Gunshot wounds consist of injuries from missiles projected by the force of explosion. As the name implies, this class of wounds is ordinarily restricted to injuries resulting from fire-arms; but it should be remembered that wounds possessing the same leading characteristics may result from objects impelled by any sudden expansive force of sufficient violence. Injuries from stones, in the process of blasting rocks, or from fragments of close vessels burst asunder by the elastic power of steam, offer familiar examples of wounds of a like nature with those from gunshot. In the following article, however, gunshot wounds will be considered as they are met with in the operations of warfare. HISTORY. From the earliest time of the application of gunpowder to implements of war, down to the present day, the wounds inflicted by its means have excited the most marked interest among surgeons; nor can this be wondered at, when the immensely superior energy of this agent in comparison with all the mechanical powers previously in use for hostile purposes, and the terrible nature of its effects on the human frame, are remembered. By its introduction the whole aspect of war was changed, in a great degree, by the distance at which opposing forces were enabled to contend with It required long years of observation in many conflicts, and the exercise of much industry, not to mention moral courage in opposing authorized custom and prejudice, before a simpler and more rational mode of practice was followed. It is satisfactory to know that though Continental surgeons have written more voluminously on the subject of gunshot wounds, the older English military surgeons and writers stand forth conspicuously in leading the way to a more practical knowledge of their nature and proper treatment. Although, however, much that was erroneous was removed by the earlier surgeons, the light of science can hardly be said to have penetrated this important province of military surgery until the great and last work of John Hunter, on the Blood, Inflammation, and Gunshot Wounds, was published in 1794. This distinguished philosopher filled some of the highest positions in the British service, having been appointed in 1776 Surgeon Extraordinary to the Army, in 1786 Deputy Surgeon-General, and subsequently Surgeon-General; but he only served abroad about three years, and The still more recent military operations in Algeria, in Sleswick-Holstein, in the Crimea, and in India have afforded The alterations made during the last five or six years in the arms of a great proportion of the troops of the leading powers of Europe, and which will, no doubt, be extended to all soldiers in regular armies—namely, the transformation of muskets into “armes de prÉcision,” with rifled barrels and graduated aims—have led to changes in the severity and almost in the nature of gunshot wounds from small balls; and the consideration of these changes requires the especial attention of army surgeons. The effects of the new rifle-balls were widely witnessed during a portion of the period of the Crimean war. The campaign just concluded in Italy will probably produce additional practical observations from the Continental surgeons engaged in it. The fearful proportion of killed and wounded—greater than in any former experience—will have shown the effects not only of rifled muskets, but of rifled cannon also; and in the French forces engaged an opportunity will have been afforded of instituting In England, one valuable result which emanated from the late war with Russia was the regular collection and arrangement, under government authority for the first time, of the observations and practice of the medical officers employed in the campaign. The value to science of such systematized historical records, if fairly and fully developed, can scarcely be overrated; and it is to be hoped that henceforth a similar course will be always adopted whenever the country may become involved in war. VARIETIES OF GUNSHOT WOUNDS. Gunshot wounds are modified in their nature by the form and kind of missile, by the degree of force with which it is propelled, and by the seat of injury. They are, in addition, affected by the circumstances in which the soldier happens to be placed, and by the state of his health when the injury is received. Form and nature of missile.—The projectiles used in warfare of the present day are cannon and musket shot, shells of various kinds, hand grenades of iron or thick glass, case-shot, slugs, and other minor varieties of such missiles. These are the ordinary instruments of direct gunshot wounds in warfare; but, in addition, there are numerous sources of indirect wounds, resulting from the discharge of cannon and musketry. These are stones, or other hard substances, struck from parapets or from the surface of the ground by cannon-shot; splinters of wood from platforms and framework, or of iron from gun-carriages; fragments of bone from wounded comrades, or articles in their possession; and any other miscellaneous The objects above enumerated present several varieties of forms. 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. Such foreign substances, though not of themselves causing the wound, often have a special bearing on the progress of its cure. Not only the form of outline, but the weight, and in some instances the matter of which the missile is composed, influence the nature of gunshot wounds. 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. The same remark is applicable to the heavier forms of shell, before explosion. The only difference surgeons may look for from the use of cylindro-conoidal balls, or Whitworth bolts applied to cannon, should they become general, independent of increase in the number of direct wounds from greater power and precision of fire, will be the less number of indirect injuries likely to result from their action, as they neither ricochet nor roll as “spent balls” in the manner that spherical shot are accustomed to do. Grape-shot, canister, and spherical case, on striking collectively—that is, before they have spread—as sometimes happens in assaulting or in accidental close proximity to guns in the field, produce the same kinds of injuries as cannon-shot, but individually resemble musket-shot in their effects. 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. With regard to musket-shot, the form presents several features for the consideration of the military surgeon. In discussing the subject, however, it must not be omitted to be borne in mind that we have no experience of the effects of round musket-balls propelled with the same amount of force as recent improvements in fire-arms have given to balls furnished with a conical vertex; although, in the old, two-grooved rifle, with its belted round ball, a momentum was procured far exceeding that of the common smooth-bore musket. The change in form from the round to the prolonged cylindro-conoidal ball seems to derive its chief importance in surgery from the conical end possessing the mechanical characteristic of a wedge, while the former acted simply as an obtuse body. From this quality the power of penetration of conical bullets is greater, independent of the increased momentum communicated to them by the construction of the weapons from which they are discharged. Thus, supposing one of the old musket-bullets to strike a limb at 80 yards, and an Enfield rifle conical bullet of the same weight at 800 yards, the rate of velocity being similar in each case, the injury from the latter may be expected to be considerably greater than that from the former, on account of its shape. The wedge-like quality of the conical bullet is rendered particularly obvious on its being driven into the shafts of the long bones of the extremities. The solid, osseous Much has been written on the comparative surgical effects of bullets of various weights and sizes; but these qualities do not, on consideration, excite so much practical interest in the mind of the surgeon as it might at first appear they are calculated to do. Some very heavy bullets were used by the Russians in the defense of Sebastopol, nearly one-third heavier than any employed by the troops opposed to them. Such bullets, if of like form and density, and propelled with equal velocity, would obviously inflict injuries—especially against osseous structures, which offer great resistance—wider in proportion to their greater size and momentum; but, in respect to simple flesh wounds, the increased size of the wound left by the larger ball would make little difference in the gravity of the wound, or the time required for its cure, Double bullets, linked together by a spiral coil of wire, something after the manner of chain cannot-shot, were introduced by the Russians during the war in the Crimea. Specimens of these bullets were found about the works around Sebastopol, but no injuries received from them have been recorded; although, after the discovery, peculiarities in the characters of some wounds, which had not previously been satisfactorily accounted for, were supposed to have probably resulted from them. It seems likely, however, that, when discharged, the divergent forces impressed on the two bullets were sufficiently great to break apart the connecting wire, which was of very slender diameter, before they came into contact with the troops against whom they were directed. Wounds caused indirectly by stones from parapets, splinters of iron or wood, and by fragments of shells are very varied in character and severity. They derive their importance chiefly from the extent of surface usually lacerated and destroyed. Unless they happen to have penetrated or torn away largely the coverings of vital parts of the body, they are often less grave, though to the sight more fearful, than injuries of less alarming appearance from direct projectiles. In missiles of this secondary kind, the amount of resistance offered to their displacement proportionably diminishes the impetus with which they strike. In like manner, the powerful opposition of the hollow iron shell to the force of the bursting charge within, as well as the shape of the portions into which it is usually rent asunder, combine to cause the momentum of each fragment at starting to be much less, and this momentum to be more rapidly retarded during its flight through the air, than happens in ordinary missiles of direct explosion. The constitutional shock, in these injuries, is consequently, as a general rule, less than in direct gunshot wounds. Occasionally simple fractures happen from indirect missiles; from direct, they are almost necessarily compound. Although there may be no communication with an external wound, however, there is often great comminution of the bone in these accidents. The laceration and bruising of the Degree of velocity.—The velocity of motion of different projectiles is an important ingredient in the consideration of the several wounds produced by them. The rates of motion imparted to missiles by the fire-arms of early times were probably, from the imperfect construction of the weapons, defective quality of gunpowder, and other circumstances, as inferior to those of the musket lately in use as the velocity of musket-balls was to that of the conical bullets of the rifles in present use. In a table showing the velocities of certain moving bodies, published in 1851, the common musket-bullet is set down as moving at the rate of 850 miles per hour, the rifle-ball of that time at 1000, the 24-lb. cannon-ball at 1600 miles per hour. But the musket-ball then could not be depended on to hit an object beyond 80 yards, the rifle 200 to 250 yards; while the present Enfield rifle is sighted to 900 yards, and the short Enfield to 1100 yards. The effects of different rates of velocity on wounds are seen in the variations which occur in proportion to the distance which the missile has traveled before inflicting the injury. A cannon-ball which, with but slight velocity of motion added to its The increased velocity, or, in other words, greater force, of modern projectiles exhibits its effects in two directions—locally, by the greater destruction of the tissues in the track of the projectile; and constitutionally, by greater disturbance in the nerve-force of the whole system. The component parts of that portion of the organized fabric through which a bullet, traveling at the rate of several miles per minute, cleaves its way are inevitably deprived of their vitality. Instances are quoted by authors, of gunshot wounds having healed by simple adhesion; but such examples are not met with from rifle-bullets retaining their original form. Moreover, when considering the course taken by balls in the body, it will have to be shown that the velocity imparted to projectiles from modern weapons has led to another change in gunshot wounds. The great power of resistance so often before exhibited by the yielding elastic tissue of the skin, by tendinous and other structures, is no longer of avail against projectiles from modern fire-arms at their usual rates of speed. The splitting and destructive effects of conical balls on the shafts of the long bones of the extremities have already been mentioned when referring to the peculiarities of their shape. But, together with form, the amount of momentum is a necessary ingredient in estimating this result. The old round balls—partly from their form, but also from the imperfect mechanism of the firelocks from which they were discharged, and consequent minor degree of velocity imparted to them—on striking bones, would simply be turned away from the direct line, or, failing this, would knock out a portion of the shaft without further fracture, or, having perforated on one side, remain in the cancellated structure, or be Number of wounds in battle.—The increased velocity of modern projectiles, together with the more rectilinear path in which they move, causes a greater number of wounds in modern warfare. The difference which has existed in the proportion of wounded to shots discharged in recent engagements, compared with the experience of former wars, is most marked. It is well known that from expansion of the bore of the musket in use a few years since, and consequent increase in the difference between its diameter and that of the bullet, after a few rounds of fire musket-balls rolled out in numerous instances in the act of elevation of the musket previous to discharge. Now every shot is propelled to a great distance, and with force sufficient, if brought into collision early in its flight, to penetrate and wound several persons. Colonel Wilford, Chief Instructor at the Government School of Musketry, stated publicly in a recent lecture the fact that 80,000 rounds of ball-cartridge were fired from the old musket in one day in Caffraria, and only 25 Caffres were Spent balls.—In connection with degree of velocity, the Lodgment of balls.