Part 5

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

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

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

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

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

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

=Internal wounds without external marks.=—Among the wide variety of injuries from gunshot, there have not unfrequently been noticed cases in which serious internal mischief has been inflicted, without any external marks of violence to indicate its having resulted from the stroke of a projectile. An important viscus of the abdomen has been ruptured, yet no bruising of the parietes observable; symptoms of cerebral concussion have shown themselves, yet no injury of the scalp to be detected. Even bones have been comminuted without any wound of the integuments or appearance of injury. The records of the Crimean campaign afforded not unfrequent examples of such wounds. Two cases occur, in the French records, of fracture of the forearm without any external apparent lesion; in one the internal structures were reduced to a mass of pulp. The difficulty of reconciling the several facts noticed in such instances, together with the vague descriptions by patients of their sensations, led surgeons to seek an explanation for them in the supposition that masses of metal projected with great velocity through the air might inflict such injuries indirectly by aerial percussion. Either the air might be forcibly driven against the part injured by the power and pressure of the ball in its flight, or a momentary vacuum might be created, and the forcible rush of air to refill this blank might be the origin of the hurt. Electricity has also been called into aid in explaining these injuries. All these hypotheses are now abandoned. So many observations have been made of cannon–balls passing close to various parts of the body, as near as conceivable without actual contact, without any such consequences as those attributed to windage, as to lead to the necessary conclusion that the theory must in all instances have been fallacious. Portions of uniform and accouterments have been torn away by cannon–balls without injury to the soldier himself. Even hair from the head has been shaved off, and cases are on record where the external ear and end of the nose have been carried away without further mischief.

The true explanation of the appearances presented in those cases which were formerly called “wind contusions,” appears to rest in the peculiar direction, the degree of obliquity, with which the missile impinges on the elastic skin, together with the situation of the structures injured beneath the surface, relatively to the weight and momentum of the ball on one side, and hard resisting substances on the other. Thus, in the case of a cannon–ball passing across the abdomen, as in two instances mentioned by Sir Gilbert Blane, where men were killed by the passage of balls across the epigastrium, the elasticity of the skin probably enabled that structure to yield to the strain to which it was exposed, while viscera were ruptured by the projectile forcing them against the vertebral column. So the weight of a ball passing obliquely over a forearm may possibly crush the bone between itself and some hard substance against which the arm may be accidentally resting, without lesion of the interposed skin. Baron Larrey, who examined many fatal cases of this kind, relates that he always found so much internal disorganization as to leave no doubt in his mind of its being the result of contact with the ball. He explained the absence of superficial lesion, by the surface having been struck by cannon–balls in the latter part of their flight, when they had undergone a change of direction from straight to curvilinear, and acquired a revolving motion, owing to atmospheric resistance and the effect of gravitation. In such a condition, he argued, they would turn round a part of the body, as a wheel passes over a limb, in place of forcing their way through it; and, while elastic structures would yield, bones and muscles, offering more opposition, would be bruised or broken.

In some recently published letters on the wounded in the late campaign in Italy, by M. Appia, this writer states that wounds from massive projectiles having been rare, he had not met with an example of internal destruction of parts with skin preserved intact, and that he had nowhere seen a wound which was attributed to vent de boulet. The hypothesis, he remarks, seems generally abandoned. It is presumed that, in stating wounds from gros projectiles to have been rare, he refers only to the wounded in the hospitals, and that it is to be inferred that the injuries from cannon–shot proved generally fatal in the field.

=Seat of injury.=—A knowledge of the seat of injury from the passage of a ball involves diagnosis of its course, the depth of its penetration, the particular organs or structures injured, and the extent of the injuries to which they have severally been subjected. The course pursued by balls in wounds presents many features of interest. The depth of penetration, in connection with direction, becomes of great importance when there is question of one of the great visceral cavities being opened. This part of the subject, however, together with that of injuries to the viscera themselves, will be more conveniently considered when treating of gunshot wounds in their special relations to particular regions. In like manner, the diagnosis of the extent of injury in wounds complicated with fractures of the long bones will be best considered under gunshot wounds of the extremities.

