Part 1

TRANSCRIBER’S NOTE

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LONGMORE

ON

GUNSHOT WOUNDS.

A TREATISE

ON

GUNSHOT WOUNDS.

BY

T. LONGMORE, ESQ.,

DEPUTY INSPECTOR–GENERAL OF HOSPITALS; PROFESSOR OF MILITARY SURGERY AT FORT PITT, CHATHAM.

PHILADELPHIA:

J. B. LIPPINCOTT & CO. 1862.

CONTENTS.

GUNSHOT WOUNDS IN GENERAL.

PAGE Definition of the term 9 History of the surgery of gunshot wounds 9

VARIETIES OF GUNSHOT WOUNDS.

Form and nature of missile 14 Grape–shot, canister, and spherical case 16 Musket–shot—Conical bullets 16 Bullets of various weights and sizes 17 Double bullets 18 Stones, and splinters of iron or wood 19

Degree of velocity 20 Increased by modern fire–arms 21 Comparison of round and conical balls 21 The Enfield and Whitworth rifles 22

Number of wounds in battle 22 Proportion to shots discharged 22

Spent balls 23

Lodgment of balls 24 Consequences of unextracted balls 25 Lodgment of an 8–pound ball 26 Illustrative cases 27 Fragments of shells 28 Fragments of bullets 29 Small foreign bodies 30

Internal wounds without external marks 32 Hypotheses concerning 32 Explanation concerning 33

Seat of injury 34

Course of balls 34

SYMPTOMS OF GUNSHOT WOUNDS.

Diagnostic symptoms 38 Appearances from various kinds of projectile 38 Apertures of entrance and exit 41

Pain of gunshot wounds 44

Shock of gunshot wounds 45 Primary hemorrhage 47

Prognosis of gunshot wounds 50

Treatment of gunshot wounds in general 51 Provisional dressing recommended 51 Surgeon’s first duty 52 Position of patient for examination 53 Instruments for conducting examination 54 Views respecting enlargement of the external orifice 54 Instruments for extracting balls 56 Means to be employed for readjusting lacerated wounds 59 Constitutional treatment 61

Progress of cure 62

GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY.

GUNSHOT WOUNDS OF THE HEAD.

Observations on 63

Wounds of the scalp and pericranium 65

Wounds complicated with fracture, but without depression on the cerebrum 67 Fissured fracture 68

Wounds complicated with fracture and depression on the cerebrum 69

Wounds with penetration of the cerebrum 70

Treatment 71 Use of the trephine 71 Opinions concerning 72

GUNSHOT WOUNDS OF THE SPINE.

Statistics of 75

Vertebral column and spinal cord 76

GUNSHOT WOUNDS OF THE FACE.

General observations on 77

Treatment 78

GUNSHOT WOUNDS OF THE CHEST.

Comparison with other wounds 80

Non–penetrating 81

Penetrating 82 Signs indicating 83 Hemorrhage from 83 Indications of the lung being penetrated 84 Treatment 85

Wounds of the heart 89

GUNSHOT WOUNDS OF THE NECK.

Abstract of 90

GUNSHOT WOUNDS OF THE ABDOMEN.

Observations on 93

Non–penetrating 94

Penetrating 94

Of the diaphragm 99 Fatality of 99

Treatment 100

GUNSHOT WOUNDS OF THE PERINEUM AND GENITOURINARY ORGANS.

Statistics of in the Crimea 101

GUNSHOT WOUNDS OF THE EXTREMITIES.

Frequency of 103

Division of 103

Pyemia from 104

Upper extremity 105 Percentage of recoveries from, without amputation 106

Lower extremity 109 When to amputate and when to be avoided 109 The femur 110 Statistics of cases of 110 Proportions of recoveries in amputations in 114 Fractures in the middle and lower third of the femur 116 Statistics in fractures of the leg, in the Crimean war 117

AMPUTATION.

Advantages of primary as compared with secondary 117

SECONDARY HEMORRHAGE.

Reasons for its occurrence 120 Not uncommon in deeply–penetrating wounds of the face 121 Rule of treatment 122

WOUNDS OF NERVES.

Temporary or complete paralysis caused by 122 Amputations sometimes necessary 122

TETANUS.

Statistics of 124 Treatment 125

HOSPITAL GANGRENE 126

PYEMIA 126

ANESTHESIA IN GUNSHOT WOUNDS.

Chloroform 126 Views respecting its use in secondary operations 129 Mode of administering 130

AFTER–USEFULNESS OF WOUNDED SOLDIERS.

Observations upon 131 General summary 131

GUNSHOT WOUNDS.

