CHAPTER XXII

.

GUNSHOT WOUNDS.

Gunshot wounds are usually considered with the special subject of military surgery. Military surgery as such, however, consists in the application of general surgical principles. Nevertheless a gunshot wound is essentially the same whether it be received upon the battle-field or in civil life, and the injury inflicted by a piece of flying shell is in no sense different from that which may be received in a blasting accident.

A gunshot wound is always contused and lacerated, and often punctured. According to its size and shape, its location, the nature and velocity of the missile, the distance at which the weapon was discharged will depend its severity and prognosis.

Shot vary in size from those which weigh but a fraction of a grain to buckshot which weigh nearly one-third of an ounce. Revolver and pistol bullets vary in diameter from 0.22″ to 0.45″, and in weight from twenty-five grains to ten times that amount, and nearly always of conical form. They are usually made of compressed lead, sometimes hardened by the addition of tin or antimony.

The old military weapons, such as the Springfield rifle, have been entirely abandoned, and for them have been substituted rifles of smaller bore, projecting bullets of from 0.25″ to 0.31″, varying in weight from one-fourth to one-half ounce and attaining a muzzle velocity of nearly 2500 feet per second. They have, therefore, a much increased range and may kill at two miles. Their trajectory is flatter and the character of the wound caused by these modern weapons is different from those inflicted, for instance, during the Civil War. The bullets now in use in the armies and navies of the world are nearly all encased in a thin covering of steel, copper, etc., which is known as the _jacket_ or _mantle_. They are from 3.5″ to 4″ in length, possessing a much greater range than a shell bullet, while the rifling of the weapon is so made as to give them a more rapid rotation. In active service, moreover, these are usually fired with smokeless powder. The so-called “dangerous zone,” _i. e._, that where mounted men or infantry can be injured, is much wider than formerly.

In India the practice has been introduced of leaving the point of the bullet uncovered by the mantle, so that when it strikes it would “mushroom”--especially in the bone. These “Dumdum bullets,” as they are called, from the place of manufacture, inflict much more serious injuries than do the relatively smooth perforations made by the others, and have been considered so cruel that they are excluded from use in civilized warfare.

During the Russo-Japanese war, in which nearly all previous records were broken, the deaths from gunshot wounds constituted but a small proportion of the entire loss in camp and warfare, a larger number of soldiers dying from disease and exposure. Statistics also show that out of every 100 cases of gunshot wounds 12 per cent. have been produced by bullets, the remaining portion being caused by shell, etc. De Nancrède has epitomized some interesting figures which may be here quoted: In the United States army during the Spanish war 4750 casualties were accurately studied; of these wounds of the lower extremities constituted nearly 33 per cent., those of the upper extremities nearly 30 per cent., those of the trunk a little over 22 per cent., and those of the head and neck a little over 15 per cent. During the South African campaign the mortality among the wounded was 5.7 per cent., essentially the same as that during our Cuban and Filipino campaigns, and in marked contrast to the 14 per cent. mortality of the Civil War. Considering that with our Mauser weapons the trajectory is practically flat up to 500 yards, and they may kill up to a distance of two miles, it will be seen that this difference in figures is important. The British discovered in their campaign against the Afghans, who were using antiquated weapons, that their own Lee-Metford bullets would pass through their enemies without disabling them, while the British soldiers who were once struck by the large, soft-lead bullets of their antagonists were far more seriously injured or absolutely disabled.

As one explanation of the injury inflicted by modern projectiles there has been advanced the theory that a bullet with a high-muzzle velocity, striking an object while it still retains most of its original speed, compresses and forces ahead of it into the wounded tissues a small column of air, which, exercising an expansive force, produces more or less explosive effect, that may be seen along the bullet track or at the point of exit. These explosive effects are proportionate to the size of the bullet, its bluntness, and its velocity. This theory was more tenable in the days of large and blunt projectiles than today, for in time past experiments have shown that when a bullet is dropped into water from a height there is forced into the water along with it a certain amount of air, estimated by Longmore at twenty times the actual volume of the bullet itself. It may be doubted, however, whether the rifle projectiles of today can produce sufficient air pressure to cause the destructive effects thus attributed to it.

