the latter part of the Crimean campaign, when the health of the
troops and means of treatment were favorable, it was often remarkable
what extensive injuries of the upper extremity, even where the joints
were involved, were repaired without amputation. The following cases
are examples: Sergeant Bacon, 7th Fusileers, aged thirty–six, at the
attack on the Redan on the 8th of September, 1855, was wounded by a
rifle–ball, which entered the head of the left humerus, shattered
the bone very much, and was extracted from below the left scapula.
Dr. Moorhead determined to try to preserve the limb. The head of the
humerus required to be removed in small, broken fragments; and the
shaft, being found to be split down between three and four inches, was
to that distance removed by the saw. The case progressed favorably,
and in 1857 this man was in London with a most useful arm. A young
soldier of the 23d Regiment was wounded, on the 15th August, 1855, by a
large grape–shot, which passed through the right arm near the shoulder,
comminuting the bone for three inches and extensively destroying the
soft parts. Staff–Surgeon Williams, in medical charge, despairing of
saving the limb, proposed to amputate, but, at the suggestion of the
late Director–General Alexander, then principal medical officer of
the Light Division, arranged to allow some days to elapse to watch
symptoms. The case progressed so well that the idea of amputation
was abandoned, and the man recovered with a very serviceable arm. In
another regiment of the Light Division, the 77th, a healthy young
soldier, under the care of Surgeon Franklin, was wounded at the last
assault of the Redan, and sustained a comminuted fracture of the
humerus, had the elbow–joint opened, both bones of the forearm broken
about two inches below the joint, and the soft parts widely opened, by
a piece of shell. Here no excision was practiced, but fragments removed
as they became loose; the arm, with its dressings, was supported on a
zinc–wire cradle, hollowed out and bent at the elbow to the desired
angle; and nourishment, with malt liquor, were freely given from the
first day. Anchylosis was established, and he left for England with
a useful limb. The fractures above and below the joint prevented the
application of passive motion.

In these injuries, where the bone is much splintered, the detached
portions, and any fragments which are only retained by very partial
periosteal connections, should be removed; projecting spiculæ sawn or
cut off;[11] the wound being extended at the most dependent opening
where two exist, or fresh incisions being made for this purpose, if
necessary; light water–dressing applied; the limb properly supported;
and the case proceeded with as in cases of compound fracture from other
causes. (See FRACTURE.) The same general rules also apply in preserving
as much of the hand as possible, in gunshot injuries. If the shoulder
or elbow joint be much injured, but the principal vessels have escaped,
the articulating surfaces and broken portions should be excised. Care
should be taken to see that the projectile has wholly passed out, or
been removed. In a case of comminuted fracture of the humerus, in the
88th Regiment, no union having taken place a month after the injury,
and some dead bone requiring removal, an incision was made for this
purpose, when half the bullet was found between the fractured ends.
Good union, with free motion of the arm, resulted, after this foreign
body and the necrosed bone were taken away. The results of excision
practiced in the shoulder and elbow joints, especially the former,
after gunshot wounds, have been exceedingly satisfactory. Especial
attention was directed to the practice of resections of joints after
gunshot injuries in the Sleswick–Holstein campaigns between 1848 and
1851; and Dr. Friedrich Esmarch has published the results in a valuable
essay on the subject. Of nineteen patients in whom the shoulder–joint
was resected, in twelve a more or less useful arm was preserved; and
seven died. Complete anchylosis did not occur in any one instance; and
in several the power of motion became so great as to enable the men
to perform heavy work. Of forty patients for whom resection of the
elbow–joint was performed six died, thirty–two recovered with a more or
less useful arm, one remained unhealed at the time Dr. Esmarch wrote,
(1851,) and in one mortification ensued and amputation was performed.
These operations present no peculiarities in the mode of performance
or their after–treatment, as compared with similar resections in civil
practice.

=Lower extremity.=—Gunshot wounds of the lower extremity vary much
more greatly in the gravity of their results, as well as in the
treatment to be adopted, according to the part of the limb injured,
than happens in those of the upper extremity. As a general rule,
ordinary fractures below the knee, from rifle–balls, should never
cause primary amputation; while, excepting in certain special cases,
in fractures above the knee, from rifle–balls, amputation is held by
most military surgeons to be a necessary measure. The special cases are
gunshot fractures of the upper third of the femur, especially where the
hip–joint is implicated; for in these the danger attending amputation
itself is so great that the question is still open, whether the safety
of the patient is best consulted by excision of the injured portion
of the femur, by simple removal of detached fragments and trusting to
natural efforts for union, or by resorting to amputation. The decision
of the surgeon must generally rest upon the extent of injury to the
surrounding structures, the condition of the patient, and other
circumstances of each particular case. If the femoral artery and vein
have been lacerated, any attempt to preserve the limb will certainly
prove fatal.

The femur—the earliest formed, the longest, most powerful, and most
compact in structure of all the long bones of the body—can only be
shattered by a ball striking it with immense force. Attention was
specially directed in the late Crimean campaign to the question of the
proper treatment of these injuries, and expectations were generally
held that the advanced experience in conservative surgery would lead to
many such cases terminating favorably with preservation of the limb,
which previously would have been subjected to amputation. Toward the
latter part of the war, all the circumstances of the patients were as
favorable for testing this practice as they have been in the various
_émeutes_ in Paris, with the advantages of immediate attention and
all the appliances of the best hospitals close at hand. Yet, in the
Surgical History of the Campaign, it is stated that only fourteen out
of 174 cases of compound fracture of the femur among the men, and five
out of twenty among the officers recovered without amputation being
performed; that those selected for the experiment of preserving the
limb were patients where the amount of injury done to the bone and
soft parts was comparatively small; that where recovery ensued, it
always proved tedious, and the risks during a long course of treatment
numerous and grave; and that the proportion of recoveries would not
appear even so large as the above, if the deaths of those who after
long treatment were subjected to amputation as a last resource were
included. Amputations of the thigh, however, were very fatal in their
results also, the recoveries being stated to be, among the men,
in the upper third 12–9/10, in the middle third 40, in the lower
third 43–3/10, per cent. of cases treated. Among the officers the
proportion was rather more favorable. But this percentage includes
those cases in which attempts had been made to preserve the limb,
and failure resulting, amputation was resorted to as a last chance
of saving the patient, so that they ought to have been excluded from
the lists of amputations, both primary and secondary, as commonly
interpreted. On account of this comparatively indifferent success
of amputation, resection of portions of the shaft of the femur was
sometimes practiced; but the records state that no success attended the
experiment, every case, without exception, having proved fatal.