Gunshot wounds consist of injuries from missiles projected by the force of explosion. As the name implies, this class of wounds is ordinarily restricted to injuries resulting from fire–arms; but it should be remembered that wounds possessing the same leading characteristics may result from objects impelled by any sudden expansive force of sufficient violence. Injuries from stones, in the process of blasting rocks, or from fragments of close vessels burst asunder by the elastic power of steam, offer familiar examples of wounds of a like nature with those from gunshot. In the following article, however, gunshot wounds will be considered as they are met with in the operations of warfare.

HISTORY.

From the earliest time of the application of gunpowder to implements of war, down to the present day, the wounds inflicted by its means have excited the most marked interest among surgeons; nor can this be wondered at, when the immensely superior energy of this agent in comparison with all the mechanical powers previously in use for hostile purposes, and the terrible nature of its effects on the human frame, are remembered. By its introduction the whole aspect of war was changed, in a great degree, by the distance at which opposing forces were enabled to contend with each other; just as, in our day, the nature of battle seems destined to undergo another change from the increased range and precision of fire obtained through the general use of rifled weapons. But though the alterations now being made in the qualities of fire–arms are of the utmost importance to those whose business and especial study is the art of war, to the army surgeon the interest they excite is chiefly limited to the degree of injury and destruction inflicted by them as compared with weapons of a less perfect kind; while to the surgeons employed at the time of the introduction of gunpowder, the wounds were wholly new in their nature as well as degree. Recollecting the ignorance which then prevailed in all departments of science and art, it can excite no surprise that the new engines of war, with the flame and noise accompanying their discharge, were regarded with superstitious terror; nor that surgeons for a long time found an explanation of the sloughing severity of the injuries they inflicted, and of their difficult cure, in the poisonous nature of gunpowder, or of the projectiles which had been acted upon by it, or in the burning effects of these latter from heat acquired in their rapid flight through the air. Unfortunately, these erroneous views did not end with the theories from which they started, but led to treatment which only aggravated the evils inflicted by the new weapons, and interrupted the progress of the healing action, which nature would otherwise have established. The wound being regarded as a poisoned wound, it was only by a long and tedious process of suppuration that the poison could be hoped to be got rid of from the surface, and prevented from entering the system of the patient. The irritative fever, the wasting and emaciation, and all the other results of the protracted cure of the injury were so many evidences of the indirect effect of the poison working in the frame; just as the constitutional shock at the time of the wound, the loss of vitality along the surface in the track of a small projectile, or of the tissues laid bare by the passage of the cannon–ball were regarded as evidences of its direct influence. On looking back at the works of successive writers on this class of injuries, the reader is surprised that the improvement in their treatment has been so gradual and slow; and cannot fail to observe that the chief impediment to a more rapid amelioration of the system pursued has been the prevailing idea of the necessity of delaying the tendency of nature to close the wound, in order that the supposed poison might be eliminated from the constitution. The openings of entrance and exit and track of the ball were incised; the wound dilated by tents or other means, and terebinthinates, or even boiling oil, poured into it; irritating compounds and ointments applied where superficial dressings were practicable; and it was only after the wound was considered to be fully purged of its venom and foul humors by the extensive suppurative action thus kept up, that cicatrization was permitted to be established.

It required long years of observation in many conflicts, and the exercise of much industry, not to mention moral courage in opposing authorized custom and prejudice, before a simpler and more rational mode of practice was followed. It is satisfactory to know that though Continental surgeons have written more voluminously on the subject of gunshot wounds, the older English military surgeons and writers stand forth conspicuously in leading the way to a more practical knowledge of their nature and proper treatment.

Although, however, much that was erroneous was removed by the earlier surgeons, the light of science can hardly be said to have penetrated this important province of military surgery until the great and last work of John Hunter, on the Blood, Inflammation, and Gunshot Wounds, was published in 1794. This distinguished philosopher filled some of the highest positions in the British service, having been appointed in 1776 Surgeon Extraordinary to the Army, in 1786 Deputy Surgeon–General, and subsequently Surgeon–General; but he only served abroad about three years, and then only had the opportunity of seeing active service as staff–surgeon in the expedition to Belleisle. Had the field of his practical observation been more extensive, there can be no doubt that his zealous and scientific mind would have turned the advantage to the most valuable results for humanity. The physiological principles which he enunciated, based on extensive study and observation in civil life, cannot be controverted; but their practical application, so far as regards the treatment of gunshot wounds, has been greatly modified since his treatise on the subject was published. There cannot be a better illustration of the special position in which this department of military surgery is placed, from the peculiar circumstances under which it is practiced, than the fact that, though men of the highest mental attainments have discussed the subject of gunshot wounds, we are nevertheless indebted to practical experience in military campaigns for every improvement, some few of recent date excepted, that has occurred in their treatment. Thus John Hunter was led to advocate very strongly the delay of amputation, after severe gunshot wounds, for weeks, that the patient’s constitution might accommodate itself to the injury; while more extended observation has demonstrated that such secondary amputations are more fatal than those which are performed shortly after the infliction of the wounds leading to them—the advantage of the patient thus coinciding with what must very constantly happen to be a practice of necessity in the field. Mr. Guthrie remarks, in his Commentaries on the Surgery of the Peninsular War, between 1808 and 1815, that the surgical principles and the practice which prevailed at the commencement of the war were superseded on almost all important points at its conclusion; and he quotes a remark of Sir Astley Cooper to the effect that the art of surgery received from the practical experience of that war an impulse and improvement unknown to it before.