[Illustration: FIG. 47

_a_, completely shattered after perforating a horse’s thigh-bone at 220 yards; steel mantle stripped; _b_, ball with mantle torn off and rolled up, core deformed, after shattering human tibia at 60 yards; _c_, wholly disorganized ball, which destroyed middle metatarsal bone of horse at 660 yards, steel-mantled; _d_, ball which shattered a human femur at about 750 yards, steel-mantled; _e_, remains of steel mantle and part of core lodged in human femur, wound inflicted at about 1100 yards; _f_, _g_, fragments of mantle found near the orifice of the wound of exit at about 1100 yards’ range, steel-mantled; _h_, piece of steel mantle split off by striking a dried horse’s metatarsal at over 1300 yards; _i_, steel-mantled ball which perforated the internal femoral condyle and lodged beneath the skin at nearly 2200 yards. (Recent foreign report.) (De Nancrède.)]

Another method of accounting for shattering effects noted in many of these wounds is hydrodynamic pressure, depending upon the incompressibility of fluid and of tissue containing it, and the narrowing of the space occupied by fluid as a result of the transfer of pressure in all directions. Other things being equal, the most marked effects would be manifest in organs containing the most fluid, the effect increasing with the amount of fluid, the speed of the bullet, its size, and any alteration of shape which it has undergone in transit. It has been shown that the hydrodynamic pressure of steel-jacketed modern bullets varies from six to eight atmospheres. This theory accounts for the peculiar destructive effects seen in the brain, the heart, the stomach, and intestines when struck at short range.

Another method of accounting for the results of a bullet wound takes account of the peculiar effect due to the rapid rotation of the bullet, the movement given it by the rifling of the barrel from which it is fired. It appears that a bullet travelling at the rate of 620 meters per second will average about four rotations per meter. Even in passing through a human body this would scarcely give it but two rotations in transit, while in passing through any given bone the force would be too slight to be appreciable.

While the theories mentioned above, the _hydraulic_ and _hydrodynamic_, are attractive, yet they are unsatisfactory; we can do little more than sum up the damage done by a rifle ball as due to arrest and divergence of its energy, penetration depending upon its remaining velocity, its preservation of its original shape, and the resistance offered by the

## part injured. If the latter be great, and its shape be but slightly

changed, there are pronounced explosive effects. Moreover, one end of the bullet is a little heavier than the other, and this will tend to produce a certain amount of tilting, by which a key-hole wound may be also produced. Fig. 47, from De Nancrède, shows the many alterations in shape which may be produced under various circumstances. Again, hard-metal jackets or mantles may be stripped off bullets before the latter reach the body, or in passing through it, as has been shown.

Bruns has shown that with the ordinary small arms the size of the wounds of entrance and exit diminishes with the decrease in velocity or increase of the distance, although allowance should be made for the manner and angle at which the bullet strikes the surface, the wound being circular or oval according to these conditions. The wound of exit will depend upon the direction of the axis of the bullet at the instant it leaves it; thus it may be oval or irregular. When the bullet in transit shatters or comminutes a bone the wound of exit may be made much larger and more ragged than otherwise. In a general way Bruns makes the statement that, other things being equal, the damage inflicted by the escape of a projectile from the body varies according to distance from the weapon. Thus up to fifty meters a considerable amount of destruction of muscle, etc., may be produced. The area is small and the track of the bullet is smooth and little larger than the caliber of the projectile. Between 100 and 300 meters there is little destruction of muscle, and the wound of exit is smooth and may contain some bone debris. Thus Bruns would make it appear that the distinguishable characteristics of near and distant shots appear in the variations to be noted between the wounds of entrance and exit.

After a careful study of the alterations in the shape of the bullets themselves, Coler and Schjerning reported at the Twelfth International Medical Congress that only in 4.5 per cent. of all hits does deforming of the bullet occur; if hits in the bones only are considered, the percentage would be much greater. In wounds of the other parts alone there is rarely any deforming effect upon the projectile. They also show that careful distinction must be made between the deformity of the bullet caused by the body and that resulting from impact upon some object before reaching the body. Thus if a bullet have first struck a branch of a tree, or some object upon the ground, it may have become so altered in shape as to correspond almost to a Dumdum bullet. The harm done by such a ricochet shot depends upon its unexpended energy and its altered shape, but will always be greater than if it had struck in the direction of its long axis.