In considering the results of gunshot fractures of the femur, the
situation of the injury is a matter of great importance, whether as
regards chances of recovery without or with amputation. In the Surgical
History of the Crimean Campaign this fact is shown in the results of
amputation; but the distinction is not made in regard to the recoveries
without amputation. Dr. Macleod, in his Notes, remarks that he has only
been able to discover three cases in which recovery followed a compound
fracture in the upper third of the femur without amputation: one, that
of an officer of the 17th Regiment; the second, of a soldier of the
62d; and a third, whose regiment is not named. A case, however, was
under the care of the writer, not included in the above, nor appearing
in the official history of the war; and one, judging from the results
described in Dr. Macleod’s Notes, more fortunate in its issue than at
least two of the number he mentions. With regard to the first patient,
Dr. Macleod states he has been informed “that although his limb was
in a very good condition when he left for England, the trouble it
has since given him, and the deformed condition in which it remains,
makes it by no means an agreeable appendage;”[12] in the second, the
fracture was in the lower part of the upper third, and the injury was
comparatively slight; in the third, a mass of callus was thrown out
which connected the bone, but he died of purulent poisoning, and never
left the Crimea. In the case which was under the writer, the fracture
was within the upper third; there is no distortion, and shortening
only of 1–1/2 inches; the officer is able to walk or ride without any
inconvenience, and competent for all duty. All the circumstances were
most favorable for recovery in this instance; and a consideration of
these on the one hand, and the experience of the unfavorable results
of amputation in this region on the other, led to the effort to save
the limb. A short history of this case will be useful. Lieutenant D.
M., 19th Regiment, aged seventeen, of sanguine temperament, healthy
frame, was brought up to camp about 4 A.M. Sept. 9th, 1855. He had
been wounded in the assault upon the Redan in the upper part of the
left thigh, and had been lying by the side of the ditch where he
fell thirteen hours. When discovered, he was carried carefully in a
soldier’s greatcoat as far as the opening of the trenches, and thence
on a stretcher to camp. He was very cold and prostrate on his arrival.
The wound in his left thigh had been caused by a ball, which had passed
out. It entered posteriorly at the fold between the left nates and
thigh, three inches from the tuberosity of the ischium; passed forward,
downward, and outward, and made its exit seven inches below the
trochanter major. The femur was broken in the line of passage of the
ball, which, from entrance to exit, appeared to be about six inches.
From the trochanter major to the seat of fracture was four inches; to
the external condyle on the same side was 15–1/2 inches. The amount of
comminution appeared slight, but, from its vicinity to the joint, the
great swelling about the limb, and desire to avoid aggravating pain,
the precise condition of fracture was not further ascertained. The
upper fragment projected forward, but any attempts at reduction caused
great suffering; and some restoratives being given, wet compresses
applied to the thigh, and the limb secured against additional
movement, the patient was left to rest. At a consultation the following
morning, from the patient’s age, so favorable for reparative action,
very healthy constitution, and the fact that, the siege being over,
full attention could be paid to the case, conservation of the limb
was settled to be attempted, and the patient was therefore treated
with this view. In addition to the wound just named, he had received
an extensive contusion of the right thigh by the fall of some heavy
substance from the explosion which occurred at one A.M., after the
Russians left the Redan.

There is not space to follow the details of the treatment of this
case. The cure was protracted by large and troublesome bed–sores; and
attention to these, to the discharges from the wound, and preserving
favorable position, occupied much time and care daily, and caused
many changes in the appliances for these objects to be from time to
time necessary. On November the 4th, union had so far taken place
that he was able to raise his body from the knee upward while in bed,
without apparent motion at the seat of fracture. On November 15th, in
consequence of the great explosion at the right siege–train, he had to
be carried to another division of the camp; this was effected without
harm. In the middle of January he was able to sit in a chair without
inconvenience; and on February 22d he left the Crimea for England,
being able to walk with the assistance of crutches. Union was then
firm; but a slight serous oozing continued from the wound of exit,
and there was much stiffness of the ankle and knee joints from the
long–continued constrained position to which he had been subjected. In
July, 1856, after his arrival in Ireland, indications of pus collecting
manifested themselves at the wound of exit; and Professor Tufnell,
on passing a bougie about seven inches in the course of the wound,
evacuated a small abscess, and felt a piece of bone trying to make its
way to the surface. This was subsequently removed, and, under Mr.
Tufnell’s able care, the stiffness of the joints gradually disappeared,
and he was enabled to return to duty.

Dr. Macleod says that, after many inquiries respecting cases of this
nature in the hospitals of the other armies engaged in the war,
excepting one presented by Baron Larrey to the Société de Chirurgie
in 1857, he never could hear of any other but that of a Russian whose
greatly shattered and deformed limb he often examined.[13] It had
united almost without treatment. Two cases of united fractures of
the femur in the upper third have arrived from the late mutiny in
India, and in both, Dr. Williamson records, a good and useful limb had
resulted, one with shortening of 1–1/2, the other 3–1/2, inches. Still
more recently, M. Jules Roux, of the St. Maudrier Hospital, at Toulon,
has given a list of no less than twenty–one cases of gunshot injuries
of the upper third of the femur, which he had examined on their return
from the Italian war of 1859, in all of which consolidation of the
fracture had taken place. We have no data by which we can estimate the
proportion of these cases of union to those in which other results
ensued.

