Part 4

=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.[3] A somewhat similar case occurred in the 38th Regiment, but the ball appears to have been a round one. M. Huguier has collected some curious cases of splitting of balls, from the records of the French revolution: among others, the division of a ball into two parts, of another into three parts, against the supra–orbital ridge, and of another into three parts against the clavicle. A case is recorded, where a grenadier in Algeria was wounded in five places, all wounds of entrance, by one ball. It was divided into five portions by first striking against a rock at five or six paces from the soldier, the fragments rebounding at various angles. John Hunter mentions the case of a young gentleman who was shot through the abdomen by means of a musket loaded with three balls. In this instance there were only two orifices of entrance and two of exit, one ball having followed in the track of one of the others; “that there were three that went through him was evident, for they afterward made three holes in the wainscot behind him, but two very near each other.” Had it not been for this proof, it being known that three balls were discharged, a suspicion might have existed that one of the three balls had lodged. The recollection that such accidents may occur will sometimes assist in the diagnosis of doubtful cases.

The number of wounds made by one ball may be increased by its traversing two adjoining extremities of the same person, or even distant parts of the body from accidental relative position at the time of the injury. On the 18th of June, 1848, at Paris, a man received a ball in his right arm, above the elbow, which caused a comminuted fracture of the humerus. It then passed across and entered the left arm below the elbow, fracturing the upper part of the radius. Dr. Hennen mentions the case of a man on a scaling–ladder, in which a ball passed from the middle of the upper arm on one side to the middle of the thigh on the opposite side. It is evident, when the ball traverses with sufficient velocity, that these accidents will not unfrequently occur, especially between the upper extremity and trunk. They correspond with such events as more than one person being wounded by the same ball, examples of which were not unfrequently noticed in the trenches before Sebastopol, from enfilading shots, especially prior to the capture of the Mamelon Vert and other outworks; and are said to have been very common in the late campaign in Italy. Should the Whitworth rifle ever be brought into general use, the proportionate number of wounds thus caused from the greater density of the ball, its immensely superior force, and low trajectory, must be still further increased.

The two openings made by one ball may hold such a relative situation as to lead to the mistake of their being supposed to be caused by two distinct balls. A case is recorded where a ball entered the scrotum, and made its exit from the right thigh, without any intermediate mark of its passage; such a wound might lead to an erroneous diagnosis of this sort. Length of traverse, and consequent distance between the two openings, parts of the body brought into unusual relations from peculiarities of posture, and peculiar deflections of the ball, may all be sources of this error.

The appearances of wounds resulting from penetrating missiles of irregular forms, as small pieces of shells, musket–balls flattened against stones, and others, differ from those caused by ordinary bullets in being accompanied with more laceration, according to their length and form. Being usually projected with considerably less force than direct missiles, such projectiles ordinarily lead only to one aperture, that of entrance.

=Pain.=—A gunshot wound by musket–shot is attended with an amount of pain which varies very much in degree according to the kind of wound, condition of mind, and state of constitution of the soldier at the time of its infliction. It will sometimes happen in simple flesh wounds, that patients will tell the surgeon they were not aware when they were struck; and examples attesting the truth of such statements occur, of soldiers continuing in action for some time without knowing they had been wounded. Sometimes the pain from the shot is described as a sudden smart stroke of a cane; in other instances as the shock of a heavy intense blow. Occasionally the pain will be referred to a part not involved in the track of the wound. Lieutenant M. of the 19th Regiment was wounded by a musket–ball at the assault of the Redan, on the 8th of September, 1855. His sensations led him to imagine that the upper part of his left arm was smashed, and he ran across the open space in front of the works, supporting the arm which he supposed to be broken. On arriving at the advanced trench, he asked for water; on trying to drink, he found that his mouth contained blood, and that he was unable to swallow. The arm, on examination, was found to be uninjured, but a ball had passed from right to left through his neck, and from its direction had no doubt struck some portion of the lower cervical or brachial plexus of nerves. Immediately after the transit of a ball, the sensibility of the track and parts adjoining is found to be partially numbed, so that examination is borne more readily for a short time after the accident than at any later period. Of course, after reaction sets in, or when inflammation has become established, the pain of the wound is proportionably increased. When a ball does not penetrate, but simply inflicts a contusion, the pain is described to be more severe than where an opening has been made by it.

