A Treatise on Gunshot Wounds

by Sir T. Longmore

Lodgment of balls.—Low rate of velocity leads to musket and other balls lodging in various parts of the body. When the smooth-bore musket was in common use, lodgment of balls was of frequent occurrence. In the first place, from absence of sufficient initial velocity to effect its passage out of the body, and, secondly, from its liability to be diverted from a direct line, a round ball might be arrested in its progress at any distance from its point of entrance. Conical balls lodge when their velocity has become nearly expended before entering the body; or, from peculiarity in the posture of the person wounded, a ball, having had force enough to traverse a limb, may afterward enter into another part of the body and lodge. A ball may reach a part so deep in the muscles of the back, for example, or be so far removed from the aperture of entrance, as to elude all attempts on the part of the surgeon, at the time of examination of the wound, to discover its retreat. Or it may have reached some position from which the surgeon fears to take the necessary steps for its extrication, judging the additional injury that would thus be inflicted more mischievous than the probable effects of allowing the ball to remain lodged.

Unextracted balls lead to consequences varying according to the site of lodgment and state of constitution of the patient. If the ball have become fixed in the body of a muscle, or in its cellular connections, adhesive inflammation may be established around it, and in time a dense sac be thus formed, in which the ball may remain without causing any, or but very slight, inconvenience. M. Baudens asserts that a cellular envelope is of very early formation around balls lodged in muscular tissues. Although thus encysted, a ball may press upon nerves, and give rise to pain and much uneasiness, or may be so situated as to embarrass the person in certain movements of the body. Foreign bodies not unfrequently change the position of their first lodgment, under the effect of gravitation or the impulse of muscular actions. The following instance, which occurred to Staff-Surgeon Dr. Daniell, illustrates the distance to which a lodged ball may travel before finding its exit: In the disastrous affair of Malageah, on the west coast of Africa, fought in May, 1855, between detachments of the West India regiments and the Moriah chiefs, a man was wounded just below the spine of the scapula by a shot fired down from an elevation. The aperture was small, no ball could be traced, and the wound healed up rapidly. Six months afterward the man attended hospital, complaining of inability to march and pain about one of his ankles. A red, painful swelling and abscess formed over the inner malleolus, disease of bone was suspected, when examination led to the discovery of a small iron ball, of irregular shape, which was removed. No pain or irritation had existed between the shoulder and the foot. When lodged in the lower extremities, balls sometimes form for themselves canal-shaped cysts, along which they can be moved freely on pressure. When, however, the health or other circumstances of the patient are not favorable, the lodgment of a ball with a smooth surface, like missiles of a more angular and irregular shape, may excite inflammation and constitutional disturbance of a very troublesome kind, and keep up a profuse suppurating discharge along the track of the wound, or perhaps lead to abscesses burrowing in other directions. Balls have been known to lodge in bones, without their positions having been suspected or inconvenience excited by their presence. On the other hand, balls similarly impacted have given rise to disease, and in some bones, as those of the pelvis, have produced such constitutional irritation as to lead to a fatal termination. Balls lodging in the circumscribed cavities of the body or their contained viscera require notice elsewhere.

