REMARKS

ON

MILITARY SURGERY.

CHAPTER I.

GUNSHOT WOUNDS IN GENERAL.

THE difficulties that the army surgeon has to encounter after an action are very great, and require that he should have great resources within himself, on account of having so many wounded to attend at once. This is the time when knowledge, skill, and decision are displayed. The peculiarities observed in gunshot wounds were, in former times, ascribed to the parts being burnt by the ball; to their being poisoned; to the effects of electricity, &c.; they, however, can be accounted for by the bluntness of the projectile, the rapidity of its course, and the force with which it is propelled. Gunshot wounds are of the contused and lacerated kind, and present peculiarities as to colour, shape, and size of the orifice, conjoined with sloughing, which always occurs in the track of the ball; although sharp splinters of shell occasionally produce incised wounds. When the patient survives, active inflammation, deep-seated suppuration, and profuse discharge generally ensue.

The kind of projectiles which are in use in modern warfare are the pistol, musket, rifle, and cannon ball, shell, grape, and canister shot, &c. The Enfield rifle ball, hollow in the base, is

1 oz. 2 scr. 1 gr. The Minié ball used by some French regiments are 1 oz. 2 dr. 2 scr. 10 gr. The siege rifle ball used by the Russian army, with a conical flat base, three rings, and two raised ribs to fit grooves in the barrel, is 1 oz. 5 dr. 3 gr.

There are also cannon of different size and formation, made to throw either round shot, or cylindrical shot, or shell percussion, as in the Armstrong gun, &c.; there is the mortar for a vertical fire, calculated to throw shell; for the smooth-bore cannon there is the solid shot, the grape shot, and the canister shot. Bar shot are two large shots joined together with an iron bar between, and chain shot with a chain between two large shots. The shrapnel shell is a hollow sphere of iron, filled partly with gunpowder and with iron balls of small size, &c.; the common shell is an iron ball filled with powder only. The wounds inflicted by these various projectiles are, of course, very different. The rifle bullet produces a very small wound compared to those caused by large shot, but still they are often as fatal in their effects.

J. R. Taylor, C.B. and I.G., in his 'Explanatory Observations on Classification of Gunshot Wounds,' states: "It may at first appear objectionable to class together wounds by bullet, cannon, shot, and shell; but taking all classes of wounds brought in off the field, it will be found that the danger is more commonly in proportion to the part struck, than to the weight or magnitude of missiles."

A pistol charged with powder, if discharged with the muzzle resting close to the chest, has been known to be the cause of death. Wadding and pieces of cloth also occasionally produce serious injury. When a gun is loaded with small shot and fired close, it causes a severe lacerated wound, from being in a solid mass; when fired at a greater distance it scatters, and is less dangerous: still, if a single shot penetrated the eye, it will destroy vision, or, if it should penetrate the heart, it may cause instant death. Several men from India lost the sight of an eye from this cause.

A musket ball generally traverses, leaving two apertures, the one of entry and that of exit; sometimes there is only one aperture, and in this case the ball is probably lodged. Occasionally, however, the ball drops out through the aperture by which it

entered, or it may be easily extracted; at another time, a spent ball merely causes a contusion, from the oblique direction with which it strikes and glances off. The apertures are usually opposite to each other when a ball traverses, but when it strikes a rib or the cranium it sometimes is deflected and runs under the skin, and makes its appearance on the opposite side, without wounding any of the important organs contained in these cavities. There is generally a considerable difference between the aperture of entrance and exit. The hole made by the entrance of the ball is small, circular, and depressed; that of exit is large, everted, and irregular. Occasionally, however, there is no difference to be observed between the two, and, in some cases, the aperture of entrance is even larger than that of exit. Mr. Guthrie explains this by stating that the amount of the difference in the two apertures depends upon the momentum of the ball, and also, in some measure, on the resistance met with. In perforating gunshot wounds where the ball is propelled in full force, the aperture of entrance is small and round, and even less than the ball itself. When its force is much diminished before striking, then the entrance aperture is large and ragged. When a ball perforates the muscular parts of a limb, where it meets with little resistance, there is almost no difference between the two apertures. When the velocity of the ball is diminished by coming in contact with a bone, the aperture of exit is large, torn, ragged, and its edges everted.

