A Treatise on Gunshot Wounds

by Sir T. Longmore

Grape-shot, canister, and spherical case, on striking collectively—that is, before they have spread—as sometimes happens in assaulting or in accidental close proximity to guns in the field, produce the same kinds of injuries as cannon-shot, but individually resemble musket-shot in their effects. Wounds from grape-shot are always of a grave character, not only from the extent of the flesh wound, but also because, from their large diameter and weight, the nerves and vessels of the part struck are less likely to escape injury, if not destruction, than in wounds from the smaller shot projected in canister or spherical case.

With regard to musket-shot, the form presents several features for the consideration of the military surgeon. In discussing the subject, however, it must not be omitted to be borne in mind that we have no experience of the effects of round musket-balls propelled with the same amount of force as recent improvements in fire-arms have given to balls furnished with a conical vertex; although, in the old, two-grooved rifle, with its belted round ball, a momentum was procured far exceeding that of the common smooth-bore musket. The change in form from the round to the prolonged cylindro-conoidal ball seems to derive its chief importance in surgery from the conical end possessing the mechanical characteristic of a wedge, while the former acted simply as an obtuse body. From this quality the power of penetration of conical bullets is greater, independent of the increased momentum communicated to them by the construction of the weapons from which they are discharged. Thus, supposing one of the old musket-bullets to strike a limb at 80 yards, and an Enfield rifle conical bullet of the same weight at 800 yards, the rate of velocity being similar in each case, the injury from the latter may be expected to be considerably greater than that from the former, on account of its shape. The wedge-like quality of the conical bullet is rendered particularly obvious on its being driven into the shafts of the long bones of the extremities. The solid, osseous texture of which the cylindrical portion of these bones is composed is split up into fragments, having mainly a direction parallel with the central cavity; and fissures not unfrequently extend from the seat of injury to their terminations in the joints, of which they form component parts. Such results were scarcely ever noticed from the impulse of round balls. The bone might be comminuted, but the fragments were of a more cuboid shape, and the long fissuring did not occur. It has been stated that the screw motion impressed on the ball by the rifling of the musket contributes to its increased power of injury on bone; but its shape, combined with its momentum, seem sufficient to explain the severity of its effects above those of the round bullet. Another result of the tapering form of the conical bullet is that it is less exposed, in its course through soft parts of the body, to opposition from tendons and other long and elastic structures, so frequently noticed to stay the progress of spherical shot. If not dividing them by direct impingement, it readily turns them aside; and it is partly due to this pointed shape, therefore, as well as to increased force, that, as will be noticed hereafter, the lodgment of balls is now so rare in comparison with the experience of former wars.

Much has been written on the comparative surgical effects of bullets of various weights and sizes; but these qualities do not, on consideration, excite so much practical interest in the mind of the surgeon as it might at first appear they are calculated to do. Some very heavy bullets were used by the Russians in the defense of Sebastopol, nearly one-third heavier than any employed by the troops opposed to them. Such bullets, if of like form and density, and propelled with equal velocity, would obviously inflict injuries—especially against osseous structures, which offer great resistance—wider in proportion to their greater size and momentum; but, in respect to simple flesh wounds, the increased size of the wound left by the larger ball would make little difference in the gravity of the wound, or the time required for its cure, while the escape of foreign substances, which it might happen to carry with it, would be facilitated by the freer means of exit and increased discharge from the surface. Mr. Guthrie mentions that, having had a wide field for observation in the effects of the heavy British musket-ball, sixteen to the pound, on the French wounded, he did not think them more mischievous in their results than the French musket-balls, twenty to the pound, on the English soldiers; while the advantages of carrying a lighter musket and greater number of rounds of ammunition were on the side of our adversaries. It is understood that in warfare the object is not so much to destroy life as to disable antagonists, and the smaller size has been supposed to be fully equal to this object by the British military authorities of the present day; for in the weapon most recently given to the troops, the Enfield rifle, the weight of the ball has been reduced two drachms and a half below that of the ball with the Minié, previously in use. After all, within the moderate limits which must be preserved to suit the circumstances of infantry soldiers, the form and velocity of musket-balls must be the qualities of interest to the surgeon in connection with the wounds inflicted by them, rather than their weight or size, as with projectiles from guns of large caliber.