=Shock.=—When a bone is shattered, a cavity penetrated, an important viscus wounded, a limb carried away by a round shot, pain is not so prominent a symptom as the general perturbation and alarm which supervene on the injury. This is generally described as the “shock” of a gunshot wound. The patient trembles and totters, is pale, complains of being faint, perhaps vomits. His features express anxiety and distress. This emotion is in great measure instinctive; it is witnessed in the horse hit mortally in action, no less than in his rider; it is sympathy of the whole frame with a part subjected to serious injury, expressed through the nervous system. Examples seem to show that it may occasionally be overpowered for a time, even in most severe injuries, by mental and nervous action of another kind; but this can rarely happen when the injury is a vital one. Panic may lead to similar results when the wound is of a less serious nature. A soldier, having his thoughts carried away from himself—his whole frame stimulated to the utmost height of excitement by the continued scenes and circumstances of the fight—when he feels himself wounded, is suddenly recalled to a sense of personal danger; and if he be seized with doubt whether his wound is mortal, depression as low as his excitement was high may immediately follow. This will happen according to individual character and intelligence, state of health, and other circumstances. For while, on the one hand, numerous examples occur in every action of men walking to the field hospital for assistance almost unsupported, and with comparatively little signs of distress, after the loss of an arm or other such severe injury; on the other, men whose wounds are slight in proportion are quite overcome, and require to be carried.

As a general rule, however, the graver the injury, the greater and more persistent is the amount of “shock.” A rifle–bullet which splits up a long bone into many longitudinal fragments, inflicts a very much more serious injury than the ordinary fracture effected by the ball from a smooth–bore musket, and the constitutional shock bears like proportion. When a portion of one or of both lower extremities is carried away by a cannon–ball, the higher toward the trunk the injury is inflicted, the greater the shock, independent of the loss of blood. Some writers, in accounting for “shock,” lay stress on the concussion, and general mechanical effects on the whole body, of the momentum of the iron shot.[4] To a certain extent this may be true, but, judging from analogy in physics, the greater the velocity, and consequently the momentum, of a ball carrying away a limb, the less would the concussion of the trunk and distal parts of the body be. A pistol–ball at full speed will take a circular portion out of a pane of glass without disturbing the remainder; if the speed be much slackened, as when fired from a distance, it will shake the whole pane to pieces.

That true “shock,” (_ébranlement_ of French writers,) as distinguished from shock resulting from mental depression after unusual excitement, or the effects of groundless alarm on the part of a patient, is a phenomenon the essential relations of which are connected with vital force, and with that endowment of the organization only, may be judged from observation of cases in which the direct result of the wound is inevitably fatal, including many where no physical effects on neighboring parts from concussion could possibly be produced. In such injuries the “shock” remains, from the time of first production of the fatal impression till life is extinguished. And the practical experience of every army surgeon teaches him that where a ball has entered the body, though its course be not otherwise indicated, the continuance of shock is a sufficient evidence that some organ essential to life has been implicated in the injury. That the shock of a severe gunshot wound may be complicated with other symptoms, or that some of its own symptoms may be exaggerated from other causes,—hopes disappointed, the approach of death, and all the attendant mental emotions,—scarcely affects the question at issue; for its existence, independent of these complications, in all such cases is undoubted.

=Primary hemorrhage.=—Primary hemorrhage of a serious nature from gunshot wounds does not often come within the sphere of the surgeon’s observation. If hemorrhage occur from one of the main arteries, it probably proves rapidly fatal; and surgeons, after an action, are usually too much occupied with the urgent necessities of the living wounded to spare time for examining the wounds of the dead, who are mostly buried on the field where they fall. Thus most surgeons speak of primary hemorrhage being exceedingly rare, more rare, perhaps, than it actually is. M. Baudens, referring to his service in Algeria, has remarked that he has often found on the field of battle wounded soldiers who had died of primary hemorrhage.