=Course of balls.=—Of the circuitous and unexpected directions pursued by bullets in their course through the human frame, which were formerly so common, we are not likely to see many instances in future warfare, when the rifle is the weapon chiefly employed. The conical shape of the ball and the force with which it is propelled have had the effect, among others already named, of changing this characteristic of the ball from the smooth–bored musket. The latter, bearing a force that scarcely carried it true to a mark at eighty yards, and usually receiving, as it left the firelock, an impulse which caused it to revolve on its axis at right angles with the line of flight, was deflected by the most trifling obliquity of surface, by the resisting obstacle of a bone, by tendons or the aponeuroses of muscles, or even by the elastic resilience of muscles themselves in a state of action, when the relative direction of their fibers was favorably placed to exert this influence. The Enfield cylindro–conoidal bullet, armed with a force that will carry it to a given spot distant one thousand yards or upwards, flies like an arrow, penetrates the softer tissues in a straight line, and on meeting bone, as before noticed, enters it like a wedge. When a bullet of this kind strikes an object point–blank, it is always the apex of the conical part which first meets the object struck; and, if sufficient resistance be met with, it is this apex which becomes first compressed and turned back. When it strikes a solid object lying nearly parallel with its line of flight, the ball is planed, as it were, from its apex toward its base. In a case before referred to—page 29—where a conical ball entered the loin of a soldier of the 19th Regiment, and was subsequently passed per anum, the apex of the bullet was found to be turned and bent round on itself, and the ball generally flattened. On examining carefully the convex surface of the convoluted apex, minute spiculæ of bone were observed to be impacted in its substance. It became evident, therefore, that the ball had struck, probably penetrated through, some portion of the lumbar vertebræ in its course from the loin to the intestine. There were no general symptoms to indicate spinal injury, but, four years afterward, the opportunity of a post–mortem examination being afforded, the track of the ball through some of the lumbar vertebræ was distinctly traced.

It will often appear, at first examination, that the track of a wound by the cylindro–conoidal bullet, even at full speed, is widely removed from a straight line, especially when this class of injuries is new to the surgeon. It is not difficult to understand the apparent irregularity in the line of the wound, when the many varied positions in which the body and its parts are liable to be placed are called to mind, and if, when making the examination, the surgeon has omitted to place the patient in a similar posture to that he was in when struck. A certain allowance must also be made for the spasmodic actions of the various muscles among themselves, and momentary displacement of other structures, at the instant of receiving the injury.

Occasionally, though rarely, an accidental concurrence of circumstances may lead to the conical bullet pursuing a circuitous instead of a direct course, especially when, after traveling a certain distance, its speed has become diminished; and, as round musket–balls are not yet wholly discarded from warfare, it is necessary to call attention to the observations which have been made on this subject. Balls have been known to pass round the outer convex and the inner concave surfaces of the abdominal and thoracic cavities, sometimes forcing their exit at points nearly opposite to those of entrance, sometimes making a complete circuit. Thus, from simple observation of the line of direction of two wounds, a ball may be supposed to have passed through the thorax or abdomen, while really it may not have penetrated the cavity, but only made its way beneath the integument. In like manner, a lung may be supposed to have been traversed by a ball, not merely from the relative position of the wounds of entrance and exit, but also by some of the characteristic signs of such an injury, when really the ball, after entering the cavity of the chest, has rolled round the costal pleura, never penetrating the lung, but at the most bruising its surface. In the same way, balls have been known to travel round the cranium beneath the scalp, and to have found their way beneath the integuments of the neck, without injury to the deeper structures. Dr. Hennen saw a case where a ball was found lying in a wound by the thyroid cartilage. It had made a complete circuit of the neck, and returned to the spot where it had entered. Cases sometimes occur where two openings are found in a man’s shoulder, in such relation that a straight line between them would necessarily pass through the head of the humerus, yet the ball has only made a half circuit, outside the joint.

