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Title: A Treatise on Gunshot Wounds Author: Thomas Longmore Release Date: November 7, 2014 [EBook #47310] Language: English Character set encoding: ISO-8859-1 *** START OF THIS PROJECT GUTENBERG EBOOK A TREATISE ON GUNSHOT WOUNDS *** Produced by Giovanni Fini, deaurider, Chris Curnow and the Online Distributed Proofreading Team at http://www.pgdp.net (This file was produced from images generously made available by The Internet Archive) TRANSCRIBER’S NOTE —Obvious print and punctuation errors were corrected. —The transcriber of this project created the book cover image using the title page of the original book. The image is placed in the public domain. J. B. LIPPINCOTT & CO.’S MILITARY PUBLICATIONS. Any book in the annexed list will be forwarded by mail to any address on receipt of the price in current funds. 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LONGMORE, Esq., DEPUTY INSPECTOR-GENERAL OF HOSPITALS; PROFESSOR OF MILITARY SURGERY AT FORT PITT, CHATHAM. PHILADELPHIA: J. B. LIPPINCOTT & CO. 1862. [ii] [iii] 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 [iv] [v] [vi] 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 [vii] [viii] 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 [9] [10] 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,” [11] [12] [13] 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 [14] [15] [16] 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 [17] [18] [19] 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 [20] [21] 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 [22] [23] [24] 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 [25] [26] [27] external mark of injury nor much pain on pressure. It was concluded to be the ball; and, on incising, an enormous grape-shot was found. It had turned round the femur without breaking it. M. Armand writes that the appearance of the wound alone would have led to the supposition that the ball had not lodged, and no one would have suspected that such a thing as a grape-shot had been the cause of it. In the British Surgical History of the Crimean War the case of a soldier of the 1st Royals, who was wounded in the face by a grape-shot weighing 1 lb. 2 oz. is recorded. The ball lodged at the back of the pharynx, and escaped observation for three weeks. Were it not for experience of many such instances, it would be deemed almost impossible that foreign substances of such size and weight could remain in the body without the knowledge of the patient, if not discovered by the surgeon. Even with so large a missile as a grape-shot, a surgeon should not be contented with examining merely by the wound, wide as it usually is, in case lodgment is suspected; it may travel in a direction which may cause its discovery to be very difficult by that track. An officer of the 19th Regiment was struck during the assault on the Redan, on September the 8th, by two grape- shot, at the back of the chest. They entered close to the spine. One of these balls lodged in the inner part of the right arm, below the axilla, whence the writer excised it. Penetrating fragments of shells, if projected edgeways, almost invariably lodge. In these cases, the appearance of the wound seldom indicates to the observer the true size of the body which has caused the injury. At an early period of the battle of the Alma, a piece of shell, about four pounds in weight, lodged in the buttock of a soldier of the 19th Regiment; and, to extract it, an incision had to be made nearly equal in extent to the length of the original wound. In this instance the concave aspect of the fragment—evidently, by the nature of the curve and thickness, a portion of a very large shell—had adapted itself to the parts lying beneath, while its convex surface so agreed with the natural roundness of the parts above, that it would have been impossible to have arrived at a knowledge of its lodgment, from any change in the external appearance of the parts. Examination by the wound alone gave decided information on the question. Such fragments become very firmly impacted among the fibers of the tissues in which they lodge, and the effused blood fills up inequalities, and rounds off edges that might otherwise show themselves prominently; so that, without due care, their presence is not unlikely to be overlooked at first examination. Dr. Macleod, of Glasgow, mentions that he saw a case at Scutari, in which a piece of shell weighing nearly three pounds was extracted from the hip of a man wounded at the Alma, which had been overlooked for a couple of months, and to which but a small opening led.[1] But bodies of still more irregular form may lodge in this region, and escape notice. A soldier in a battery in the Crimea was wounded, during a heavy artillery fire, in the left hip. A twelvemonth afterward he was in the General Hospital at Chichester, with a narrow sinus, which allowed a probe to pass deeply among the gluteal muscles. On cutting down in the direction indicated, a piece of stone was extracted, upwards of four ounces in weight. This man had passed through several hospitals before his arrival at Chichester. Bullets scattered from canister or spherical case not unfrequently lodge; apparently in consequence of the direct velocity received from the primary discharge being disturbed, and lessened by the force of the secondary explosion of the case in which they were contained. A small layer of metal, like a portion of one of the coats of an onion, occasionally becomes detached from a leaden bullet, and lodges. The writer was once applied to by a discharged soldier, suffering from some troublesome granulations at the bottom of the left orbit. The globe of the eye had been destroyed nearly two years before by a musket-ball shot from above, which, after traversing the orbit, had descended, and was excised from the right side of the neck. On examining the granulations by a probe, the point came into contact with a hard substance, which further examination showed to be a small projecting point of lead. It proved to be a scale from the bullet which had caused the original wound, being equal in length to half its circumference, and in width, at the broadest part, about a third of the same dimension. It retained the curved form of the bullet from which it had been detached. The following case shows that similar sections may be separated from cylindro-conical as well as from round bullets. An officer of the 41st Regiment was struck in the Crimea by a conical bullet, which destroyed the forearm in such a manner as to necessitate amputation below the elbow. Secondary hemorrhage occurred on the eleventh day, and on the following day the stump was opened and examined. “While searching for the bleeding vessel, a slice of the bullet, about the size of a worn sixpence, was found deeply imbedded in the muscle.” In the case of a soldier of the 19th Regiment, who was wounded before Sebastopol in the loin by a conical bullet, which was discharged per anum, and who died in Guy’s Hospital of albuminuria, nearly four years afterward, a small scale of lead from the bullet was found at the post-mortem examination fixed in the spleen. Strange to say, in this instance the lodgment did not appear to have exc...