Cannon balls generally produce wounds of the most formidable description, either completely carrying away a limb or the fleshy parts of the arm or leg, or shattering the bones, &c. On other occasions a spent cannon ball may cause a contusion without even producing an external wound. This was formerly attributed to the wind of the ball, or to the air set in motion by the ball. On these occasions, although the skin, from its elasticity, is entire, still the muscles, vessels, and bones may be entirely disorganized and converted into pulp, or the internal organs may be ruptured without any external wound.

In general, there is very little hæmorrhage from gunshot wounds, provided none of the larger arteries are wounded.

When organs of importance, as the large cavities and joints, are wounded, the shock to the nervous system is almost always

very great, and in some cases most appalling, and is indicative of the amount of injury received; still, the amount of shock is not, in every case, a diagnostic indication of the severity of the wound, as much depends upon the constitution and nerve of the soldier. When a wound is received in a fleshy part, it may not be perceived at the moment of the excitement of a battle, and even a limb may be carried away without the man being conscious of it.

In general, after every gunshot wound there is more or less inflammation, swelling, and tension of parts. In some cases this is often very severe, followed by extensive suppuration in the track of the ball, and also in the neighbouring parts.

The sloughs are separated, from the tenth to the twentieth day, from the track of the ball, and at this period consecutive hæmorrhage is liable to occur, which may suddenly prove fatal, and is more dangerous than the primary hæmorrhage, from the difficulty of arresting it and from the patient being weakened from tedious suppuration.

Occasionally a large, round shot, or more usually a portion of shell, may lodge in the hip, without producing any very large wound or causing much deformity.

Musket balls, striking the shaft of the long bone, or even a flat bone, generally fracture and split it, to a greater or less extent, according to the force with which they are propelled, and the angle at which they strike.

Occasionally a ball is flattened and thrown off without causing fracture; sometimes it only produces an indentation, or a partial fracture, and passes out or remains lodged. The new conical ball splits and comminutes much more extensively than the old round ball, rendering the chances of saving life much less. Occasionally a ball is lodged in the cancellated structure of the head of a long bone, without causing any splinters. In the late war with Russia, the conical ball was not found to be often split on the sharp crist of the bone, but almost always splintered the bone against which it struck, although there is a case, of which the preparation is in the museum at Netley, that occurred in the 19th Regiment, where the ball was split on entering the cranium.

Treatment. Superficial gunshot wounds require to be treated

on the ordinary principles of surgery. Immediate dressings and attentions are necessary (if this can be done) in gunshot wounds before the patients are sent to hospital.

When the head and neck are wounded, cold-water dressing and a bandage should be applied. When the chest is wounded, a bandage should be placed round the body, and the patient placed on the wounded side.

When the lateral part of the abdomen is wounded, the patient should be placed upon his side, and if it is in the centre, on his back, with his knees bent over a knapsack, and any protruding intestine cleaned and returned.

In wounds of the extremities, where no vessel or bone of importance is injured, cold-water dressing should be applied. When there is considerable venous hæmorrhage, the limb should be raised and a compress applied; a tourniquet should be applied when the bleeding is arterial. When a limb is partly smashed or torn away, a tourniquet should be applied, with the object of arresting the hæmorrhage and quieting the shaking of the limb.

The shock should be counteracted by the administration of brandy-and-water, to allay the thirst. The period of collapse varies in different cases, which also, in a great measure, determines whether immediate amputation should be resorted to, or to wait for a more favorable opportunity.

The arrest of hæmorrhage should be first attended to, and this is to be done by the application of a compress and bandage, or a tourniquet, or some other substitute that may be at hand.

All foreign bodies, viz., the ball, splinters of bone, wadding, &c., should at once be removed. Detached pieces of bone should be extracted, but not those that remain attached to the fracture; they should be left until loosened by suppuration.

The inflammation and sloughing which occur along the whole track of the ball are to be treated in the first instance with cold applications and rest; and as inflammation, tension, and suppuration take place, fomentations are to be employed, so as to hasten the separation of the slough, with free incisions in the direction of the limb, to lessen the inflammation, tension, and to favour the escape of matter; but poultices should not be resorted to any more than can be avoided; spungio-pilin is,