—Low rate of velocity leads to musket and other balls lodging in various parts of the body. When the smooth-bore musket was in common use, lodgment of balls was of frequent occurrence. In the first place, from absence of sufficient initial velocity to effect its passage out of the body, and, secondly, from its liability to be diverted from a direct line, a round ball might be arrested in its progress at any distance from its point of entrance. Conical balls lodge when their velocity has become nearly expended before entering the body; or, from peculiarity in the posture of the person wounded, a ball, having had force enough to traverse a limb, may afterward enter into another part of the body and lodge. A ball may reach a part so Unextracted balls lead to consequences varying according to the site of lodgment and state of constitution of the patient. If the ball have become fixed in the body of a muscle, or in its cellular connections, adhesive inflammation may be established around it, and in time a dense sac be thus formed, in which the ball may remain without causing any, or but very slight, inconvenience. M. Baudens asserts that a cellular envelope is of very early formation around balls lodged in muscular tissues. Although thus encysted, a ball may press upon nerves, and give rise to pain and much uneasiness, or may be so situated as to embarrass the person in certain movements of the body. Foreign bodies not unfrequently change the position of their first lodgment, under the effect of gravitation or the impulse of muscular actions. The following instance, which occurred to Staff-Surgeon Dr. Daniell, illustrates the distance to which a lodged ball may travel before finding its exit: In the disastrous affair of Malageah, on the west coast of Africa, fought in May, 1855, between detachments of the West India regiments and the Moriah chiefs, a man was wounded just below the spine of the scapula by a shot fired down from an elevation. The aperture was small, no ball could be traced, and the wound healed up rapidly. Six months afterward the man attended hospital, complaining of inability to march and pain about one of his ankles. A red, painful swelling and abscess formed over the inner malleolus, disease of bone was suspected, when examination led to the discovery of a small iron ball, of irregular Grape-shot, and even balls of larger size from field guns, occasionally lodge. The large, gaping wounds inflicted by such missiles usually render the detection of their lodgment and position very easy; but still remarkable instances have occurred where the presence of bodies of this nature of very large size has been overlooked. Mr. Guthrie’s experience of the war in the Peninsula led him to record that “it was by no means uncommon for such missiles as a grape-shot to lodge wholly unknown to the patient, and to be discovered by the surgeon at a subsequent period, when much time had been lost and misery endured.” The same distinguished surgeon mentions a case where a ball weighing eight pounds was not discovered till the operation of amputating the thigh in which it had lodged was being performed. Baron Larrey describes a similar case: An artilleryman had his femur fractured by a ball, which, according to the man’s description, had afterward struck another artilleryman by his side. On Penetrating fragments of shells, if projected edgeways, almost invariably lodge. In these cases, the appearance of the wound seldom indicates to the observer the true size of the body which has caused the injury. At an early period of the battle of the Alma, a piece of shell, about four pounds in weight, lodged in the buttock of a soldier of the 19th Regiment; and, to extract it, an incision had to be made nearly equal in extent to the length of the original wound. In this instance the concave aspect of the fragment—evidently, by the nature of the curve and thickness, a portion of a very large shell—had adapted itself to the parts lying beneath, while its convex surface so agreed with the natural roundness of the parts above, that it would have been impossible to have arrived at a knowledge of its lodgment, from any change in the external appearance of the parts. Examination by the wound alone gave decided information on the question. Such fragments become very firmly impacted among the fibers of the tissues in which they lodge, and the effused blood fills up inequalities, and rounds off edges that might otherwise show themselves prominently; so that, without due care, their presence is not unlikely to be overlooked at first examination. Dr. Macleod, of Glasgow, mentions that he saw a case at Scutari, in which a piece of shell weighing nearly three pounds was extracted from the hip of a man wounded at the Alma, which had been overlooked for a couple of months, and to which but a small opening led. Bullets scattered from canister or spherical case not unfrequently lodge; apparently in consequence of the direct velocity received from the primary discharge being disturbed, and lessened by the force of the secondary explosion of the case in which they were contained. A small layer of metal, like a portion of one of the coats of an onion, occasionally becomes detached from a leaden bullet, and lodges. The writer was once applied to by a discharged soldier, suffering from some troublesome granulations at the bottom of the left orbit. The globe of the eye had been destroyed nearly two years before by a musket-ball shot from above, which, after traversing the orbit, had descended, and was excised from the right side of the neck. On examining the granulations by a probe, the point came into contact with a hard substance, which further examination showed to be a small projecting point of lead. It proved to be a scale from the bullet which had caused the original wound, being equal in length to half its circumference, and in width, at the broadest part, about a third of the same dimension. It retained the curved form of the bullet from which it had been detached. The following case shows that similar sections may be separated from cylindro-conical as well as from round bullets. An officer of the 41st Regiment was struck in the Crimea by a conical bullet, which destroyed the forearm in such a manner as to necessitate amputation below the elbow. Secondary hemorrhage occurred on the eleventh day, and on the following day the stump was opened and examined. “While searching for the bleeding vessel, a slice of the bullet, about the size of a worn sixpence, was found deeply imbedded in the muscle.” In the case of a soldier of the 19th Regiment, who was wounded before Sebastopol in the loin by a conical bullet, Lodgment of small foreign bodies, angular pieces of metal, as slugs, nails, and others, and of soft textures, as shreds of linen or woolen cloth, often give rise to much inconvenience. The track of a musket-ball may be prevented from healing, and a troublesome sinus formed, by such small fibers of cloth as would hardly attract notice if within means of observation. Although a wound be closed, and apparently healed, if any shreds of cloth remain, it will probably open from time to time, when small fibers may be noticed in the discharge; and this will continue until the whole is thus got rid of. The probability of cloth entering a wound with the conical ball is not so great as it was with the spherical ball, which not unfrequently tore out a little cap, as it were, of cloth in its passage. This is another result of its shape and velocity. John Hunter and others make mention of circular pieces of the skin being cut out by bullets, and then lodging, and acting as foreign bodies in the wounds. When the MiniÉ-ball, with the iron cup at its base, was first brought into use, surgeons anticipated that the addition of the iron cup would complicate the ill effects of the wounds inflicted by it. It does not appear that this has proved to be the case. The iron is usually so far driven into the lead by the force of the exploded gunpowder, and so firmly fixed by the alteration in shape and pressure of the lower part of the ball, that it but rarely becomes detached so as to form a separate lodgment. Gravel and small stones struck up by shells at the time of their explosion, or by shot ricochetting against the ground, often lodge, and give much trouble in their extraction, especially about the face. In the assault of Sebastopol, at the Foreign substances derived from persons standing near a wounded man, sometimes fragments of the bodies of other wounded men, have been already named as occasionally lodging. In a severe injury to the face, which occurred in a man of the 1st brigade of the Light Division, in the Crimea, the surgeon was at first puzzled by the strange displacement of a part of the upper jaw. After closer examination, and obtaining a clearer view by the removal of clot, it was found that a piece of the jaw of another man, whose head had been smashed by a round shot by his side in the battery, had been driven into the palate, and was there impacted. Among other cases recorded in the Surgical History of the Crimean War, is one of a double tooth of a comrade having been found imbedded in the globe of the eye; and another, where a portion of a comrade’s skull was removed from between the eyelids of a soldier. In such injuries as these, where one of two men standing side by side is wounded by a portion of the body of his neighbor, the fragment striking is usually detached from a corresponding region with that struck. The late Mr. Guthrie extracted from the thigh of a Hanoverian soldier, on the third day after his admission into hospital, two five-franc pieces and a copper coin. The man had had no money about him previously to the injury, nor pocket to contain any. The coins had been carried from the pocket of a neighbor, who stood before him in the ranks, and who had been hit by the same grape-shot. These coins, flattened out and jammed together by the force of the shot, are in the museum at Fort Pitt. Similar examples might 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. The records of the Crimean campaign afforded not unfrequent examples of such wounds. Two cases occur, in the French records, of fracture of the forearm without any external apparent lesion; in one the internal structures were reduced to a mass of pulp. The difficulty of reconciling the several facts noticed in such instances, together with the vague descriptions by patients of their sensations, led surgeons to seek an explanation for them in the supposition that masses of metal projected with great velocity through the air might inflict such injuries indirectly by aerial percussion. Either the air might be forcibly driven against the part injured by the power and pressure of the ball in its flight, or a momentary vacuum might be created, and the forcible rush of air to refill this blank might be the origin of the hurt. Electricity has also been called into aid in explaining these injuries. All these hypotheses are now abandoned. So many observations have been made of cannon-balls passing close to various parts of the body, as near as conceivable without actual contact, without any such consequences as those attributed to windage, as to lead to the necessary conclusion that the theory must in all instances The true explanation of the appearances presented in those cases which were formerly called “wind contusions,” appears to rest in the peculiar direction, the degree of obliquity, with which the missile impinges on the elastic skin, together with the situation of the structures injured beneath the surface, relatively to the weight and momentum of the ball on one side, and hard resisting substances on the other. 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. Baron Larrey, who examined many fatal cases of this kind, relates that he always found so much internal disorganization as to leave no doubt in his mind of its being the result of contact with the ball. He explained the absence of superficial lesion, by the surface having been struck by cannon-balls in the latter part of their flight, when they had undergone a change of direction from straight to curvilinear, and acquired a revolving motion, owing to atmospheric resistance and the effect of gravitation. In such a condition, he argued, they would turn round a part of the body, as a wheel passes over a limb, in place of forcing their way through it; and, while elastic structures would In some recently published letters on the wounded in the late campaign in Italy, by M. Appia, this writer states that wounds from massive projectiles having been rare, he had not met with an example of internal destruction of parts with skin preserved intact, and that he had nowhere seen a wound which was attributed to vent de boulet. The hypothesis, he remarks, seems generally abandoned. It is presumed that, in stating wounds from gros projectiles to have been rare, he refers only to the wounded in the hospitals, and that it is to be inferred that the injuries from cannon-shot proved generally fatal in the field. Seat of injury.—A knowledge of the seat of injury from the passage of a ball involves diagnosis of its course, the depth of its penetration, the particular organs or structures injured, and the extent of the injuries to which they have severally been subjected. The course pursued by balls in wounds presents many features of interest. The depth of penetration, in connection with direction, becomes of great importance when there is question of one of the great visceral cavities being opened. This part of the subject, however, together with that of injuries to the viscera themselves, will be more conveniently considered when treating of gunshot wounds in their special relations to particular regions. In like manner, the diagnosis of the extent of injury in wounds complicated with fractures of the long bones will be best considered under gunshot wounds of the extremities. Course of balls.—Of the circuitous and unexpected directions pursued by bullets in their course through the human frame, which were formerly so common, we are not likely to see many instances in future warfare, when the rifle is the weapon chiefly employed. The conical shape of the ball and the force with which it is propelled have had the effect, among others already named, of changing this characteristic of the ball from the smooth-bored musket. The latter, bearing It will often appear, at first examination, that the track of a wound by the cylindro-conoidal bullet, even at full speed, is widely removed from a straight line, especially when this class of injuries is new to the surgeon. 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. Occasionally, though rarely, an accidental concurrence of circumstances may lead to the conical bullet pursuing a circuitous instead of a direct course, especially when, after traveling a certain distance, its speed has become diminished; and, as round musket-balls are not yet wholly discarded from warfare, it is necessary to call attention to the observations which have been made on this subject. Balls have been known to pass round the outer convex and the inner concave surfaces of the abdominal and thoracic cavities, sometimes forcing their exit at points nearly opposite to those of entrance, sometimes making a complete circuit. Thus, from simple observation of the line of direction of two wounds, a ball may be supposed to have passed through the thorax or abdomen, while really it may not have penetrated the cavity, but only made its way beneath the integument. 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 Many examples of such injuries will be found in the works of all writers on gunshot wounds until the recent introduction of rifled weapons, while those who have only seen the latter in use are almost inclined to doubt the accuracy of previous statements on this subject, from not meeting with similar instances in their own experience. In the early part of the late war with Russia, the musket wounds were nearly all inflicted by the round bullet; but during the year 1855 conical bullets of various shapes and sizes were brought into use by the Russians generally, as they had been for some time previously by nearly the whole of the English army, and a large proportion of the French army. As early as the battle of Inkerman, however, the Russians were partly armed with the LiÈge rifle, with its conical bullet. Among 3000 wounded from the recent battles of Palestro and Magenta, assembled in the hospitals at Turin, M. Appia, whose letters on the wounded in the late Italian campaign have been before quoted from, writes that he was astonished not to meet one case of a cylindrical ball having taken a curved direction in its passage. He mentions the case of an officer being wounded by a ball, which entered at the epigastrium and passed out by the side of one of the lumbar vertebrÆ, without penetration of the abdomen, a red mark or zone connecting the two wounds and indicating the circuit which the ball had made. In another case, a ball had traversed the chest from right to left, and still had sufficient force SYMPTOMS OF GUNSHOT WOUNDS. The leading symptoms of gunshot wounds are the diagnostic marks of these injuries, and the constitutional disturbance, pain, hemorrhage, edema, and other circumstances with which they are attended. Some of these require to be noticed separately. Diagnosis.—The external distinguishing signs of a penetrating gunshot wound are generally manifest enough, but exact diagnosis of the nature and extent of the wound is not always so simple as it might at first appear to be. It is necessary to describe, firstly, the external appearances. These, although possessing certain universal characteristics, vary to a wide extent, according to the different forms, already described, of the missiles causing the injuries, their velocity, the part of the body struck, and its position relative to the projectile at the time of injury. 