The question of the heat imparted to a projectile in its course and the possibility of its being sterilized by such heating are questions which have been carefully investigated. The heat of a bullet produced by penetration into a hard material will depend upon the striking distance and the density of the material. In the human tissues the heat attained by a bullet, even when penetrating a bone at short range, is rarely 100°C., while at long range it will scarcely amount to half of that. There is no accurate measure of the heat that may be engendered in its passage through the atmosphere, but the question is one of interest, in that it brings up the possible sterilization of the bullet and its capacity for destroying such septic material as it may carry in with it. A series of experiments made in Baltimore and elsewhere permit the following conclusions to be drawn:

1. The majority of cartridges in their original packages are free from septic germs, this freedom being due to the precautions observed during their manufacture.

2. As a result of this cleanliness the majority of gunshot wounds are not septic.

3. Such resistant germs as those of anthrax, when applied to the small bullet of a hand weapon, are rarely completely destroyed by the act of firing, and it is possible to infect an experimental animal with such a projectile.

4. The ordinary germs of suppuration are not always destroyed, and may also cause infection.

These conclusions may be epitomized in these two statements: that bullets from small hand weapons are not necessarily sterilized by the act of firing, and that they also may infect.

The principal features to be noted in a case of gunshot wound are the following:

1. Hemorrhage.

2. Shock.

3. Pain.

4. Powder burn.

5. Localizing symptoms.

6. Multiplicity of wounds.

7. Entrance of foreign material.

8. Explosive effects.

9. Perforation of large vessels and the viscera.

1. =Hemorrhage.=--Hemorrhage may be internal or external. When internal it is rarely so accessible as to permit of the saving of life, yet the effort should be made to ascertain the source of the hemorrhage, as only in this way can life be saved. For example: A patient may bleed to death from injury to an intercostal artery, an epigastric, etc., while in either case a very simple expedient would tend to save life. External hemorrhage is generally due to injury of main vessels, and may end fatally unless first help be instantly rendered. Since the introduction into the army of a trained hospital corps, and a widespread diffusion of a knowledge of “first-aid dressings,” this is much less likely to occur than in the days previous to the use of the emergency packet. Recent military experiences have been that hemorrhages from limb vessels are much more likely to subside spontaneously than those of the viscera.

2. =Shock.=--Shock is present in a large proportion of gunshot injuries, especially those of the viscera and the region of the spine. Experienced army surgeons speak of the peculiar facial expression in those cases of shock which demand immediate attention.

3. =Pain.=--The symptom of pain is exceedingly variable. It is rarely complained of at the time of infliction, especially when the individual is laboring under stress of excitement. The pain of a wound will be increased by every movement of the body. When momentary pain is followed by local anesthesia, and especially if the latter be permanent, it will indicate the division of a nerve trunk, which will justify an operation for exposure of the site of the injury and nerve suture.

4. =Powder Burn.=--Powder burn is met with only as one of the complications of a short range and injury of an exposed part. Its degree is modified by the distance of the injured part from the muzzle, by the character of the powder, and the dimensions of the barrel. Fish has shown that in a pistol wound at short range the burning or scorching effects, which he calls the “_brand_,” are always found on the hammer side of the weapon which inflicted the wound, _i. e._, if the hammer were held up the brand would be above the entrance wound. The bullet wound in such a case shows the direction of the aim, but the recoil will so far change the direction of the barrel as to divert the stream of gases of combustion, so that they follow the new direction of the barrel, which is always toward the side of the hammer. This is a point in medical jurisprudence which has been testified to in the courts. The use of smokeless powder minimizes any effect of this kind. It has been claimed that a homicide has been recognized in the dark by the flash of the old-fashioned gunpowder used in the weapon, but the use of smokeless powder would obviate this possibility. The most distinctive part of a powder burn is the appearance of the tattooing caused by the lodgement under the skin of grains of unconsumed powder. Such grains, when accidentally or purposely contaminated with germs, are not purified by the act of firing. This is less true of certain brands of smokeless powder. Nevertheless the opinion prevails that gunpowder may serve for conveyance of infection. The so-called _smokeless powders_ are of secret composition, although it is known that in a general way they are composed of gun-cotton, dynamite (_i. e._, nitroglycerin), or picric acid. Melinite is composed of picric acid and collodium--_i. e._, gun-cotton. There are many of the modern explosives which depend for their final effect upon the combination of two or more substances. In the smokeless powers there is usually enough nitroglycerin to have a very noticeable effect should they be touched to the tongue, while even the fumes might be disagreeable or disabling.

