^ |L85€t 1863 Mi.* \ i\ tUv »*x>x\\v*\\\\>*\yt\%iA\x\*Aiy*'~ \ i mm USyyy S MEDICAL BOOKS II PUBLISHED BY J. B. LIPPINCOTT & CO. Bartholow on Enlisting and Discharging Soldiers. A Manual of Instructions for Enlisting and Discharging Soldiers, with special reference to the Medical Examination of Recruits, and the Detection of Disqualifying and Feigned Diseases. By Roberts Bartuolow, A.M., M.D., Assistant Surgeon U.S.A. 12mo. $1.2">. Adopted by the Surgeon-General for issue to medical officers of the Army. Da Costa's Medical Diagnosis. Medical Diagnosis with special refer- ence to Clinical Medicine. By J. Da Costa, M.D. One vol. 8vo, ®g-3£- ••■■ 3- 3- 3- 3- 3-> 3- 3- 3- 3- 3- 3- 3- 3- 3- 3:5- 3- 3-S3- 3- 3- ••• He B _________T_„™.T,n^^M £ -ealDis- A. One SURGEON GENERAL'S OFFICE LIBRARY Re Be Section, 0. jver, us ■lidcnce. k, M.D. I of Drs. if Medi- bons of Smith's Surgery The Principles and Practice of Surgery, embracing Operative Surgery. Arranged for the use of Students, by Henry H. Smith, M.D., Professor of the Principles and Practice of Surgery in the University of Pennsylvania. Illustrated with numerous steel and wood engravings. Two vols. 8vo. Wood's Practice of Medicine. A Treatise on the Theory and Prac- tice of Medicine. By Geo. B. Wood, M.D., Professor of Theory and Practice of Medicine in the University of Pennsylvania, &c. &c. Fifth edition, enlarged. Two vols. 8vo. mggmmmmm!S9Ssm MEDICAL BOOKS. Wood's Therapeutics and Pharmacology. A Treatise on Thera- peutics and Pharmacology or Materia Medica. By Geo. B. Wood, M.D. Second edition. Two vols. 8vo. ...,: ■' Wood & Bache's Dispensatory. Dispensatory of the United States. By Drs. Wood and Bache. Twelfth edition, much enlarged and S carefully revised. In press. il }M Nelaton's Surgery. Clinical Lectures on Surgery. By M. Net.aton. S' jjjjjlj • From Notes taken by Walter F. Atlee, M.D. 8vo. ft1,1, \ii;i;i, Stromeyer and Esmarch on Gunshot Fractures. On the Fractures !;::!'■ ^'"//i •nit"': mm of Bones occurring in Gunshot Injuries, by Dr. Lor is Stromeyer; !"!!!// u'ffl and Resection in Gunshot Injuries, by Dr. Fkiedrich Esmarch. V*i""'' ■ O-^Wo- |..... Ill Leidy's Anatomy. Human Anatomy. An Elementary Text-Book for ill '110 Students. By JosErn Leidy, M.D., Professor of Anatomy in the •• ||(fji| University of Pennsylvania. One vol. 8vo. Elegantly illustrated '; ^p from original designs. 5 iP f ' jijjl Longmore on Gunshot Wounds. A Treatise on Gunshot Wounds. )//li By T. Longmore, Deputy Instructor of Hospitals, Professor of Mili- '& tary Surgery at Fort Pitt, Chatham. In two parts. Part I., Gun- !§ shot Wounds in General. -Part II., Gunshot AVounds in Special B Regions of the Body. One vol. 12mo. . " S 0) Malgaigne's Fractures. A Treatise on Fractures. By Prof. Malgaigne, [;/|f of Paris. Translated from the French by John II. Packard, M.D. M 8vo, with numerous illustrations. ]M M m 1 "in1,1, m Gerhard on the Chest. The Diagnosis, Pathology, and Treatment a of the Diseases of the Chest. By AV. AV. Gerhard, M.D., Fellow < t the College of Physicians of Philadelphia, Member of the American ||| Philosophical Society, and one of the Physicians to the Pennsylvania &« Hospital, &c. Fourth edition, revised and enlarged. One vol. 8vo » J. B. LIPPINCOTT & CO., Publishers, PHILADELPHIA. '!'. „ 1WIIIIMWWIWIIIWIIIWW1IIIII!' umssBKBS® LONGMORE on GUNSHOT WOUNDS. A TREATISE GUNSHOT WOUNDS. BY T. LONGM.ORE, Esq., DEPUTY INSPECTOR-UENERAL OF HOSPITALS; PROFESSOR OF MILITARY 8CRGER7 AT FORT PITT, CHATHAM. AUTHORIZED AND ADOPTED BY THE SUKGEON-GENERAL OF THE UNITED STATES ARMY FOR THE USE OF SURGEONS IN THE FIELD AND GENERAL HOSPITALS. fy PHILADELPHIA: J. B. LIPPINCOTT & 1863. CO. (SI 3 CONTENTS. GUNSHOT WOUNDS IN GENERAL. PAOI Definition of the term......................................................... ® History of the surgery of gunshot wounds.............................. " VARIETIES OF GUNSHOT WOUNDS. Form and nature of missile................................................. Grape-shot, canister, and spherical case........................... 1° Musket-shot—Conical bullets.......................................... 16 Bullets of various weights and sizes................................. 1' Double bullets.............................................................. 18 Stones, and splinters of iron or wood............................... I9 20 Degree of velocity.............................................................. Increased by modern fire-arms....................................... Comparison of round and conical balls............................. The Enfield and AVhitworth rifles.................................... 22 22 Number of wounds in battle................................................ Proportion to shots discharged....................................... 2- Spent balls........................................................................ " Lodgment of balls.............................................................. Consequences of unextracted balls................................. , Lodgment of an 8-pound ball.......................................... 26 Illustrative cases......................................................... Fragments of shells...................................................... Fragments of bullets..................................................... Small foreign bodies...................................................... Internal wounds without external marks..................-............. *- Hypotheses concerning................................................. "J Explanation concerning.............................................. Seat of injury................................................................... g4 Course of balls.................................................................. !* v VI CONTENTS. SYMPTOMS OF GUNSHOT WOUNDS. PAOl Diagnostic symptoms.......................................................... 38 Appearances from various kinds of projectile.................... 38 Apertures of entrance and exit....................................... 41 Pain of gunshot wounds...................................................... 44 Shock of gunshot wounds.................................................... 45 Primary hemorrhage.................................................... 47 Prognosis of gunshot wounds............................................... 60 Treatment of gunshot wounds in general................................ 51 Provisional dressing recommended.................................. 51 Surgeon's first duty...................................................... 52 Position of patient for examination................................. 53 Instruments for conducting examination.......................... 54 Views respecting enlargement of the external orifice........... 54 Instruments for extracting balls..................................... 56 Means to be employed for readjusting lacerated wounds...... 59 Constitutional treatment................................................ 61 Progress of cure................................................................ 62 GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY. GUNSHOT WOUNDS OF THE HEAD. Observations on................................................................. 63 Wounds of the scalp and pericranium.................................... 65 Wounds complicated with fracture, but without depression on the cerebrum................................................................. 67 Fissured fracture......................................................... 08 Wounds complicated with fracture and depression on the cere- brum...................................................................... 69 Wounds with penetration of the cerebrum.............................. 70 Treatment........................................................................ 71 Use of the trephine......................................................• 71 Opinions concerning..................................................... 