A Treatise on Gunshot Wounds

by Sir T. Longmore

The leading symptoms of gunshot wounds are the diagnostic marks of these injuries, and the constitutional disturbance, pain, hemorrhage, edema, and other circumstances with which they are attended. Some of these require to be noticed separately.

Diagnosis.—The external distinguishing signs of a penetrating gunshot wound are generally manifest enough, but exact diagnosis of the nature and extent of the wound is not always so simple as it might at first appear to be. It is necessary to describe, firstly, the external appearances. These, although possessing certain universal characteristics, vary to a wide extent, according to the different forms, already described, of the missiles causing the injuries, their velocity, the part of the body struck, and its position relative to the projectile at the time of injury.

When a cannon-ball at full speed strikes in direct line a part of the body, it carries away all before it. If the head, chest, or abdomen are exposed to the shot, an opening corresponding with the size of the ball is effected, the contiguous viscera are scattered, and life is at once extinguished. If it be part of one of the extremities which is thus removed, the end remaining attached to the body presents a stump with nearly a level surface of darkly contused, almost pulpified, tissues. The skin and muscles do not retract, as they would had they been divided by incision. Minute particles of bone will be found among the soft tissues on one side, but the portion of the shaft of the bone remaining in situ is probably entire.

In ricochet firing, or in any case where the force of the cannon-shot is partly expended, the extremity, or portion of the trunk, may be equally carried away, but the laceration of the remaining parts of the body will be greater. The surface of the wound will be less even. Muscles will be separated from each other, and hang loosely, offering at their divided ends little appearance of vitality; spiculæ of bone of larger size will probably be found among them; and the shaft may be found shattered and split far above the line of its transverse division. The injury to nerves and vessels may be proportionally higher and greater. Occasionally it happens, even where the limb seems to have been struck in direct line, that it is nevertheless not completely detached, but remains connected by shreds of the skin and parts of the tissues, on which the bone, reduced to minute fragments, is mixed with the contused muscles and other soft parts in a shapeless mass.

If the speed be still further diminished, so that the projectile becomes what is termed a “spent ball,” there will not be removal of the part of the body struck, but the external appearances will be limited usually to ecchymosis and tumefaction, without division of surface; or even these may be wanting, notwithstanding the existence of serious internal disorganization. The rationale of such phenomena has been previously described.

Should the cannon-ball strike in a slanting direction, the external appearances of the wound will be similar to those just described, according to its velocity, modified only in extent by the degree of obliquity with which the shot is carried into contact with the trunk or extremity wounded.

Large fragments of heavy shells generally produce immense laceration and separation of the parts against which they strike, but do not carry away or grind, as round shot. Ordinarily, the line of direction in which they move forms an obtuse angle with the part of the body wounded. When they happen to strike in a more direct line, so as to penetrate, the external wound, as alluded to under the head of lodgment of projectiles, is mostly much smaller than the fragment itself, from the projectile not having had force enough to destroy the vitality and elasticity of the soft parts through which it entered.

Small projectiles, with force enough to penetrate the body, leave one or more openings, the external appearances of which also vary according to their form and velocity. The appearance of a wound from a rifle-ball, at its highest rate of speed, may be sometimes witnessed in cases of suicide. A soldier, in thus destroying himself, mostly stoops over the muzzle of his firelock, pressing it against the upper part of his body, and springing the trigger by means of his foot. The muzzle is usually applied beneath the chin. In such a case, a circular hole, without any puckering or inversion of the marginal skin, together with dark discoloration of the integument for several inches round, is observed at the wound of entrance. The vertex of the head is shattered; fragments of the parietal and occipital bones, together with small portions of brain, are carried away and scattered about; the bones not broken are loosened from their sutures; the mass of brain is torn to pieces, but held by its membranes; the superficial vessels of the face are distended with blood. These effects are not wholly due to the passage of the ball, but partly to the flame from the ignited gunpowder jetting out at the mouth of the musket, and in part also to the expansive force exerted within the cavity of the cranium, by the gases resulting from the explosion.

When the musket-ball strikes at a distance from the weapon by which it was propelled, but still preserves great velocity, the appearances of the wound are changed. An opening is observed, irregularly circular, with edges generally a little torn; and the whole wound is slightly inverted. There may be darkening of the margin, of a livid purple tinge, from the effects of contusion, or it may be simply deadlike and pale. Should the ball have passed out, the wound of exit will be probably larger, more torn, with slight eversion of its edges and protrusion of the subcutaneous fat, which is thus rendered visible. These appearances are the more easily recognized, the earlier the wound is examined. They are more obvious if a round musket-ball has caused the injury than when it has been inflicted by a cylindro-conoidal bullet. Indeed, with the latter, where it has simply passed through the soft tissues of an extremity of the body at full speed, it is usually very difficult to distinguish by its appearance the wound of entrance from that of exit. In medico-legal investigations concerning gunshot wounds, it must be often a matter of great importance to decide this point; but to the military surgeon, more especially from the circumstances connected with the new projectiles, it has become a subject of little practical interest. When the indirect and tortuous penetration of balls was the rule rather than the exception, a knowledge of the spot at which the ball entered was often useful in diagnosing the mischief it had probably committed in its passage, and in determining the part of the wound where foreign bodies might be supposed to be carried and to be lodging. When the track of the ball is nearly in a straight line, as now usually happens, such information cannot be looked for from knowing the relation of either opening to the entrance or passage of the missile.

A musket-ball ordinarily causes either one wound, as when after entering it lodges, or, as sometimes happens, from its escaping again by the wound of entrance; or two wounds, from making its exit at some point remote from the spot where it entered; but occasionally leads to a greater number of openings. This last result may happen from the ball splitting into two or more portions within the body, and causing so many wounds of exit. A case occurred to M. Dupuytren, where a ball split against the spine of the tibia; and after traversing the calf of the leg in two directions, entered the other leg at two points,—one ball thus causing five orifices. A case occurred to the writer, in the Crimea, where a cylindro-conoidal rifle-ball with three canalures, after fracturing the cranium, was cut in two by the upper edge of bone at the seat of fracture, smoothly as if by a sharp instrument. One part glanced off, the other entered the cranium. A strange feature in this case was, that the depressed portion, after admitting the ball, closed up again; so that no aperture, but only a slight depressed line of fracture, was visible.[3] A somewhat similar case occurred in the 38th Regiment, but the ball appears to have been a round one. M. Huguier has collected some curious cases of splitting of balls, from the records of the French revolution: among others, the division of a ball into two parts, of another into three parts, against the supra-orbital ridge, and of another into three parts against the clavicle. A case is recorded, where a grenadier in Algeria was wounded in five places, all wounds of entrance, by one ball. It was divided into five portions by first striking against a rock at five or six paces from the soldier, the fragments rebounding at various angles. John Hunter mentions the case of a young gentleman who was shot through the abdomen by means of a musket loaded with three balls. In this instance there were only two orifices of entrance and two of exit, one ball having followed in the track of one of the others; “that there were three that went through him was evident, for they afterward made three holes in the wainscot behind him, but two very near each other.” Had it not been for this proof, it being known that three balls were discharged, a suspicion might have existed that one of the three balls had lodged. The recollection that such accidents may occur will sometimes assist in the diagnosis of doubtful cases.