The proportion of recoveries in amputations in the upper third of the
femur in the Crimean war was under 13 per cent. Amputation at the
hip–joint, both in the French and English armies, in all instances
proved fatal. The two patients who survived the longest were operated
on by the late Director–General after the battle of the Alma: one, a
soldier of the 33d Regiment, died at Scutari three weeks after the
operation; the second, a Russian, died on the thirtieth day after,
from “extensive sloughing and great debility.”[14] One case of
excision of the head, neck, and trochanter of the femur in the Crimea
recovered, operated upon by Dr. O’Leary; the only known successful
case of excision of the hip–joint after a gunshot wound. The operation
was performed on the same day that the wound was received. In the
Sleswick–Holstein campaigns, amputation at the hip–joint was performed
seven times; one patient only survived, a young man, aged seventeen
years, operated upon by Dr. Langenbeck. Resection of the upper part
of the femur, including the head and two inches below the small
trochanter, was performed once, but the patient died from pyemia.
At the post–mortem examination, the right shoulder and ankle joints
were found to be filled with pus. The operation in this instance was
performed three weeks after the injury. No case of amputation, nor
of resection, at the hip–joint has returned from the Indian mutiny.
M. Legouest, in a recent essay in the _Memoirs of the Society of
Surgery_, at Paris, maintains that amputation at the hip–joint should
be reserved for cases of fracture with injury to the great vessels, and
that where the vessels have escaped, resection should invariably be
performed. He also inculcates, as a general principle, not to perform
immediate _primary_ amputation at the hip–joint in any case; but, even
in the severest forms of injury, to postpone the operation as long
as possible.[15] For the _consecutive_ results of gunshot wounds,
the operation presents a less unfavorable aspect than for immediate
injuries. M. Jules Roux has recently, at Toulon, performed amputation
at the hip–joint six times for the consequences of wounds received
during the war in Italy, and of these, four have been successful.

With regard to gunshot fractures in the middle and lower third of the
femur, the experience of the French and English armies in the Crimea
has tended to confirm the doctrine of the older military surgeons, that
many lives are lost which might be otherwise preserved, by trying to
save limbs; and that, of the limbs preserved, many are little better
than incumbrances to their possessors. In the late Italian battles,
the practice of trying to save lower extremities, after comminuted
fractures in these situations of the thigh, appears to have been
abandoned. Eight cases of union after compound gunshot fractures of
the femur in these situations have, however, returned from the late
mutiny in India; and this is a much larger proportion than was that
of the recoveries from the Crimea. Dr. Williamson, who records these
cases, is inclined to attribute this success in a great measure to the
use of dooleys for the conveyance of wounded, and argues that it would
be advantageous to introduce them into European warfare. But wounds
generally, where proper care is taken, heal more favorably in southern
latitudes, east or west, probably owing to the climate admitting of
so much more free an access of fresh air by day and night to the
patient than can be afforded, without inconvenience, in colder or more
variable climates. The dooley is most advantageous and comfortable as
used in the East, where it is an ordinary mode of conveyance among all
classes, and the bearers—a special race in each Presidency—are trained
from childhood to the occupation; but, from experience of the peculiar
habits and tenets of these men, both Madrassees and those of Bengal, it
seems scarcely probable that they would prove efficient, even if they
could exist, or that their wants could be provided for in the numbers
necessary to be serviceable, with armies in northern latitudes. French
surgeons have remarked how much more favorably, _cæteris paribus_,
wounds heal in Algeria, where they have only the same kinds of
conveyance for wounded as in Europe; and the difference is accounted
for by the favorable influence in this respect of a warmer climate.

In fractures of the leg, where neither the knee nor ankle joints
are implicated, the results of conservative attempts have been more
favorable. In the Crimea, the recoveries without amputation being
resorted to were: in fractures of both bones, nearly 19; tibia only,
36·3; fibula only, 40·9 per cent. When the fracture is comminuted, and
implicates the knee or ankle joint, opening the capsule, amputation
is necessary. The knee–joint was once excised in the Crimea, but the
patient died; as was the case in the only other instance where this
operation is known to have been performed for gunshot injury in the
Sleswick–Holstein campaign. In the treatment of fractures of the leg,
where it has been determined to seek union, the same remarks apply as
those made above in respect to fractures in the upper extremity. In
wounds of the foot it is especially necessary to remove as early as
possible all the comminuted fragments of the bones injured, or tedious
abscesses and much pain and constitutional irritation are likely to
ensue.




AMPUTATION.


