Gunshot wound

“ If every ordinary bullet-wound which did not call for immediate operation because of injury to some essential or vital part—such as a large blood-vessel or nerve-trunk, or some of the viscera—were antiseptically and hermetically sealed at the very outset, there would be a much smaller percentage of death from gunshot wounds, either in civil or military practice, than now obtains. ”

“ And often, the sound of a gun leads to death.
A gunshot wound is three times more likely to lead to death today, in part because there are so many assault weapons, and the average victim of a gunshot wound now has over two bullets in him or her. ”

“ The contents of all gunshot wounds should be preserved, as they may be useful in evidence. A pocket revolver, as a rule, leaves the bullet in the body.
Wounds inflicted by firearms may be due to accident, homicide, or suicide. Blackening of the wound, singeing of the hair, scorching of the skin and clothing, show that the weapon was fired at close quarters, whilst blackening of the hand points to suicide. Even when the weapon is fired quite close there may be no blackening of the skin, and the hand is not always blackened in cases of suicide. Smokeless powder does not blacken the skin. ”

“ When a ball does not penetrate, but simply inflicts a contusion, the pain is described to be more severe than where an opening has been made by it.
[45]
Shock.—When a bone is shattered, a cavity penetrated, an important viscus wounded, a limb carried away by a round shot, pain is not so prominent a symptom as the general perturbation and alarm which supervene on the injury. This is generally described as the “shock” of a gunshot wound. The patient trembles and totters, is pale, complains of being faint, perhaps vomits. His features express anxiety and distress. ”

“ The constitutional treatment in an ordinary gunshot wound, uncomplicated with injury to bone or structures of first importance, should be very simple. The avoidance of all irregularity in habits tending to excite febrile symptoms or to aggravate local inflammation, attention to the due performance of the excretory functions, and support of the general strength, are chiefly to be considered. ”

“ Martini-Henry bullets make larger apertures, while soft-nosed or “dum-dum” bullets spread out as soon as the bullet strikes, causing great mutilation and destruction of the tissues. Shell wounds cause extensive lacerations. Small shot may inflict serious injury should one of the pellets enter the eye. In gunshot wounds at short distance the skin may be blackened owing to the particles of carbon lodging in it. The chief dangers of gunshot wounds are hemorrhage, shock and the carrying in of septic material or clothing into the wound. ”

“ Death from Surgical Operations Necessitated by Gunshot Wound.—The modern treatment of serious or so-called penetrating gunshot wounds where the cranium, thoracic viscera, or the abdominal viscera, especially the intestines, have been perforated one or more times, calls for surgical procedures which are of severity and danger in proportion to the gravity of the wound which necessitates them, and which, while they often save life, must necessarily often fail. Indeed, such operations may prove fatal upon the operating-table, i.e., patients may die before the conclusion of the operation. ”

“ The severe concussion of the whole osseous sphere by the stroke of the projectile, the bruising and injury to the bony texture immediately surrounding the spot against which it has directly impinged, as well as the contusion of the external soft parts, so that the wound cannot close by the adhesive process, constitute very important differences between gunshot injuries on the one side, and others caused by instruments impelled solely by muscular force on the other. So, also, the injury to the brain within, and its investments, is proportionably greater in such injuries from gunshot. ”

“ It must not be forgotten, in thus bringing the parts together, that the purpose is not to obtain union by adhesion, which cannot be looked for, but simply to prevent avoidable irritation and malposition of parts, during the subsequent stages of cure by granulation and cicatrization. In all gunshot wounds, much discomfort to the patient is prevented by carefully sponging away all blood and clot from the surface adjoining the wound, and by adopting measures to prevent its spreading again in consequence of oozing. ”

“ 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 punctured, incised, or gunshot wound, going fairly through both cavities of the chest, is usually believed to be quickly if not immediately mortal—an opinion generally correct with respect to wounds made by musket-balls, although it is certainly not the case with regard to punctured wounds, and does not always occur in those made by pistol or musket-balls. ”

“ This is explained by the fact that in a rapid plunge the vessels were compressed, and only after the drawing of the knife and relieving of the pressure blood began to flow, or possibly the blood may have been wiped off the knife by the elasticity of the skin.
When a person has died of a gunshot wound, especially at close range, it is important to look for any wadding or paper found in the wound, as in a number of instances the finding of such has led to the detection of the criminal. ”

“ The wound is an example of the misnamed “explosive” action of a rifle bullet. The force and direction of the missile, in high velocity, split the bone into many fragments, and, transmitting its energy to some of the fragments, carried them through the skin and caused the large laceration at the point of exit by the simultaneous escape of the bullet and fragments. The wound was so heavily infected, that a cellulitis advanced to the shoulder and to the wrist to such extent that the arm was marked by eminent surgical opinion for amputation. ”