72 GUNSHOT WOUNDS OF THE SPINE. Statistics of....................................................................... 75 Vertebral column and spinal cord.......................................... 76 OUNSHOT WOUNDS OF THE FACE. General observations on...................................................... 77 Treatment......................................................................... 78 CONTENTS. vii GUNSHOT WOUNDS OF THE CHEST. . FAOl Comparison with other wounds............................................ 80 Non-penetrating....................................... gj Penetrating.......,...................................... g2 Signs indicating......................................................... 83 Hemorrhage from............................................. 83 Indications of the lung being penetrated........................ 84 Treatment.......................................................... 85 Wounds of the heart......................................................... 89 GUNSHOT WOUNDS OF THE NECK. Abstract of...................................................................... 90 GUNSHOT WOUNDS OF THE ABDOMEN. Observations on............................................................... 93 Non-penetrating............................................................... 94 Penetrating..................................................................... 94 Of the diaphragm............................................................ 99 Fatality of................................................................. 99 Treatment....................................................................... 100 GUNSHOT WOUNDS OF THE PERINEUM AND QENITO-URINARY ORGANS. Statistics of in the Crimea................................................. 101 GUNSHOT WOUNDS OF THE EXTREMITIES. Frequency of................................................................... 103 Division of....................................................................... 103 Pyemia from.................................................................... 104 Upper extremity.............................1................................. 105 Percentage of recoveries from, without amputation.......... 106 Lower extremity............................................................... 109 When to amputate, and when to be avoided..................... 109 The femur................................................................. 110 Statistics of cases of................................................... 110 Proportions of recoveries in amputations in..................... 114 Fractures in the middle and lower third of the femur........ 116 Statistics in fractures of the leg, in the Crimean war......... 117 AMPUTATION. Advantages of primary as compared with secondary............... 117 VU1 CONTENTS. SECONDARY HEMORRHAGE. PAOl Reasons for its occurrence.................................................. 120 Not uncommon in deeply-penetrating wounds of the face......... 121 Rule of treatment............................................................. 122 WOUNDS OF NERVES. Temporary or complete paralysis caused by........................... 122 Amputations sometimes necessary....................................... 122 TETANUS. Statistics of..................................................................... 124 Treatment....................................................................... 125 Hospital gangrene......................................................... 126 Pyemia........................................................................... 126 anesthesia in gunshot wounds. Chloroform..................................................................... 126 Views respecting its use in secondary operations.................... 129 Mode of administering..............................'........................ 130 after-usefulness of wounded soldiers. Observations upon............................................................ 131 General summary.............................................................. 131 GUNSHOT WOUNDS. G-unshot wounds consist of injuries from missiles pro- jected 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 in- flicted 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 pur- poses, 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 dis- tance at which opposing forces were enabled to contend with 9 10 gunshot wounds. each other; just as, in our day, the nature of battle seems destined to undergo another change from the increased range and precision of fire obtained through the general use of rifled weapons. But though the alterations now being made in the qualities of fire-arms are of the utmost import- ance to those whose business and especial study is the art of war, to the army surgeon the interest they excite is chiefly limited to the degree of injury and destruction inflicted by them as compared with weapons of a less perfect kind; while to the surgeons employed at the time of the introduc- tion of gunpowder, the wounds were wholly new in their nature as well as degree. Recollecting the ignorance which then prevailed in. all departments of science and art, it can excite no surprise that the new engines of war, with the flame and noise accompanying their discharge, were re- garded with superstitious terror; nor that surgeons for a long time found an explanation of the sloughing severity of the injuries they inflicted, and of their difficult cure, in the poisonous nature of gunpowder, or of the projectiles which had been acted upon by it, or in the burning effects of these latter from heat acquired in their rapid flight through the air. Unfortunately, these erroneous views did not end with the theories from which they started, but led to treatment which only aggravated the evils inflicted by the new weapons, and interrupted the progress of the healing action, which nature would otherwise have established. The wound being regarded as a poisoned wound, it was only by a long and tedious process of suppuration that the poison could be hoped to be got rid of from the surface, and prevented from entering the system of the patient. The irritative fever, the wasting and emaciation, and all the other results of the pro- tracted cure of the injury were so many evidences of the indirect effect of the poison working in the frame; just as the constitutional shock at the time of the wound, the loss of vitality along the surface in the track of a small projec- tile, or of the tissues laid bare by the passage of the cannon- n I STORY. 11 ball were regarded as evidences of its direct influence. On looking back at the works of successive writers on this class of injuries, the reader is surprised that the improvement in their treatment has been so gradual and slow; and cannot fail to observe that the chief impediment to a more rapid amelioration of the system pursued has been the prevailing idea of the necessity of delaying the tendency of nature to close the wound, in order that the supposed poison might be eliminated from the constitution. The openings of en- trance and exit and track of the ball were incised; the wound dilated by tents or other means, and terebinthinates, or even boiling oil, poured into it; irritating compounds and ointments applied where superficial dressings were prac- ticable ; and it was only after the wound was considered to be fully purged of its venom and foul humors by the exten- sive suppurative action thus kept up, that cicatrization was permitted to be established. 