| GUNSHOT WOUNDS IN GENERAL. | |
| PAGE | |
| Definition of the term | [9] |
| History of the surgery of gunshot wounds | [9] |
| VARIETIES OF GUNSHOT WOUNDS. | |
| Form and nature of missile | [14] |
| Grape-shot, canister, and spherical case | [16] |
| Musket-shot—Conical bullets | [16] |
| Bullets of various weights and sizes | [17] |
| Double bullets | [18] |
| Stones, and splinters of iron or wood | [19] |
| Degree of velocity | [20] |
| Increased by modern fire-arms | [21] |
| Comparison of round and conical balls | [21] |
| The Enfield and Whitworth rifles | [22] |
| Number of wounds in battle | [22] |
| Proportion to shots discharged | [22] |
| Spent balls | [23] |
| Lodgment of balls | [24] |
| Consequences of unextracted balls | [25] |
| Lodgment of an 8-pound ball | [26] |
| Illustrative cases | [27] |
| Fragments of shells | [28] |
| Fragments of bullets | [29] |
| Small foreign bodies | [30] |
| Internal wounds without external marks | [32] |
| Hypotheses concerning | [32] |
| Explanation concerning | [33] |
| Seat of injury | [34] |
| Course of balls | [34] |
| SYMPTOMS OF GUNSHOT WOUNDS. | |
| Diagnostic symptoms | [38] |
| Appearances from various kinds of projectile | [38] |
| Apertures of entrance and exit | [41] |
| Pain of gunshot wounds | [44] |
| Shock of gunshot wounds | [45] |
| Primary hemorrhage | [47] |
| Prognosis of gunshot wounds | [50] |
| Treatment of gunshot wounds in general | [51] |
| Provisional dressing recommended | [51] |
| Surgeon’s first duty | [52] |
| Position of patient for examination | [53] |
| Instruments for conducting examination | [54] |
| Views respecting enlargement of the external orifice | [54] |
| Instruments for extracting balls | [56] |
| Means to be employed for readjusting lacerated wounds | [59] |
| Constitutional treatment | [61] |
| Progress of cure | [62] |
| GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY. | |
| GUNSHOT WOUNDS OF THE HEAD. | |
| Observations on | [63] |
| Wounds of the scalp and pericranium | [65] |
| Wounds complicated with fracture, but without depression on thecerebrum | [67] |
| Fissured fracture | [68] |
| Wounds complicated with fracture and depression on the cerebrum | [69] |
| Wounds with penetration of the cerebrum | [70] |
| Treatment | [71] |
| Use of the trephine | [71] |
| Opinions concerning | [72] |
| GUNSHOT WOUNDS OF THE SPINE. | |
| Statistics of | [75] |
| Vertebral column and spinal cord | [76] |
| GUNSHOT WOUNDS OF THE FACE. | |
| General observations on | [77] |
| Treatment | [78] |
| GUNSHOT WOUNDS OF THE CHEST. | |
| Comparison with other wounds | [80] |
| Non-penetrating | [81] |
| Penetrating | [82] |
| Signs indicating | [83] |
| Hemorrhage from | [83] |
| Indications of the lung being penetrated | [84] |
| Treatment | [85] |
| Wounds of the heart | [89] |
| GUNSHOT WOUNDS OF THE NECK. | |
| Abstract of | [90] |
| GUNSHOT WOUNDS OF THE ABDOMEN. | |
| Observations on | [93] |
| Non-penetrating | [94] |
| Penetrating | [94] |
| Of the diaphragm | [99] |
| Fatality of | [99] |
| Treatment | [100] |
| GUNSHOT WOUNDS OF THE PERINEUM AND GENITOURINARY ORGANS. | |
| Statistics of in the Crimea | [101] |
| GUNSHOT WOUNDS OF THE EXTREMITIES. | |
| Frequency of | [103] |
| Division of | [103] |
| Pyemia from | [104] |
| Upper extremity | [105] |
| Percentage of recoveries from, without amputation | [106] |
| Lower extremity | [109] |
| When to amputate and when to be avoided | [109] |
| The femur | [110] |
| Statistics of cases of | [110] |
| Proportions of recoveries in amputations in | [114] |
| Fractures in the middle and lower third of the femur | [116] |
| Statistics in fractures of the leg, in the Crimean war | [117] |
| AMPUTATION. | |
| Advantages of primary as compared with secondary | [117] |
| SECONDARY HEMORRHAGE. | |
| Reasons for its occurrence | [120] |
| Not uncommon in deeply-penetrating wounds of the face | [121] |
| Rule of treatment | [122] |
| WOUNDS OF NERVES. | |
| Temporary or complete paralysis caused by | [122] |
| Amputations sometimes necessary | [122] |
| TETANUS. | |
| Statistics of | [124] |
| Treatment | [125] |
| Hospital gangrene | [126] |
| Pyemia | [126] |
| ANESTHESIA IN GUNSHOT WOUNDS. | |
| Chloroform | [126] |
| Views respecting its use in secondary operations | [129] |
| Mode of administering | [130] |
| AFTER-USEFULNESS OF WOUNDED SOLDIERS. | |
| Observations upon | [131] |
| General summary | [131] |
GUNSHOT WOUNDS.