In those wounds to which the surgeon’s care is called, the primary hemorrhage is ordinarily small in quantity and of short duration—a sudden flow at the moment of injury, and nothing more. When a part of the body is carried away by round shot or shell, the arteries are observed to be nearly in the same state as they are found to be in when a limb is torn off by machinery. The lacerated ends of the middle and inner coats are retracted within the outer cellular coat; the caliber of the vessel is diminished, and tapers to a point near the line of division; it becomes plugged within by coagulum; and the cellulo–fibrous investing sheath, and the clot which combines with it, form on the outside an additional support and restraint against hemorrhage. When large arteries are torn across, and their hemorrhage thus spontaneously prevented, they are seldom withdrawn so far but that their ends may be seen protruding and pulsating among the mass of injured structures; yet, though the impulse may appear very powerful, further hemorrhage is rarely met with from such wounds. There is more danger of continued hemorrhage from wounds by pieces of shell, as the arteries are liable to be wounded without complete transverse section of their coats. The sharp edges, less velocity, and oblique direction in which the fragments usually impinge sufficiently explain this difference.

It comparatively rarely happens that arteries are cut across by musket–bullets, either round or conical. The lax cellular connections of these vessels, the smallness of their diameters in comparison with their length, the elasticity as well as toughness of the tissues forming their coats, the fluidity of their contents, and, in consequence of all these conditions, the extreme readiness with which they slip aside under pressure, act as means of preservation when these important structures are subjected to such danger as the passage of a musket–ball in their direction. Endless examples occur where the ball appears to have passed through in the direct line of the artery, so that it must have been pushed aside by it to have escaped division. Mr. Guthrie mentions a case where a ball even opened the sheath of the femoral vessels, and passed between the artery and vein, in a soldier at Toulouse, without destroying the substance of either vessel. So close was the ball, and such contusion was produced, together with, doubtless, injury to the vasa vasorum, that the artery became plugged with coagulum, and obliterated. A preparation of these vessels is in the museum at Fort Pitt. Another case is mentioned by Mr. Guthrie, where the direction of a ball between the left clavicle and first rib, and permanent diminution of the pulse in the arm on the same side, led to the conclusion that the subclavian had escaped direct destruction by the missile in a similar way.

Vessels do not always thus happily elude division by the ball. Captain V., of the 97th Regiment, whose death led to so much interest in England, was struck by a ball which divided the axillary artery on the right side. The arm had apparently been extended when he received the injury, as if in the act of holding up his sword. The night was very dark, the distance from the place where the sortie took place in which he was wounded to the camp hospital was more than a mile and a half, and he sunk from hemorrhage while being carried up. The death of an officer from division of the femoral artery is recorded in the Surgical History of the Crimean War, where also cases are mentioned, though not immediately fatal, of a wound of the femoral vein and profunda artery in the same subject from a conical bullet; and another, of the popliteal artery and vein, also from a rifle–ball. Mr. Guthrie mentions the cases of two officers who were killed, almost instantaneously, one by direct division of the common iliac artery, the other of the carotid. Primary but indirect hemorrhage, in consequence of a gunshot injury, usually occurs as a complication of fractured long bones, the sharp points and edges of which, extensively torn up as they now are by conical bullets, are well calculated to cause such injuries. They are not as frequent as might be expected, from the limits within which the dispersion of the fragments is restricted by their periosteal and other connections, and the yielding mobility, before mentioned, of the vessels themselves. We have no data, however, to guide us in determining the proportionate frequency of fatal results from primary hemorrhage after wounds; nor can we have them until proper examination and classification of the particular causes of death on the field of battle are instituted.

PROGNOSIS.