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. Minute particles of bone will be found among the soft tissues on one side, but the portion of the shaft of the bone remaining in situ is probably entire. In ricochet firing, or in any case where the force of the cannon-shot is partly expended, the extremity, or portion of the trunk, may be equally carried away, but the laceration If the speed be still further diminished, so that the projectile becomes what is termed a “spent ball,” there will not be removal of the part of the body struck, but the external appearances will be limited usually to ecchymosis and tumefaction, without division of surface; or even these may be wanting, notwithstanding the existence of serious internal disorganization. The rationale of such phenomena has been previously described. Should the cannon-ball strike in a slanting direction, the external appearances of the wound will be similar to those just described, according to its velocity, modified only in extent by the degree of obliquity with which the shot is carried into contact with the trunk or extremity wounded. Large fragments of heavy shells generally produce immense laceration and separation of the parts against which they strike, but do not carry away or grind, as round shot. Ordinarily, the line of direction in which they move forms an obtuse angle with the part of the body wounded. When they happen to strike in a more direct line, so as to penetrate, the external wound, as alluded to under the head of lodgment of projectiles, is mostly much smaller than the fragment itself, from the projectile not having had force 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. The muzzle is usually applied beneath the chin. In such a case, a circular hole, without any puckering or inversion of the marginal skin, together with dark discoloration of the integument for several inches round, is observed at the wound of entrance. The vertex of the head is shattered; fragments of the parietal and occipital bones, together with small portions of brain, are carried away and scattered about; the bones not broken are loosened from their sutures; the mass of brain is torn to pieces, but held by its membranes; the superficial vessels of the face are distended with blood. These effects are not wholly due to the passage of the ball, but partly to the flame from the ignited gunpowder jetting out at the mouth of the musket, and in part also to the expansive force exerted within the cavity of the cranium, by the gases resulting from the explosion. When the musket-ball strikes at a distance from the weapon by which it was propelled, but still preserves great velocity, the appearances of the wound are changed. An opening is observed, irregularly circular, with edges generally a little torn; and the whole wound is slightly inverted. There may be darkening of the margin, of a livid purple tinge, from the effects of contusion, or it may be simply deadlike and pale. Should the ball have passed out, the wound of exit will be probably larger, more torn, with slight eversion of its edges and protrusion of the subcutaneous A musket-ball ordinarily causes either one wound, as when after entering it lodges, or, as sometimes happens, from its escaping again by the wound of entrance; or two wounds, from making its exit at some point remote from the spot where it entered; but occasionally leads to a greater number of openings. This last result may happen from the ball splitting into two or more portions within the body, and causing so many wounds of exit. A case occurred to M. Dupuytren, where a ball split against the spine of the tibia; and after traversing the calf of the leg in two directions, entered the other leg at two points,—one ball thus causing five orifices. A case occurred to the writer, in the Crimea, where a cylindro-conoidal rifle-ball with three canalures, The number of wounds made by one ball may be increased by its traversing two adjoining extremities of the same person, or even distant parts of the body from accidental relative The two openings made by one ball may hold such a relative situation as to lead to the mistake of their being supposed to be caused by two distinct balls. A case is recorded where a ball entered the scrotum, and made its exit from the right thigh, without any intermediate mark of its passage; such a wound might lead to an erroneous diagnosis of this sort. Length of traverse, and consequent distance between the two openings, parts of the body brought into unusual relations from peculiarities of posture, and peculiar deflections of the ball, may all be sources of this error. The appearances of wounds resulting from penetrating missiles of irregular forms, as small pieces of shells, musket-balls flattened against stones, and others, differ from those caused by ordinary bullets in being accompanied with more laceration, according to their length and form. Being Pain.—A gunshot wound by musket-shot is attended with an amount of pain which varies very much in degree according to the kind of wound, condition of mind, and state of constitution of the soldier at the time of its infliction. It will sometimes happen in simple flesh wounds, that patients will tell the surgeon they were not aware when they were struck; and examples attesting the truth of such statements occur, of soldiers continuing in action for some time without knowing they had been wounded. Sometimes the pain from the shot is described as a sudden smart stroke of a cane; in other instances as the shock of a heavy intense blow. Occasionally the pain will be referred to a part not involved in the track of the wound. Lieutenant M. of the 19th Regiment was wounded by a musket-ball at the assault of the Redan, on the 8th of September, 1855. His sensations led him to imagine that the upper part of his left arm was smashed, and he ran across the open space in front of the works, supporting the arm which he supposed to be broken. On arriving at the advanced trench, he asked for water; on trying to drink, he found that his mouth contained blood, and that he was unable to swallow. The arm, on examination, was found to be uninjured, but a ball had passed from right to left through his neck, and from its direction had no doubt struck some portion of the lower cervical or brachial plexus of nerves. Immediately after the transit of a ball, the sensibility of the track and parts adjoining is found to be partially numbed, so that examination is borne more readily for a short time after the accident than at any later period. Of course, after reaction sets in, or when inflammation has become established, the pain of the wound is proportionably increased. 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. 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. This emotion is in great measure instinctive; it is witnessed in the horse hit mortally in action, no less than in his rider; it is sympathy of the whole frame with a part subjected to serious injury, expressed through the nervous system. Examples seem to show that it may occasionally be overpowered for a time, even in most severe injuries, by mental and nervous action of another kind; but this can rarely happen when the injury is a vital one. Panic may lead to similar results when the wound is of a less serious nature. A soldier, having his thoughts carried away from himself—his whole frame stimulated to the utmost height of excitement by the continued scenes and circumstances of the fight—when he feels himself wounded, is suddenly recalled to a sense of personal danger; and if he be seized with doubt whether his wound is mortal, depression as low as his excitement was high may immediately follow. This will happen according to individual character and intelligence, state of health, and other circumstances. For while, on the one hand, numerous examples occur in every action of men walking to the field hospital for assistance almost unsupported, and with comparatively little signs of distress, after the loss of an arm or other such severe injury; on the other, men whose wounds are slight in proportion are quite overcome, and require to be carried. As a general rule, however, the graver the injury, the greater and more persistent is the amount of “shock.” 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 That true “shock,” (Ébranlement of French writers,) as distinguished from shock resulting from mental depression after unusual excitement, or the effects of groundless alarm on the part of a patient, is a phenomenon the essential relations 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. M. Baudens, referring to his service in Algeria, has remarked that he has often found on the field of battle wounded soldiers who had died of primary hemorrhage. In those wounds to which the surgeon’s care is called, the primary hemorrhage is ordinarily small in quantity and of short duration—a sudden flow at the moment of injury, and nothing more. When a part of the body is carried away by It comparatively rarely happens that arteries are cut across by musket-bullets, either round or conical. The lax cellular connections of these vessels, the smallness of their diameters in comparison with their length, the elasticity as well as toughness of the tissues forming their coats, the fluidity of their contents, and, in consequence of all these conditions, the extreme readiness with which they slip aside under pressure, act as means of preservation when these important structures are subjected to such danger as the passage of a musket-ball in their direction. Endless examples occur where the ball appears to have passed through in the direct line of the artery, so that it must have been pushed aside by it to have escaped division. Mr. Guthrie mentions a case where a ball even opened the sheath of the femoral vessels, and passed between the artery and vein, in a soldier at Toulouse, without destroying the substance of either vessel. So Vessels do not always thus happily elude division by the ball. Captain V., of the 97th Regiment, whose death led to so much interest in England, was struck by a ball which divided the axillary artery on the right side. The arm had apparently been extended when he received the injury, as if in the act of holding up his sword. The night was very dark, the distance from the place where the sortie took place in which he was wounded to the camp hospital was more than a mile and a half, and he sunk from hemorrhage while being carried up. The death of an officer from division of the femoral artery is recorded in the Surgical History of the Crimean War, where also cases are mentioned, though not immediately fatal, of a wound of the femoral vein and profunda artery in the same subject from a conical bullet; and another, of the popliteal artery and vein, also from a rifle-ball. Mr. Guthrie mentions the cases of two officers who were killed, almost instantaneously, one by direct division of the common iliac artery, the other of the carotid. Primary but indirect hemorrhage, in consequence of a gunshot injury, usually occurs as a complication of fractured long bones, the sharp points and edges of which, extensively torn up as they now are by conical bullets, are well calculated to cause such injuries. They are not as frequent as might be expected, from the limits within which the dispersion of the fragments is restricted by their periosteal and other connections, and the yielding mobility, before mentioned, of the vessels themselves. We have no data, however, PROGNOSIS. 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. In estimating the probable issue of a particular wound, not only the state of health at the time, but, if a soldier, the previous service, and diseases under which he has labored during it, must be taken into account, and the circumstances in which he is placed with respect to opportunity of proper care and treatment must also be carefully weighed. The time which has elapsed after the receipt of the injury is another important matter in forming a prognosis. 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. Tables may be found in works showing statistically the nature and relative numbers of wounds and injuries received TREATMENT OF GUNSHOT WOUNDS IN GENERAL. When the circumstances of a battle admit of the arrangement, the wounded should receive surgical attention preliminary to their being transported to the regimental or general field hospitals in rear. A slight provisional dressing, a few judicious directions to the bearers, may occasionally prevent the occurrence of fatal hemorrhage, or avert serious aggravation of the original injury from malposition, shaking, and spasmodic muscular action, in the course of conveyance from the neighborhood of the scene of conflict to the hospital. In the siege operations before Sebastopol, this was accomplished by assistant surgeons in the trenches, or, according to the French system, by regular ambulance hospitals in the ravines leading to them. The provisional treatment should be of the simplest kind, and chiefly directed to the prevention of additional injury during the passage to the hospital, where complete and accurate examination of the nature of the wound can alone be made, and where the patient can remain at rest after being subjected to the required treatment. The removal On arrival at the hospital, where comparative leisure and absence of exposure afford means of careful diagnosis and definitive treatment, the following are the points to be attended to by the surgeon: firstly, examination of the wound with a view to obtaining a correct knowledge of its nature and extent; secondly, removal of any foreign bodies which may have lodged; thirdly, adjustment of lacerated structures; and fourthly, the application of the primary dressings. The diagnosis should be established as early as possible after the arrival at hospital. An examination can then be One of the earliest rules for examining a gunshot wound is to place the patient, as nearly as can be ascertained, in a position similar to that in which he was, in relation to the missile, at the time of being struck by it. In almost every instance the examination will be facilitated by attention to this precept. Occasionally it will at once indicate the probable injury to vessels or other important structures, in cases where the mutual relations of the wounds of entrance and exit, in the erect or horizontal posture of the body, would lead to no such information. Even in the direct course taken by a rifle-ball in a simple flesh wound, an erroneous opinion of the line in which the ball has moved may be formed from the first view, in consequence of the ready mobility of the several structures among themselves and their varying degrees of elasticity. 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. Portions of clothing, and, as has already been shown, other harder substances, are not unfrequently carried into a wound by a ball; and, though it itself may pass out, these may remain behind either from being diverted from the straight line of the wound or from becoming caught and impacted in the fibrous tissue through which the ball has passed. Of all instruments for conducting an examination of a gunshot wound, the finger of the surgeon is the most appropriate. By its means the direction of the wound can be ascertained with least disturbance of the several structures through which it takes its course. If bones are fractured, the number, shape, length, position, and degree of looseness of the fragments may be more readily observed. In case of lodgment of foreign bodies, not only is their presence more obvious to the finger direct than through the agency of a probe or other metallic instrument, but by its means intelligence of their qualities is also communicated. A piece of cloth lying in a wound is recognized at once by a finger, while, saturated with clot as it is under such circumstances, it would probably be confounded among the other soft parts by any other mode of examination. The index finger naturally occurs as the most convenient for this employment; but the opening through the skin is sometimes too contracted to admit its entrance, and in this case the substitution of the little finger will usually answer all the purposes intended. When the finger fails to reach sufficiently far, owing to the depth of the wound, the examination is often facilitated by pressing the soft parts from an opposite direction toward the finger-end. It was formerly the custom to enlarge the external orifice of all gunshot wounds by incision, and not merely the opening, but the walls of the wound itself, as soon after the injury as possible. This was not done as a means of rendering the examination easier, but as a prophylactic measure. Dilatation was also employed by tents and various other means with a view to secure the escape of sloughs and discharges. The opinions held by the older surgeons respecting Where the finger is not sufficiently long to reach the bottom of the wound, even when the soft parts have been approximated by pressure from an opposite direction, and when the lodgment of a projectile is suspected, a long silver probe, that admits of being bent by the hand if required, is the best substitute. Elastic bougies or catheters are apt to become curled