Grape-shot, and even balls of larger size from field guns, occasionally lodge. The large, gaping wounds inflicted by such missiles usually render the detection of their lodgment and position very easy; but still remarkable instances have occurred where the presence of bodies of this nature of very large size has been overlooked. Mr. Guthrie’s experience of the war in the Peninsula led him to record that “it was by no means uncommon for such missiles as a grape-shot to lodge wholly unknown to the patient, and to be discovered by the surgeon at a subsequent period, when much time had been lost and misery endured.” The same distinguished surgeon mentions a case where a ball weighing eight pounds was not discovered till the operation of amputating the thigh in which it had lodged was being performed. Baron Larrey describes a similar case: An artilleryman had his femur fractured by a ball, which, according to the man’s description, had afterward struck another artilleryman by his side. On being brought to hospital, no one doubted that the ball, after fracturing the limb, had glanced off; but on amputating, the ball, weighing five pounds, was found in the hollow of the thigh toward the groin. The wound of entrance was on the outside of the thigh; and the ball had not only fractured, but had turned round, the bone. M. Armand, surgeon attached to the French Imperial Guard, has related the case of a soldier who was brought to the ambulance, after the taking of the Mamelon Vert, in the Crimea, with his left thigh wounded; one opening, such as might be made by a large musket-ball, was found on the outside of the thigh. There was no second opening. On examination, a swelling was detected in the popliteal space, without any external mark of injury nor much pain on pressure. It was concluded to be the ball; and, on incising, an enormous grape-shot was found. It had turned round the femur without breaking it. M. Armand writes that the appearance of the wound alone would have led to the supposition that the ball had not lodged, and no one would have suspected that such a thing as a grape-shot had been the cause of it. In the British Surgical History of the Crimean War the case of a soldier of the 1st Royals, who was wounded in the face by a grape-shot weighing 1 lb. 2 oz. is recorded. The ball lodged at the back of the pharynx, and escaped observation for three weeks. Were it not for experience of many such instances, it would be deemed almost impossible that foreign substances of such size and weight could remain in the body without the knowledge of the patient, if not discovered by the surgeon. Even with so large a missile as a grape-shot, a surgeon should not be contented with examining merely by the wound, wide as it usually is, in case lodgment is suspected; it may travel in a direction which may cause its discovery to be very difficult by that track. An officer of the 19th Regiment was struck during the assault on the Redan, on September the 8th, by two grape-shot, at the back of the chest. They entered close to the spine. One of these balls lodged in the inner part of the right arm, below the axilla, whence the writer excised it.

Penetrating fragments of shells, if projected edgeways, almost invariably lodge. In these cases, the appearance of the wound seldom indicates to the observer the true size of the body which has caused the injury. At an early period of the battle of the Alma, a piece of shell, about four pounds in weight, lodged in the buttock of a soldier of the 19th Regiment; and, to extract it, an incision had to be made nearly equal in extent to the length of the original wound. In this instance the concave aspect of the fragment—evidently, by the nature of the curve and thickness, a portion of a very large shell—had adapted itself to the parts lying beneath, while its convex surface so agreed with the natural roundness of the parts above, that it would have been impossible to have arrived at a knowledge of its lodgment, from any change in the external appearance of the parts. Examination by the wound alone gave decided information on the question. Such fragments become very firmly impacted among the fibers of the tissues in which they lodge, and the effused blood fills up inequalities, and rounds off edges that might otherwise show themselves prominently; so that, without due care, their presence is not unlikely to be overlooked at first examination. Dr. Macleod, of Glasgow, mentions that he saw a case at Scutari, in which a piece of shell weighing nearly three pounds was extracted from the hip of a man wounded at the Alma, which had been overlooked for a couple of months, and to which but a small opening led.[1] But bodies of still more irregular form may lodge in this region, and escape notice. A soldier in a battery in the Crimea was wounded, during a heavy artillery fire, in the left hip. A twelvemonth afterward he was in the General Hospital at Chichester, with a narrow sinus, which allowed a probe to pass deeply among the gluteal muscles. On cutting down in the direction indicated, a piece of stone was extracted, upwards of four ounces in weight. This man had passed through several hospitals before his arrival at Chichester.

Bullets scattered from canister or spherical case not unfrequently lodge; apparently in consequence of the direct velocity received from the primary discharge being disturbed, and lessened by the force of the secondary explosion of the case in which they were contained.

