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.