among the soft parts, and do not convey to the sense of touch the same amount of information as metallic As soon as the presence of a ball or other foreign body is ascertained it should be removed. If it be lying within reach from the wound of entrance, it should be extracted through this opening by means of some of the various instruments devised for the purpose. In case of a leaden bullet, Coxeter’s Extractor, corresponding with Baron Percy’s instrument for the same purpose, and consisting of a scoop for holding and central pin for fixing the bullet, has been found a very convenient appliance, from the comparatively limited space required for its action. Instruments of two blades, or scoops, with ordinary hinge action, dilate the track of the wound injuriously before the ball can be grasped by them. The way to the removal of a bullet may often be smoothed by judiciously clearing away the fibers, among which it is lodged, during the examination, by the finger; and sometimes, by means of the finger in the wound, and external pressure of the surrounding parts, the projectile may be brought near to the aperture of entrance, so that its extraction is still further facilitated. Such foreign substances as pieces of cloth can usually be brought out by the finger alone, or by pressing them between the finger and a silver probe inserted for the purpose. Sometimes a long pair of dressing forceps, guided by the finger, is found necessary for effecting this object. Caution must be used in employing In instances where the foreign body has not completely penetrated, but is found lying beneath the skin away from the wound of entrance, an incision must be made for its extraction. Before using the knife, the substance to be removed should be fixed in situ, by pressure on the surrounding parts. In the instance of a round ball, the incision should be carried beyond the length of its diameter; an addition of half a diameter is usually sufficient to admit of the easy extraction of the ball. In removing conical balls, slugs, fragments of shells, stones, and other irregularly-shaped bodies, the surgeon cannot be too guarded in arranging that the fragment is drawn away with its long axis in line with the track of the wound. By proper care in this respect, much injury to adjoining structures may be avoided. If balls are impacted in bone, as happens in the spongy heads of bones, in bones of the pelvis, and occasionally, though rarely, in other parts of long bones, they should be removed. This can be effected by means of a steel elevator, of convenient size; or, should this fail from the ball being too firmly impacted, a thin layer of the bone on one side of the ball may be gouged away, so that a better purchase may be obtained for the elevator, in effecting its removal. The fact is now fully established that, although in a few isolated cases balls remain lodged in bones without sensible inconvenience, in the majority the lodgment leads to such disease of the bony structure as often to entail troublesome abscesses, and in some instances eventually to necessitate amputation. The lodgment of balls will not often occur without extensive fracture in warfare where rifled arms of such force as the MiniÉ or Enfield are the chief weapons employed, but will not unfrequently be met with in such campaigns as have lately happened in India. Should there be reason for concluding that a ball or other foreign body has lodged, but after manual examination, and observation as well by varied posture of the part of the body supposed to be implicated as by indications derived from the patient’s sensations, effects of pressure or injury to nerves, and all other circumstances which may lead to information, should the site of the lodgment not be ascertained, the search should not be persevered in to the distress of the patient. Neither, although the site of lodgment be ascertained, if extensive incisions are required, or if there is danger of wounding important organs, should the attempts at extraction be continued. Either during the process of suppuration, by some accidental muscular contraction, or by gradual approach toward the surface, its escape may be eventually effected; or, if of a favorable form, and if not in contact with nerve, bone, or other important organ, it may become encysted, and remain without causing pain or mischief. 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. More extensive experience has, however, shown that not only is the risk of subsequent ill results greater in those cases where foreign bodies remain lodged than when they have been cut out, but also that the advantages of a second opening for the escape of the necessary sloughs and discharges greatly preponderate over the disadvantages connected with it, as regards the additional extent of injured surface. The advantage also of the satisfaction to the mind of a patient from whom a ball has been removed must not be overlooked; for men suffering from gunshot wounds are invariably rendered When a gunshot wound has been accompanied with much laceration and disturbance of the parts involved in the injury, it is necessary, after the removal of all foreign substances that can be detected, to readjust and secure the disjointed structures as nearly as possible in their normal relations to each other. The simplest means—strips of adhesive plaster, light pledgets of moist lint, a linen roller, favorable position of the limb or part of the body wounded—should be adopted for this purpose. Pressure, weight, and warmth should be avoided as much as possible in these applications, consistent with the end in view. 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. This can be readily done with the aid of a little warm water, and arrangement when the wound is first dressed, but can only be accomplished with considerable inconvenience after the thin clots have become hard and firmly adherent to the skin. When the parts of a lacerated gunshot wound have been brought into apposition, as in simple penetrating wounds, the only dressing necessary is moistened lint. It should be kept moist either by the renewed application of water dropped upon it, or by preventing evaporation by covering it with oiled silk. The sensations of the patient may be consulted in the selection of either of these, and climate and temperature will be often found to determine the choice. In hot climates cold applications are the more grateful, and by checking the amount of inflammatory action and circumscribing its extent are usually the more advantageous. M. When suppurative action has been fully established, the 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. Bleeding, with a view to prevent the access of inflammation in such cases, is now never practiced, as formerly, by English surgeons. Progress of cure.—Simple flesh wounds from gunshot usually heal in five or six weeks. In the course of the first day the part wounded becomes stiff, slightly swelled, tender, a slight inflammatory blush surrounds the apertures through GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY. The circumstances connected with wounds in particular situations of the body, or in particular organs, are in many respects common to injuries from other causes than gunshot; and in the following remarks the attention is chiefly drawn only to those leading peculiarities which constantly demand the consideration of the army surgeon, and which spring either from the nature of gun projectiles, or the circumstances under which this branch of military practice has for the most part to be pursued. GUNSHOT WOUNDS OF THE HEAD. No injuries met with in war require more earnest observation and caution in their treatment than wounds of the head. The vital importance of the brain; the varied symptoms which accompany the injuries to which this organ may be subjected, directly or indirectly; the difficulty in tracing out their exact causes; the many complications which may arise in consequence of them; the sudden changes in condition Wounds of the head may be divided, for convenience of description, into wounds of the scalp and pericranium, without fracture of bone; similar wounds complicated with fracture of the outer or of both tables, without pressure on the encephalon; wounds with fracture and depression; and lastly, wounds in which the encephalon itself has been penetrated. Severe contusion of the bones of the cranium, followed by necrosis, and even fracture, with or without depression, may occur without an open wound of the superficial investments. The case of an officer is mentioned in Dr. Wounds of the scalp and pericranium.—These wounds are usually inflicted by projectiles which are brought into contact at a very acute angle, so that little direct injury to the brain or its membranes is inflicted, and the surgeon’s attention need only be directed to the same considerations as must occur in any contused wounds of the scalp from other causes than gunshot. But even in these accidents, though appearing to be simple flesh wounds, serious cerebral concussion and other lesions are occasionally met with. The usual stupor and other signs of concussion may be very evanescent, or may last for several days, disappearing gradually and wholly, or entailing subsequent evils at more or less remote periods. It must not be forgotten that when the pericranium is removed by a musket-ball, however superficial the injury may seem, there is always a certain degree of injury and bruising to the bone from which it is torn, and necessary laceration of the vessels which inosculate with the nutritive capillaries of the diploË, and through them of the vessels of the meninges with which they are connected. The injury to this vascular system almost invariably leads to necrosis of the portion of the skull from which the coverings are carried away; and sometimes, even when the pericranium is not torn off, sufficient injury is inflicted to lead to a like result. The death of bone is generally limited to a thin layer of the outer table, which in due time exfoliates. The injury to the vessels ramifying between the inner surface of the cranium and dura mater may lead to serious results. There may be rupture of a sinus, leading to compression, or fatal results may ensue from inflammation and suppuration. The case of a young soldier in whom the longitudinal sinus was thus ruptured occurred to the writer. In this instance a rifle-ball had divided the scalp and pericranium about four inches in length obliquely across the skull, just anterior to The treatment of an ordinary gunshot wound of the scalp should be very simple. Cleansing the surface of the wound, removing the hair from its neighborhood for the easier application of dressings, lint moistened with clean water, very spare diet, and careful regulation of the excretions are the only requirements in most cases. The patient must be closely watched, so that measures may be taken to counteract inflammatory symptoms in their earliest stages. Even after one of these wounds has healed, and the patient to all appearance has quite recovered, it is necessary to enjoin continued abstinence from excesses of all kinds. Instances are frequently quoted where intoxication, a long time after the date of injury, has induced symptoms of apoplexy and death. In the Surgical History of the Crimean Campaign, the case of a soldier of the 31st Regiment, thirty-eight years old, who received a contused wound at the back Wounds complicated with fracture, but without depression on the cerebrum.—These are very uncertain in their effects, and often apt to mislead the surgeon, from the absence of urgent symptoms in their early stages. The occurrence of fracture is, however, sufficient to show the force with which the projectile has struck the head, and to indicate the mischief which the brain and its immediate coverings have not improbably sustained. In these injuries there may be a simple furrowing of the outer table, without injury to the inner; or there may be fissure extending to a greater or less degree of length, or radiating in several lines; or both tables may be comminuted in the direction the ball has traversed in such small portions that they lie loosely on the dura mater without much alteration in the general outline of the cranial curve. The chief and only means, in many cases, of concluding that no depression upon the cerebrum has taken place is the absence of the usual symptoms of compression; for it is well known that simple observation of the injury to the outer table, whether by sight or touch, will by no means necessarily lead to a knowledge of the amount of injury or change of position in the inner table. When simple removal of a portion of the outer surface of the skull has been caused by the passage of the ball or other missile, the wound will sometimes heal, under judicious treatment, Fissured fractures, when the fissure extends through the skull, usually result from injuries by shell. The passage of a ball may fracture and very slightly depress a portion of the outer table of the cranium, and then the line of fracture will very closely simulate fissured fracture extending through both tables, and the diagnosis between them be excessively doubtful. When fissured fracture exists, the distance to which it may be prolonged is often quite unindicated by symptoms, and its extent is very uncertain. Fissures often extend to long distances. They may occur at a part remote from the spot directly injured. In the case of a lieutenant of the 11th Hussars, who was apparently slightly wounded at Balaklava in the middle of the forehead by a piece of shell, a fissured fracture was found, after death, across the base of the skull, quite unconnected with the primary wound, and seemingly from contre-coup. Death resulted from inflammation and suppuration set up near this indirectly-injured part. Fissured fracture of the inner table may also occur from the action of a ball without external evidence of the fracture. Such a case occurred in the 55th Regiment, in the Crimea. The soldier had a wound of the scalp along the upper edge of the right parietal bone. The ball in passing had denuded the bone; but there was no depression. The The cases where comminution has resulted from the track of a ball across the skull generally present less unfavorable results than those where a single fissured fracture, extending through both tables, exists. The small, loose fragments can be removed; and if the dura mater be intact, the case, with proper care to prevent inflammatory action, may not improbably be attended with a favorable recovery. Wounds complicated with fracture and depression on the cerebrum.—Such wounds are most serious, and the prognosis must be very unfavorable. They must not be judged of by comparison with cases of fracture with depression caused by such injuries as are usually met with in civil practice. 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. The experience of the Crimean campaign shows that, when these With penetration of the cerebrum.—It is obvious that, where a projectile has power not only to fracture, but also to penetrate the cranium, it will rarely be arrested in its progress near the wound of entrance. Either splinters of bone, or the ball, or a portion of it will be carried through the membranes into the cerebral mass. Sometimes a ball, if not making its exit by a second opening in the cranium, will lodge at the point of the cerebral substance opposite to that of its place of entrance; but the course a projectile may follow within the cranium is very uncertain. Instances have occurred where balls have lodged in the cerebrum without giving rise to serious symptoms of danger for a long time. Such cases might lead to throwing surgeons off their guard in making a prognosis, from supposition that the ball by some accident had not lodged. The case of a soldier wounded by a ball in the posterior part of the side of the head is mentioned by Mr. Guthrie. The wound healed, and the man returned to duty; a year afterward he got drunk, and died suddenly. The ball was found in a sac lying in the corpus callosum. Another soldier wounded at Waterloo had a similar recovery, and also died after intoxication. The ball was found deeply lodged in a cyst in the posterior part of the brain. An artillery soldier was wounded, in the Crimea, by a rifle-ball, which entered near the inner angle of the left superciliary ridge. The wound progressed without a bad symptom until a month afterward, Treatment.