Many examples of such injuries will be found in the works of all writers on gunshot wounds until the recent introduction of rifled weapons, while those who have only seen the latter in use are almost inclined to doubt the accuracy of previous statements on this subject, from not meeting with similar instances in their own experience. In the early part of the late war with Russia, the musket wounds were nearly all inflicted by the round bullet; but during the year 1855 conical bullets of various shapes and sizes were brought into use by the Russians generally, as they had been for some time previously by nearly the whole of the English army, and a large proportion of the French army. As early as the battle of Inkerman, however, the Russians were partly armed with the Liège rifle, with its conical bullet. Among 3000 wounded from the recent battles of Palestro and Magenta, assembled in the hospitals at Turin, M. Appia, whose letters on the wounded in the late Italian campaign have been before quoted from, writes that he was astonished not to meet one case of a cylindrical ball having taken a curved direction in its passage. He mentions the case of an officer being wounded by a ball, which entered at the epigastrium and passed out by the side of one of the lumbar vertebræ, without penetration of the abdomen, a red mark or zone connecting the two wounds and indicating the circuit which the ball had made. In another case, a ball had traversed the chest from right to left, and still had sufficient force to wound the left arm. Both these injuries, however, were caused by spherical balls.

SYMPTOMS OF GUNSHOT WOUNDS.

The leading symptoms of gunshot wounds are the diagnostic marks of these injuries, and the constitutional disturbance, pain, hemorrhage, edema, and other circumstances with which they are attended. Some of these require to be noticed separately.

=Diagnosis.=—The external distinguishing signs of a penetrating gunshot wound are generally manifest enough, but exact diagnosis of the nature and extent of the wound is not always so simple as it might at first appear to be. It is necessary to describe, firstly, the external appearances. These, although possessing certain universal characteristics, vary to a wide extent, according to the different forms, already described, of the missiles causing the injuries, their velocity, the part of the body struck, and its position relative to the projectile at the time of injury.

When a cannon–ball at full speed strikes in direct line a part of the body, it carries away all before it. If the head, chest, or abdomen are exposed to the shot, an opening corresponding with the size of the ball is effected, the contiguous viscera are scattered, and life is at once extinguished. If it be part of one of the extremities which is thus removed, the end remaining attached to the body presents a stump with nearly a level surface of darkly contused, almost pulpified, tissues. The skin and muscles do not retract, as they would had they been divided by incision. Minute particles of bone will be found among the soft tissues on one side, but the portion of the shaft of the bone remaining in situ is probably entire.

In ricochet firing, or in any case where the force of the cannon–shot is partly expended, the extremity, or portion of the trunk, may be equally carried away, but the laceration of the remaining parts of the body will be greater. The surface of the wound will be less even. Muscles will be separated from each other, and hang loosely, offering at their divided ends little appearance of vitality; spiculæ of bone of larger size will probably be found among them; and the shaft may be found shattered and split far above the line of its transverse division. The injury to nerves and vessels may be proportionally higher and greater. Occasionally it happens, even where the limb seems to have been struck in direct line, that it is nevertheless not completely detached, but remains connected by shreds of the skin and parts of the tissues, on which the bone, reduced to minute fragments, is mixed with the contused muscles and other soft parts in a shapeless mass.

If the speed be still further diminished, so that the projectile becomes what is termed a “spent ball,” there will not be removal of the part of the body struck, but the external appearances will be limited usually to ecchymosis and tumefaction, without division of surface; or even these may be wanting, notwithstanding the existence of serious internal disorganization. The rationale of such phenomena has been previously described.

Should the cannon–ball strike in a slanting direction, the external appearances of the wound will be similar to those just described, according to its velocity, modified only in extent by the degree of obliquity with which the shot is carried into contact with the trunk or extremity wounded.