5. =Localizing Symptoms Due to the Presence of the Bullet.=--The greater the distance and the smaller the velocity the more likely is a bullet to lodge within some portion of the body instead of passing through it. In the Cuban campaign the proportion of cases of lodgement was less than 10 per cent. of the entire number of bullet wounds. A bullet which rests within the body either will or will not produce disturbances which may be more or less lasting. In a large proportion of cases the latter will prevail. The number of pensioned soldiers who are carrying unremoved bullets in some portions of their body is by no means small. A rifle bullet may remain in certain portions of the cranium without producing much disturbance. _Bullets which cause no trouble are best left undisturbed. Those which produce serious symptoms should be removed._ To Esmarch is attributed the dictum that the harm produced by a bullet is usually done during its passage, and after it has found lodgement it ceases to be a source of trouble. While not invariably true, this is so generally the case that acceptance of this statement has revolutionized the previously prevailing view, _i. e._, that a bullet should be always removed if it be possible to locate and extract it. In some instances it may be located by a study of the symptoms; as, for instance, in certain areas of the brain, or when lying in close proximity to joint surfaces it interferes with their function; although a bullet embedded in bone often does not seriously interfere with the use of the affected part. The bullet which divides a nerve trunk rarely lodges in such position as to be considered when the repair of the nerve injury is undertaken; such wounds will generally be found to be perforating.

[Illustration: FIG. 48

Multiple shot wounds of arms and back. The ulcer over the spine was produced by pressure, not by the ball (case in Cincinnati Hospital, 1884). (Conner, Dennis’ System of Surgery.)]

6. =Multiple Wounds.=--The same bullet may sometimes inflict _multiple wounds_, and, with modern projectiles, these are now more common, as many as six wounds having been made by one missile in its passage, _e. g._, wounds of the arm and body. Thus multiplicity of wounds may not indicate that the patient has really been shot more than once. In cases of perforation, for each wound of entrance there should be found one of exit, and at the first examination of the patient the discovery and consideration of each of these injuries should be part of the routine. If on examination but one wound be discovered, then the inference is natural and unavoidable that the bullet is still within the patient’s body (Fig. 48).

7. =Entrance of Foreign Material.=--The entrance of fragments of cloth or other extraneous matter is now less frequent, for bullets of tremendous velocity rarely carry in any perceptible material, their diameter being small and their surfaces polished. A ricochet bullet may carry tetanus or other spores from the earth, and lockjaw may be the result. In other words, gunshot wounds now are less likely to become infected wounds than they were years ago.

8. =Explosive Effects.=--The shattering and explosive effects of the impact of bullets upon certain of the viscera are sometimes disastrous, and yet not easily seen from the outside. This is especially true in the brain, heart, liver, spleen, kidneys, and bones. Almost complete pulpification of the semisolid viscera may occur as the result of perforation by a small missile, and the general condition of the patient should be relied upon to indicate this fact.

9. =Perforation of the Large Cavities of the Body= usually implies perforation of at least a portion of their contained viscera. Thus if a man be shot through the chest it may be assumed that perforation of the lung has occurred, while in a case of bullet wound of the abdomen it will rarely be found that the viscera, especially the intestines, have escaped perforation. Still, remarkable cases are occasionally recorded. Thus I have seen a man who had been shot through the abdomen from front to back, the bullet entering just above the pubis and escaping near the lumbar spine, who never seemed to have suffered seriously from his injury, although the bullet was a large soft one from the old Springfield musket.