—The treatment of the various kinds of fractures from gunshot, and their complications, may be considered together. Formerly, a gunshot wound of the head was supposed to be in itself a sufficient indication for the use of the trephine; indeed, even where no fracture was caused, an opening was recommended by comparatively recent surgeons to be made in the cranium, to meet symptoms which might be expected to result. Modern surgeons, however, generally have made use of the trephine only when there was reason for concluding that depressed bone was leading to permanent interruption of cerebral function, or that an abscess had formed within reach, and was capable of evacuation. Preventive trephining has been proved to be useless, as well as dangerous, and is no longer an admissible operation. The tendency of the most recent experience has been to limit the practice of trephining to the narrowest sphere; and when the very great difficulty of making accurate diagnosis in these cases is considered,—whether as to the distinguishing signs of compression; the precise seat of its cause, if the compression exist; the space over which this cause, when ascertained, may extend; its persistent or temporary character; its complications; and certain dangers connected with the operation itself,—no wonder need be excited that this tendency should exist. Besides, the numerous cases which have now been noted where bone has evidently been depressed, but the brain has accommodated itself to the pressure without serious disability being caused, or where compression from effusion has been removed by absorption under proper constitutional treatment, are further causes of hesitation in respect to trephining. In the Surgical Report of the Crimean Campaign, it is stated that the trephine was only successfully applied in four cases (and none of these were from rifle-balls) during the whole war; and GUNSHOT WOUNDS OF THE SPINE. Gunshot wounds of the spine are closely associated with similar injuries of the head. In both classes corresponding considerations must be entertained by the surgeon in reference to the important nerve-structures, with their membranes, which are likely to be involved in the injury to their osseous envelope; in both, the effects of concussion, compression, laceration of substance, or subsequent inflammatory action, chiefly attract attention. In the Surgical History of the Crimean Campaign, twenty-seven cases are noted in which vertebrÆ were fractured, eight being without apparent lesion of the spinal cord, and nineteen with evident lesion. Of these, twenty-five died; and two, in which the fractures were confined to the processes of the vertebrÆ, survived to be invalided. The gunshot wounds affecting the spinal column have not been separated from injuries in other regions in the French returns. Six men only wounded in the spine, during the late mutiny in India, arrived in Chatham. In all, they were the results of musket-balls. Two were wounds of the sacrum; in the remainder, the portions of the vertebrÆ fractured were the spinous processes. Concussion of the spinal column, leading to paralysis more or less persistent, is usually occasioned by fragments of shell, or stones from parapets; and in these cases the accidents are mostly accompanied by extensive lesions of the neighboring structures. In one fatal case in the Crimea, the ball passed through the spine rather below the first dorsal vertebra, leading to complete loss of sensation and voluntary motion below the seat of injury, and death on the sixteenth day afterward; in another, a rifle-bullet entered the right side of the second lumbar vertebra, traversed the spinal canal at that part, and lodged in the body of the bone. In this latter case, violent pain was complained of in the lower extremities, shooting along the groins. The patient was In injuries of the vertebral column and spinal cord occurring in military practice, the mischief is usually so complicated and extensive, and the medulla itself so bruised, that the cases must be very rare indeed in which the operation of trephining, if justifiable in any case, can offer the slightest prospect of benefit. M. Baudens extracted, with an elevator supplied with a canula, a ball which had lodged in the eleventh dorsal vertebra and was causing compression with complete paraplegia. The paralysis disappeared immediately after the extraction of the bullet; but tetanus came on four days afterward, and proved speedily fatal. Balls have been known to pass through the bodies of vertebrÆ, and apparent cure follow; but as such patients in military practice GUNSHOT WOUNDS OF THE FACE. Wounds of the face from musket-shot, grape, and small fragments of shell are usually more distressing from the deformity they occasion than dangerous to life. The absence of vital organs, the natural divisions among the bones, and their comparatively soft structure, rendering them less liable to extensive splitting; the copious vascular reticulation and supply rendering necrosis so much less likely and repair so much easier than in other bones; the limited amount of space occupied by the osseous structure between their respective periosteal investments, and the opportunities from the number of cavities and passages connected with this region for the escape of discharges, lead to this result. On the other hand, the vascularity of this region leads to danger both of primary and especially secondary hemorrhage—a circumstance which, in all deep wounds of this region, must be looked for as a not improbable complication. The other complications of these gunshot wounds are lesions of the organs of special sense, injury to the base of the skull, paralysis from injury to nerves, wounds of glands, their ducts, and of the lachrymal apparatus; but it is scarcely necessary to do more than allude to them, as the considerations connected with their treatment will be found elsewhere. Wounds from cannon-shot occasionally illustrate what terrible injuries may be borne in this region without life being at once extinguished. They are the more distressing because the patient lives conscious of his sufferings without possibility of surgical alleviation. The case of an officer of Zouaves, wounded in the Crimea, is recorded, who had his whole face and lower jaw carried away by a ball, the eyes and tongue included, so that there remained only the cranium, supported In the treatment of gunshot wounds of the face where the bones are splintered and torn, the surgeon should always retain and replace as many of the broken portions as possible. It is often surprising how small connections with neighboring soft parts will suffice to maintain vitality and lead to restored union in this region. A case which occurred to the writer in August, 1855, in a private of the 19th Regiment, is detailed in the Lancet, p. 436, of that year. The wound was caused by a fragment of shell. The right half of the arch of the palate was jammed in and fixed at right angles to the other half, and the upper maxillary bone was so comminuted that it was scarcely possible to note the directions of the lines of fracture. The lower maxilla was broken in three places, and there was extensive laceration of the soft parts. Great difficulty was met with at first in unlocking the parts of the palate which had been driven into each other, and, when they were separated, the right half hung down loosely in the mouth; yet favorable union was obtained between all these fractures, the broken portions being adjusted so that the man recovered with both the upper and lower maxillÆ consolidated in their normal relations to each other. No teeth had been driven out of their sockets, and they were very useful as points of support in the steps taken to procure coaptation of the disunited fragments. In the Lancet of February 24th, 1855, may be found the description of a series GUNSHOT WOUNDS OF THE CHEST. These always form a large proportion of the injuries from warfare, both in the open field and more especially in sieges, where the upper part of the body is chiefly exposed. Dr. Scrive’s returns show that the proportion of chest to other wounds was 1 in 12 in the trenches, and 1 in 20 in ordinary engagements. In the British forces they are returned as 1 in 10 among the officers during the whole war, and nearly 1 in 17 among the men, from 1st April, 1855, to the end of the war. The ample space of this region, and the exposed surface it offers as a target toward the enemy, would lead to an anticipation of such results. The serious complications which ensue when the cavity of the chest is penetrated, and the dangerous consequences of wounds of its viscera, cause the proportionate mortality to be very great. The British returns show that among the officers treated for these wounds 31-1/2 per cent. and among the men 28-1/10 per cent. died. Out of 603 wounded men who returned to England from the late Indian mutiny, the number who had received wounds of the chest was only 19. 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. Non-penetrating wounds become subdivided into simple contused wounds of the soft parietes; contused and lacerated wounds; the same accompanied with injury to bones or cartilage; and, lastly, those complicated with lesion of some of the contents of the chest, the pleura remaining Non-penetrating wounds.—Of the simpler wounds in which the soft parietes only are involved little need be observed, excepting that the healing process is often prolonged by the natural movements of the ribs to which the wounded structures are attached, especially when the ball has taken a circuitous course beneath the skin, and that the surgeon must be on his guard to watch for pleuritis arising as an occasional consequence of these injuries. In two deaths recorded in the Director-General’s History of the Crimean War, under simple flesh wounds, without fracture or pleural opening, from bullets, the fatal termination arose from pleuro-pneumonia. When the force has been great, as when fragments of shell or rifle-balls strike at full speed against a man’s breast-plate, not only may troublesome superficial abscesses and sinuses follow, but the lungs may have been compressed and ecchymosed at the time of the injury, and hemoptysis be one of the symptoms presented. When the projectile has been of large size, although no opening of the parietes or fracture exists, death sometimes ensues by suffocation as the direct result of pulmonary engorgement. The danger of pleuritis or pneumonia will be greater when the injury has been so severe as to cause division of bone or cartilage, and the subsequent suppuration and process of exfoliation will not unfrequently prove very tedious and troublesome. Although the pleura has Notwithstanding a projectile has not penetrated the parietes of the chest, a pleural cavity may be opened, as in injuries from other causes, and the lung wounded by the sharp edges of fractured ribs. This will be indicated by emphysema, pneumothorax, hemoptysis, probably signs of internal hemorrhage, and inflammation. Such wounds will generally be the result of injuries from fragments of shell. Penetrating wounds.—These wounds, especially when the lung is perforated or the projectile lodges, are necessarily exceedingly dangerous. Fatal consequences are to be feared, either from hemorrhage, leading to exhaustion or suffocation; from inflammation of the pulmonary structure or pleurÆ; from irritative fever accompanying profuse discharges; or from fluid accumulations in one or both of the pleural sacs. In gunshot injuries a penetrating wound of the chest is in most instances readily obvious to the sense of sight or touch; but it will be found by no means easy always to decide whether a lung has been penetrated or otherwise. The train of symptoms usually described as characterizing wounds of the lung must not be expected to be all constantly present; they are each liable to be modified by a great variety of circumstances, and may each severally exist in penetrating wounds of the chest where the lung has escaped perforation. Nor is it always easy to determine whether the ball has lodged or not; or, the ball having passed through, whether fragments of bone, or other substances, have remained behind. When the chest has been opened by a projectile, the following signs may be expected in addition to the external physical evidences of the injury: a certain amount of constitutional shock; collapse from loss of blood; and, if the lung be wounded, effusion into the pleural cavity, hemoptysis, dyspnoea, and an exsanguine appearance. These will generally, but not invariably, be followed, after twenty-four hours or later, by the usual signs of inflammation in some of the structures injured. The shock of penetrating wounds of the chest, apart from the collapse consequent on hemorrhage, is not generally so great as happens in extensive injuries to the extremities or in penetrating wounds of the abdomen. There is often much more “shock” when a ball has not penetrated; but, having met with something to oppose its course, has nevertheless inflicted a violent percussion of the whole chest and its contents. When loss of blood occurs without the lung being wounded, the hemorrhage is probably proceeding from a wound of one of the intercostal arteries, which has been torn by the sharp ends of fractured bone. Serious hemorrhage, however, is exceedingly rare from vessels external to the cavity of the chest. When blood is effused in any large quantity into the pleural sac—as indicated by the exsanguine appearance of the patient, increasing dyspnoea, occasional hemoptysis, and the stethoscopic signs on auscultation,—the inference is, that the lung has been opened, and that it is from its structure the blood is flowing. The amount of hemorrhage in wounds of the lungs will greatly vary according to the direction of the track of the ball; for the large vessels cannot here glide away from the action of the projectile, as they may in the neck or extremities of the body. Wounds, therefore, near the root of each lung, where the pulmonary arteries and veins are largest, are attended with the greatest amount of Hemoptysis indicates injury to the lung, but does not give assurance that this organ has been penetrated. It generally accompanies gunshot wounds of the lung in a greater or less degree, no doubt always when a bronchial tube of large size is penetrated; but, as may be ascertained by careful perusal of recorded cases, is sometimes wholly absent, even though the patient may be troubled by cough. Dr. Fraser, in a recent monograph on Wounds of the Chest, states that out of nine fatal cases observed by him in the Crimea in which the lungs were wounded, only one had hemoptysis; and out of seven in which the lungs were found not to be wounded, two had hemoptysis. This, however, from the writer’s observation, would appear to be an unusual proportion of cases in which hemoptysis was not present after wounds of the lungs. Dyspnoea is a frequent accompaniment of wounds penetrating the lung, but not a constant symptom before inflammatory action has set in. When dyspnoea is great in the early period, it will often be found to depend upon the injuries to the parietes, and to the pain caused on taking a full inspiration; as a sign of subsequent mischief in the progress of the case, it is, of course, very constantly present. It is now known that the opening of the pleura does not necessarily induce collapse of the lung, even though unfettered by adhesions, during life. 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 It is not necessary to refer at any length in this place to the inflammations which may supervene. Diffused inflammation of the lung after wounds is not so common as might perhaps be expected. In unfavorable cases, the pleural cavity is generally found to be the seat of extensive inflammatory action or unhealthy accumulations, especially where irritation has been kept up by the presence of foreign bodies or the patient’s constitution has become from any cause debilitated. Treatment.