It is not necessary to refer at much length to the question which
was formerly disputed upon—the advantages of _primary_ as compared
with _secondary_ amputation in gunshot wounds—for military surgeons,
whether acting at sea or on land, have practically determined the
subject. For a long time the directions of John Hunter, that amputation
should not be performed until the first inflammation was over, based
on the argument that the “amputation is a violence superadded to the
injury, and therefore heightens the danger,” and that this danger is
aggravated in the instance of a man laboring under mental agitation,
as on the field of battle, had great weight among English surgeons;
but experience has led to a different practice. The greater success
of primary amputation appears to be attributable to the facts, that
a contused and mangled limb is a constant source of accumulating
irritation; that the exciting circumstances connected with battle
lead a man to bear with courage at an early stage what subsequent
suffering and anxiety may render him less willing to submit to; that a
soldier, when first wounded, is most probably in stronger health than
he will be after hospital restraint and confinement; that though the
amputation is a violence, it is one the patient is likely to submit to
with resignation, knowing that it is performed to remove parts which,
if unremoved, will destroy life; and lastly, because the operation
takes away a source of dread which must weigh down the sufferer so long
as it is impending. The present practice has resulted from testing
both modes of amputation. Mr. Guthrie showed, from the experience
of the Peninsular war, that the loss in secondary amputations had
constantly exceeded that from primary amputations in both the upper
and lower extremities. More recent observations in both English and
French campaigns have confirmed this result. Dr. Scrive records that
the experience of the French army in the Crimea showed the success of
primary amputation sometimes exceeded by two–thirds that of secondary
amputation. He excepts amputations at the hip–joint, and cites, as
his reason for this exception, that in nine cases where the hip–joint
amputation was performed primarily, death followed the operation a
few instants or a few hours afterward; while in three cases which
he witnessed, where the amputation was consecutive, one lived five,
another twelve, and the third twenty days. In respect to the particular
time at which primary amputation is to be performed, the general
practice of the present day is, when the operation is inevitable, to
perform it as soon as it can be done; provided the more intense effects
of “shock,” where it has supervened on the injury, have passed off;
and this practice generally accords with the feelings of soldiers, who
not unfrequently press the surgeon for an early turn in being relieved
from the suffering resulting from a shattered limb. In the cases where
primary amputation is to be performed, a further reason given by Dr.
Scrive for the operation being done on the same day that the wound
is received is, that chloroform acts then so much more benignantly
and readily; while, on the following day, or day after, traumatic
excitement becomes very energetic, and considerable resistance is
offered to its influence by wounded men, and longer time and a much
larger dose of the chloroform are required to produce the state of
anesthesia. If only a moderate amount of “shock” exist, this does
not appear to be a sufficient reason for delaying amputation; for a
moderate exhibition of stimulus and a few consolatory words will often
remove this, and, even though some faintness, pallor, and depression
remain, no ill consequences ensue. The late Director–General, in a
letter to the late Mr. Guthrie, written in 1855, mentioned the case
of a soldier of the 90th Regiment, whose right arm he removed at the
shoulder–joint on the 10th of July, for great destruction of soft parts
and extensive injury to the bone: “The patient was so low when placed
on the table that brandy and water were given to him, and he was then
immediately afterward placed under chloroform. When I had finished, it
was observed that his pulse was stronger than before the operation.”
This man recovered without a bad symptom, and is now one of the
Commissionaires in London. Indeed, in the Crimea, primary amputations
were repeatedly performed where shock had not wholly disappeared, and
no harm resulted from the practice. The introduction of chloroform, by
its negative operation of preventing pain or alarm, and by its positive
action as a stimulus, has done much to remove many of the objections
which were urged by John Hunter against early amputations after gunshot
wounds. If collapse be intense, more than is accounted for by the
wound to the extremity, suspicion will be excited that some internal
injury has been also inflicted, and delay will be necessary for further
observation of the patient. When active operations are proceeding, and
it is necessary to carry the wounded to any distance, the advantages of
early removal of shattered limbs are obvious.




SECONDARY HEMORRHAGE.


Army surgeons meet in practice with secondary more frequently than
primary hemorrhage in gunshot wounds. It may arise in several ways.
Sometimes it results from the coagulum being forced out of an artery
in which hemorrhage had previously been spontaneously averted by the
ordinary natural process, this accident being consequent upon muscular
exertion or increased impulse of the circulating system from any cause.
This occurrence in the bottom of a deep wound will be often found to
be a very troublesome complication. Sometimes an artery which did
not appear to be injured in the first instance ulcerates or sloughs;
or, without direct injury, a vessel may become involved in unhealthy
deterioration of the wound, and give way; or, in a granulating wound,
general capillary hemorrhage may be excited by stimulus of any kind,
such as venereal excitement or excess in drinking; or the coats of the
vessel may ulcerate under pressure from a detached fragment of bone or
from some foreign body; or the artery may be accidentally penetrated
by the end of a sharp spiculum. Secondary hemorrhage has been said to
arise from increased arterial action, from the first to the fifth day;
from sloughing, the effects of contusion, from the fifth to the tenth;
from ulceration, to any more distant date. M. Baudens has remarked
that he has observed secondary hemorrhage to be most frequent about
the sixth day after the wound—the traumatic fever having then reached
its highest point of intensity, and the sharp, hurried contractions of
the heart having most power in forcing out the coagula. If we could
compare all the cases of hemorrhage which occur, secondary would,
perhaps, statistically appear less dangerous than primary hemorrhage;
for the latter, when happening from large vessels, must be very
generally fatal, while, when hemorrhage occurs in them secondarily, the
collateral branches have become partially adapted to the interruption
of the flow of blood through the regular channel. Moreover, the
larger arteries, when once filled with coagula and well contracted,
fortunately do not frequently yield to the impulse which serves to
produce secondary hemorrhage in vessels of smaller caliber.

Secondary hemorrhage is not uncommon after deeply–penetrating gunshot
wounds of the face, and sometimes it is difficult to determine the
site of the bleeding vessel. It may be so situated that the rule of
tying both ends of the bleeding artery in the wound cannot be carried
out, and where, if the ordinary styptics fail, resort must be had
to the ligature of the common trunk from which the bleeding vessel
branches. In the museum at Fort Pitt is a cranium showing the passage
of a musket–ball from the inner side of the right orbit to the entrance
of the carotid canal in the petrous portion of the temporal bone,
where the ball had lodged. Death ensued, ten days after the wound, by
hemorrhage from the internal carotid. In another case, a branch of
the external carotid artery was wounded by a ball which penetrated at
the zygomatic fossa. Secondary hemorrhage ensued, and the usual means
failed to arrest it. The external carotid was tied; but blood continued
to flow, though less abundantly than before. Compression in the wound,
which failed previously, now served to arrest the hemorrhage, and cure
followed. Care must be taken, before tying the trunk, that pressure
upon it exerts control over the hemorrhage from the wound; for the
irregular course of projectiles is not unlikely to lead to mistakes,
such as tying the common carotid, which is stated to have been done
when the hemorrhage has been from the vertebral artery.