=Diagnosis.=--More or less characteristic appearances pertain to most wounds of entrance and of exit, which render them reasonably distinct and recognizable, even though no history be obtained. Nevertheless much depends upon distance, velocity, and any deformation of the bullet due to its impact upon some other substance previous to its entering the body. An elongated wound may suggest that the direction of the bullet was at an angle with the surface struck. Such wounds are known as “key-hole” wounds. A bullet already deformed may inflict a wound that will baffle speculation. The wound of exit is usually a little larger than that of entrance. When much larger a bone lesion should be expected. Trifling punctures, perhaps made by particles of the bullet, may be found around the principal wound or in the bone which it has shattered.

Diagnosis may include a recognition not merely of the general character of the injury, but whether it was inflicted by one or more bullets; whether these bullets have escaped; and if not, in what part they are probably lodged. In the preantiseptic days much of this information was gathered by the use of the probe, and the porcelain-tipped probe devised by Nélaton was relied on for much more than it could possibly safely tell. In those days probing was indiscriminately practised, and accomplished more harm than good. Now the probe is rarely used, at least at first, and when used, it is connected with some electrical device by which results are attained with a minimum of handling. For this purpose the telephone probe of Girdner was formerly a popular and ingenious device, which has been more recently supplanted by a simpler mechanism by which, when the end of the probe comes in contact with metal, a little bell, or buzzer, is rung. No probe or other instrument should be introduced into a gunshot wound, for diagnostic or other purposes, without observing aseptic precautions.

The most valuable expedient for the detection and location of bullets, as of other foreign bodies, is the Röntgen ray. With a suitable apparatus of this kind the surgeon can not only decide as to the location of the missile, but whether it is best to attempt an operation for its removal.

=Prognosis.=--In gunshot wounds not speedily fatal the prognosis depends upon the part injured, the size and shape of the missile, its velocity, the distance from the weapon, the amount of blood lost before attention was given, the character of the attention first received, and the absence of such complications as exposure, rough handling, etc. The dictum that the _fate of a wounded man is in the hands of the surgeon who first attends him_ made its author, Esmarch, famous. The patient having escaped the dangers of hemorrhage and shock is to be carefully guarded from sepsis, and if thus guarded can be protected against most of the other visible dangers save those due to perforations of large cavities. If, therefore, a gunshot wound can be promptly provided with a primary aseptic or antiseptic dressing, and in other respects be let alone, the outlook for the patient will be encouraging. The prognosis often depends upon how completely the patient is let alone after the application of occlusive dressing.

=Treatment.=--_Hemorrhage_ is the first consideration, and should be the first care of the surgeon. Digital pressure may be resorted to, which may suffice until a temporary expedient has been supplied. Next in importance is disinfection of the area surrounding the wound and the application of a sterilized absorbent dressing, with pressure to prevent loss of blood. The use of the probe, or any attempt to at once ascertain the location of the bullet, is not advisable. The question is not, “Where is the bullet?” but, “_How much harm has it already done?_” And the first attention should be addressed to atoning for any harm that may have been done. Even though the intestines have been perforated, or the heart wounded, there is no need in doing anything more than meeting the immediate emergency. If shock be extreme it may be atoned for in some measure by lowering the head and bandaging the extremities; while in extreme cases hypodermoclysis or venous infusion of saline solution, often with the addition of a little adrenalin, will be of service.

Again, physiological rest of the part injured, _i. e._, _immobilization_, as well as absolute rest of the patient’s body and mind, must not be neglected.

Primary laparotomy has been done upon the battle-field, and is of itself a testimony to the intrepidity and zeal of those who have done it; yet, as a practice, it is to be condemned. All operations upon gunshot wounds should be done in a well-equipped hospital.

[Illustration: FIG. 49

Gunshot wound of forearm. Bullet _in situ_ in bone.]