—The object of the surgeon’s care must be in the first place to arrest hemorrhage; afterward, to remove pieces or jagged projections of bone, or any other sources of local irritation; and to adopt means to prevent interference with the natural process of cure, which takes place by adhesion of the opposite pleural surfaces near the wound in the first instance, and subsequently by cicatrization of the wound itself, or, as shown in an interesting preparation in the museum of the Army Medical Department at Fort Pitt, by contraction into a narrow sinus lined with a distinct adventitious membrane into which the small bronchial tubes open. Although the shock may happen to be considerable, attempts to rally the patient, if any be made, should be conducted very cautiously; the prolongation of the depressed condition may be valuable in enabling the injured structures to assume the necessary state for preventing hemorrhage. Hemorrhage from vessels belonging to the costal parietes should be arrested by ligature, as in other parts, if the source from which it proceeds can be ascertained, and if the flow of blood be so free as not to be controlled by the ordinary styptics. Operative interference of this kind is chiefly called for on account of secondary, not primary, hemorrhage. Hemorrhage from the lung itself must be treated on the general principles adopted in all such cases; the application of cold to the chest, perfect quiet, the administration of opium, The extensive bleedings formerly recommended in all penetrating gunshot wounds of the chest are now practiced with much greater limitations—indeed, should never be employed simply with a view to prevent mischief from arising. Venesection carried to a great extent does harm by lessening the restorative powers of the frame. It appears to interrupt the process of adhesion between the pleural surfaces and the steps taken by nature to repair the existing mischief, while it leads the injured structures into a condition favorable for gangrene, or encourages the formation of ill-conditioned purulent effusions. When inflammation has arisen, venesection may be joined with other means to control its excessive action, and to give relief, which it certainly does, to the patient; and where hemorrhage is manifestly going on internally, it may be practiced with a view of draining the blood from the system and more speedily inducing faintness, to give an opportunity to the pulmonic vessels to become closed; but, even when thus applied, the general state of the patient will not be unconsidered by a judicious surgeon, nor caution neglected, lest the venesection cause him to sink more rapidly from the additional shock to the system and abstraction of restorative force. Taking away blood certainly does not prevent pneumonia from supervening, but occasionally seems to give the inflammation, when it arises, more power over the weakened structures, or even to cause it to be accompanied with typhoid symptoms. Many cases will be found in the various published records derived from The case of an officer of the 19th Regiment, who was shot at the assault of the Great Redan, and under the care of the writer, will serve to illustrate some of the points before named. In this instance, a rifle-ball passed through the upper part of the left scapula near its superior posterior angle, comminuting the bone and entering the chest. The ball, together with a piece of cloth, was excised in front, two inches above and internal to the fold of the axilla. The mouth was filled with blood immediately after the injury; bloody expectoration continued for three days; there was hacking cough on increased inspiration; the respiratory murmur was accompanied with slight crepitating rÁles in the upper part of the lung; there was weakness, but not much shock. The small degree of the latter symptom, and the absence of evidence of effusion of blood into the pleural cavity, led at the time to a suspicion that the ball had glanced round the costal pleura and had only contused the lung; but the fact of the absence of vessels of large size at this part of the lung, especially if there were pleural adhesions, may have been the cause of these results. This officer had been much weakened in frame by scorbutic diarrhoea in the winter of 1854-55, and though the cure was protracted by occasional attacks of diarrhoea subsequently to the injury, by profuse discharge from the wounds, and separation from time to time of spiculÆ of bone, he left for England two months afterward with his recovery nearly completed, and no inconvenience has been experienced in the discharge of his duties since. No venesection was practiced in this case; but tonics, nourishing diet, and port wine were given as soon as suppurative action had been established. But in discountenancing great bleeding, mention should not at the same time be omitted that, in many cases, recorded by numerous authors, and judging post factum, the To remove splinters of bone, and readjust indented portions of the ribs, the finger should be introduced into the wound, and care taken that in doing so no pieces of cloth or fragments be separated and projected into the pleural sac. Notice must at the same time be taken of any bleeding vessel requiring to be secured. A pledget of lint should be laid over the wound, and a broad bandage placed round the chest, just tight enough to support the ribs and in some degree to restrain their movements, but with an opening over each wound large enough to permit the ready access of the surgeon to it if necessary. If the patient’s comfort admits of it, he should be laid with the wound downward, with a view to prevent accumulation of fluid in the pleura; and if there be two openings, as will be most frequently the case in rifle-ball wounds, one wound should be thus placed, and If the presence of a ball within the cavity be ascertained, efforts should be made for its removal. But any attempt to determine where the ball has lodged should be made very cautiously, as more harm may result from the interference than from the lodgment of the foreign body. The existence of old adhesions will modify the effects of a penetrating wound, by excluding the track of the ball from the general pleural cavity, and may influence the result of the injury, especially if there be hemorrhage, or lodgment of foreign bodies, which may thus be brought within the sphere of removal more readily. Wounds of the heart seldom come to the military surgeon’s notice, as they ordinarily prove fatal on the battlefield. Still it is right to mention, that examples occur in which musket-balls are lodged in the heart without immediately fatal results; and one case is recorded, where a ball was found imbedded in its substance six years after the injury was received, and death then ensued from causes unconnected with the wound. GUNSHOT WOUNDS OF THE NECK. Gunshot wounds of this region do not appear to be so fatal as might be anticipated from the large vessels and important canals leading to the thorax and abdomen, which at first sight appear to be so exposed and unprotected. In no region are so many examples offered of large vessels meeting but escaping from balls in their passage as in this; because the cause which operates elsewhere—ready mobility among long and yielding structures—exists in a greater degree in the neck than in any other part. Where the large vessels happen to be divided, death must follow almost immediately. Superficial wounds of the neck offer no peculiarities. The larynx and trachea being the organs most prominent, and most frequently injured, are those which chiefly attract the surgeon’s notice in warfare; but a consideration of the anatomical structure will at once show what numerous other complications, whether from direct injury or consequent inflammation, projectiles are likely to cause when driven deeply into or perforating this region. A brief abstract of some wounds of the neck, which occurred during the Crimean campaign, will serve to exhibit the leading symptoms connected with them when the larynx, or larynx and oesophagus, are involved. Four cases may be found in the Lancet of January 19th, 1856, to which Seven cases of gunshot wounds of the neck returned to England from the late mutiny in India. They were all simple flesh wounds. In one the musket-ball had not been discovered, and its position remained unknown. The man was wounded at Lucknow, and the ball entered the left side of the neck, close to the thyroid cartilage. Baron Percy reports a similar wound and case of lodgment in his Army Surgeon’s Manual; in this instance, the ball was known to pass away by the bowels, a fortnight after the injury was received. The liability to concussion of the cervical portion of the vertebral column, and to injury of the deep cervical and other nerves, must not be overlooked. Wounds of the neck are often accompanied by more or less loss of power in one of the upper extremities; and more extensive paralysis occasionally succeeds, although there was no primary evidence of the spine being implicated in the injury. GUNSHOT WOUNDS OF THE ABDOMEN. Gunshot wounds of the abdomen, like those of the chest, are, for the sake of convenience, divided into non-penetrating and penetrating. The NON-PENETRATING may be either simple flesh wounds, or may be accompanied with fracture of some of the pelvic bones, or with injury to some of the contained viscera. In PENETRATING wounds, the peritoneum only, or, together with it, one or more of the abdominal viscera, may be wounded; or, in comparatively rare cases, a viscus may be penetrated without the peritoneum being involved. It is in the regional cavity of the abdomen that the proportion of penetrating wounds is the greatest. The cranium, from its form, structure, and coverings, serves as a strong defense even against gunshot; the osseous yet elastic and movable ribs, the sternum, and muscular parietes greatly protect the contents of the cavity which they inclose; but the extensively exposed surface of the abdomen, anteriorly and laterally, has no power of resistance to offer against a projectile directly impinging it; and when this important cavity is once penetrated by these means, death is the almost inevitable result. Even the chances of a favorable termination which may exist in wounds from other causes are generally wanting; and much of their treatment, such as the use of sutures, and other means to insure the apposition of cut edges, is inapplicable, from the parts to a certain distance Non-penetrating wounds require but few remarks in this place. 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. If the parietes have been much contused, abscess or sloughing may be expected; and a tendency to visceral protrusion must be afterward guarded against. When portions of the pelvic parietes are fractured by heavy projectiles, very protracted abscesses generally arise, connected with necrosed bone; and the vital powers of the patient are greatly tried by the necessary restraint and long confinement. The great force by which these wounds must be produced, and the general contusion of the surrounding structures, cause a large proportion sooner or later to prove fatal, notwithstanding the peritoneal cavity may have escaped. Of twenty-nine such cases which came under treatment in the Crimea, sixteen died. Even apparently slight cases, as where a portion of the crest of the ilium is carried away by shell, or ball lodged in one of the pelvic bones, often prove very tedious, from the long-continued exfoliations and abscesses which result. Penetrating wounds.—A penetrating wound of the abdomen, whether viscera be wounded or not, is usually attended with a great amount of “shock.” The prognosis will be extremely unfavorable, if there is reason to fear the projectile has lodged in the cavity of the peritoneum; and in all cases the danger will be very great from inflammation of this serous investment. The liability to accumulation of When, in addition to the cavity being opened, viscera are penetrated, and death does not directly ensue from rupture of some of the larger arteries, the shock is not only very severe, but the collapse attending it is seldom recovered from up to the time of the fatal termination of the case. This is sometimes the only symptom which will enable the surgeon to diagnose that viscera are perforated. The mind remains clear; but the prostration, oppressive anxiety, and restlessness are intense; and, as peritonitis supervenes, pain, dyspnoea, diffused tenderness, irritability of the stomach, distention, and the other signs of this inflammation are superadded. In ordinary wounds from musket-shot, scarcely any matter will escape from the opening of the parietes, the margin of which becomes quickly tumefied; but if any escape, it will probably indicate what viscus has been wounded. If the stomach has been penetrated, there will probably be vomiting of blood from the first. If the spleen or liver be wounded, death from hemorrhage is likely to follow quickly. In some instances patients, however, recover after gunshot wounds involving these viscera, and examples in illustration may be found in various works on military surgery. Two particularly manifest instances, where officers were shot through the liver by musket-balls, occurred lately in India, one at Lucknow, the other at the siege of Delhi: both recovered. The cases are described in the Indian Annals of Medical Science for January, 1859. If the small intestines have been perforated, and death follows soon after from peritonitis, the bowels usually remain unmoved, so that no evidence is offered of the nature of the wound from evacuations; but in any case of penetrating wound of the abdomen, when the opportunity is offered, steps should be taken—a matter not unlikely to be omitted under the circumstances of camp hospitals full of patients—to isolate and examine all evacuations which may follow. By attending Curious instances are recorded in which balls have passed directly through the abdomen without perforating any important viscus, as proved by examination after death. As an example, on the other hand, of the number of wounds which may thus be inflicted, a soldier of the 19th Regiment, on duty in the trenches before Sebastopol, who was shot through the abdomen in the act of defecation, was found by the writer, on post-mortem examination, to have had as many as sixteen openings made in the small intestine. He survived the wound nineteen hours. Gunshot wounds of the colon, especially of the sigmoid flexure, appear to be less fatal, probably from structural causes as well as circumstances of position, than wounds of the small intestine. In the Museum of Fort Pitt, however, is a preparation of jejunum exhibiting three constrictions, and supposed to have been perforated in three places, from a private of the 80th Regiment, who was shot through the abdomen at Ferozeshah, in 1845, and who died from cholera in 1851. Inspector-General Taylor, C.B., then surgeon of the regiment, who made the examination post mortem, thus described the injured part of the intestine: “The intestines neither there nor elsewhere were morbidly adherent; but the fold of intestines immediately opposed to the cicatrix presented a line of contraction as if a ligature had been tied round the gut. The same appearance existed in two other places.” It seems more likely that the gut was contused than perforated, and that contraction gradually supervened, especially as no adhesions were found; and, when wounded, the symptoms were so slight as to have led to the supposition that the ball had gone round the abdominal wall. A gunshot wound of the intestine, more especially the colon, may lead to fecal fistula, and life be thus saved for a time. One such case only occurred in the Crimea, in the 19th Regiment, of which the writer was then the surgeon; this case, which has been before casually mentioned, subsequently passed under the care of his friend Mr. Birkett, of Guy’s Hospital, in which institution the patient died, from the effects of albuminuria, four years after the receipt of the wound referred to. The surgical history of this case has been already published at some length in the Lancet; Wounds of the diaphragm.—Musket-balls occasionally pass through the diaphragm; and Mr. Guthrie has remarked that these wounds, in instances where the patients survive, only become closed under rare and particular circumstances. Hence the danger of portions of some of the viscera of the abdomen, as the stomach or colon, passing into the chest, and thus forming diaphragmatic herniÆ, and of these, eventually, from some cause becoming strangulated. Two very interesting preparations of these accidents from gunshot exist in the museum at Fort Pitt. In both instances, the stomach, colon, and omentum form the hernial protrusions. In one, death occurred, a year after the wound, from strangulation induced suddenly after a full meal; in the other, the soldier continued at duty twenty-two years after, and died from other causes. All the cases which occurred in the Crimea in which openings had thus been established between the cavities of the chest and abdomen proved fatal. A case is detailed in the Surgical History of the War where the patient survived a double perforation of the diaphragm, together with a wound of the liver, six days; in another instance, where the lung, diaphragm, liver, and spleen were wounded, the soldier lived sixteen hours. The direction of the ball, hiccough, dyspnoea accompanied with spasmodic inspiration, and inflammatory signs more particularly connected with the chest will be the usual indications of such a wound; and in case of recovery, the risk of hernial protrusion and strangulation must be explained to the patient. Treatment.