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 re- moved by the earlier surgeons, the light of science can hardly be said to have penetrated this important province of mili- tary surgery until the great and last work of John Hunter, on the Blood, Inflammation, and Gunshot "Wounds, was pub- lished 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 12 gunshot wounds. then only had the opportunity of seeing active service as staff-surgeon in the expedition to Belleisle. Had the field of his practical observation been more extensive, there can be no doubt that his zealous and scientific mind would have turned the advantage to the most valuable results for hu- manity. The physiological principles which he enunciated, based on extensive study and observation in civil life, cannot be controverted; but their practical application, so far as regards the treatment of gunshot wounds, has been greatly modified since his treatise on the subject was published. There cannot be a better illustration of the special position in which this department of military surgery is placed, from the peculiar ciroumstances under which it is practiced, than the fact that, though men of the highest mental attainments have discussed the subject of gunshot wounds, we are never- theless indebted to practical experience in military campaigns for every improvement, some few of recent date excepted, that has occurred in their treatment. Thus John Hunter was led to advocate very strongly the delay of amputation, after severe gunshot wounds, for weeks, that the patient's constitution miglit accommodate itself to the injury; while more extended observation has demonstrated that such sec- ondary amputations are more fatal than those which are performed shortly after the infliction of the wounds leading to them—the advantage of the patient thus coinciding with what must very constantly happen to be a practice of neces- sity in the field. Mr. Guthrie remarks, in his Commentaries on the Surgery of the Peninsular War, between 1808 and 1815, that the surgical principles and the practice which prevailed at the commencement of the war were superseded on almost all important points at its conclusion; and he quotes a remark of Sir Astley Cooper to the effect that the art of surgery received from the practical experience of that war an impulse and improvement unknown to it before. The still more recent military operations in Algeria, in Sleswick-Holstein, in the Crimea, and in India have afforded HISTORY. 13 the opportunity of testing practically the applicability to army practice of some of the great improvements which have been accomplished in the civil practice of surgery in Europe since the termination of the war in 1815. Among these may be particularly enumerated the avoidance of amputation of limbs by recourse to excision of joints; re- sections of injured portions of the shafts of long bones; mitigated amputations, by removal only of those terminal portions of the extremities which had been destroyed by the original injury; and the practice generally of what has been styled conservative surgery. In these wars, too, the value of chloroform as an anesthetic agent in military surgery has been fully established. They have also especially illustrated the influence of various states of health and climates on the results of gunshot wounds. All the anticipations which were held out at the commencement of some of these cam- paigns have not been realized, but still they have added much valuable information and many improvements to mil- itary surgery. 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 " amies de precision," 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 pro- portion 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 institu- 2 14 GUNSHOT WOUNDS. ting a comparison of the results of their treatment under circumstances of bodily health and hospital accommodation very different from those of the French army in the Crimea. It may be hoped that the experience thus gained will ad- vance the knowledge of gunshot wounds and their treatment a still further stride toward accuracy. In England, one valuable result which emanated from the late war with llussia was the regular collection and arrange- ment, 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 stoues, 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 mis- VARIETIES—NATURE OP MISSILE. 15 cellancous objects which may happen to come into contact with the solid ball or shell in its course. 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 be- longing to rifled cannon and rifled muskets; 3d, irregular, but generally bounded by linear and jagged edges, as frag- ments of shells and splinters. A gunshot wound, whether received from a direct or indi- rect projectile, may be complicated by the entrance of extra- neous 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, influ- ence the nature of gunshot wounds. In the largest kinds of balls, such as are projected from field-pieces or guns of po- sition, 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 com- posed, so long will their weight be the most important in- gredient 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, be- fore 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 indi- rect 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. 16 GUNSHOT WOUNDS. Grape-shot, canister, and spherical case, on striking Col- lectively—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 can- non-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 fur- nished 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 pro- longed cylindro-conoidal ball seems to derive its chief im- portance 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 construc- tion 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, os- VARIETIES—NATURE OF MISSILE. 17 seous texture of which the cylindrical portion of these bones is composed is split up into fragments, having mainly a di- rection parallel with the central cavity; and fissures not unfrequently extend from the seat of injury to their termi- nations in the joints, of which they form component parts. Such results were scarcely ever noticed from the impulse of round balls. The bone might be comminuted, but the frag- ments were of a more cuboid shape, and the long Assuring did not occur. It has been stated that the screw motion impressed on the ball by the rifling of the musket contributes to its increased power of injury on bone; but its shape, com- bined with its momentum, seem sufficient to explain the se- verity of its effects above those of the round bullet. Another result of the tapering form of the conical bullet is that it is less exposed, in its course through soft parts of the body, to opposition from tendons and other long and elastic struc- tures, so frequently noticed to stay the progress of spherical shot. If not dividing them by direct impingement, it read- ily turns them aside; and it is partly due to this pointed shape, therefore, as well as to increased force, that, as will be noticed hereafter, the lodgment of balls is now so rare in comparison with the experience of former wars. 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 "ravity of the wound, or the time required for its cure, 2* 18 GUNSHOT WOUNDS. while the escape of foreign substances, which it might hap- pen to carry with it, would be facilitated by the freer means of exit and increased discharge from the surface. Mr. Guth- rie mentions that, having had a wide field for observation in the effects of the heavy British musket-ball, sixteen to the pound, on the French wounded, he did not think them more mischievous in their results than the French musket-balls, twenty to the pound, on the English soldiers; while the ad- vantages of carrying a lighter musket and greater number of rounds of ammunition were on the side of our adversaries. It is understood that in warfare the object is not so much to destroy life as to disable antagonists, and the smaller size has been supposed to be fully equal to this object by the British military authorities of the present day; for in the weapon most recently given to the troops, the Enfield rifle, the weight of the ball has been reduced two drachms and a half below that of the ball with the Mini6, previously in use. After all, within the moderate limits which must be preserved to suit the circumstances of infantry soldiers, the form and velocity of musket-balls must be the qualities of interest to the surgeon in connection with the wounds inflicted by them, rather than their weight or size, as with projectiles from guns of large calibre. Double bullets, linked together by a spiral coil of wire, something after the manner of chain cannon-shot, were in- troduced 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 re- corded ; 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. VARIETIES—NATURE OF MISSILE. 