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.