A Treatise on Gunshot Wounds

by Sir T. Longmore

Internal wounds without external marks.—Among the wide variety of injuries from gunshot, there have not unfrequently been noticed cases in which serious internal mischief has been inflicted, without any external marks of violence to indicate its having resulted from the stroke of a projectile. An important viscus of the abdomen has been ruptured, yet no bruising of the parietes observable; symptoms of cerebral concussion have shown themselves, yet no injury of the scalp to be detected. Even bones have been comminuted without any wound of the integuments or appearance of injury. The records of the Crimean campaign afforded not unfrequent examples of such wounds. Two cases occur, in the French records, of fracture of the forearm without any external apparent lesion; in one the internal structures were reduced to a mass of pulp. The difficulty of reconciling the several facts noticed in such instances, together with the vague descriptions by patients of their sensations, led surgeons to seek an explanation for them in the supposition that masses of metal projected with great velocity through the air might inflict such injuries indirectly by aerial percussion. Either the air might be forcibly driven against the part injured by the power and pressure of the ball in its flight, or a momentary vacuum might be created, and the forcible rush of air to refill this blank might be the origin of the hurt. Electricity has also been called into aid in explaining these injuries. All these hypotheses are now abandoned. So many observations have been made of cannon-balls passing close to various parts of the body, as near as conceivable without actual contact, without any such consequences as those attributed to windage, as to lead to the necessary conclusion that the theory must in all instances have been fallacious. Portions of uniform and accouterments have been torn away by cannon-balls without injury to the soldier himself. Even hair from the head has been shaved off, and cases are on record where the external ear and end of the nose have been carried away without further mischief.

The true explanation of the appearances presented in those cases which were formerly called “wind contusions,” appears to rest in the peculiar direction, the degree of obliquity, with which the missile impinges on the elastic skin, together with the situation of the structures injured beneath the surface, relatively to the weight and momentum of the ball on one side, and hard resisting substances on the other. Thus, in the case of a cannon-ball passing across the abdomen, as in two instances mentioned by Sir Gilbert Blane, where men were killed by the passage of balls across the epigastrium, the elasticity of the skin probably enabled that structure to yield to the strain to which it was exposed, while viscera were ruptured by the projectile forcing them against the vertebral column. So the weight of a ball passing obliquely over a forearm may possibly crush the bone between itself and some hard substance against which the arm may be accidentally resting, without lesion of the interposed skin. Baron Larrey, who examined many fatal cases of this kind, relates that he always found so much internal disorganization as to leave no doubt in his mind of its being the result of contact with the ball. He explained the absence of superficial lesion, by the surface having been struck by cannon-balls in the latter part of their flight, when they had undergone a change of direction from straight to curvilinear, and acquired a revolving motion, owing to atmospheric resistance and the effect of gravitation. In such a condition, he argued, they would turn round a part of the body, as a wheel passes over a limb, in place of forcing their way through it; and, while elastic structures would yield, bones and muscles, offering more opposition, would be bruised or broken.

In some recently published letters on the wounded in the late campaign in Italy, by M. Appia, this writer states that wounds from massive projectiles having been rare, he had not met with an example of internal destruction of parts with skin preserved intact, and that he had nowhere seen a wound which was attributed to vent de boulet. The hypothesis, he remarks, seems generally abandoned. It is presumed that, in stating wounds from gros projectiles to have been rare, he refers only to the wounded in the hospitals, and that it is to be inferred that the injuries from cannon-shot proved generally fatal in the field.

Seat of injury.—A knowledge of the seat of injury from the passage of a ball involves diagnosis of its course, the depth of its penetration, the particular organs or structures injured, and the extent of the injuries to which they have severally been subjected. The course pursued by balls in wounds presents many features of interest. The depth of penetration, in connection with direction, becomes of great importance when there is question of one of the great visceral cavities being opened. This part of the subject, however, together with that of injuries to the viscera themselves, will be more conveniently considered when treating of gunshot wounds in their special relations to particular regions. In like manner, the diagnosis of the extent of injury in wounds complicated with fractures of the long bones will be best considered under gunshot wounds of the extremities.