19 Dr. Scrive, in his History of the Eastern Campaign, men- tions also that incendiary balls were employed by the Rus- sians. They consisted of a small cylinder of copper con- taining a detonating composition, and made up into the form of an ordinary cartridge, so as to be discharged from a mus- ket. On hitting its object, the projectile burst with violence. These balls were not known till after the conclusion of the siege; and it was only then, M. Scrive remarks, that a key was obtained to some wounds of a frightful character which could not be accounted for by the action of ordinary bullets or fragments of shell. No similar observation is recorded in the British surgical history of the war. Wounds caused indirectly by stones from parapets, splin- ters of iron or wood, and by fragments of shells are very varied in character and severity. They derive their import- ance 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 pow- erful 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 20 GUNSHOT WOUNDS. soft parts are frequently rendered more dangerous from in- direct projectiles in consequence of large vessels or nerves being implicated in the injuries, leading more often to pri- mary hemorrhage and subsequent sloughing of wider tracts than in wounds from direct projectiles of corresponding size. Such sloughing may lead to a fracture of bone becoming compound which was at first simple. Fragments of shells sometimes wound by falling after having been projected up- ward in the air. These do not generally produce such seri- ous injuries as fragments striking at once from the exploded shell; not that the force is different, but because the parts chiefly exposed—the shoulders, back, etc.—are more protected from injury, and offer less resistance, from relative form and position, than do the abdomen, loins, and other parts of the body, which usually meet the fragments shot upward when the shell explodes on the ground. 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 de- pended 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 varia- tions 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 VARIETIES—VELOCITY OF MISSILE. 21 weight, would knock a man over, at ordinary speed will carry away a limb without disturbing the general equilibrium of the body. A musket-ball that would be arrested half way through a limb is now replaced by a ball which, at like dis- tance from the point of discharge, will pass through several bodies in succession. 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, travelling at the rate of several miles per minute, cleaves its way are inevitably deprived of their vitality. In- stances 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. More- over, when considering the course taken by balls in the body, it will have to be shown that the velocity imparted to projec- tiles from modern weapons has led to another change in gun- shot wounds. The great power of resistance so often before exhibited by the yielding elastic tissue of the skin, by tendi- nous and other structures, is no longer of avail against pro- jectiles 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 im- perfect mechanism of the firelocks from which they were dis- charged, 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 por- tion of the shaft without further fracture, or, having perfo- rated on one side, remain in the cancellated structure, or be GUNSHOT WOl NDS. simply flattened without penetrating. It seems not unlikely, also, that the modern conical bullets are denser, from the cir- cumstance of their manufacture by mechanical pressure, than bullets, such as are still used in some places, cast in moulds. The influence of density with respect to power of penetra- tion is very great. In the two most perfect of modern Eng- lish rifles, the Enfield and the Whitworth, the projectiles and charges being of the same weight, when lead is used, the pen- etration at S00 yards is one-third greater with the Whitworth than the Enfield; but if a less yielding projectile is used, (as when the lead is mixed with tin,) its penetration is as 17 to 4 at 800 yards. Whether this cause operates or not, the fact is certain that conical balls in action exhibit almost invaria- bly an overpowering force over all the structures, bone in- cluded, with which they come into contact in the human body, and are rarely met with flattened, or so much altered in form as bullets not unfrequently were formerly under like circumstances. 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 en- gagements, 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 col- lision early in its flight, to penetrate and wound several per- sons. 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 VARIETJKS;—NUMHER OF WOUNDS. 23 known to be hit; while at Cawnpore, one company of sol- diers, armed with the Enfield rifle, brought down 69 out of a body of horsemen by whom they were attacked, at one dis- charge. At the battle of Salamanca, only one ball in 3000 fired by the British took effect. Another result is, that we may now expect to meet more frequently the occurrence of several bullet-wounds in the same individual. It is men- tioned that, among the wounded from Solferino, it was not uncommon to see several wounds of different origins in one body; and M. Appia mentions a case, in one of the hospi- tals at Hrescia, where a soldier had been struck at the same time by four balls. These circumfltanoes become important in estimating the amount of surgical attendance that is re- quired in modern engagements. At the battle of Solferino, just referred to, some returns show that, in twenty-four hours, 11,500 French, 5300 Sardinians, and 21,000 Austrians were laid hors de cennbat. The surgeons had no time to attend to the first necessities of a great proportion of the wounded. A multitude of those unfortunates were hastily conveyed to the little village of Castiglione, and had to wait hours, many even days, before their wounds could be dressed. To relieve thirst, and apply wet compresses of linen to ease the pain of the wounds, by calling into service the people of the neigh- borhood, was as much as could be done to a great number for the first day or two, on account of the vast number of wounds inflicted by the new weapons. At Brescia, within a short time after this battle, 15,000 wounded were congre- gated in thirty-eight fixed and temporary hospitals. From the actions in Flanders on the 16th, 17th, and 18th of June, 181."), including the battles of Quatre Bras and Waterloo, the returns show the number of wounded, not including those killed in action, in the Duke of Wellington's army, to have been rather more than S000. In the whole Crimean cam- paign, the total number of British wounded amounted to 11.361, exclusive of men killed in action. Spent balls.