2. Shock.
—Shock is present in a large proportion of gunshot injuries, especially those of the viscera and the region of the spine. Experienced army surgeons speak of the peculiar facial expression in those cases of shock which demand immediate attention.
3. Pain.
—The symptom of pain is exceedingly variable. It is rarely complained of at the time of infliction, especially when the individual is laboring under stress of excitement. The pain of a wound will be increased by every movement of the body. When momentary pain is followed by local anesthesia, and especially if the latter be permanent, it will indicate the division of a nerve trunk, which will justify an operation for exposure of the site of the injury and nerve suture.
4. Powder Burn.
—Powder burn is met with only as one of the complications of a short range and injury of an exposed part. Its degree is modified by the distance of the injured part from the muzzle, by the character of the powder, and the dimensions of the barrel. Fish has shown that in a pistol wound at short range the burning or scorching effects, which he calls the “brand,” are always found on the hammer side of the weapon which inflicted the wound, i. e., if the hammer were held up the brand would be above the entrance wound. The bullet wound in such a case shows the direction of the aim, but the recoil will so far change the direction of the barrel as to divert the stream of gases of combustion, so that they follow the new direction of the barrel, which is always toward the side of the hammer. This is a point in medical jurisprudence which has been testified to in the courts. The use of smokeless powder minimizes any effect of this kind. It has been claimed that a homicide has been recognized in the dark by the flash of the old-fashioned gunpowder used in the weapon, but the use of smokeless powder would obviate this possibility. The most distinctive part of a powder burn is the appearance of the tattooing caused by the lodgement under the skin of grains of unconsumed powder. Such grains, when accidentally or purposely contaminated with germs, are not purified by the act of firing. This is less true of certain brands of smokeless powder. Nevertheless the opinion prevails that gunpowder may serve for conveyance of infection. The so-called smokeless powders are of secret composition, although it is known that in a general way they are composed of gun-cotton, dynamite (i. e., nitroglycerin), or picric acid. Melinite is composed of picric acid and collodium—i. e., gun-cotton. There are many of the modern explosives which depend for their final effect upon the combination of two or more substances. In the smokeless powers there is usually enough nitroglycerin to have a very noticeable effect should they be touched to the tongue, while even the fumes might be disagreeable or disabling.
5. Localizing Symptoms Due to the Presence of the Bullet.
—The greater the distance and the smaller the velocity the more likely is a bullet to lodge within some portion of the body instead of passing through it. In the Cuban campaign the proportion of cases of lodgement was less than 10 per cent. of the entire number of bullet wounds. A bullet which rests within the body either will or will not produce disturbances which may be more or less lasting. In a large proportion of cases the latter will prevail. The number of pensioned soldiers who are carrying unremoved bullets in some portions of their body is by no means small. A rifle bullet may remain in certain portions of the cranium without producing much disturbance. Bullets which cause no trouble are best left undisturbed. Those which produce serious symptoms should be removed. To Esmarch is attributed the dictum that the harm produced by a bullet is usually done during its passage, and after it has found lodgement it ceases to be a source of trouble. While not invariably true, this is so generally the case that acceptance of this statement has revolutionized the previously prevailing view, i. e., that a bullet should be always removed if it be possible to locate and extract it. In some instances it may be located by a study of the symptoms; as, for instance, in certain areas of the brain, or when lying in close proximity to joint surfaces it interferes with their function; although a bullet embedded in bone often does not seriously interfere with the use of the affected part. The bullet which divides a nerve trunk rarely lodges in such position as to be considered when the repair of the nerve injury is undertaken; such wounds will generally be found to be perforating.
Fig. 48