Large fragments of heavy shells generally produce immense laceration and separation of the parts against which they strike, but do not carry away or grind, as round shot. Ordinarily, the line of direction in which they move forms an obtuse angle with the part of the body wounded. When they happen to strike in a more direct line, so as to penetrate, the external wound, as alluded to under the head of lodgment of projectiles, is mostly much smaller than the fragment itself, from the projectile not having had force enough to destroy the vitality and elasticity of the soft parts through which it entered.

Small projectiles, with force enough to penetrate the body, leave one or more openings, the external appearances of which also vary according to their form and velocity. The appearance of a wound from a rifle–ball, at its highest rate of speed, may be sometimes witnessed in cases of suicide. A soldier, in thus destroying himself, mostly stoops over the muzzle of his firelock, pressing it against the upper part of his body, and springing the trigger by means of his foot. The muzzle is usually applied beneath the chin. In such a case, a circular hole, without any puckering or inversion of the marginal skin, together with dark discoloration of the integument for several inches round, is observed at the wound of entrance. The vertex of the head is shattered; fragments of the parietal and occipital bones, together with small portions of brain, are carried away and scattered about; the bones not broken are loosened from their sutures; the mass of brain is torn to pieces, but held by its membranes; the superficial vessels of the face are distended with blood. These effects are not wholly due to the passage of the ball, but partly to the flame from the ignited gunpowder jetting out at the mouth of the musket, and in part also to the expansive force exerted within the cavity of the cranium, by the gases resulting from the explosion.

When the musket–ball strikes at a distance from the weapon by which it was propelled, but still preserves great velocity, the appearances of the wound are changed. An opening is observed, irregularly circular, with edges generally a little torn; and the whole wound is slightly inverted. There may be darkening of the margin, of a livid purple tinge, from the effects of contusion, or it may be simply deadlike and pale. Should the ball have passed out, the wound of exit will be probably larger, more torn, with slight eversion of its edges and protrusion of the subcutaneous fat, which is thus rendered visible. These appearances are the more easily recognized, the earlier the wound is examined. They are more obvious if a round musket–ball has caused the injury than when it has been inflicted by a cylindro–conoidal bullet. Indeed, with the latter, where it has simply passed through the soft tissues of an extremity of the body at full speed, it is usually very difficult to distinguish by its appearance the wound of entrance from that of exit. In medico–legal investigations concerning gunshot wounds, it must be often a matter of great importance to decide this point; but to the military surgeon, more especially from the circumstances connected with the new projectiles, it has become a subject of little practical interest. When the indirect and tortuous penetration of balls was the rule rather than the exception, a knowledge of the spot at which the ball entered was often useful in diagnosing the mischief it had probably committed in its passage, and in determining the part of the wound where foreign bodies might be supposed to be carried and to be lodging. When the track of the ball is nearly in a straight line, as now usually happens, such information cannot be looked for from knowing the relation of either opening to the entrance or passage of the missile.

A musket–ball ordinarily causes either one wound, as when after entering it lodges, or, as sometimes happens, from its escaping again by the wound of entrance; or two wounds, from making its exit at some point remote from the spot where it entered; but occasionally leads to a greater number of openings. This last result may happen from the ball splitting into two or more portions within the body, and causing so many wounds of exit. A case occurred to M. Dupuytren, where a ball split against the spine of the tibia; and after traversing the calf of the leg in two directions, entered the other leg at two points,—one ball thus causing five orifices. A case occurred to the writer, in the Crimea, where a cylindro–conoidal rifle–ball with three canalures, after fracturing the cranium, was cut in two by the upper edge of bone at the seat of fracture, smoothly as if by a sharp instrument. One part glanced off, the other entered the cranium. A strange feature in this case was, that the depressed portion, after admitting the ball, closed up again; so that no aperture, but only a slight depressed line of fracture, was visible. 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.