This section is from the book "Smith's Family Physician", by William Henry Smith. See also: Natural Physician's Healing Therapies: Proven Remedies that Medical Doctors Don't Know.
Under the term gun-shot wounds are included all the injuries caused by the discharge or bursting of fire-arms. They consist of severe contusions with or without wounds. When a musket or pistol ball has penetrated an ordinary fleshy part, there is seen a hole, perhaps rather smaller than the ball itself, with its edge livid and inverted; and if the ball has passed completely through, there will be another larger and more ragged orifice, with its edge everted. The wound will, besides, be attended with more or less pain, haemorrhage, and constitutional disturbance.
The pain in these cases is said, by most authors, to be inconsiderable at the moment of infliction. Mr. Guthrie, however, both from observation and personal experience, affirms that this is by no means the case, and says that in general the pain is severe; that it is a dead heavy painful blow, although still the injury may not be felt at the moment, if it is inflicted while the patient's; whole attention is absorbed by other objects.
Most authors state that gun-shot wounds are attended with very little haemorrhage, unless some considerable blood-vessel has been divided. But Mr. Guthrie, asserts that this is equally erroneous, that there is in general considerable haemorrhage of an arterial colour; but that a wound of a large artery is only to be feared if the blood continues to be poured out in large quantities, and in jerks.
The constitutional disturbance accompanying these wounds is severe and peculiar. The surface is pale and bedewed with cold perspiration; every limb trembles; the patient cannot stand without support; and sutlers from vomiting, faintness, and peculiar alarm, anxiety, and confusion of mind. The severity of these symptoms will in general be determined by the extent of the injury, the importance of the part wounded, and the habitual fortitude of the sufferer.
A remarkable circumstance connected with gun-shot wounds is the facility with which the ball may be diverted from its course by the slightest obstacles. Any trifling obliquity of surface, or difference of density in the parts which it traverses, may cause it to take a most circuitous route. Thus, a ball may enter on one side of the head, the chest, or abdomen, and may pass out at a point exactly opposite, just as if it had gone entirely through the cavity, whereas it may be found to have travelled round beneath the skin. Sometimes it will make a complete circuit, as in the case of a friend of Dr. Hennen, who was struck about the pomum Adami by a bullet, which passed completely round the neck, and was found lying in the very orifice by which it entered. The track of the ball in these cases will often be indicated by a blush, or dusky red line, or wheal on the skin, or sometimes by a peculiar crackling.
It is always important to ascertain whether the shot has pa-out of the body or whether it is lodged; and supposing that there are two holes, it must be considered whether they are produced by the entrance and exit of one ball, or by the entrance of two distinct balls. If there are two holes, and they are distant from each other, some light may be thrown on the question by ascertaining the position of the patient at the time he was wounded, and the posture of his assailant. Balls sometimes make strange journeys: in one instance, a soldier who was ascending a scaling-ladder, was wounded in the right arm, and the ball was found under the skin of the opposite thigh. In some instances a ball has been unable to perforate a fold of linen, but has carried it for the distance of one or even three or four inches into the wound; and on drawing this out, the ball of course comes out with it. Mr. Home, in his report on gun-shot wounds in Canada, in 1838, speaks of the great power which the canvas lining of soldiers' stocks has in resisting the passage of balls.
Again, it is very possible that two balls may enter by the same aperture, one of which may pass out, and the other diverge, and wound some important organ. Sometimes it will happen that a ball splits, either from a defect in the casting, or from its striking against some sharp bony ridge, as the bridge of the nose or the shin.
It frequently happens that large masses of metal are impacted in the substance of a part without much external indication of their presence, it appearing as though they made room for themselves by compressing the surrounding soft parts. Guthrie gives a case, in which a ball of eight pounds' weight lodged in the thigh without making a large opening, and was not discovered till it accidentally rolled out on amputating the limb.
Gun-shot wounds may be complicated by the presence of other foreign bodies besides the ball. Three pieces of coin were extracted on the fifth day after the battle of Waterloo, from a wound in the thigh of a poor Hanoverian soldier. As he possessed neither money nor pocket to put it into, they evidently came from a comrade who stood before him, and who was killed by the same shot.
