Sir T. Longmore

“ The difficulties which have been already enumerated in the way of arriving at a safe diagnosis of the true nature and extent of the injury, and the liabilities above mentioned to which a patient with a gunshot wound is exposed, should put a surgeon on his guard against giving a hasty judgment in any case that is not very plain and simple. Military surgery abounds with examples of wounds of such extent and gravity as apparently to warrant the most unfavorable prognosis, which have nevertheless terminated in cure; while others, regarded as proportionably trifling, have led to fatal results. ”

“ A rifle-bullet which splits up a long bone into many longitudinal fragments, inflicts a very much more serious injury than the ordinary fracture effected by the ball from a smooth-bore [46] musket, and the constitutional shock bears like proportion. When a portion of one or of both lower extremities is carried away by a cannon-ball, the higher toward the trunk the injury is inflicted, the greater the shock, independent of the loss of blood. Some writers, in accounting for “shock,” lay stress on the concussion, and general mechanical effects on the whole body, of the momentum of the iron shot. ”

“ In the largest kinds of balls, such as are projected from field-pieces or guns of position, the form offers little subject for consideration to the surgeon. So long as there is momentum enough to carry forward the mass of iron of which these missiles are composed, so long will their weight be the most important ingredient in the production of the wounds inflicted by them. Whether the shot come as a solid cone or bolt from one of the new guns or as a round ball from an ordinary cannon, the injury will be equally destructive to life or limb. ”

“ Primary hemorrhage.—Primary hemorrhage of a serious nature from gunshot wounds does not often come within the sphere of the surgeon’s observation. If hemorrhage occur from one of the main arteries, it probably proves rapidly fatal; and surgeons, after an action, are usually too much occupied with the urgent necessities of the living wounded to spare time for examining the wounds of the dead, who are mostly buried on the field where they fall. Thus most surgeons speak of primary hemorrhage being exceedingly rare, more rare, perhaps, than it actually is. ”

“ 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. ”

“ When a cannon-shot strikes a limb and carries it away, the immense velocity and momentum of the impinging force can scarcely be supposed to have no physical effect upon the neighboring or even distant parts independent of, and in addition to, the ‘shock,’ in the ordinary acceptation of the term, which would result from the removal of the same part by the knife of the surgeon, or the crushing of it by a heavy stone or the wheel of a railway wagon. ”

“ 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. ”

“ It must frequently happen in military practice that several operations have to be performed in rapid succession on the same person, from necessity of a speedy removal of the wounded; and, moreover, from the number of cases which are suddenly thrown on the care of the army surgeons after a general engagement, it must frequently occur that the diagnosis of a case is more or less doubtful. In such instances, the use of chloroform, by diminishing pain and preventing shock, and thus giving the opportunity of more accurate examination of parts, becomes particularly valuable in army practice. ”

“ And the practical experience of every army surgeon teaches him that where a ball has entered the body, though its course be not otherwise indicated, the continuance of shock is a sufficient evidence that some organ essential to life has been implicated in the injury. That the shock of a severe gunshot wound may be complicated with other symptoms, or that some of its own symptoms may be exaggerated from other causes,—hopes disappointed, the approach of death, and all the attendant mental emotions,—scarcely affects the question at issue ”

“ Injury to nerves inducing paralysis, contusions of blood-vessels leading to secondary hemorrhage or gangrene, may thus, without sufficient circumspection, be overlooked on the first admission to hospital.
When only one opening has been made by a ball, it is to be presumed that it is lodged somewhere in the wound, and search must be made for it accordingly. But even where two openings exist, and evidence is afforded that these are the apertures of entrance and exit of one projectile, examination should still be made to detect the presence of foreign bodies. ”

“ The fatal injuries which occasionally occur from masses of shell or round shot, in which the liver, spleen, or other viscera are ruptured without penetration of parietes, and where death ensues from shock, hemorrhage, or peritonitis, have already been alluded to. If, although the viscera have been contused, the injury does not amount to being mortal, the patient should be subjected to perfect quiet, extreme abstinence, and, only when inflammation arises, to the necessary treatment for its control. ”

“ 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. ”

“ 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. ”

“ 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 [37] their way beneath the integuments of the neck, without injury to the deeper structures. ”

“ To a certain extent this may be true, but, judging from analogy in physics, the greater the velocity, and consequently the momentum, of a ball carrying away a limb, the less would the concussion of the trunk and distal parts of the body be. A pistol-ball at full speed will take a circular portion out of a pane of glass without disturbing the remainder; if the speed be much slackened, as when fired from a distance, it will shake the whole pane to pieces. ”

“ Guthrie has laid down as a rule that injuries of the head, of apparently equal extent, are more dangerous on the forehead than on the side or middle portion, and still more so than those on the back part; and that a fracture of the vertex is infinitely less important than one at the base of the cranium. When the injuries are caused by rifle-balls, however, these considerations are rarely of much avail, for the power of injury is such that it can scarcely ever be confined to the immediate neighborhood of the part directly struck. ”

“ 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. ”

“ The decision of the surgeon must generally rest upon the extent of injury to the surrounding structures, the [110] condition of the patient, and other circumstances of each particular case. If the femoral artery and vein have been lacerated, any attempt to preserve the limb will certainly prove fatal.
The femur—the earliest formed, the longest, most powerful, and most compact in structure of all the long bones of the body—can only be shattered by a ball striking it with immense force. ”

“ The strictest attention to cleanliness and the complete removal of all foul dressings are essentially necessary, not merely for the comfort of the patient, but to prevent the accumulation of noxious effluvia, and also to obviate the access of flies to the wounds. In tropical climates, and in field-hospitals in mild weather, where many wounded are congregated, flies propagate with wonderful rapidity, and the utmost care is necessary to prevent the deposit of ova and generation of larvæ in the openings of gunshot wounds, especially while sloughs are in process of separation. ”

“ It was formerly supposed that the escape of air by the wound was a sufficient proof that the lung had been opened by the projectile; but it is evident that it is not so, as the air may enter by the wound and be forced out again by the expansion of the lung in inspiration, or by the action of the chest on expiration. If air and frothy mucus with blood, as noticed in one of the cases recorded in the Crimean campaign, escape by the wound, there can be no doubt of the nature of the injury. Emphysema is not common in penetrating gunshot wounds, but occasionally [85] happens. ”

“ 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. ”