—Iu connection with degree of velocity, the 24 GUNSHOT WOUNDS. subject of what are called "spent balls" naturally occurs. After a cannon-ball has ceased to pursue its course through the air or to proceed by ricochet, it not unfrequently travels to a considerable distance, rolling along the surface of the ground. When its rate of movement is not much faster than that at which a man can walk, and when to all appearance it might be stopped by the pressure of the foot as readily ;ts a cricket- ball, it yet possesses the power of inflicting serious injury on such an attempt being put into execution. This power is easily understood if the amount of force is remembered which must still be inherent in the cannon-ball for it to overcome the inertia of its own mass, and the resistance to which it is exposed in passing over the ground on which it is rolling. It is this force, multiplied by the weight of the ball, which gives it the destructive power. If this ball is brought into collision with the foot of a person, such destruction ensues as generally to necessitate amputation. Should it impinge on other parts of the body, as in the instance of a man lying on the ground, it may cause mortal injury to internal organs, and that without exhibiting external evidence of the amount of injury it has inflicted. So, also, though powerless to carry away a limb, it may cause comminuted fractures of bones and extensive contusions of the softer structures. Lodgment of balls.—Low rate of velocity leads to mus- ket 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 VARIETIES—LODGMENT OF BALLS. 25 deep in the muscles of the back, for example, or be so far removed from the aperture of entrance, as to elude all at- tempts on the part of the surgeon, at the time of examina- tion of the wound, to discover its retreat. Or it may have reached some position from which the surgeon fears to take the necessary steps for its extrication, judging the additional injury that would thus be inflicted more mischievous than the probable effects of allowing the ball to remain lodged. Unextracted balls lead to consequences varying according to the site of lodgment and state of constitution of the pa- tient. If the ball have become fixed in the body of a mus- cle, 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 un- easiness, or may be so situated as to embarrass the person in certain movements of the body. Foreign bodies not un- lrc(|ucutly change the position of their first lodgment, under the effect of gravitation or the impulse of muscular actions. The following instance, which occurred to StatV-Surgcon Dr. Danicll, 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 mau 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 3 26 GUNSHOT WOUNDS. irregular shape, which was removed. No pain or irritation had existed between the shoulder and the foot. When lodged in the lower extremities, balls sometimes form for themselves canal-shaped cysts, along which they can be moved freely on pressure. When, however, the health or other cir- cumstances of the patient are not favorable, the lodgment of a ball with a smooth surface, like missiles of a more angular and irregular shape, may excite inflammation and constitu- tional disturbance of a very troublesome kind, and keep up a profuse suppurating discharge along the track of the wound, or perhaps lead to abscesses burrowing in other directions. Balls have been known to lodge in bones, without their po- sitions having been suspected or inconvenience excited by their presence. On the other hand, balls similarly impacted have given rise to disease, and in some bones, as those of the pelvis, have produced such constitutional irritation as to lead to a fatal termination. Balls lodging in the circum- scribed cavities of the body or their contained viscera require notice elsewhere. 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 thi"h 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 VARIETIES—LODGMENT OF BALLS. 27 being brought to hospital, no one doubted that the ball, after fracturing the limb, had glanced off; but on amputating, the ball, weighing five pounds, was found in the hollow of the thigh toward the groin. The wound of entrance was on the outside of the thigh; and the ball had not only fractured, but had turned round, the bone. M. Armand, surgeon attached to the French Imperial Guard, has related the case of a soldier who was brought to the ambulance, after the taking of the Mamelou Vert, in the Crimea, with his left thigh wounded; one opening, such as might be made by a large musket-ball, was found on the outside of the thigh. There was no second opening. On examination, a swelling was detected in the popliteal space, without any external mark of injury nor much pain on pressure. It was concluded to be the ball; and, on incising, an enormous grape-shot was found. It had turned round the femur without breaking it. M. Armand writes that the appearance of the wound alone would have led to the supposition that the ball had not lodged, and no one would have suspected that such a thing as a grape-shot had been the cause of it. In the British Surgical History of the Crimean War the case of a soldier of the 1st Royals, who was wounded in the face by a grape-shot weighing 1 lb. 2 oz., is recorded. The ball lodged at the back of the pharynx, and escaped observation for three weeks. Were it not for experience of many such instances, it would be deemed al- most impossible that foreign substances of such size and weight could remain in the body without the knowledge of the patient, if not discovered by the surgeon. Even with so large a missile as a grape-shot, a surgeon should not be con- tented with examining merely by the wound, wide as it usually is, in case lodgment is suspected; it may travel in a direction which may cause its discovery to be very difficult bv that track. An officer of the 19th Regiment was struck during the assault on the Redan, on September the 8th, by two grape-shot, at the back of the chest. They entered close to the spine. One of these balls lodged in the inner 28 GUNSHOT WOUNDS. part of the right arm, below the axilla, whence the writer excised it. 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—evi- dently, 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 im- possible 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 im- pacted among the fibres 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 Glas- gow, 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.* But bodies of still more irregular form may lodge in this region, and escape notice. A soldier in a battery in the Crimea was wounded, during a heavy artil- lery fire, in the left hip. A twelvemonth afterward he was in the General Hospital at Chichester, with a narrow sinus, which allowed a probe to pass deeply among the gluteal * Notes on the Surgery of the Crimean War, p. 104, J. B. Lippin- cott & Co.'s edition. VARIETIES—LODGMENT OF BALLS. 29 muscles. On cutting down in the direction indicated, a piece of stone was extracted, upwards of four ounces in weight. This man had passed through several hospitals before his arrival at Chichester. Bullets scattered from canister or spherical case not un- frequently lodge; apparently in consequence of the direct velocity received from the primary discharge being dis- turbed, 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 granu- lations 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 examina- tion 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 circumfer- ence, and in width, at the broadest part, about a third of the same dimensions. 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 necessi- tate 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, 3* 30 GUNSHOT WOUNDS. which was discharged per anum, and who died in Guy's Hospital of albuminuria, nearly four years afterward, a small scale of lead from the bullet was found at the post-mortem examination fixed in the spleen. Strange to say, in this in- stance the lodgment did not appear to have excited any inflammatory action or mischief. 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 heal- ing, and a troublesome sinus formed, by such small fibers of cloth as would hardly attract notice if within means of ob- servation. 