A small layer of metal, like a portion of one of the coats of an onion, occasionally becomes detached from a leaden bullet, and lodges. The writer was once applied to by a discharged soldier, suffering from some troublesome granulations at the bottom of the left orbit. The globe of the eye had been destroyed nearly two years before by a musket-ball shot from above, which, after traversing the orbit, had descended, and was excised from the right side of the neck. On examining the granulations by a probe, the point came into contact with a hard substance, which further examination showed to be a small projecting point of lead. It proved to be a scale from the bullet which had caused the original wound, being equal in length to half its circumference, and in width, at the broadest part, about a third of the same dimension. It retained the curved form of the bullet from which it had been detached. The following case shows that similar sections may be separated from cylindro-conical as well as from round bullets. An officer of the 41st Regiment was struck in the Crimea by a conical bullet, which destroyed the forearm in such a manner as to necessitate amputation below the elbow. Secondary hemorrhage occurred on the eleventh day, and on the following day the stump was opened and examined. “While searching for the bleeding vessel, a slice of the bullet, about the size of a worn sixpence, was found deeply imbedded in the muscle.” In the case of a soldier of the 19th Regiment, who was wounded before Sebastopol in the loin by a conical bullet, which was discharged per anum, and who died in Guy’s Hospital of albuminuria, nearly four years afterward, a small scale of lead from the bullet was found at the post-mortem examination fixed in the spleen. Strange to say, in this instance the lodgment did not appear to have excited any inflammatory action or mischief.

Lodgment of small foreign bodies, angular pieces of metal, as slugs, nails, and others, and of soft textures, as shreds of linen or woolen cloth, often give rise to much inconvenience. The track of a musket-ball may be prevented from healing, and a troublesome sinus formed, by such small fibers of cloth as would hardly attract notice if within means of observation. Although a wound be closed, and apparently healed, if any shreds of cloth remain, it will probably open from time to time, when small fibers may be noticed in the discharge; and this will continue until the whole is thus got rid of. The probability of cloth entering a wound with the conical ball is not so great as it was with the spherical ball, which not unfrequently tore out a little cap, as it were, of cloth in its passage. This is another result of its shape and velocity. John Hunter and others make mention of circular pieces of the skin being cut out by bullets, and then lodging, and acting as foreign bodies in the wounds.

When the Minié-ball, with the iron cup at its base, was first brought into use, surgeons anticipated that the addition of the iron cup would complicate the ill effects of the wounds inflicted by it. It does not appear that this has proved to be the case. The iron is usually so far driven into the lead by the force of the exploded gunpowder, and so firmly fixed by the alteration in shape and pressure of the lower part of the ball, that it but rarely becomes detached so as to form a separate lodgment.

Gravel and small stones struck up by shells at the time of their explosion, or by shot ricochetting against the ground, often lodge, and give much trouble in their extraction, especially about the face. In the assault of Sebastopol, at the Great Redan, the attacking parties in their approach, the ground being rocky and having been much broken up by shell explosions, were particularly exposed to such injuries; and in several instances men were placed hors de combat by dust and small fragments of stone thus projected, though the injuries were not of a permanently serious character. One case is recorded where both eyes were penetrated and totally destroyed by gravel thrown up by a shell explosion.

Foreign substances derived from persons standing near a wounded man, sometimes fragments of the bodies of other wounded men, have been already named as occasionally lodging. In a severe injury to the face, which occurred in a man of the 1st brigade of the Light Division, in the Crimea, the surgeon was at first puzzled by the strange displacement of a part of the upper jaw. After closer examination, and obtaining a clearer view by the removal of clot, it was found that a piece of the jaw of another man, whose head had been smashed by a round shot by his side in the battery, had been driven into the palate, and was there impacted. Among other cases recorded in the Surgical History of the Crimean War, is one of a double tooth of a comrade having been found imbedded in the globe of the eye; and another, where a portion of a comrade’s skull was removed from between the eyelids of a soldier. In such injuries as these, where one of two men standing side by side is wounded by a portion of the body of his neighbor, the fragment striking is usually detached from a corresponding region with that struck. The late Mr. Guthrie extracted from the thigh of a Hanoverian soldier, on the third day after his admission into hospital, two five-franc pieces and a copper coin. The man had had no money about him previously to the injury, nor pocket to contain any. The coins had been carried from the pocket of a neighbor, who stood before him in the ranks, and who had been hit by the same grape-shot. These coins, flattened out and jammed together by the force of the shot, are in the museum at Fort Pitt. Similar examples might be multiplied; but sufficient have been mentioned to show the necessity of careful examination in warfare, not only for direct missiles which may effect lodgment in the body, but for many other foreign substances which may be forced in by their agency.