Double bullets, linked together by a spiral coil of wire, something after the manner of chain cannot-shot, were introduced by the Russians during the war in the Crimea. Specimens of these bullets were found about the works around Sebastopol, but no injuries received from them have been recorded; although, after the discovery, peculiarities in the characters of some wounds, which had not previously been satisfactorily accounted for, were supposed to have probably resulted from them. It seems likely, however, that, when discharged, the divergent forces impressed on the two bullets were sufficiently great to break apart the connecting wire, which was of very slender diameter, before they came into contact with the troops against whom they were directed. Dr. Scrive, in his History of the Eastern Campaign, mentions also that incendiary balls were employed by the Russians. They consisted of a small cylinder of copper containing a detonating composition, and made up into the form of an ordinary cartridge, so as to be discharged from a musket. On hitting its object, the projectile burst with violence. These balls were not known till after the conclusion of the siege; and it was only then, M. Scrive remarks, that a key was obtained to some wounds of a frightful character which could not be accounted for by the action of ordinary bullets or fragments of shell. No similar observation is recorded in the British surgical history of the war.

Wounds caused indirectly by stones from parapets, splinters of iron or wood, and by fragments of shells are very varied in character and severity. They derive their importance chiefly from the extent of surface usually lacerated and destroyed. Unless they happen to have penetrated or torn away largely the coverings of vital parts of the body, they are often less grave, though to the sight more fearful, than injuries of less alarming appearance from direct projectiles. In missiles of this secondary kind, the amount of resistance offered to their displacement proportionably diminishes the impetus with which they strike. In like manner, the powerful opposition of the hollow iron shell to the force of the bursting charge within, as well as the shape of the portions into which it is usually rent asunder, combine to cause the momentum of each fragment at starting to be much less, and this momentum to be more rapidly retarded during its flight through the air, than happens in ordinary missiles of direct explosion. The constitutional shock, in these injuries, is consequently, as a general rule, less than in direct gunshot wounds. Occasionally simple fractures happen from indirect missiles; from direct, they are almost necessarily compound. Although there may be no communication with an external wound, however, there is often great comminution of the bone in these accidents. The laceration and bruising of the soft parts are frequently rendered more dangerous from indirect projectiles in consequence of large vessels or nerves being implicated in the injuries, leading more often to primary hemorrhage and subsequent sloughing of wider tracts than in wounds from direct projectiles of corresponding size. Such sloughing may lead to a fracture of bone becoming compound which was at first simple. Fragments of shells sometimes wound by falling, after having been projected upward in the air. These do not generally produce such serious injuries as fragments striking at once from the exploded shell; not that the force is different, but because the parts chiefly exposed—the shoulders, back, etc.—are more protected from injury, and offer less resistance, from relative form and position, than do the abdomen, loins, and other parts of the body, which usually meet the fragments shot upward when the shell explodes on the ground.

Degree of velocity.—The velocity of motion of different projectiles is an important ingredient in the consideration of the several wounds produced by them. The rates of motion imparted to missiles by the fire-arms of early times were probably, from the imperfect construction of the weapons, defective quality of gunpowder, and other circumstances, as inferior to those of the musket lately in use as the velocity of musket-balls was to that of the conical bullets of the rifles in present use. In a table showing the velocities of certain moving bodies, published in 1851, the common musket-bullet is set down as moving at the rate of 850 miles per hour, the rifle-ball of that time at 1000, the 24-lb. cannon-ball at 1600 miles per hour. But the musket-ball then could not be depended on to hit an object beyond 80 yards, the rifle 200 to 250 yards; while the present Enfield rifle is sighted to 900 yards, and the short Enfield to 1100 yards. The effects of different rates of velocity on wounds are seen in the variations which occur in proportion to the distance which the missile has traveled before inflicting the injury. A cannon-ball which, with but slight velocity of motion added to its weight, would knock a man over, at ordinary speed will carry away a limb without disturbing the general equilibrium of the body. A musket-ball that would be arrested half way through a limb is now replaced by a ball which, at like distance from the point of discharge, will pass through several bodies in succession.

The increased velocity, or, in other words, greater force, of modern projectiles exhibits its effects in two directions—locally, by the greater destruction of the tissues in the track of the projectile; and constitutionally, by greater disturbance in the nerve-force of the whole system. The component parts of that portion of the organized fabric through which a bullet, traveling at the rate of several miles per minute, cleaves its way are inevitably deprived of their vitality. Instances are quoted by authors, of gunshot wounds having healed by simple adhesion; but such examples are not met with from rifle-bullets retaining their original form. Moreover, when considering the course taken by balls in the body, it will have to be shown that the velocity imparted to projectiles from modern weapons has led to another change in gunshot wounds. The great power of resistance so often before exhibited by the yielding elastic tissue of the skin, by tendinous and other structures, is no longer of avail against projectiles from modern fire-arms at their usual rates of speed.