Gunshot wounds consist of injuries from missiles projected by the force of explosion. As the name implies, this class of wounds is ordinarily restricted to injuries resulting from fire-arms; but it should be remembered that wounds possessing the same leading characteristics may result from objects impelled by any sudden expansive force of sufficient violence. Injuries from stones, in the process of blasting rocks, or from fragments of close vessels burst asunder by the elastic power of steam, offer familiar examples of wounds of a like nature with those from gunshot. In the following article, however, gunshot wounds will be considered as they are met with in the operations of warfare.
HISTORY.
From the earliest time of the application of gunpowder to implements of war, down to the present day, the wounds inflicted by its means have excited the most marked interest among surgeons; nor can this be wondered at, when the immensely superior energy of this agent in comparison with all the mechanical powers previously in use for hostile purposes, and the terrible nature of its effects on the human frame, are remembered. By its introduction the whole aspect of war was changed, in a great degree, by the distance at which opposing forces were enabled to contend with each other; just as, in our day, the nature of battle seems destined to undergo another change from the increased range and precision of fire obtained through the general use of rifled weapons. But though the alterations now being made in the qualities of fire-arms are of the utmost importance to those whose business and especial study is the art of war, to the army surgeon the interest they excite is chiefly limited to the degree of injury and destruction inflicted by them as compared with weapons of a less perfect kind; while to the surgeons employed at the time of the introduction of gunpowder, the wounds were wholly new in their nature as well as degree. Recollecting the ignorance which then prevailed in all departments of science and art, it can excite no surprise that the new engines of war, with the flame and noise accompanying their discharge, were regarded with superstitious terror; nor that surgeons for a long time found an explanation of the sloughing severity of the injuries they inflicted, and of their difficult cure, in the poisonous nature of gunpowder, or of the projectiles which had been acted upon by it, or in the burning effects of these latter from heat acquired in their rapid flight through the air. Unfortunately, these erroneous views did not end with the theories from which they started, but led to treatment which only aggravated the evils inflicted by the new weapons, and interrupted the progress of the healing action, which nature would otherwise have established. The wound being regarded as a poisoned wound, it was only by a long and tedious process of suppuration that the poison could be hoped to be got rid of from the surface, and prevented from entering the system of the patient. The irritative fever, the wasting and emaciation, and all the other results of the protracted cure of the injury were so many evidences of the indirect effect of the poison working in the frame; just as the constitutional shock at the time of the wound, the loss of vitality along the surface in the track of a small projectile, or of the tissues laid bare by the passage of the cannon-ball were regarded as evidences of its direct influence. On looking back at the works of successive writers on this class of injuries, the reader is surprised that the improvement in their treatment has been so gradual and slow; and cannot fail to observe that the chief impediment to a more rapid amelioration of the system pursued has been the prevailing idea of the necessity of delaying the tendency of nature to close the wound, in order that the supposed poison might be eliminated from the constitution. The openings of entrance and exit and track of the ball were incised; the wound dilated by tents or other means, and terebinthinates, or even boiling oil, poured into it; irritating compounds and ointments applied where superficial dressings were practicable; and it was only after the wound was considered to be fully purged of its venom and foul humors by the extensive suppurative action thus kept up, that cicatrization was permitted to be established.
It required long years of observation in many conflicts, and the exercise of much industry, not to mention moral courage in opposing authorized custom and prejudice, before a simpler and more rational mode of practice was followed. It is satisfactory to know that though Continental surgeons have written more voluminously on the subject of gunshot wounds, the older English military surgeons and writers stand forth conspicuously in leading the way to a more practical knowledge of their nature and proper treatment.
Although, however, much that was erroneous was removed by the earlier surgeons, the light of science can hardly be said to have penetrated this important province of military surgery until the great and last work of John Hunter, on the Blood, Inflammation, and Gunshot Wounds, was published in 1794. This distinguished philosopher filled some of the highest positions in the British service, having been appointed in 1776 Surgeon Extraordinary to the Army, in 1786 Deputy Surgeon-General, and subsequently Surgeon-General; but he only served abroad about three years, and then only had the opportunity of seeing active service as staff-surgeon in the expedition to Belleisle. Had the field of his practical observation been more extensive, there can be no doubt that his zealous and scientific mind would have turned the advantage to the most valuable results for humanity. The physiological principles which he enunciated, based on extensive study and observation in civil life, cannot be controverted; but their practical application, so far as regards the treatment of gunshot wounds, has been greatly modified since his treatise on the subject was published. There cannot be a better illustration of the special position in which this department of military surgery is placed, from the peculiar circumstances under which it is practiced, than the fact that, though men of the highest mental attainments have discussed the subject of gunshot wounds, we are nevertheless indebted to practical experience in military campaigns for every improvement, some few of recent date excepted, that has occurred in their treatment. Thus John Hunter was led to advocate very strongly the delay of amputation, after severe gunshot wounds, for weeks, that the patient’s constitution might accommodate itself to the injury; while more extended observation has demonstrated that such secondary amputations are more fatal than those which are performed shortly after the infliction of the wounds leading to them—the advantage of the patient thus coinciding with what must very constantly happen to be a practice of necessity in the field. Mr. Guthrie remarks, in his Commentaries on the Surgery of the Peninsular War, between 1808 and 1815, that the surgical principles and the practice which prevailed at the commencement of the war were superseded on almost all important points at its conclusion; and he quotes a remark of Sir Astley Cooper to the effect that the art of surgery received from the practical experience of that war an impulse and improvement unknown to it before.