A Treatise on Gunshot Wounds

by Sir T. Longmore

Of all instruments for conducting an examination of a gunshot wound, the finger of the surgeon is the most appropriate. By its means the direction of the wound can be ascertained with least disturbance of the several structures through which it takes its course. If bones are fractured, the number, shape, length, position, and degree of looseness of the fragments may be more readily observed. In case of lodgment of foreign bodies, not only is their presence more obvious to the finger direct than through the agency of a probe or other metallic instrument, but by its means intelligence of their qualities is also communicated. A piece of cloth lying in a wound is recognized at once by a finger, while, saturated with clot as it is under such circumstances, it would probably be confounded among the other soft parts by any other mode of examination. The index finger naturally occurs as the most convenient for this employment; but the opening through the skin is sometimes too contracted to admit its entrance, and in this case the substitution of the little finger will usually answer all the purposes intended. When the finger fails to reach sufficiently far, owing to the depth of the wound, the examination is often facilitated by pressing the soft parts from an opposite direction toward the finger-end.

It was formerly the custom to enlarge the external orifice of all gunshot wounds by incision, and not merely the opening, but the walls of the wound itself, as soon after the injury as possible. This was not done as a means of rendering the examination easier, but as a prophylactic measure. Dilatation was also employed by tents and various other means with a view to secure the escape of sloughs and discharges. The opinions held by the older surgeons respecting the nature of these injuries, already briefly adverted to in the historical remarks on the subject, sufficiently explain their object in making incisions—namely, to convert what they regarded as a poisoned into a simple wound, and to obviate tension, and prevent strangulation of neighboring tissues by tumefaction or inflammation arising in its track. Even so late as 1792, Baron Percy, in his Manuel du Chirurgien d’Armée, writes: “The first indication of cure is to change the nature of the wound as nearly as possible into an incised one.” English surgeons have, however, generally discarded the practice since the arguments used by John Hunter against it, just about the same date as Baron Percy wrote, excepting only in cases where it is required to allow of the extraction of some extraneous body to secure a wounded artery, to replace parts in their natural situation, as in protrusion of viscera in wounds of the abdomen, or, “in short, when anything can be done to the part wounded after the opening is made for the present relief of the patient or the future good arising from it.” It does not often happen that it is necessary to enlarge the openings of wounds to remove balls, although a certain amount of constriction of the skin may be expected from the addition of the instrument employed in the extraction; but if much resistance is offered to their passage out, it is better to divide the edges of the fascia and skin to the amount of enlargement required than to use force. In removing fragments of shells or detached pieces of bone, the fascia and skin have almost invariably to be divided to a considerable extent.

Where the finger is not sufficiently long to reach the bottom of the wound, even when the soft parts have been approximated by pressure from an opposite direction, and when the lodgment of a projectile is suspected, a long silver probe, that admits of being bent by the hand if required, is the best substitute. Elastic bougies or catheters are apt to become curled among the soft parts, and do not convey to the sense of touch the same amount of information as metallic instruments do. The probe should be employed with great nicety and care, for it may inflict injury on vessels or other structures which have escaped from direct contact with the ball, but have returned, by their elasticity, to the situations from which they had been pushed or drawn aside during its passage. The above directions for examining wounds apply more particularly to such as penetrate the extremities, or extend superficially in other parts of the body; where a missile has entered any of the important cavities, search for it is not to be made, but the surgeon’s attention is to be directed to matters of more vital importance to be hereafter noticed.

As soon as the presence of a ball or other foreign body is ascertained it should be removed. If it be lying within reach from the wound of entrance, it should be extracted through this opening by means of some of the various instruments devised for the purpose. In case of a leaden bullet, Coxeter’s Extractor, corresponding with Baron Percy’s instrument for the same purpose, and consisting of a scoop for holding and central pin for fixing the bullet, has been found a very convenient appliance, from the comparatively limited space required for its action. Instruments of two blades, or scoops, with ordinary hinge action, dilate the track of the wound injuriously before the ball can be grasped by them. The way to the removal of a bullet may often be smoothed by judiciously clearing away the fibers, among which it is lodged, during the examination, by the finger; and sometimes, by means of the finger in the wound, and external pressure of the surrounding parts, the projectile may be brought near to the aperture of entrance, so that its extraction is still further facilitated. Such foreign substances as pieces of cloth can usually be brought out by the finger alone, or by pressing them between the finger and a silver probe inserted for the purpose. Sometimes a long pair of dressing forceps, guided by the finger, is found necessary for effecting this object. Caution must be used in employing forceps, where the foreign substance is out of sight and of such a quality that the soft tissues may be mistaken for it.