The probing of bullet wounds is so unwise that it may be well to state the reasons for its general condemnation:

1. As it used to be practised, neither probe nor skin nor the operator’s hands were sterilized.

2. Even when carefully done it is often absolutely disappointing, the probe failing to reveal the presence of the bullet.

3. By the time the probe is introduced the wound will be usually more or less filled with blood clot. To stir this with a probe is to invite a secondary hemorrhage or annoying oozing.

4. Even when properly used the probe may carry in infectious material from the surface.

5. Most wounds made by modern bullets, even pistol bullets, are of such a character that it is difficult to follow their track without using force.

6. I have known a wound on the anterior surface of the body to be probed for a bullet that had escaped, as shown by an examination of the other side of the body, which the attendants had failed to search.

7. If there be good reason for exploration of a wound let it be postponed until the surgeon is prepared to follow a bullet and extract it. _When it does not call for extraction, it does not call for probing._

8. The best probe is the surgeon’s finger, and for its use the patient generally requires an anesthetic and free incision.

When muscle is torn and needs suturing, or when tendons or nerves are divided and need the same resource; when bones are shattered and fragments need to be removed; when the skull has been fractured and portions of bone driven into or upon the brain; when the intestines have been perforated; when even the heart has been wounded and the pericardium is filling with blood so that the heart’s action is becoming impeded; in any or all of these emergencies the patient needs surgical relief. But this should be of a kind that, save in an emergency, should be postponed until suitable preparation can be afforded.

[Illustration: FIG. 50

Wound inflicted at 1300 yards by steel-mantled ball (from a recent foreign report). (De Nancrède.)]

[Illustration: FIG. 51

Shattering of humerus at long range with modern projectile; fusible metal cast showing extent and character of laceration of soft parts (from a recent foreign report).]

In regard to _regional indications_ in the treatment of gunshot wounds it will only be possible here to give some brief general hints, the reader being referred to the chapters on Regional Surgery for more specific instructions. Nearly all gunshot wounds of bones are compound fractures, and are comminuted as well. The best treatment is primary aseptic occlusion and immobilization, without effort in the direction of exploration. In an open wound the vessels should be secured, loose pieces of bone removed, and jagged bone ends trimmed; while in some instances a wire suture or other mechanical expedient may be resorted to with advantage. Provision should also be made for drainage.

In the regions of the _large joints_ the same general principles are applicable. Under the old _regime_ a gunshot wound of the knee would condemn a person to amputation in the middle of the thigh. Now, if such a limb be promptly provided with suitable antiseptic dressing, and placed at rest, the patient may save not only the limb, but the use of the joint. Extensive comminution may call for excision. Amputation is seldom necessary, except when important bloodvessels have been divided.

[Illustration: FIG. 52

Perforating bullet wound of head, wound of exit showing brain protrusion. Sloughing pressure-sore of scalp. Complete paralysis of motion and loss of speech. Battle of Mukden. (Major Charles Lynch.)]

[Illustration: FIG. 53

Perforating bullet wound of head, with prolapse of brain at wound of entrance. Operation done in Russian Red Cross Hospital at Mukden. Left hemiplegia; mind clear. (Major Charles Lynch.)]

[Illustration: PLATE XIII

Radiograph of Head viewed from the Left Side, showing Mauser Bullet Lodged in Brain. (Surgeon-General’s Report on Use of Röntgen Ray, 1900.)]

[Illustration: FIG. 54

Perforating gunshot wound of head; two wounds converted into one by removal of comminuted bone. From Russian Red Cross Hospital, Mukden. (Major Charles Lynch.)]

[Illustration: FIG. 55

Result of accidental explosion of hand grenade, in a Chinese coolie with Fourth Division of Japanese Army, near Mukden. (Major Lynch.)]

[Illustration: FIG. 56

Shrapnel wound of leg necessitating amputation. Japanese soldier at battle of Mukden. (Major Lynch.)]

_About the head_ may be seen all varieties of gunshot wounds and their complications. The bullets from small weapons may not penetrate, but those from larger ones usually penetrate and sometimes perforate. Infection is not an uncommon sequel to all of these injuries, even if involving the skin alone; the skull, especially the diploë; the membranes, or the brain itself. (See