The rule of treatment, however, holds good in secondary as in primary
hemorrhage—the bleeding vessel must be secured at the wounded part
whenever practicable, and it must be tied both above and below the line
of division, taking care to ascertain that the spot where each ligature
is applied is sound. Hemorrhage from general oozing, from sloughing,
and other causes must be treated on the general principles applicable
in all such cases.




WOUNDS OF NERVES.


Temporary paralysis from contusion of a nerve in the passage of a
projectile is not unfrequent. Complete loss of power of motion and
sensibility in a limb occasionally follows gunshot injuries, and
generally indicates complete division of the nerve. Instead of complete
paralysis, there may remain only modified deprivation of sensibility,
partial loss of muscular force, and diminished power of resisting cold,
with or without pain; and these symptoms may either be the result
of contusion, with the effects perhaps of inflammatory action or of
partial division. When a foreign body is lodged in or among nerves, it
may induce tetanic symptoms of a fatal character, or great irritation
and intense pain may result; and unless the source of these latter
symptoms can be found and removed, if in a large nervous trunk of
one of the extremities, they will sometimes lead to the necessity of
amputation. The gunshot injuries which cause division of large nerves,
however, are usually attended with so much destruction of other parts
that the question of amputation has scarcely ever to be considered
in reference to lesions of nerves alone. Atrophy of tissues and
contractions of muscles are common results of injuries to nerves from
gunshot, and often lead to soldiers being disabled for further service.
Occasionally, after severe injuries, the functions of sensation and
power of motion gradually return, in some instances with perfect
cure, but mostly with impaired power of resisting rapid alternations
of temperature, especially cold. A case is mentioned in the Surgical
History of the Crimean War where a soldier had the right sciatic
nerve severely injured by the passage of a musket–ball. Total loss of
sensation in the right foot followed. The wound was healed a month
after it was received, and sensation slowly returned in the foot; but
the restoration was attended with intensely burning pain, unrelieved
by any applications. Gradual recovery took place. Dr. Williamson’s
returns show eight cases of gunshot wounds with direct injury to nerves
among the men invalided from India, after the late mutiny; all were
wounds involving the brachial plexus, and in all there was paralysis,
partial or complete, of the upper extremity on the injured side. In one
case, the loss of function appears to have been almost confined to the
hand; all the fingers were fixed in a straight position, and numb, and
any attempt at bending them occasioned intense pain in the course of
the median nerve. The hand was cold and affected with nervous tremor,
but the motor power and sensibility of the thumb were preserved. The
following hitherto unrecorded case illustrates several points: A
soldier of the 37th Regiment was wounded at Azinghur, on the 27th of
March, 1858, by a musket–ball, through the right side of the neck. It
entered just below the horizontal ramus of the jaw, and made its exit
behind, over the scapula. About three pints of blood escaped, supposed
to be from the external jugular vein. The wound healed favorably, but
he lost the use of his right arm, at first completely, and afterward
partially, for three months. At the expiration of that period the
power of the arm was restored; but he was invalided home on account
of severe pain in the back of the neck, “resembling toothache,” which
all treatment failed to relieve. This pain spontaneously and gradually
ceased; there is still some loss of substance of the trapezius muscles
of the right side of the neck, and of the right as compared with the
other arm, with occasional numbness when the man is in heavy marching
order; but in all other respects he is well, and is at his regular duty.




TETANUS.


One cause of fatal termination in gunshot wounds is tetanus. It is
generally believed that the proportion of deaths from this source is
greater after actions in tropical climates, and that exposure to the
night air in such regions has some especial effect in producing them.
The most common cause appears to be, however, the local injury to
nerves, already mentioned, producing irritation along their course,
and so leading to some morbid condition of the ganglionic portions
of the motor tracts of the spinal cord. In the Crimean campaign, the
proportion of tetanus was remarkably small as compared with former
wars, being, according to the returns, only 0·2 per cent. of the number
wounded. Dr. Scrive records that not more than thirty cases of tetanus
occurred among the French wounded during the whole Crimean war, and
this would show a somewhat less ratio even than in the British army.
Dr. Stromeyer records only six cases of tetanus among 2000 wounded
in the campaign of 1849 against the Danes. Three of these, in which
the disease assumed a chronic form, recovered. There was only in one
case injury of bone. Warm baths and opium were the remedies in the
successful cases.

Sir G. Ballingall made the calculation that one in seventy–nine is
the average number of tetanic cases among wounded, and states that
the proportion of recoveries is so small as scarcely to be taken into
account. Three cases occurred to the writer, in the Crimea, after
gunshot wounds; all proved fatal. In one there was a severe fracture
of the ischium and injury of testicle by grape–shot. In a second, a
rifle–ball entered just above the left knee, and lodged. Eight days
after the injury an abscess was opened near the tuberosity of the
ischium, and the ball was removed from that spot. The same day tetanus
set in, and he died three days afterward. The ball had injured the
sciatic nerve, which was found to be reddened superficially; while the
neurilema, also, under an ordinary magnifying–glass, showed indications
of inflammation. A piece of cloth was found lying midway in the long,
sinus–like wound made by the ball. In a third, the bullet passed
through the axillary region. The patient progressed favorably for some
days, when tetanic symptoms appeared, and under these he sank. At the
post–mortem examination, some detached pieces of woolen cloth were
found lying entangled among the axillary plexus of nerves. Twenty–one
cases altogether supervening on gunshot injuries are shown in a table
in the Crimean records. Of these, ascertained injuries to nerves by
projectiles, or division of nerves by amputation, occurred in eleven
cases; three followed compound fractures, and seven flesh wounds. The
average period at which the tetanic symptoms appeared was eight days
and a half after the receipt of the injury; their duration prior to
death, three days and a half. One case only recovered—a soldier of the
93d Regiment, wounded in the right buttock by a shell explosion. A
fragment nearly a pound in weight was removed soon after the injury.
Seventeen days after trismus set in, when a further examination of the
wound led to the discovery of an angular fragment of shell which had
been previously overlooked. It was deeply lodged, and resting on the
sciatic nerve. On removing this, which weighed eighteen ounces, the
sheath of the nerve was seen to be lacerated to nearly one inch in
extent. Calomel and opium were now given; salivation appeared three
days afterward, the trismus subsided, and the man gradually convalesced.