“ The wound of exit is always smaller than the wound of entrance (Casper) . In this opinion Casper agrees with M. Malle, Olliver d‘Angers, and M. Huguier, but is opposed by Taylor, M. Matthysens, and others. “The characters of a gunshot wound,” says Assistant-Surgeon Neill, “are those of a contusion and laceration of all the tissues. Sometimes they are so simple as to bear resemblance to a punctured wound, particularly if a rifle-ball (conoidal) , revolving on its long axis, has passed through the soft parts at a great speed, but within a few hours it resembles a contusion. ”

“ A man having received a gunshot wound of the shoulder is doing well, when in another quarrel he receives a penetrating stab-wound of the thorax and abdomen. [502] He dies after lingering for a time, under the effects of these wounds. If the wound of the shoulder could be proven to be the cause of death, the second assailant could not be convicted of manslaughter, and so too with the first assailant if it could be shown that the victim died of the stab-wound. ”

“ The nature and extent of the wounds does not afford much assistance; with the exception of contused wounds which are usually homicidal or accidental, any other form of wound, particularly incised or punctured wounds, may be suicidal or homicidal, and with regard to gunshot wounds, much depends upon their position and extent. As a rule, the suicide does not make several wounds, and the homicide may not only inflict several but of a greater severity than are necessary to carry out his purpose. ”

“ Army surgeons meet in practice with secondary more frequently than primary hemorrhage in gunshot wounds. It may arise in several ways. Sometimes it results from the coagulum being forced out of an artery in which hemorrhage had previously been spontaneously averted by the ordinary natural process, this accident being consequent upon muscular exertion or increased impulse of the circulating system from any cause. This occurrence in the bottom of a deep wound will be often found to be a very troublesome complication. ”

“ The introduction of chloroform, by its negative operation of preventing pain or alarm, and by its positive action as a stimulus, has done much to remove many of the [120] objections which were urged by John Hunter against early amputations after gunshot wounds. If collapse be intense, more than is accounted for by the wound to the extremity, suspicion will be excited that some internal injury has been also inflicted, and delay will be necessary for further observation of the patient. ”

“ In many instances men thus wounded do not live long enough to come under treatment, but die on the field of action from penetration of the heart, hemorrhage, suffocation, or shock; and the proportion of chest wounds returned as “killed in action,” or as “died under treatment,” will constantly vary according to circumstances connected with the nature of the military operations, and the opportunities of early removal from the field to hospital.
Gunshot wounds of the chest may conveniently be divided for study into two classes, viz., non-penetrating and penetrating. ”

“ The chief are—1st, spherical, as cannon-balls, grape, musket-shot, and shells; 2d, cylindro-conoidal, as balls belonging to rifled cannon and rifled muskets; 3d, irregular, but generally bounded by linear and jagged edges, as fragments of shells and splinters.
A gunshot wound, whether received from a direct or indirect projectile, may be complicated by the entrance of extraneous bodies of various kinds, most commonly portions of the cloth or buttons of the dress worn by the person wounded. ”

“ Was the Weapon Fired from a Distance or Near By?—A gunshot injury from a bullet implies at least one wound, namely, that of entrance, and perhaps another, that of exit. It does not always happen that the bullet passes through the body. The appearance of the wound of entrance is usually one of irregular circular puncture, its edges perhaps slightly torn or lacerated, with a purplish or dark areola, varying in width from a line or two to one-half inch. ”

“ 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. ”

“ Gunshot wounds vary in gravity from the simplest laceration of cuticle to the instantaneous destruction of life. Death may take place primarily from direct causes already alluded to, viz.: from the destruction of vital organs, from extreme shock to the vital forces through the nervous system, or from hemorrhage; or it may ensue indirectly from secondary hemorrhage, gangrene, erysipelas, hectic fever, pyemia, or from the results of operations necessarily required in consequence of the original injury. ”

“ Every sore place is burnt; and for all sorts of illnesses, in cases of rheumatism, etc., etc., the patient is scored, perhaps all over his chest or back—"fired" like a horse. Sores are always cauterized. Bullets are never extracted. Wounds are bound up with earth and rags. A serious gunshot wound, means death. Certainly there is a wide field for women doctors in Morocco. ”

“ 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. ”

“ 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. ”

“ In another fatal case, a rifle-bullet passed through the right cheek, and lodged near the base of the skull. There was no paralysis, but delirium and coma supervened, and the patient died five days after receiving the wound. The bullet was found after death, lying just below the basilar process, and a large piece of the atlas was broken off and almost detached. The spinal cord did not appear to have been primarily injured, but acute inflammation had been set up, and had extended to the membranes of the brain. ”

“ When John Hunter wrote on gunshot wounds, he remarks, the practice of searching after a ball, broken bones, or any other extraneous bodies, had been in a great measure given up, from experience of the little harm caused by them when at rest, and not in a vital part; and he himself advises, even when a ball can be felt beneath skin that is sound, that it should be let alone, chiefly on the ground that two wounds are more objectionable than one, and that the extent of inflamed surface is proportionably increased by incision. ”

“ 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. ”