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 Minie-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 "round often lodge, and give much trouble in their extraction, espe- cially about the face. In the assault of Sebastopol, at the VARIETIES— LODGMENT OF BALLS, ETC. 31 Great Redan, the attacking parties in their approach, the ground being rocky and having been much broken up by shell explosions, were particularly exposed to such injuries; and in several instances men were placed hors de combat by du-56, published by authority, vol. ii. p. 265, the physical effects of concussion in producing " shock" arc strongly dwelt upon. It is remarked: "The shock of the accidents frequently witnessed by the military surgeon differs, often in a very material degree, and possibly in kind also, from that witnessed in civil life. When a cannon-shot strikes a limb and carries it away, the immense velocity and momentum of the impinging force can scarcely be sup- posed to have no physical effect upon the neighboring or even distant parts independent of, and in addition to, the ' shock,' in the ordinary acceptation of the term, which would result from the removal of the same part by the knife of the surgeon, or the crushing of it by a heavy stone or the wheel of a railway wngon. * * In the great majority of cases, the whole frame is likewise violently shaken and contused, and, probably, independent of these physical effects, a fur- ther vital influence is exerted, which exists in a very minor degree, if at all, in the last-named injuries, and may possibly depend upon the ganglionic nervous system." SYMPTOMS—PRIMARY HEMORRHAGE. 47 tions of which are connected with vital force, and with that endowment of the organization only, may be judged from observation of cases in which the direct result of the wound is inevitably fatal, including many where no physical effects on neighboring parts from concussion could possibly be pro- duced. In such injuries the " shock" remains, from the time of first production of the fatal impression till life is extin- guished. And the practical experience of every army sur- geon teaches him that where a ball has entered the body, though its course be not otherwise indicated, the continu- ance of shock is a sufficient evidence that some organ essen- tial to life has been implicated in the injury. That the shock of a severe gunshot wound may be complicated with other symptoms, or that some of its own symptoms may be exag- gerated from other causes,—hopes disappointed, the ap- proach of death, and all the attendant mental emotions,— scarcely affects the question at issue; for its existence, independent of these complications, in all such cases is undoubted. 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 48 GUNSHOT WOUNDS. round shot or shell, the arteries are observed to be nearly in the same state as they are found to be in when a limb is torn off by machinery. The lacerated ends of the middle and inner coats are retracted within the outer cellular coat; the caliber of the vessel is diminished, and tapers to a point near the line of division ; it becomes plugged within by coagulum; and the cellulo-fibrous investing sheath, and the clot which combines with it, form on the outside an additional support and restraint against hemorrhage-. When large arteries arc torn across, and their hemorrhage thus spontaneously pre- vented, they are seldom withdrawn so far but that their ends may be seen protruding and pulsating among the mass of injured structures; yet, though the impulse may appear very powerful, further hemorrhage is rarely met with from such wounds. There is more danger of continued hemorrhage from wounds by pieces of shell, as the arteries are liable to be wounded without complete transverse section of their coats. The sharp edges, less velocity, and oblique direc- tion in which the fragments usually impinge sufficiently explain this difference. 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. (iuthrie 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 Tou- louse, without destroying the substance of either vessel. So SYMl'TOMS—PRIMARY HEMORRHAGE. 49 close was the ball, and such contusion was produced, together with, doubtless, injury to the vasa vasorum, that the artery became plugged with coagulum, and obliterated. A prepa- ration of these vessels is in the museum at Fort Pitt. An- other case is mentioned by Mr. (iuthrie, where the direction of a ball between the left clavicle and first rib, and perma- nent diminution of the pulse in the arm on the same side, led to the conclusion that the subclavian had escaped direct destruction by the missile in a similar way. 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 divi- sion of the common iliac artery, the other of the carotid. Primary but indirect hemorrhage, in consequence of a gun- shot 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 calcu- lated to cause such injuries. They are not as frequent as might be expected, from the limits within which the disper- sion of the fragments is restricted by their periosteal and other connections, and the yielding mobility, before men- tioned, of the vessels themselves. We have no data, how- 5 50 GUNSHOT WOUNDS. ever, to guide us in determining the proportionate frequency of fatal results from primary hemorrhage after wounds; nor can we have them until proper examination and classifica- tion of the particular causes of death on the field of battle are instituted. PROGNOSIS. Gunshot wounds vary in gravity from the simplest lacera- tion 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 hem- orrhage, 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 care- fully weighed. The time which has elapsed after the receipt of the injury is another important matter in forming a prog- nosis. 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 sur- gery abounds with examples of wounds of such extent and gravity as apparently to warrant the most unfavorable prog- nosis, 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 re- TREATMENT IN GENERAL. 51 ceived in various actions, with their immediate and remote consequences, as well as the results of the surgical opera- tions they have led to; but these afford little aid toward the prognosis of particular cases, each of which must be esti- mated in its own individual circumstances. Such tables are chiefly of value where they afford indications of the effects of different modes of treatment in wounds of a corresponding nature, and then only in patients under like circumstances of age and condition. Kven moral circumstances must not be disregarded. The probable issue in any given case will be very different in one soldier, who is supported by the stimu- lating reflection that he has received his wound in a combat which has been attended with victory, from what it will be in another, who labors under the depression consequent upon the circumstances of defeat. TREATMENT OF GUNSHOT WOUNDS IN GENERAL. When the circumstances of a battle admit of the arrange- ment, the wounded should receive surgical attention prelim- inary 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 aggrava- tion 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 accom- plished 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 re- 52 GUNSHOT WOUNDS. moval of any missiles or foreign bodies which may be readily obvious; the application of a piece of lint to the wound; the arrangement of any available support for a broken limb; protection against dust, cold, or other objectionable circum- stances likely to occur in the transit; if "shock" exist, the administration of a little wine, aromatic ammonia, or other restorative, in water,—need little time in their execution, and may prove of great service to the patient. If hemor- rhage exist from injury to a large vessel, it must of course receive the surgeon's first and most earnest care. He should not trust to the pressure of a tourniquet, but secure it at once by ligature. Without this safeguard during the trans- port, and while in the hands of uneducated attendants, the life of the wounded man might be endangered, either from debility consequent upon gradual loss of blood or from sud- den fatal hemorrhage. It has been recommended by some surgeons that all attendants whose duties consist in carrying the wounded from a field of battle should be directed, when bleeding is observed, to place a finger in the wound, and keep it there during the transport until the aid of a surgeon is ob- tained. The precise spot where compression by the finger is wanted, and the degree of pressure necessary, will be quickly made manifest to the sight by the effects on the flow of blood. Such a practice seems to offer less objection than the use of tourniquets by men whose knowledge of their proper appli- cation must be exceedingly limited. 