Beyond the extraction of any foreign bodies which may have lodged,
as in this last case, it is not known that there are any indications
for special treatment of tetanus as occurring after gunshot injuries.
The employment of woorali has again been brought into notice by its
successful administration by M. Vella, of Turin, in the case of a
French sergeant wounded in the metatarsus of the right foot, on the 4th
of June, 1859, at the battle of Magenta, by a musket–ball which lodged.
The projectile was extracted three days after his admission into
hospital at Turin, on the 10th of June, and tetanus set in three days
afterward. But the woorali failed in two other cases; and it has yet to
be determined, should it be found to possess any peculiar power over
tetanic spasm, to what class of cases its properties are applicable.

=Hospital gangrene=, a common disease of wounded soldiers when
circumstances of war lead to overcrowding in ill–ventilated buildings,
and to deficiency in the proper number of attendants for securing
personal cleanliness and purity of atmosphere, with inferior diet;
and =Pyemia=, a frequent cause of fatal termination after gunshot
fractures, injuries of joints, and other suppurating wounds, especially
under the influence of circumstances like those above named, are
treated separately under their respective heads.




ANESTHESIA IN GUNSHOT WOUNDS.


The complete applicability of chloroform on the field to injuries
caused by gunshot, as to all others in civil practice, is established
among Continental surgeons, and among a majority of British army
surgeons. The first opportunity of testing chloroform largely as an
anesthetic agent in British military surgery occurred in the Crimean
war, and a long report on the subject will be found in the published
Surgical History of the Campaign. The general tenor of this report is
to limit considerably the use of chloroform—in minor operations, on
the ground of occasional bad results, even when the drug is of good
quality and properly administered; or, in cases where the shock is very
severe, on the ground that such do not rally, owing to the depressing
effect of the drug, after the anesthesia has gone off; or in secondary
operations, from the systems of the patients having been much reduced
by purulent discharges. But from the report it appears that only one
patient died from the effects of chloroform; and in this instance,
Professor Maclagan, of Edinburgh, to whom a portion was forwarded
for examination, reported the drug to be “acrid and nauseous when
inhaled,” and “totally unfit for use.” On the other hand, Dr. Scrive,
chief of the French Medical Department in the East, has written, in
his Relation Médico–Chirurgicale de la Campagne d’Orient, p. 465: “De
tous les moyens thérapeutiques employés par l’art chirurgicale, aucun
n’a été aussi efficace et n’a réussi avec un succès aussi complet que
le chloroforme; jamais, dans aucune circonstance, son maniement sur
des milliers de blessés n’a causé le moindre accident sérieux;” and,
more recently, Surgeon–Major M. Armand has written: “During the Italian
war, chloroform was as extensively used and was as harmless as in the
Crimea. I never heard of an accident from its use.”

At the commencement of the Crimean war, the Inspector–General at
the head of the British Medical Department circulated a memorandum
“cautioning medical officers against the use of chloroform in the
severe shock of serious gunshot wounds, as he thinks few will survive
where it is used;” but as far as chloroform was available, it was
used by many medical officers from the commencement of the campaign,
and its employment became more general as the campaign advanced. It
was constantly used in the division to which the writer belonged
throughout the war; and no harm was ever met with from its use, while
certain advantages appeared especially to fit it for military surgical
practice. So far from adding to the shock of such cases as an army
surgeon would select for operation, the use of chloroform seemed to
support the patient during the ordeal; and the writer has several times
seen soldiers, within a brief period after amputation for extensive
gunshot wounds, and restoration to consciousness, calmly subside into
natural and refreshing sleep. One reason for not using chloroform
in the Inspector–General’s caution was, that the smart of the knife
is a powerful stimulant; but “pain,” it has been remarked by a great
surgeon, “when amounting to a certain degree of intensity and duration,
is itself destructive;” and there can be little doubt that the acute
pain of surgical operations, superadded to the pain which has been
endured in consequence of severe gunshot fractures, has often, where
chloroform has not been used, intensified the shock, and led to fatal
results. In civil surgery, statistical evidence has demonstrated that
the mortality after surgical operations has lessened since the use
of chloroform; and it is believed the same result would be shown, if
opportunity existed, in army practice. In the report of a case in the
Crimea, instancing, perhaps, the greatest complication of injuries from
gunshot of any which recovered, Dr. Macleod remarks casually in his
Notes, p. 265: “This amputation was of course done under chloroform,
otherwise it is questionable whether the operation could have been
performed at all, the patient was so much depressed.” Mr. Guthrie,
in the Addenda to his Commentaries, remarked, from the reports and
cases which had reached him, that chloroform had been administered in
all the divisions of the army save the second, and had been generally
approved; and that the evidence was sufficient to authorize surgeons
to administer it even in such wounds as those requiring amputation at
the hip–joint. The late Director–General amputated in three instances
at the hip–joint, after the battle of the Alma, under chloroform—two
on the 21st and one on the 22d September—and all these lived to be
carried on board ship on the latter–named day, and two, as before
stated, lived several weeks. The absence of increased shock from
pain during the amputation very probably enabled these patients to
withstand the fatigue of removal to the coast and embarkation on board
ship. With regard to the objection of occasional bad results, a recent
estimate has shown that the probable proportion of all the deaths
which have occurred from chloroform to the operations performed under
its influence, exclusive of its use in midwifery, dental surgery, and
private practice, has been one in 16,000; and as these accidents may
equally occur during “minor operations,” in army practice as in civil
life, it should be used or not at the option of the patient.

