A Treatise on Gunshot Wounds

by Sir T. Longmore

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.

Gunshot wounds vary in gravity from the simplest laceration of cuticle to the instantaneous destruction of life. Death may take place primarily from direct causes already alluded to, viz.: from the destruction of vital organs, from extreme shock to the vital forces through the nervous system, or from hemorrhage; or it may ensue indirectly from secondary hemorrhage, gangrene, erysipelas, hectic fever, pyemia, or from the results of operations necessarily required in consequence of the original injury. In estimating the probable issue of a particular wound, not only the state of health at the time, but, if a soldier, the previous service, and diseases under which he has labored during it, must be taken into account, and the circumstances in which he is placed with respect to opportunity of proper care and treatment must also be carefully weighed. The time which has elapsed after the receipt of the injury is another important matter in forming a prognosis. The difficulties which have been already enumerated in the way of arriving at a safe diagnosis of the true nature and extent of the injury, and the liabilities above mentioned to which a patient with a gunshot wound is exposed, should put a surgeon on his guard against giving a hasty judgment in any case that is not very plain and simple. Military surgery abounds with examples of wounds of such extent and gravity as apparently to warrant the most unfavorable prognosis, which have nevertheless terminated in cure; while others, regarded as proportionably trifling, have led to fatal results. Tables may be found in works showing statistically the nature and relative numbers of wounds and injuries received in various actions, with their immediate and remote consequences, as well as the results of the surgical operations they have led to; but these afford little aid toward the prognosis of particular cases, each of which must be estimated in its own individual circumstances. Such tables are chiefly of value where they afford indications of the effects of different modes of treatment in wounds of a corresponding nature, and then only in patients under like circumstances of age and condition. Even moral circumstances must not be disregarded. The probable issue in any given case will be very different in one soldier, who is supported by the stimulating reflection that he has received his wound in a combat which has been attended with victory, from what it will be in another, who labors under the depression consequent upon the circumstances of defeat.

TREATMENT OF GUNSHOT WOUNDS IN GENERAL.

When the circumstances of a battle admit of the arrangement, the wounded should receive surgical attention preliminary to their being transported to the regimental or general field hospitals in rear. A slight provisional dressing, a few judicious directions to the bearers, may occasionally prevent the occurrence of fatal hemorrhage, or avert serious aggravation of the original injury from malposition, shaking, and spasmodic muscular action, in the course of conveyance from the neighborhood of the scene of conflict to the hospital. In the siege operations before Sebastopol, this was accomplished by assistant surgeons in the trenches, or, according to the French system, by regular ambulance hospitals in the ravines leading to them. The provisional treatment should be of the simplest kind, and chiefly directed to the prevention of additional injury during the passage to the hospital, where complete and accurate examination of the nature of the wound can alone be made, and where the patient can remain at rest after being subjected to the required treatment. The removal of any missiles or foreign bodies which may be readily obvious; the application of a piece of lint to the wound; the arrangement of any available support for a broken limb; protection against dust, cold, or other objectionable circumstances likely to occur in the transit; if “shock” exist, the administration of a little wine, aromatic ammonia, or other restorative, in water,—need little time in their execution, and may prove of great service to the patient. If hemorrhage exist from injury to a large vessel, it must of course receive the surgeon’s first and most earnest care. He should not trust to the pressure of a tourniquet, but secure it at once by ligature. Without this safeguard during the transport, and while in the hands of uneducated attendants, the life of the wounded man might be endangered, either from debility consequent upon gradual loss of blood or from sudden fatal hemorrhage. It has been recommended by some surgeons that all attendants whose duties consist in carrying the wounded from a field of battle should be directed, when bleeding is observed, to place a finger in the wound, and keep it there during the transport until the aid of a surgeon is obtained. The precise spot where compression by the finger is wanted, and the degree of pressure necessary, will be quickly made manifest to the sight by the effects on the flow of blood. Such a practice seems to offer less objection than the use of tourniquets by men whose knowledge of their proper application must be exceedingly limited.

On arrival at the hospital, where comparative leisure and absence of exposure afford means of careful diagnosis and definitive treatment, the following are the points to be attended to by the surgeon: firstly, examination of the wound with a view to obtaining a correct knowledge of its nature and extent; secondly, removal of any foreign bodies which may have lodged; thirdly, adjustment of lacerated structures; and fourthly, the application of the primary dressings.

The diagnosis should be established as early as possible after the arrival at hospital. An examination can then be made with more ease to the patient and more satisfactorily to the surgeon than at a later period. Not only is the sensibility of the parts adjoining the track of the ball numbed, but there is less swelling to interfere with the examination, so that the amount of disturbance effected among the several structures is more obviously apparent.

One of the earliest rules for examining a gunshot wound is to place the patient, as nearly as can be ascertained, in a position similar to that in which he was, in relation to the missile, at the time of being struck by it. In almost every instance the examination will be facilitated by attention to this precept. Occasionally it will at once indicate the probable injury to vessels or other important structures, in cases where the mutual relations of the wounds of entrance and exit, in the erect or horizontal posture of the body, would lead to no such information. Even in the direct course taken by a rifle-ball in a simple flesh wound, an erroneous opinion of the line in which the ball has moved may be formed from the first view, in consequence of the ready mobility of the several structures among themselves and their varying degrees of elasticity. Injury to nerves inducing paralysis, contusions of blood-vessels leading to secondary hemorrhage or gangrene, may thus, without sufficient circumspection, be overlooked on the first admission to hospital.

When only one opening has been made by a ball, it is to be presumed that it is lodged somewhere in the wound, and search must be made for it accordingly. But even where two openings exist, and evidence is afforded that these are the apertures of entrance and exit of one projectile, examination should still be made to detect the presence of foreign bodies. Portions of clothing, and, as has already been shown, other harder substances, are not unfrequently carried into a wound by a ball; and, though it itself may pass out, these may remain behind either from being diverted from the straight line of the wound or from becoming caught and impacted in the fibrous tissue through which the ball has passed. The inspection of the garments worn over the part wounded may often serve as a guide in determining whether foreign bodies have entered or not, and, if so, their kind, and thus save time and trouble in the examination of the wound itself.