Part 3

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 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 excited any inflammatory action or mischief.

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

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

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

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

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

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

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

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

=Course of balls.=—Of the circuitous and unexpected directions pursued by bullets in their course through the human frame, which were formerly so common, we are not likely to see many instances in future warfare, when the rifle is the weapon chiefly employed. The conical shape of the ball and the force with which it is propelled have had the effect, among others already named, of changing this characteristic of the ball from the smooth–bored musket. The latter, bearing a force that scarcely carried it true to a mark at eighty yards, and usually receiving, as it left the firelock, an impulse which caused it to revolve on its axis at right angles with the line of flight, was deflected by the most trifling obliquity of surface, by the resisting obstacle of a bone, by tendons or the aponeuroses of muscles, or even by the elastic resilience of muscles themselves in a state of action, when the relative direction of their fibers was favorably placed to exert this influence. The Enfield cylindro–conoidal bullet, armed with a force that will carry it to a given spot distant one thousand yards or upwards, flies like an arrow, penetrates the softer tissues in a straight line, and on meeting bone, as before noticed, enters it like a wedge. When a bullet of this kind strikes an object point–blank, it is always the apex of the conical part which first meets the object struck; and, if sufficient resistance be met with, it is this apex which becomes first compressed and turned back. When it strikes a solid object lying nearly parallel with its line of flight, the ball is planed, as it were, from its apex toward its base. In a case before referred to—page 29—where a conical ball entered the loin of a soldier of the 19th Regiment, and was subsequently passed per anum, the apex of the bullet was found to be turned and bent round on itself, and the ball generally flattened. On examining carefully the convex surface of the convoluted apex, minute spiculæ of bone were observed to be impacted in its substance. It became evident, therefore, that the ball had struck, probably penetrated through, some portion of the lumbar vertebræ in its course from the loin to the intestine. There were no general symptoms to indicate spinal injury, but, four years afterward, the opportunity of a post–mortem examination being afforded, the track of the ball through some of the lumbar vertebræ was distinctly traced.[2]

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

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

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

SYMPTOMS OF GUNSHOT WOUNDS.

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