In respect to the danger of anesthetics in the secondary operations
connected with gunshot wounds, Dr. Scrive’s experience has led him
to remark: “When consecutive amputation is rendered necessary by
the gradually increasing debility of a wounded man from purulent
discharges, chloroformization takes place with the most perfect
calm on the part of the patient;” and he classes its use under
“chloroformization de nécessité.” The general rules followed in civil
surgery must be equally applicable in these cases.

It must frequently happen in military practice that several operations
have to be performed in rapid succession on the same person, from
necessity of a speedy removal of the wounded; and, moreover, from the
number of cases which are suddenly thrown on the care of the army
surgeons after a general engagement, it must frequently occur that the
diagnosis of a case is more or less doubtful. In such instances, the
use of chloroform, by diminishing pain and preventing shock, and thus
giving the opportunity of more accurate examination of parts, becomes
particularly valuable in army practice. After the battles of Alma and
Inkerman, when orders were given to remove the wounded as speedily
as possible, the first–named consideration frequently occurred. The
case of Sir T. Trowbridge is quoted by Mr. Guthrie. This officer had
both feet completely destroyed by round shot at Inkerman, and it was
necessary to amputate, on one side at the ankle–joint, on the other
in the leg: the use of chloroform enabled the two operations to be
performed within a few minutes of each other with perfect success. The
amputations were done by the late Director–General of the Army Medical
Department. In illustration of the second casualty, the following,
which happened to the writer at Alma, may be named. A man of the
Grenadier company of the 19th Regiment had a leg smashed by round
shot. It was a question whether the fracture of bone extended into the
knee–joint. Two superior staff–surgeons were near; a hasty consultation
was held, and it was decided that the probabilities were in favor of
the joint being intact. Amputation was performed, and the tibia sawn
off close to the tubercle. It was then rendered evident that there was
fissured fracture into the joint. As soon as the man had recovered
from the state of anesthesia, the necessity of amputation above the
knee was explained to him, and he readily assented. This was shortly
afterward done, and the man recovered without any unusual symptoms, and
was invalided to England. It is not likely, without chloroform, in a
doubtful case of this kind, that the chance of saving the knee would
have been conceded.

In the British army in the Crimea chloroform was generally applied by
simply pouring a little on lint. The chief objection against this in
the open air is probably the waste which is likely to be occasioned.
Dr. Scrive says it always appeared to him most advantageous to
use a special apparatus, as well to measure exactly the doses, as
to guarantee a proper amount of mixture of air; and that although
he never saw a fatal result, he had several times seen excess of
chloroformization from the use of lint rolled up in the shape of a
funnel. The instructions which he gave were, never to pass the stage
of strict insensibility to pain, never to wait for complete muscular
relaxation; and to this direction being carried out he attributes the
fact that no death occurred from chloroform in the French army in
the Crimea. In an article on anesthetics, in the _Medico–Chirurgical
Review_, October, 1859, Dr. Hayward, of Boston, has strongly advocated
the use of sulphuric ether above all other anesthetics. The quantity
required to produce anesthesia—from four to eight ounces—would render
the use of this agent almost impracticable in extensive army operations
in the field.




AFTER–USEFULNESS OF WOUNDED SOLDIERS.


The results of wounds unfit soldiers for military service in many
ways, according to the nature of the wound and the region in which it
is inflicted; and the pensions consequent on their discharge entail
heavy expenses of long duration on the country. It was hoped that
the improvements in conservative surgery would have diminished the
number of disabled soldiers as compared with former wars; but the
corresponding improvements in the power and means of destruction, with
other circumstances, have defeated this hope, and the returns do not
show such to be the result. Even the cases where resections of the
joints have been performed, and fractures united, which previously
would have been treated by amputation, have rarely presented such
cures as to render the men available for military service, though the
preserved limb may still be of use in the work of civil life. Formerly,
all men who thus became unfitted to perform any of the duties to which
a soldier is liable were removed from the army; but, by an order from
the Horse Guards of 1858, wounded soldiers, though rendered unfit for
active service in the field, were directed to be retained for modified
duty in such employments as they are capable of executing. The results
of the increased practice of conservative surgery may, therefore, prove
valuable to the public service, now that the opportunity of secondary
employment is laid open. The reports from the hospitals in Italy
show that during the recent campaign in that country the practice of
conservative surgery after gunshot fractures has been very limited,
and in the lower extremity has been almost wholly abandoned, early
amputation being practiced instead.

       *       *       *       *       *

It is believed, that should England become again involved in war, a
greater amount of systematic scientific observation will be brought
to bear upon the subject of gunshot wounds than circumstances have
ever previously admitted. Hitherto, the majority of the younger
medical officers of the army have found themselves, on the occasion
of war, suddenly in possession of a large number of wounded officers
and soldiers to treat, with only those general principles of surgery
to guide them which they had originally obtained in their studies
in civil hospitals and schools; but this knowledge, essential and
absolutely necessary above all other as it is, has been long admitted
in the first–class powers of the Continent, whose military experience
is necessarily greatest, to be incomplete for this purpose. Now that
an Army Medical School has been established in England, and that in
it the large number of sick and wounded who annually return from all
parts of the world—serving to illustrate, among other subjects, the
consequences of wounds and of the surgical operations performed for
them in all their varieties—will be turned to account, as well as the
great collection of preparations in the museum of the Army Medical
Department, it is only reasonable to hope that the opportunities of
study in these specialties which will be afforded to every medical
officer at his entrance into the army will cause each individual, not
only to be ready to apply at any moment all the improvements derived
from experience and observation, up to the most advanced period, in
this branch of the profession of surgery, but will also best prepare
the members of the department for extending still further the sphere of
usefulness which has been cultivated by their predecessors.

                               THE END.