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 at- tended 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 struc- tures ; 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 TREATMENT IN GENERAL. 53 made with more ease to the patient and more satisfactorily to the surgeon than at a later period. Not only is the sensi- bility of the parts adjoining the track of the ball numbed, but there is less swelling to interfere with the examination, so that the amount of disturbance effected among the several structures is more obviously apparent. 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 prob- able 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 sev- eral structures among themselves and their varying degrees of elasticity. Injury to nerves inducing paralysis, contu- sions 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, exam- ination 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 pa^s out, these may remain behind either from- being diverted from the straight line of the wound or from becoming caught and im- pacted in the fibrous tissue through which the ball has passed. 54 GUNSHOT WOUNDS. The inspection of the garments worn over the part wounded may often serve as a guide in determining whether foreign bodies have entered or not, and, if so, their kind, and thus save time and trouble in the examination of the wound itself. Of all instruments for conducting an examination of a gun- shot wound, the finger of the surgeon is the most appropri- ate. By its means the direction of the wound can be ascer- tained with least disturbance of the several structures through which it takes its course. If bones are fractured, the num- ber, shape, length, position, and degree of looseness of the fragments may be more readily observed. In case of lodg- ment of foreign bodies, not only is their presence more ob- vious 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, satu- rated 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 open- ing, but the walls of the wound itself, as soon after the injury as possible. This was not done as a means of ren- dering 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 dis- charges. The opinions held by the older surgeons respect- TREATMENT IN GENERAL. 55 ing the nature of these injuries, already briefly adverted to in the historical remarks on the subject, sufficiently explain their object in making incisions—namely, to convert what they regarded as a poisoned into a simple wound, and to obviate tension, and prevent strangulation of neighboring tissues by tumefaction on inflammation arising in its track. Even so late as 17,446 " = 45 13 2 14 Charpie................. 47,770 " = 46 19 3 4 And estimates the following as the proportion consumed by each of the wounded:— English weight avoirdupois. lb. oz. dr. gr. Linen cloth...............2 kil. 482 grammes = 6 7 0 10 Rolled bandages........0 " 891 " = 1 15 7 13 Charpie...................1 " 181 " = 2 9 11 0 Total.................4 " 554 " = 10 0 2 23 In an Army Medical Department Circular, dated 27th of May, 1855, it was announced that the Secretary of State for War had decided the following " Field Dressing" should form part of every British soldier's kit on active service, so as to be available at all times and in all places as a first dressing for wounds: — Bandage of fine calico, 4 yds. long, 3 in. wide. Fine lint, 8 in. wide, 12 in. long. Folded flat and fastened by 4 pins. TREATMENT IN GENERAL. 61 surgeon must be guided by the general rules applicable to all other such cases. Care must be taken to prevent the accumulation of pus, lest it burrow, and sinuses become established—not an unfrequent result of want of sufficient caution in this regard. If much tumefaction of muscular tissues beneath fascia) occurs, or abscesses form in them, free incisions should be at once made for their relief. In wounds where the communication between the apertures of entrance and exit is tolerably direct, occasional syringing with tepid water may be useful, by removing discharges and any fibers of cloth which may be lying in the course of the wound. Weak astringent solutions are occasionally employed in a similar way, with a view to improving the tone of the ex- halents and exciting a more vigorous action in the process of granulation. The strictest attention to cleanliness and the complete removal of all foul dressings are essentially neces- sary, not merely for the comfort of the patient, but to pre- vent the accumulation of noxious effluvia, and also to obviate the access of flies to the wounds. In tropical climates, and in field-hospitals in mild weather, where many wounded are congregated, flies propagate with wonderful rapidity, and the utmost care is necessary to prevent the deposit of ova and generation of larva} in the openings of gunshot wounds, especially while sloughs are in process of separation. Cloths dipped in weak solutions of creasote or disinfecting fluids, laid over the wound, are found necessary for this purpose when the insects abound in great numbers. 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 per- formance of the excretory functions, and support of the gen- eral 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. 6 62 GUNSHOT WOUNDS. The diet should be nutritious, but not stimulating. A pure fresh atmosphere is a very important ingredient in the means of recovery. If from previous habits of the patient, or from circumstances to which he is unavoidably exposed, the local inflammation has become aggravated,—indicated by pain, increased swelling, and redness about the wound,—topical depletion by leeches or cupping, bleeding from the arm, saline and antimonial medicines, and strict rest in the recum- bent position, must be had recourse to, the extent being regulated by the circumstances of each case. In instances such as these, when the inflammation has become diffused, the purulent secretion is not confined to the track of the wound, but is liable to extend among the areolar connections of the muscles; and if the cure be protracted, attention will be necessary to prevent the formation of sinuses. If stiff- ness or contractions result, attempts must be made to coun- teract them by passive motion and friction, with appropriate liniments; if a tendency to edema and debility remain in a limb after the wound is healed, the cold-water douche will be found to be one of the most efficient topical remedies. In French practice, the administration of a chalybeate tinct- ure,* as a tonic, or diluted as an injection, in wounds threat- ening to assume an unhealthy character, is very highly praised. It is stated that under the conjoined employment of this remedy internally and externally, in wounds of a pallid, un- healthy aspect, accompanied by nervous irritability and symp- toms of approaching pyemia, the granulations have resumed a red and healthy appearance, and the general state of health become rapidly favorable. 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 *Perchlorure de fer, 30 drops, two or three times daily as a tonic, and diluted with six parts of water as an injection. WOUNDS OF THE nEAD. 63 which the missile has passed, and a slight serous exudation escapes from them. Suppuration commences on the third or fourth day, and h\ about ten days or a fortnight the sloughs are thrown off. Granulation now progresses, more or less quickly according to the health and vigor of the patient's constitution. The opening of exit is usually the first closed. When the wound is complicated with unfavorable circum- stances, whether inducing in the patient a condition of asthenia or leading to excess of inflammatory action, the progress of the cure may be extended over as many months as, under favorable circumstances, weeks are occupied in the process. 