A Treatise on Gunshot Wounds

by Sir T. Longmore

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.