The still more recent military operations in Algeria, in Sleswick–Holstein, in the Crimea, and in India have afforded the opportunity of testing practically the applicability to army practice of some of the great improvements which have been accomplished in the civil practice of surgery in Europe since the termination of the war in 1815. Among these may be particularly enumerated the avoidance of amputation of limbs by recourse to excision of joints; resections of injured portions of the shafts of long bones; mitigated amputations, by removal only of those terminal portions of the extremities which had been destroyed by the original injury; and the practice generally of what has been styled conservative surgery. In these wars, too, the value of chloroform as an anesthetic agent in military surgery has been fully established. They have also especially illustrated the influence of various states of health and climates on the results of gunshot wounds. All the anticipations which were held out at the commencement of some of these campaigns have not been realized, but still they have added much valuable information and many improvements to military surgery.

The alterations made during the last five or six years in the arms of a great proportion of the troops of the leading powers of Europe, and which will, no doubt, be extended to all soldiers in regular armies—namely, the transformation of muskets into “_armes de précision_,” with rifled barrels and graduated aims—have led to changes in the severity and almost in the nature of gunshot wounds from small balls; and the consideration of these changes requires the especial attention of army surgeons. The effects of the new rifle–balls were widely witnessed during a portion of the period of the Crimean war. The campaign just concluded in Italy will probably produce additional practical observations from the Continental surgeons engaged in it. The fearful proportion of killed and wounded—greater than in any former experience—will have shown the effects not only of rifled muskets, but of rifled cannon also; and in the French forces engaged an opportunity will have been afforded of instituting a comparison of the results of their treatment under circumstances of bodily health and hospital accommodation very different from those of the French army in the Crimea. It may be hoped that the experience thus gained will advance the knowledge of gunshot wounds and their treatment a still further stride toward accuracy.

In England, one valuable result which emanated from the late war with Russia was the regular collection and arrangement, under government authority for the first time, of the observations and practice of the medical officers employed in the campaign. The value to science of such systematized historical records, if fairly and fully developed, can scarcely be overrated; and it is to be hoped that henceforth a similar course will be always adopted whenever the country may become involved in war.

VARIETIES OF GUNSHOT WOUNDS.

Gunshot wounds are modified in their nature by the form and kind of missile, by the degree of force with which it is propelled, and by the seat of injury. They are, in addition, affected by the circumstances in which the soldier happens to be placed, and by the state of his health when the injury is received.

=Form and nature of missile.=—The projectiles used in warfare of the present day are cannon and musket shot, shells of various kinds, hand grenades of iron or thick glass, case–shot, slugs, and other minor varieties of such missiles. These are the ordinary instruments of _direct_ gunshot wounds in warfare; but, in addition, there are numerous sources of _indirect_ wounds, resulting from the discharge of cannon and musketry. These are stones, or other hard substances, struck from parapets or from the surface of the ground by cannon–shot; splinters of wood from platforms and framework, or of iron from gun–carriages; fragments of bone from wounded comrades, or articles in their possession; and any other miscellaneous objects which may happen to come into contact with the solid ball or shell in its course.

The objects above enumerated present several varieties of forms. The chief are—1st, spherical, as cannon–balls, grape, musket–shot, and shells; 2d, cylindro–conoidal, as balls belonging to rifled cannon and rifled muskets; 3d, irregular, but generally bounded by linear and jagged edges, as fragments of shells and splinters.

A gunshot wound, whether received from a direct or indirect projectile, may be complicated by the entrance of extraneous bodies of various kinds, most commonly portions of the cloth or buttons of the dress worn by the person wounded. Such foreign substances, though not of themselves causing the wound, often have a special bearing on the progress of its cure.