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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.