—In the general treatment of penetrating wounds of the abdomen by gunshot, the surgeon can do little more than to soothe and relieve the patient by the administration of opiates, and to treat symptoms of inflammation when they arise on the same principles as in all other cases. The usual directions to attempt agglutination of the opposite portions of peritoneum by favorable posture cannot generally be carried out, the attempts being defeated by the restlessness of the patient. The collapse which attends such injuries may be useful in checking hemorrhage; and the exhibition of stimulants is further contra-indicated by the risk of exciting too much reaction, should the wound not prove directly fatal. If the wound be caused by grape-shot or a piece of shell, and intestine protrudes, it must be returned; if the intestine be wounded, sutures are inapplicable, as in an incised wound, without previously removing the contused edges. When the bladder is penetrated, care must be taken to provide for the removal of the urine, either by an elastic catheter, or, if this cannot be retained, by perineal incision. A freely communicating external wound prevents the employment of the catheter from being essential. A soldier of the 57th Regiment was wounded, on the 18th June, 1855, by a musket-ball, which entered the left buttock, fractured the pelvis, and came out about three inches above the os pubis and one inch to the right of the median line. The bladder was perforated; urine escaped by both openings, chiefly by the one in front. Here the catheter caused so much irritation that it was withdrawn; but the posterior wound soon ceased to discharge urine, and in eighteen days the anterior wound was free from discharge also. Seven weeks after the date of injury symptoms resembling those of stone in the bladder came on; these were relieved on three spiculÆ of bone making their escape by the urethra. About GUNSHOT WOUNDS OF THE PERINEUM AND GENITOURINARY ORGANS. From the position of these parts of the body, uncomplicated gunshot wounds of them are comparatively rare. Throughout the whole of the Crimean war, the number of cases treated amounted, among the men, to 70; among the officers, only to 4. The number of deaths which resulted were 21 among the men, chiefly cases of extensive laceration involving the urinary apparatus; among the officers, none. Three men only, out of 603 who returned from the late mutiny in India to Chatham, are recorded under this class. In one, the injury was from a spent shot, which caused a bruise without laceration over the symphysis pubis, and produced persistent incontinence of urine; in each of the other two, a musket-ball wounded the left testicle, injured the urethra, and led to urinary fistula, which was, however, afterward healed. In one, the testicle was so much injured that it was removed on the day the wound was received; in the other, it sloughed away shortly after. A corporal of the 19th Regiment, wounded in this region on the 8th September, 1855, was under the care of the writer. A portion of the ascending ramus of the ischium on the right side was driven into the perineum, the soft parts were much injured, and the right testicle was destroyed. The viscera of the pelvis escaped. He was doing well until Perineal wounds are not unfrequently caused by shells bursting and projecting fragments upward; but they are generally mixed with lesions of viscera of the pelvis, or fracture of its structure, or injuries about the upper parts of the thighs or buttocks. In one such case, a portion of the scrotum, the whole of one testicle, and the greater part of the other were carried away. This wound healed without fungous growth from the remaining portion of the testis. Separate wounds of the external organs of generation are usually caused by bullets. In two cases in the Crimea, a bullet entered between the glans penis and prepuce, and traversed upward without penetrating the erectile tissue. M. Appia records a case where the ball entered the summit of the glans, traversed the whole length of the corpus cavernosum, passed under the pubic arch, and went out by the right buttock. The urethra was not opened. Double orchitis and scrotal abscesses followed; but favorable cure took place. In another case, a ball carried away the inferior part of the glans but did not wound the urethra. A soldier of the Rifle Brigade was wounded in the Crimea by a musket-ball, which entered the right buttock and came out by the body of the penis, just below the glans, having ruptured the urethra about four inches from the meatus. The wound of the penis closed favorably. Mr. C. Hutchinson has recorded the case of a soldier of the 42d Regiment, treated at the Deal Naval Hospital, who was wounded in the upper part of the thigh by a musket-ball, which lodged. Three weeks afterward, the ball was found imbedded in the pubes, the urethra being stretched around the convex surface; and this explained the cause of a distressing distention of the penis and dribbling of urine which had existed without intermission from the time of the injury, but ceased at once on the removal of the bullet. GUNSHOT WOUNDS OF THE EXTREMITIES. These injuries, always very numerous in warfare, offer many subjects of consideration for the military surgeon. No class of wounds includes so many cases that fall under his prolonged care as this. A large proportion of wounds of the head and trunk are immediately fatal, or from the commencement contain the elements of fatal results; while wounds of the extremities, if those of the thigh be excepted, are free from this extremely serious character. The treatment to be pursued, including questions of conservation, resection, amputation, and the proper time for the adoption of these latter if determined upon, often demands the closest attention of the surgeon. These subjects will be considered in their general bearing in other parts of this work, and only those points especially connected with the circumstances of warfare will be here referred to. Gunshot wounds of the extremities divide themselves into flesh wounds and contusions, and those complicated with fracture of one or more bones. Flesh wounds may be simple, and these offer few peculiarities, whatever their site; or they may be accompanied with lesion to nerves, or blood-vessels, or both, and these usually increase in gravity in proportion as they approach the trunk. When complicated with fracture, the lesion is usually rendered compound by the direct contact of the projectile with the bone injured; but the fracture is sometimes simple, when caused by indirect projectiles, such as stones or splinters, or by spent balls. These injuries are liable to become further aggravated by the fracture extending into or being complicated with an opening of one of the joints. Joints may be contused or opened by projectiles, without apparent lesion of any portion of the bones entering into their composition; but these are exceptions to the usual order of such cases from gunshot. Simple flesh wounds have already been referred to both in respect to their nature and treatment in the commencement of this essay. It is in connection with fractures of bones and their proper treatment that the interest of surgeons is chiefly attracted in gunshot wounds of the extremities. From the nature of the injuries, already described, to which bones are subjected by the modern weapons of war, together with the irreparable nature of the wound in the softer structures, except after a long process of suppuration and granulation, as well as from the usual circumstances of military life, it might be anticipated that difficulty would often arise in determining which of the double set of risks and evils—those attending amputation, and those connected with attempts to preserve the limb with a profitable result—would be least likely to prove disadvantageous to the patient. Experience in such injuries has established certain rules which are now generally acted upon; some still remain sub judice. Although the subject of pyemia is considered in its general bearings elsewhere, it is right to mention here that this serious complication, as met with in gunshot wounds, appears to be especially induced by injuries of bones, particularly those of long bones in which the medullary canal has been laid open and extensively splintered. Several circumstances probably conduce to this result: the prolonged suppurative action during the removal of sequestra, the irritation caused by sharp points and edges, sometimes increased by transport from primary to secondary hospitals, the patulous condition of veins in bones leading to thrombosis, being its chief local sources; while depressed vital power from any cause, and continued exposure to an impure atmosphere from the congregation of numerous patients with suppurating wounds, are the principal agents in producing the state of constitution favorable to its development and progress. Unless the hospital miasmata engendered in this way are constantly removed as they arise, or very greatly diluted by Upper Extremity.—Fractures of the bones of the arm are well known to be very much less dangerous than like injuries in the corresponding bones of the lower extremity. Unless extremely injured by a massive projectile, or longitudinal comminution exist to a great extent, especially if also involving a joint, or the state of the patient’s health be very unfavorable, attempts should always be made to preserve the upper extremity after a gunshot wound. In the Director-General’s History of the Crimean Campaign, the In the latter part of the Crimean campaign, when the health of the troops and means of treatment were favorable, it was often remarkable what extensive injuries of the upper extremity, even where the joints were involved, were repaired without amputation. The following cases are examples: Sergeant Bacon, 7th Fusileers, aged thirty-six, at the attack on the Redan on the 8th of September, 1855, was wounded by a rifle-ball, which entered the head of the left humerus, shattered the bone very much, and was extracted from below the left scapula. Dr. Moorhead determined to try to preserve the limb. The head of the humerus required to be removed in small, broken fragments; and the shaft, being found to be split down between three and four inches, was to that distance removed by the saw. The case progressed In these injuries, where the bone is much splintered, the detached portions, and any fragments which are only retained by very partial periosteal connections, should be removed; projecting spiculÆ sawn or cut off; Lower extremity.—Gunshot wounds of the lower extremity vary much more greatly in the gravity of their results, as well as in the treatment to be adopted, according to the part of the limb injured, than happens in those of the upper extremity. As a general rule, ordinary fractures below the knee, from rifle-balls, should never cause primary amputation; while, excepting in certain special cases, in fractures above the knee, from rifle-balls, amputation is held by most military surgeons to be a necessary measure. The special cases are gunshot fractures of the upper third of the femur, especially where the hip-joint is implicated; for in these the danger attending amputation itself is so great that the question is still open, whether the safety of the patient is best consulted by excision of the injured portion of the femur, by simple removal of detached fragments and trusting to natural efforts for union, or by resorting to amputation. The decision of the surgeon must generally rest upon the extent of injury to the surrounding structures, the 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. Attention was specially directed in the late Crimean campaign to the question of the proper treatment of these injuries, and expectations were generally held that the advanced experience in conservative surgery would lead to many such cases terminating favorably with preservation of the limb, which previously would have been subjected to amputation. Toward the latter part of the war, all the circumstances of the patients were as favorable for testing this practice as they have been in the various Émeutes in Paris, with the advantages of immediate attention and all the appliances of the best hospitals close at hand. Yet, in the Surgical History of the Campaign, it is stated that only fourteen out of 174 cases of compound fracture of the femur among the men, and five out of twenty among the officers recovered without amputation being performed; that those selected for the experiment of preserving the limb were patients where the amount of injury done to the bone and soft parts was comparatively small; that where recovery ensued, it always proved tedious, and the risks during a long course of treatment numerous and grave; and that the proportion of recoveries would not appear even so large as the above, if the deaths of those who after long treatment were subjected to amputation as a last resource were included. Amputations of the thigh, however, were very fatal in their results also, the recoveries being stated to be, among the men, in the upper third 12-9/10, in the middle third 40, in the lower third 43-3/10, per cent. of cases treated. Among the officers the proportion was rather more favorable. But this percentage includes In considering the results of gunshot fractures of the femur, the situation of the injury is a matter of great importance, whether as regards chances of recovery without or with amputation. In the Surgical History of the Crimean Campaign this fact is shown in the results of amputation; but the distinction is not made in regard to the recoveries without amputation. Dr. Macleod, in his Notes, remarks that he has only been able to discover three cases in which recovery followed a compound fracture in the upper third of the femur without amputation: one, that of an officer of the 17th Regiment; the second, of a soldier of the 62d; and a third, whose regiment is not named. A case, however, was under the care of the writer, not included in the above, nor appearing in the official history of the war; and one, judging from the results described in Dr. Macleod’s Notes, more fortunate in its issue than at least two of the number he mentions. With regard to the first patient, Dr. Macleod states he has been informed “that although his limb was in a very good condition when he left for England, the trouble it has since given him, and the deformed condition in which it remains, makes it by no means an agreeable appendage;” There is not space to follow the details of the treatment of this case. The cure was protracted by large and troublesome bed-sores; and attention to these, to the discharges from the wound, and preserving favorable position, occupied much time and care daily, and caused many changes in the appliances for these objects to be from time to time necessary. On November the 4th, union had so far taken place that he was able to raise his body from the knee upward while in bed, without apparent motion at the seat of fracture. On November 15th, in consequence of the great explosion at the right siege-train, he had to be carried to another division of the camp; this was effected without harm. In the middle of January he was able to sit in a chair without inconvenience; and on February 22d he left the Crimea for England, being able to walk with the assistance of crutches. Union was then firm; but a slight serous oozing continued from the wound of exit, and there was much stiffness of the ankle and knee joints from the long-continued constrained position to which he had been subjected. In July, 1856, after his arrival in Ireland, indications of pus collecting manifested themselves at the wound of exit; and Professor Tufnell, on passing a bougie about seven inches in the course of the wound, evacuated a small abscess, and felt a piece of bone trying to make its way to the surface. This was subsequently removed, and, under Dr. Macleod says that, after many inquiries respecting cases of this nature in the hospitals of the other armies engaged in the war, excepting one presented by Baron Larrey to the SociÉtÉ de Chirurgie in 1857, he never could hear of any other but that of a Russian whose greatly shattered and deformed limb he often examined. The proportion of recoveries in amputations in the upper third of the femur in the Crimean war was under 13 per cent. Amputation at the hip-joint, both in the French and English armies, in all instances proved fatal. The two patients who survived the longest were