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 =Macleod’s Surgery of the Crimean War.= Notes on the Surgery of the
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                              FOOTNOTES:

[1] Notes on the Surgery of the Crimean War, p. 104, J. B. Lippincott &
Co.’s edition.

[2] See Guy’s Hospital Reports, 3d series, vol. v., 1859—case of
Gunshot Wound in the Loins, by S. O. Habershon, M.D.

[3] The portion of cranium referred to, with the piece of ball weighing
half an ounce, which lodged in the cerebrum, are in the museum at Fort
Pitt.

[4] In the Medical and Surgical History of the War against Russia in
the Years 1854–55–56, published by authority, vol. ii. p. 265, the
physical effects of concussion in producing “shock” are strongly dwelt
upon. It is remarked: “The shock of the accidents frequently witnessed
by the military surgeon differs, often in a very material degree,
and possibly in kind also, from that witnessed in civil life. When a
cannon–shot strikes a limb and carries it away, the immense velocity
and momentum of the impinging force can scarcely be supposed to have no
physical effect upon the neighboring or even distant parts independent
of, and in addition to, the ‘shock,’ in the ordinary acceptation of the
term, which would result from the removal of the same part by the knife
of the surgeon, or the crushing of it by a heavy stone or the wheel of
a railway wagon. * * In the great majority of cases, the whole frame
is likewise violently shaken and contused, and, probably, independent
of these physical effects, a further vital influence is exerted, which
exists in a very minor degree, if at all, in the last–named injuries,
and may possibly depend upon the ganglionic nervous system.”

[5] M. Scrive gives the following as the weight of the linen dressings
consumed by the wounded of the French army in the campaign in the
Crimea:—

                                                  English weight.
                                                  tons. cwt. qr. lb.
  Linen cloth         101,779 kilogrammes       = 100    2   1   23
  Rolled bandages      46,446     ”             =  45   13   2   14
  Charpie              47,776     ”             =  46   19   3    4

And estimates the following as the proportion consumed by each of the
wounded:—

                                          English weight avoirdupois.
                                                  lb. oz. dr. gr.
  Linen cloth          2 kil. 482 grammes       =  5   7   0  10
  Rolled bandages      0  ”   891    ”          =  1  15   7  13
  Charpie              1  ”   181    ”          =  2   9  11   0
                       ——————————                 ——————————————
  Total                4  ”   554    ”          = 10   0   2  23

In an Army Medical Department Circular, dated 27th May, 1855, it was
announced that the Secretary of State for War had decided the following
“Field Dressing” should form part of every British soldier’s kit on
active service, so as to be available at all times and in all places as
a first dressing for wounds:—

  Bandage of fine calico, 4 yds. long, 3 in. wide.
  Fine lint, 3 in. wide, 12 in. long.

  Folded flat and fastened by 4 pins.


[6] Perchlorure de fer, 30 drops, two or three times daily as a tonic,
and diluted with six parts of water as an injection.

[7] Dict. des Sciences Méd., Paris, 1813, p. 217.

[8] See Edin. Med. and Surg. Journal, vol. xiv.—Case of gunshot wound
of the heart, by J. Fuge, Esq.

[9] For 1855, vol. i. p. 606, and vol. ii. p. 437.

[10] Bulletin de l’Académie Impériale de Médecine, 24th April, 1860.
See also Des Amputations consécutives à l’Ostéomyélite dans les
Fractures des Membres par armes à feu, par M. H. Baron Larrey, Paris,
1860.

[11] Dupuytren made a division of the splinters of bone broken by
gunshot into three classes, viz.: primary sequestra, those directly
and completely separated by the force of the projectile; secondary
sequestra, those retaining partial connections by periosteal, muscular,
or other attachments, but afterward thrown off during the suppurative
process; and tertiary sequestra, or necrosed portions, produced by the
effects of the contusion and prolonged inflammatory action in parts
adjoining the seat of fracture. In accordance with this arrangement,
the removal by the surgeon of the primary and secondary splinters
has been regarded as simply anticipating nature in her work; but Dr.
Esmarch states, as one result of the experience of the surgeons of the
Sleswick–Holstein army, that, in the majority of comminuted fractures,
the removal of splinters retaining any connection with periosteum is
unnecessary and often injurious, as is also the practice of sawing
off the broken ends of the bone projecting from the comminuted part.
By proper treatment and under favorable circumstances, he asserts,
such splinters become impacted in callus, and in time unite with the
other fragments of the bone, and in this manner a cure is completed
without operative interference. It is a matter, however, of frequent
observation that splinters which have thus become impacted in callus
lead to mischief in various ways, or are subsequently discharged as
if they were so many foreign bodies, while the removal of the jagged
ends of the broken bone seems to be a valuable means of preventing
irritation, and thus of favoring union between them; and English
surgeons, therefore, generally pursue the practice above recommended.

[12] The officer referred to must have greatly improved in condition
since Dr. Macleod wrote, as he has been of late on active service in
India.

[13] Notes on the Surgery of the Crimean War, p. 264.

[14] In the surgical history of this war, this statement, which was
quoted by the late Mr. Guthrie, in the Addenda to his Commentaries, is
said to be a mistake, on account of the absence (not to be wondered at,
amid the confusion of that period) of official records on the subject.
Special reports on these cases were obtained at the time from Scutari,
and were shown to the writer by the late Director–General shortly
before his decease.

[15] A committee was appointed by the Surgical Society of Paris to
examine and report upon this essay of Dr. Legouest on Coxo–femoral
Disarticulation for Gunshot Wounds. Baron Larrey drew up the report,
which will be found in the 5th vol. of the Mémoires de la Société de
Chirurgie, 1860. It confirms the principle laid down by Dr. Legouest,
excepting only those cases of fracture where the mutilation of the limb
from a heavy projectile has been so great as to partly separate it from
the pelvis, and those in which there has been simultaneous lesion of
the crural vessels and femur near the pelvis, with extensive laceration
of the surrounding tissues.






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