Injuries from spent balls have at all times attracted great attention from the extreme violence of the injury inflicted, with very little external appearance of it. In some rare cases a cannon-ball has passed close to the head, and has caused death, either immediately or within a few hours, without leaving any morbid appearance that could be detected by dissection. But in the majority of instances it is found that, although the skin may be intact, or but slightly grazed, still that the parts beneath have been irreparably disorganized; the muscles pulpified, the bones ground to powder, and large vessels and nerves torn across. The patient is severely stunned; and the part injured is motionless, and senseless, and benumbed for some distance; swelling soon comes on, and is followed by gangrene which spreads to the neighbouring parts. These cases were formerly called wind contusions.
In favourable cases,inflammation generally comes on from twelve to twenty-four hours after a gun-shot wound of some common part. The wound becomes swelled, stiff and painful, and exudes a little reddish serum. On the third or fourth day pus begins to be formed; about the fifth day the parts in the immediate track of the ball, which have been killed by the violence of the contusion, begin to separate, and change from a blackish red to a brownish yellow colour; and on the tenth or fifteenth day, sooner or later, according to the vigour of the constitution, the slough is thrown off. In the meantime granulations form, the wound contracts, and becomes impervious at the centre, and generally heals by the end of six weeks or two months.
But if the patient, previously to the receipt of his wound, or after it, has committed excesses, or has been exposed to vicissitudes of temperature, or if the wound has been irritated by want of rest, or improper applications, the local and constitutional affections will be much more formidable. The pain will be more severe, the redness and swelling more extensive, the wound dry, and fever violent. When suppuration is established, instead of being confined to the track of the ball, it is diffused among the neighbouring muscles, and under fasciae, forming numerous and irregular sinuses; so that the treatment is protracted for many months; and even after the cure is completed, the limb remains disabled by contractions and adhesions of the muscles, and is liable to swellings.
If the ball or other foreign bodies remain lodged, the inflammation and constitutional disturbance will be more severe, and the resulting suppuration more profuse and exhausting, and it will besides be accompanied with more or less pain, till the intruding substance is removed. In some cases, however, if the ball is small and smooth, and does not press upon any sensitive part, it may remain for months or years without creating any trouble.
When a ball has passed completely through some fleshy part, such as the thigh or buttock, the wound should be sponged clean; and when the bleeding is stopped, the best application is a piece of lint or cotton batting, and which should be secured by two or three strips of plaister. Tremor and mental confusion may be allayed by a mouthful of wine and spirits, or, if severe, by an opiate. When the patient is somewhat recovered from the shock, a compress or pad of linen, wetted with cold water, or with some cooling lotion, will be the only other application needed. If the patient can be kept at rest in bed, all bandages, at this stage, will be unnecessary and injurious.
These primary dressings need not be removed for the first three or four days; and if they have become dry and stiff, they should be well moistened with warm water previous to their removal. During the succeeding inflammatory stage, there is the choice of hot or cold applications,each of which has its advocates. Mr. Guthrie greatly prefers the use of cold water, and considers a poultice applied to a compound fracture, or wounded joint, as the sure precursor of amputation. When suppuration is well established, the cure is to be completed by mild stimulating lotions and bandages. The diet of the patient must be cooling and unstimulating, and if there is much inflammation, leeches may be applied.
Supposing amputation to be necessary, that the limb, if preserved, could be but a burthen to the patient, and that the attempt to preserve it would endanger his life; the question next arises, whether amputation ought to be primary; that is, performed within the first forty-eight hours, before fever and inflammation have set in; or whether it ought to be secondary; that is, delayed till inflammation has subsided, and suppuration is established, which is not generally the case in less than from three to six weeks. Now, this question is one which cannot be decided by argument, but by experience; and the general experience of modern military surgeons has decided that amputation, when necessary, ought to be primary. According to Mr. Guthrie, the loss after secondary operations is at least three times as great as that after primary.