GENERAL MEDICO-LEGAL CONSIDERATIONS.
The result of the wonderful advance in the practice of surgery made during the past fifteen years has been in a large measure to revolutionize the treatment of gunshot wounds, and inasmuch as the result of many homicidal attempts will depend in large measure upon what the surgeon can do for the victim of assault, it may not be amiss to very briefly epitomize in this place something of what modern surgeons believe with regard to the best treatment of bullet-wounds, expressed in a general way. They have learned, among other things, that the harm which a bullet does is done by it during its flight, and that after it has come to a stop it is, per se, an almost invariably harmless foreign body. This is practically always the case unless it has carried in with it foreign material which may serve as a source of septic infection.
In time past there has always been a strong feeling, which had, however, nothing scientific to justify it, that every gunshot wound was a poisoned one. Of late, since bacteriology has attained the proportion of a science, it has been held that bullets were necessarily sterilized by the heat of the discharge of powder behind them. Very recently Dr. B. Von Beck, Medical Director of the 14th German Army Corps, has made experiments upon the amount of heat imparted to leaden and other bullets after firing. After making an allowance for specific heat and the conductivity of the different metals used, he found that even when the projectiles encountered resistance from three to four times greater than that offered by the human body the results were as follows: Temperature of leaden bullets of .45 calibre, when recovered, 69° C.; of .30 calibre, covered with steel, when recovered, 78° C.; of .30 calibre, covered with copper, when recovered, 101° C. He states that these experiments disprove the theory that certain lesions in wounds can be in any way attributed to the heat imparted by the bullet.
While these experiments prove that the bullets may be heated to the above degrees when recovered, they by no means prove that they are so heated at the time when they inflicted the wound. During the year 1892 some very interesting experiments were carried on by Dr. Lagarde, of the Army Medical Department (New York Medical Journal, Oct. 22d, 1892, p. 458). He experimented by deliberately infecting bullets and then firing them into cotton, and animals as well, studying the effect both on the bullets themselves and upon the animals. Some of these bullets were taken from the original packages, while others had been intentionally rolled in dirt. The experiments were carefully carried out and appear reliable, and the conclusions given by the author, which interest us here, are as follows:
(1) The vast majority of cartridges in original packages are sterile or free from septic germs because of the disinfection and absolute cleanliness observed in the process of their manufacture.
(2) The majority of gunshot wounds are aseptic because the vast majority of the projectiles inflicting them are either sterile or free from septic germs.
(3) The heat developed by the act of firing is not sufficient to destroy all the organic matter of the projectile, the cherished notions of three centuries or more to the contrary notwithstanding.
The results as set forth justify the assumption that a septic bullet can infect a gunshot wound. The average bullet-wound, however, is sterile so far as infection from the bullet is concerned, and in accordance with this view of its usual innocence there need be no longer the clamor for removal of the missile which the fears of previous generations have nearly always called for; and the best practice among military surgeons of to-day is rather to let the bullet remain where lodged than to make a more serious wound for its removal. Exceptions to this rule occur only in cases where operation is called for on account of injury done by the bullet while still in motion. It is also held to be a violation of simple physiological and surgical rules to probe or carelessly search for a bullet whose location cannot be made out from a study of signs and symptoms in a given case. The act of probing breaks up blood-clot, often brings on fresh hemorrhage, is in a majority of cases unsatisfactory, frequently introduces specific elements from without, and really gives little, if any, more information than can be gathered from a study of the case without the use of the probe. If every ordinary bullet-wound which did not call for immediate operation because of injury to some essential or vital part—such as a large blood-vessel or nerve-trunk, or some of the viscera—were antiseptically and hermetically sealed at the very outset, there would be a much smaller percentage of death from gunshot wounds, either in civil or military practice, than now obtains. And it might be a matter upon which to go to the jury whether violation of such rules, to-day, does not mitigate the offence of the accused.
Recent discoveries in so-called cerebral localization have instigated numerous operations upon the skull and brain for the relief of pressure, as from blood-clot, or for removal of depressed bone or a bullet which twenty years ago would have been impossible. The brain is no longer the terra incognita of the past generation of medical men, and it is now often possible for the surgeon to intervene in such a way as to save life in cases previously considered hopeless; in fact, such is now his duty when consent can be gained, and it should be held that he is culpable when deficient in general knowledge in this respect.
In wounds of the thoracic cavity it should now be held that so long as air has entered through a bullet-wound there are cases where free incision, even with removal of ribs, can scarcely increase the dangers, while permitting opportunity for much more accurate exploration and determination of life-saving methods. The experiments of numerous investigators, the writer included, have shown that bullet-wounds of the heart need not be always and invariably fatal, and have afforded an element of hope from the possible surgery of even this organ. The writer looks forward to the time when some accomplished yet daring surgeon, getting the right patient at the right time and in the right place, i.e., where conveniences are at hand, shall, in some case of perforating wound of the pericardium or of the heart itself, resect some portion of the anterior thoracic wall, lay open the pericardium, maintaining meanwhile artificial respiration if necessary, and suture a wound in the heart-substance, thereafter closing the pericardium and external wound, and save life which would otherwise be surely sacrificed. With others he has done this upon animals, hence why may it not be done in man?
In the mean time for, first, the recognition and, second, the surgical treatment of perforating wounds of the abdominal viscera, American surgeons have won for themselves the greatest credit, and an already long list of successful laparotomies after gunshot wounds of the intestines, with intestinal suture or resection, has shown the very great value of this procedure, even though it has kept some would-be murderers from the gallows.
These lines are inserted here because the time and effort which surgeons have devoted to this kind of surgery deserve only the highest encomiums and encouragement from the legal profession, although to our deep regret they have not always met with the same.