In instances where the foreign body has not completely penetrated, but is found lying beneath the skin away from the wound of entrance, an incision must be made for its extraction. Before using the knife, the substance to be removed should be fixed in situ, by pressure on the surrounding parts. In the instance of a round ball, the incision should be carried beyond the length of its diameter; an addition of half a diameter is usually sufficient to admit of the easy extraction of the ball. In removing conical balls, slugs, fragments of shells, stones, and other irregularly-shaped bodies, the surgeon cannot be too guarded in arranging that the fragment is drawn away with its long axis in line with the track of the wound. By proper care in this respect, much injury to adjoining structures may be avoided.

If balls are impacted in bone, as happens in the spongy heads of bones, in bones of the pelvis, and occasionally, though rarely, in other parts of long bones, they should be removed. This can be effected by means of a steel elevator, of convenient size; or, should this fail from the ball being too firmly impacted, a thin layer of the bone on one side of the ball may be gouged away, so that a better purchase may be obtained for the elevator, in effecting its removal. The fact is now fully established that, although in a few isolated cases balls remain lodged in bones without sensible inconvenience, in the majority the lodgment leads to such disease of the bony structure as often to entail troublesome abscesses, and in some instances eventually to necessitate amputation. The lodgment of balls will not often occur without extensive fracture in warfare where rifled arms of such force as the Minié or Enfield are the chief weapons employed, but will not unfrequently be met with in such campaigns as have lately happened in India.

Should there be reason for concluding that a ball or other foreign body has lodged, but after manual examination, and observation as well by varied posture of the part of the body supposed to be implicated as by indications derived from the patient’s sensations, effects of pressure or injury to nerves, and all other circumstances which may lead to information, should the site of the lodgment not be ascertained, the search should not be persevered in to the distress of the patient. Neither, although the site of lodgment be ascertained, if extensive incisions are required, or if there is danger of wounding important organs, should the attempts at extraction be continued. Either during the process of suppuration, by some accidental muscular contraction, or by gradual approach toward the surface, its escape may be eventually effected; or, if of a favorable form, and if not in contact with nerve, bone, or other important organ, it may become encysted, and remain without causing pain or mischief. When John Hunter wrote on gunshot wounds, he remarks, the practice of searching after a ball, broken bones, or any other extraneous bodies, had been in a great measure given up, from experience of the little harm caused by them when at rest, and not in a vital part; and he himself advises, even when a ball can be felt beneath skin that is sound, that it should be let alone, chiefly on the ground that two wounds are more objectionable than one, and that the extent of inflamed surface is proportionably increased by incision. More extensive experience has, however, shown that not only is the risk of subsequent ill results greater in those cases where foreign bodies remain lodged than when they have been cut out, but also that the advantages of a second opening for the escape of the necessary sloughs and discharges greatly preponderate over the disadvantages connected with it, as regards the additional extent of injured surface. The advantage also of the satisfaction to the mind of a patient from whom a ball has been removed must not be overlooked; for men suffering from gunshot wounds are invariably rendered uneasy by a vague apprehension of danger, for some time after the injury, if the missile has remained undiscovered.

When a gunshot wound has been accompanied with much laceration and disturbance of the parts involved in the injury, it is necessary, after the removal of all foreign substances that can be detected, to readjust and secure the disjointed structures as nearly as possible in their normal relations to each other. The simplest means—strips of adhesive plaster, light pledgets of moist lint, a linen roller, favorable position of the limb or part of the body wounded—should be adopted for this purpose. Pressure, weight, and warmth should be avoided as much as possible in these applications, consistent with the end in view. It must not be forgotten, in thus bringing the parts together, that the purpose is not to obtain union by adhesion, which cannot be looked for, but simply to prevent avoidable irritation and malposition of parts, during the subsequent stages of cure by granulation and cicatrization. In all gunshot wounds, much discomfort to the patient is prevented by carefully sponging away all blood and clot from the surface adjoining the wound, and by adopting measures to prevent its spreading again in consequence of oozing. This can be readily done with the aid of a little warm water, and arrangement when the wound is first dressed, but can only be accomplished with considerable inconvenience after the thin clots have become hard and firmly adherent to the skin.

When the parts of a lacerated gunshot wound have been brought into apposition, as in simple penetrating wounds, the only dressing necessary is moistened lint. It should be kept moist either by the renewed application of water dropped upon it, or by preventing evaporation by covering it with oiled silk. The sensations of the patient may be consulted in the selection of either of these, and climate and temperature will be often found to determine the choice. In hot climates cold applications are the more grateful, and by checking the amount of inflammatory action and circumscribing its extent are usually the more advantageous. M. Velpeau and other French surgeons have strongly recommended the use of linseed-meal poultices, above all wet linen applications. Charpie is still extensively employed in French military hospitals.[5] M. Baudens and Dr. Stromeyer have strongly recommended the topical application of ice placed in bladders; others, the continued irrigation of the wound with tepid water. The means of applying such remedies are rarely available in the military hospitals where gunshot wounds are ordinarily treated in their early stages. When much local inflammation has set in, and when there is much constitutional fever even without unusual local irritation, the non-evaporating or warm applications will be found to be the most advantageous.