operated on by the late Director-General after the battle of the Alma: one, a soldier of the 33d Regiment, died at Scutari three weeks after the operation; the second, a Russian, died on the thirtieth day after, from “extensive sloughing and great debility.” With regard to gunshot fractures in the middle and lower third of the femur, the experience of the French and English armies in the Crimea has tended to confirm the doctrine of the older military surgeons, that many lives are lost which might be otherwise preserved, by trying to save limbs; and that, of the limbs preserved, many are little better than incumbrances to their possessors. In the late Italian battles, the practice of trying to save lower extremities, after comminuted fractures in these situations of the thigh, appears to have been abandoned. Eight cases of union after compound gunshot fractures of the femur in these situations have, however, returned from the late mutiny in India; and this is a much larger proportion than was that of the recoveries from the Crimea. Dr. Williamson, who records these cases, is inclined to attribute this success in a great measure to the use of dooleys for the conveyance of wounded, and argues that it would be advantageous to introduce them into European warfare. But wounds generally, where proper care is taken, heal more favorably in southern latitudes, east or west, probably owing to the climate admitting of so much more free an access of fresh air by day and night to the patient than can be afforded, without inconvenience, in colder or more variable climates. The dooley is most advantageous and comfortable as used in the East, where it is an ordinary mode of conveyance among all classes, and the bearers—a special race in each Presidency—are trained from childhood to the occupation; but, from experience of the peculiar habits and tenets of these men, both Madrassees and those of Bengal, it seems scarcely probable that they would prove efficient, even if they could exist, or that their wants could be provided for in the numbers necessary to be In fractures of the leg, where neither the knee nor ankle joints are implicated, the results of conservative attempts have been more favorable. In the Crimea, the recoveries without amputation being resorted to were: in fractures of both bones, nearly 19; tibia only, 36·3; fibula only, 40·9 per cent. When the fracture is comminuted, and implicates the knee or ankle joint, opening the capsule, amputation is necessary. The knee-joint was once excised in the Crimea, but the patient died; as was the case in the only other instance where this operation is known to have been performed for gunshot injury in the Sleswick-Holstein campaign. In the treatment of fractures of the leg, where it has been determined to seek union, the same remarks apply as those made above in respect to fractures in the upper extremity. In wounds of the foot it is especially necessary to remove as early as possible all the comminuted fragments of the bones injured, or tedious abscesses and much pain and constitutional irritation are likely to ensue. AMPUTATION. It is not necessary to refer at much length to the question which was formerly disputed upon—the advantages of primary as compared with secondary amputation in gunshot wounds—for military surgeons, whether acting at sea or on land, have practically determined the subject. For a long time the directions of John Hunter, that amputation should not be performed until the first inflammation was over, based on the argument that the “amputation is a violence superadded SECONDARY HEMORRHAGE. 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. Sometimes an artery which did not appear to be injured in the first instance ulcerates or sloughs; or, without direct injury, a vessel may become involved in unhealthy deterioration of the wound, and give way; or, in a granulating wound, general capillary hemorrhage may be excited by stimulus of any kind, such as venereal excitement or excess in drinking; or the coats of the vessel may ulcerate under pressure from a detached fragment of bone or from some foreign body; or the artery may be accidentally penetrated by the end of a sharp spiculum. Secondary hemorrhage has been said to arise from increased arterial action, from the first to the fifth day; from sloughing, the effects of contusion, from the fifth to the tenth; from ulceration, to any more distant date. M. Baudens has remarked that he has observed secondary hemorrhage to be most frequent about the sixth day after the wound—the traumatic fever having Secondary hemorrhage is not uncommon after deeply-penetrating gunshot wounds of the face, and sometimes it is difficult to determine the site of the bleeding vessel. It may be so situated that the rule of tying both ends of the bleeding artery in the wound cannot be carried out, and where, if the ordinary styptics fail, resort must be had to the ligature of the common trunk from which the bleeding vessel branches. In the museum at Fort Pitt is a cranium showing the passage of a musket-ball from the inner side of the right orbit to the entrance of the carotid canal in the petrous portion of the temporal bone, where the ball had lodged. Death ensued, ten days after the wound, by hemorrhage from the internal carotid. In another case, a branch of the external carotid artery was wounded by a ball which penetrated at the zygomatic fossa. Secondary hemorrhage ensued, and the usual means failed to arrest it. The external carotid was tied; but blood continued to flow, though less abundantly than before. Compression in the wound, which failed previously, now served to arrest the hemorrhage, and cure followed. Care must be taken, before tying the trunk, that pressure upon it exerts control over the hemorrhage from the wound; for the irregular course of projectiles is not unlikely to lead to mistakes, such as tying the common carotid, The rule of treatment, however, holds good in secondary as in primary hemorrhage—the bleeding vessel must be secured at the wounded part whenever practicable, and it must be tied both above and below the line of division, taking care to ascertain that the spot where each ligature is applied is sound. Hemorrhage from general oozing, from sloughing, and other causes must be treated on the general principles applicable in all such cases. WOUNDS OF NERVES. Temporary paralysis from contusion of a nerve in the passage of a projectile is not unfrequent. Complete loss of power of motion and sensibility in a limb occasionally follows gunshot injuries, and generally indicates complete division of the nerve. Instead of complete paralysis, there may remain only modified deprivation of sensibility, partial loss of muscular force, and diminished power of resisting cold, with or without pain; and these symptoms may either be the result of contusion, with the effects perhaps of inflammatory action or of partial division. When a foreign body is lodged in or among nerves, it may induce tetanic symptoms of a fatal character, or great irritation and intense pain may result; and unless the source of these latter symptoms can be found and removed, if in a large nervous trunk of one of the extremities, they will sometimes lead to the necessity of amputation. The gunshot injuries which cause division of large nerves, however, are usually attended with so much destruction of other parts that the question of amputation has scarcely ever to be considered in reference to lesions of nerves alone. Atrophy of tissues and contractions of muscles are common results of injuries to nerves from gunshot, and often lead to soldiers being disabled for further service. Occasionally, after severe injuries, the functions of sensation and TETANUS. One cause of fatal termination in gunshot wounds is tetanus. It is generally believed that the proportion of deaths from this source is greater after actions in tropical climates, and that exposure to the night air in such regions has some especial effect in producing them. The most common cause appears to be, however, the local injury to nerves, already mentioned, producing irritation along their course, and so leading to some morbid condition of the ganglionic portions of the motor tracts of the spinal cord. In the Crimean campaign, the proportion of tetanus was remarkably small as compared with former wars, being, according to the returns, only 0·2 per cent. of the number wounded. Dr. Scrive records that not more than thirty cases of tetanus occurred among the French wounded during the whole Crimean war, and this would show a somewhat less ratio even than in the British army. Dr. Stromeyer records only six cases of tetanus among 2000 wounded in the campaign of 1849 against the Danes. Three of these, in which the disease assumed a chronic form, recovered. There was only in one case injury of bone. Warm baths and opium were the remedies in the successful cases. Sir G. Ballingall made the calculation that one in seventy-nine is the average number of tetanic cases among wounded, and states that the proportion of recoveries is so small as scarcely to be taken into account. Three cases occurred to the writer, in the Crimea, after gunshot wounds; all proved fatal. In one there was a severe fracture of the ischium and injury of testicle by grape-shot. In a second, a rifle-ball entered just above the left knee, and lodged. Eight days after the injury an abscess was opened near the tuberosity Beyond the extraction of any foreign bodies which may have lodged, as in this last case, it is not known that there are any indications for special treatment of tetanus as occurring after gunshot injuries. The employment of woorali has Hospital gangrene, a common disease of wounded soldiers when circumstances of war lead to overcrowding in ill-ventilated buildings, and to deficiency in the proper number of attendants for securing personal cleanliness and purity of atmosphere, with inferior diet; and Pyemia, a frequent cause of fatal termination after gunshot fractures, injuries of joints, and other suppurating wounds, especially under the influence of circumstances like those above named, are treated separately under their respective heads. ANESTHESIA IN GUNSHOT WOUNDS. The complete applicability of chloroform on the field to injuries caused by gunshot, as to all others in civil practice, is established among Continental surgeons, and among a majority of British army surgeons. The first opportunity of testing chloroform largely as an anesthetic agent in British military surgery occurred in the Crimean war, and a long report on the subject will be found in the published Surgical History of the Campaign. The general tenor of this report is to limit considerably the use of chloroform—in minor operations, on the ground of occasional bad results, even when the drug is of good quality and properly administered; or, in cases where the shock is very severe, on the ground that such do not rally, owing to the depressing effect of the drug, after the anesthesia has gone off; or in secondary operations, At the commencement of the Crimean war, the Inspector-General at the head of the British Medical Department circulated a memorandum “cautioning medical officers against the use of chloroform in the severe shock of serious gunshot wounds, as he thinks few will survive where it is used;” but as far as chloroform was available, it was used by many medical officers from the commencement of the campaign, and its employment became more general as the campaign advanced. It was constantly used in the division to which the writer belonged throughout the war; and no harm was ever met with from its use, while certain advantages appeared especially to fit it for military surgical practice. So far from adding to the shock of such cases as an army surgeon would select for operation, the use of chloroform seemed to support the patient during the ordeal; and the writer has several times seen soldiers, within a brief period after amputation for extensive gunshot wounds, and restoration to consciousness, calmly subside into natural and refreshing sleep. In respect to the danger of anesthetics in the secondary operations connected with gunshot wounds, Dr. Scrive’s experience has led him to remark: “When consecutive amputation is rendered necessary by the gradually increasing debility of a wounded man from purulent discharges, chloroformization takes place with the most perfect calm on the part of the patient;” and he classes its use under “chloroformization de nÉcessitÉ.” The general rules followed in civil surgery must be equally applicable in these cases. 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. After the battles of Alma and Inkerman, when orders were given to remove the wounded as speedily as possible, the first-named consideration frequently occurred. The case of Sir T. Trowbridge is quoted by Mr. Guthrie. This officer had both feet completely destroyed by round shot at Inkerman, and it was necessary to amputate, on one side at the ankle-joint, on the other in the leg: the use of chloroform enabled the two operations to be performed within a few minutes of each other with perfect success. The amputations were done by the late Director-General of the Army Medical Department. In illustration of the second In the British army in the Crimea chloroform was generally applied by simply pouring a little on lint. The chief objection against this in the open air is probably the waste which is likely to be occasioned. Dr. Scrive says it always appeared to him most advantageous to use a special apparatus, as well to measure exactly the doses, as to guarantee a proper amount of mixture of air; and that although he never saw a fatal result, he had several times seen excess of chloroformization from the use of lint rolled up in the shape of a funnel. The instructions which he gave were, never to pass the stage of strict insensibility to pain, never to wait for complete muscular relaxation; and to this direction being carried out he attributes the fact that no death occurred from chloroform in the French army in the Crimea. In an article on anesthetics, in the Medico-Chirurgical Review, October, 1859, Dr. Hayward, of Boston, has strongly advocated the use of sulphuric ether above all other anesthetics. The quantity required to produce anesthesia—from four to eight ounces—would render the use of this agent almost impracticable in extensive army operations in the field. AFTER-USEFULNESS OF WOUNDED SOLDIERS. The results of wounds unfit soldiers for military service in many ways, according to the nature of the wound and the region in which it is inflicted; and the pensions consequent on their discharge entail heavy expenses of long duration on the country. It was hoped that the improvements in conservative surgery would have diminished the number of disabled soldiers as compared with former wars; but the corresponding improvements in the power and means of destruction, with other circumstances, have defeated this hope, and the returns do not show such to be the result. Even the cases where resections of the joints have been performed, and fractures united, which previously would have been treated by amputation, have rarely presented such cures as to render the men available for military service, though the preserved limb may still be of use in the work of civil life. Formerly, all men who thus became unfitted to perform any of the duties to which a soldier is liable were removed from the army; but, by an order from the Horse Guards of 1858, wounded soldiers, though rendered unfit for active service in the field, were directed to be retained for modified duty in such employments as they are capable of executing. The results of the increased practice of conservative surgery may, therefore, prove valuable to the public service, now that the opportunity of secondary employment is laid open. The reports from the hospitals in Italy show that during the recent campaign in that country the practice of conservative surgery after gunshot fractures has been very limited, and in the lower extremity has been almost wholly abandoned, early amputation being practiced instead. It is believed, that should England become again involved in war, a greater amount of systematic scientific observation will be brought to bear upon the subject of gunshot wounds THE END. MEDICAL BOOKS PUBLISHED BY J. B. LIPPINCOTT & CO. Power’s Anatomy of the Arteries. Anatomy of the Arteries of the Human Body. By John Hatch Power, Fellow of the Royal College of Surgeons. Profusely illustrated. Authorized and adopted by the Surgeon-General for Field and Hospital Use. 12mo. $2.00. Guthrie’s Surgery of War. 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