The splitting and destructive effects of conical balls on the shafts of the long bones of the extremities have already been mentioned when referring to the peculiarities of their shape. But, together with form, the amount of momentum is a necessary ingredient in estimating this result. The old round balls—partly from their form, but also from the imperfect mechanism of the firelocks from which they were discharged, and consequent minor degree of velocity imparted to them—on striking bones, would simply be turned away from the direct line, or, failing this, would knock out a portion of the shaft without further fracture, or, having perforated on one side, remain in the cancellated structure, or be simply flattened without penetrating. It seems not unlikely, also, that the modern conical bullets are denser, from the circumstance of their manufacture by mechanical pressure, than bullets, such as are still used in some places, cast in moulds. The influence of density with respect to power of penetration is very great. In the two most perfect of modern English rifles, the Enfield and the Whitworth, the projectiles and charges being of the same weight, when lead is used, the penetration at 800 yards is one-third greater with the Whitworth than the Enfield; but if a less yielding projectile is used, (as when the lead is mixed with tin,) its penetration is as 17 to 4 at 800 yards. Whether this cause operates or not, the fact is certain that conical balls in action exhibit almost invariably an overpowering force over all the structures, bone included, with which they come into contact in the human body, and are rarely met with flattened, or so much altered in form as bullets not unfrequently were formerly under like circumstances.

Number of wounds in battle.—The increased velocity of modern projectiles, together with the more rectilinear path in which they move, causes a greater number of wounds in modern warfare. The difference which has existed in the proportion of wounded to shots discharged in recent engagements, compared with the experience of former wars, is most marked. It is well known that from expansion of the bore of the musket in use a few years since, and consequent increase in the difference between its diameter and that of the bullet, after a few rounds of fire musket-balls rolled out in numerous instances in the act of elevation of the musket previous to discharge. Now every shot is propelled to a great distance, and with force sufficient, if brought into collision early in its flight, to penetrate and wound several persons. Colonel Wilford, Chief Instructor at the Government School of Musketry, stated publicly in a recent lecture the fact that 80,000 rounds of ball-cartridge were fired from the old musket in one day in Caffraria, and only 25 Caffres were known to be hit; while at Cawnpore, one company of soldiers, armed with the Enfield rifle, brought down 69 out of a body of horsemen by whom they were attacked, at one discharge. At the battle of Salamanca, only one ball in 3000 fired by the British took effect. Another result is, that we may now expect to meet more frequently the occurrence of several bullet wounds in the same individual. It is mentioned that, among the wounded from Solferino, it was not uncommon to see several wounds of different origins in one body; and M. Appia mentions a case, in one of the hospitals at Brescia, where a soldier had been struck at the same time by four balls. These circumstances become important in estimating the amount of surgical attendance that is required in modern engagements. At the battle of Solferino, just referred to, some returns show that, in twenty-four hours, 11,500 French, 5300 Sardinians, and 21,000 Austrians were laid hors de combat. The surgeons had no time to attend to the first necessities of a great proportion of the wounded. A multitude of those unfortunates were hastily conveyed to the little village of Castiglione, and had to wait hours, many even days, before their wounds could be dressed. To relieve thirst, and apply wet compresses of linen to ease the pain of the wounds, by calling into service the people of the neighborhood, was as much as could be done to a great number for the first day or two, on account of the vast number of wounds inflicted by the new weapons. At Brescia, within a short time after this battle, 15,000 wounded were congregated in thirty-eight fixed and temporary hospitals. From the actions in Flanders on the 16th, 17th, and 18th of June, 1815, including the battles of Quatre Bras and Waterloo, the returns show the number of wounded, not including those killed in action, in the Duke of Wellington’s army, to have been rather more than 8000. In the whole Crimean campaign, the total number of British wounded amounted to 11,361, exclusive of men killed in action.

Spent balls.—In connection with degree of velocity, the subject of what are called “spent balls” naturally occurs. After a cannon-ball has ceased to pursue its course through the air or to proceed by ricochet, it not unfrequently travels to a considerable distance, rolling along the surface of the ground. When its rate of movement is not much faster than that at which a man can walk, and when to all appearance it might be stopped by the pressure of the foot as readily as a cricket-ball, it yet possesses the power of inflicting serious injury on such an attempt being put into execution. This power is easily understood if the amount of force is remembered which must still be inherent in the cannon-ball for it to overcome the inertia of its own mass, and the resistance to which it is exposed in passing over the ground on which it is rolling. It is this force, multiplied by the weight of the ball, which gives it the destructive power. If this ball is brought into collision with the foot of a person, such destruction ensues as generally to necessitate amputation. Should it impinge on other parts of the body, as in the instance of a man lying on the ground, it may cause mortal injury to internal organs, and that without exhibiting external evidence of the amount of injury it has inflicted. So, also, though powerless to carry away a limb, it may cause comminuted fractures of bones and extensive contusions of the softer structures.