Course of balls.—Of the circuitous and unexpected directions pursued by bullets in their course through the human frame, which were formerly so common, we are not likely to see many instances in future warfare, when the rifle is the weapon chiefly employed. The conical shape of the ball and the force with which it is propelled have had the effect, among others already named, of changing this characteristic of the ball from the smooth-bored musket. The latter, bearing a force that scarcely carried it true to a mark at eighty yards, and usually receiving, as it left the firelock, an impulse which caused it to revolve on its axis at right angles with the line of flight, was deflected by the most trifling obliquity of surface, by the resisting obstacle of a bone, by tendons or the aponeuroses of muscles, or even by the elastic resilience of muscles themselves in a state of action, when the relative direction of their fibers was favorably placed to exert this influence. The Enfield cylindro-conoidal bullet, armed with a force that will carry it to a given spot distant one thousand yards or upwards, flies like an arrow, penetrates the softer tissues in a straight line, and on meeting bone, as before noticed, enters it like a wedge. When a bullet of this kind strikes an object point-blank, it is always the apex of the conical part which first meets the object struck; and, if sufficient resistance be met with, it is this apex which becomes first compressed and turned back. When it strikes a solid object lying nearly parallel with its line of flight, the ball is planed, as it were, from its apex toward its base. In a case before referred to—page 29—where a conical ball entered the loin of a soldier of the 19th Regiment, and was subsequently passed per anum, the apex of the bullet was found to be turned and bent round on itself, and the ball generally flattened. On examining carefully the convex surface of the convoluted apex, minute spiculæ of bone were observed to be impacted in its substance. It became evident, therefore, that the ball had struck, probably penetrated through, some portion of the lumbar vertebræ in its course from the loin to the intestine. There were no general symptoms to indicate spinal injury, but, four years afterward, the opportunity of a post-mortem examination being afforded, the track of the ball through some of the lumbar vertebræ was distinctly traced.[2]

It will often appear, at first examination, that the track of a wound by the cylindro-conoidal bullet, even at full speed, is widely removed from a straight line, especially when this class of injuries is new to the surgeon. It is not difficult to understand the apparent irregularity in the line of the wound, when the many varied positions in which the body and its parts are liable to be placed are called to mind, and if, when making the examination, the surgeon has omitted to place the patient in a similar posture to that he was in when struck. A certain allowance must also be made for the spasmodic actions of the various muscles among themselves, and momentary displacement of other structures, at the instant of receiving the injury.

Occasionally, though rarely, an accidental concurrence of circumstances may lead to the conical bullet pursuing a circuitous instead of a direct course, especially when, after traveling a certain distance, its speed has become diminished; and, as round musket-balls are not yet wholly discarded from warfare, it is necessary to call attention to the observations which have been made on this subject. Balls have been known to pass round the outer convex and the inner concave surfaces of the abdominal and thoracic cavities, sometimes forcing their exit at points nearly opposite to those of entrance, sometimes making a complete circuit. Thus, from simple observation of the line of direction of two wounds, a ball may be supposed to have passed through the thorax or abdomen, while really it may not have penetrated the cavity, but only made its way beneath the integument. In like manner, a lung may be supposed to have been traversed by a ball, not merely from the relative position of the wounds of entrance and exit, but also by some of the characteristic signs of such an injury, when really the ball, after entering the cavity of the chest, has rolled round the costal pleura, never penetrating the lung, but at the most bruising its surface. In the same way, balls have been known to travel round the cranium beneath the scalp, and to have found their way beneath the integuments of the neck, without injury to the deeper structures. Dr. Hennen saw a case where a ball was found lying in a wound by the thyroid cartilage. It had made a complete circuit of the neck, and returned to the spot where it had entered. Cases sometimes occur where two openings are found in a man’s shoulder, in such relation that a straight line between them would necessarily pass through the head of the humerus, yet the ball has only made a half circuit, outside the joint.

Many examples of such injuries will be found in the works of all writers on gunshot wounds until the recent introduction of rifled weapons, while those who have only seen the latter in use are almost inclined to doubt the accuracy of previous statements on this subject, from not meeting with similar instances in their own experience. In the early part of the late war with Russia, the musket wounds were nearly all inflicted by the round bullet; but during the year 1855 conical bullets of various shapes and sizes were brought into use by the Russians generally, as they had been for some time previously by nearly the whole of the English army, and a large proportion of the French army. As early as the battle of Inkerman, however, the Russians were partly armed with the Liège rifle, with its conical bullet. Among 3000 wounded from the recent battles of Palestro and Magenta, assembled in the hospitals at Turin, M. Appia, whose letters on the wounded in the late Italian campaign have been before quoted from, writes that he was astonished not to meet one case of a cylindrical ball having taken a curved direction in its passage. He mentions the case of an officer being wounded by a ball, which entered at the epigastrium and passed out by the side of one of the lumbar vertebræ, without penetration of the abdomen, a red mark or zone connecting the two wounds and indicating the circuit which the ball had made. In another case, a ball had traversed the chest from right to left, and still had sufficient force to wound the left arm. Both these injuries, however, were caused by spherical balls.

SYMPTOMS OF GUNSHOT WOUNDS.