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 circum- stances 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 observa- tion 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 64 GUNSHOT WOUNDS. which not unfrequently occur without auy previous warn- irig)—all these circumstances will keep a prudent surgeon who has charge of such wouuds continually on the alert. Injuries of this class, the most slight in appearance at their onset, not unfrequently prove most grave as they proceed, from encephalitis and its consequences, or from plugging of the sinuses by coagula, leading to coma, paralysis, or pyemia; and the converse sometimes holds good with injuries pre- senting at first the most threatening aspects, where care is taken to avert these serious results. Much will depend on the part of the head struck, both as regards the thicker and stronger processes or portions of the skull, and the situation of the sinuses and parts of the cerebrum within; on the force and shape of the projectile; the angle at which it strikes; the age and condition of the patient; and other matters already referred to in the general remarks on gun- shot wounds. Mr. Guthrie has laid down as a rule that injuries of the head, of apparently equal extent, are more dangerous on the forehead than on the side or middle por- tion, and still more so than those on the back part; and that a fracture of the vertex is infinitely less important than one at the base of the cranium. When the injuries are caused by rifle-balls, however, these considerations are rarely of much avail, for the power of injury is such that it can scarcely ever be confined to the immediate neighborhood of the part directly struck. Wounds of the head may be divided, for convenience of description, into wounds of the scalp and pericranium, with- out fracture of bone; similar wounds complicated with frac- ture 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 depres- sion, may occur without an open wound of the superficial investments. The case of an officer is mentioned in Dr. WOUNDS OF TnE SCALP. 65 Macleod's Notes of the Crimean War, who was thus killed by a round shot. The scalp was not cut, almost uninjured, but the skull was most extensively comminuted. 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 cere- bral 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 gradu- ally 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 super- ficial 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 diploe, 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 cover- ings are carried away; and sometimes, even when the peri- cranium 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 w;b 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 6* 66 GUNSnOT WOUNDS. the angle of the lambdoidal suture, the posterior end of tho sagittal suture being exposed midway in the line of the wound. The patient vomited at the instant of the blow, and symptoms of compression, mixed with some of concus- sion, soon followed. He died eleven hours after the injury. At a post-mortem examination, the superior longitudinal sinus was found to be ruptured, and about four ounces of coagulated blood were lying on the brain. Two darkly- congested spots were observed in the cerebrum, one on each hemisphere, corresponding with the line of direction in which the ball had passed, and these, when cut into, presented tho usual characters of ecchymoses. There was no fracture of bone. The case may be found detailed at some length in the Lancet, vol. i., 1855. When inflammation follows the passage of a ball, whether terminating in resolution or lead- ing to abscess, the symptoms and treatment required will be the same as in similar affections from other causes. In like manner, the occurrence of erysipelas, or other complications to which these wounds of the scalp are liable, will be found treated elsewhere. (See Injuries of the Head.) 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 ap- plication 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 in- flammatory symptoms in their earliest stages. Even after one of these wounds has healed, and the patient to all ap- pearance has quite recovered, it is necessary to enjoin con- tinued 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 Cam- paign, 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. 67 of the head from a piece of shell, without section of the scalp and without lesion of the bone, is related. In this instance a small abscess formed under the scalp, and was evacuated. After the wound was healed the man suffered from constant headaches, and was invalided to England. Soon after land- ing he drank freely, coma followed, and he died shortly afterward. The post-mortem examination showed traces of inflammatory action in the dura mater, and "just anterior and superior to the corpora quadrigemina was a tumor the size of a walnut, composed of organized fibrin and some clotted blood." Wounds complicated with fracture, but without de- pression on the cerebrum.—These are very uncertain in their (fleets, and often apt to mislead the surgeon, from the absence of urgent symptoms in their early stages. The oc- currence 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 altera- tion in the general outline of the cranial curve. The chief and only means, in many cases, of concluding that no depres- sion 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 injur}7 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 treat- 68 GUNSHOT WOUNDS. ment, without any untoward symptom. A. layer of the ex- posed surface of bone will probably exfoliate, and the wound granulate and become closed without further trouble. But such injuries, for reasons before named, are very likely to be followed by inflammation, and not improbably abscess, be- tween the internal table and dura mater; and further, as a consequence of the vascular supply being stopped, and per- haps also partly from the effects of the original contusion by necrosis of the inner table itself. Care must be taken not to mistake one of these injuries for a depressed fracture, as is not unlikely to happen when the excavation effected by the projectile is rather deep and the edges of tho bone bor- dering the excavation are sharp. 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-coiip. Death resulted from in- flammation 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 Uegiment, in the Crimea. The soldier had a wound of the scalp ulonf the upper edge of the right parietal bone. The ball in passin" had denuded the bone; but there was no depression. The GUNSHOT FRACTURE OF THE SKULL. 69 man walked to camp from the trenches without assistance, and there were no cerebral symptoms on his arrival at hos- pital; but five days afterward there was general edema of the scalp and right side of face, the wound became unhealthy, and slight paralysis appeared on the left side. The next day hemiphlegia was more marked, convulsion and coma followed, and he died on the thirteenth day after the injury. Pressure from a large clot of coagulum and extensive in- flammatory action were the immediate causes of death; but a fissure, confined to the inner table, running in line with the course of the ball, was also discovered. A preparation of the calvarium in this case was presented by Dr. Cowan, 55th Regiment, to the museum at Fort Pitt. 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 he removed; and if the dura mater be intact, the case, with proper care to prevent inflammatory action, may not im- probably 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 depres- sion 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 ex- ternal soft parts, so that the wouud cannot close by the ad- hesive process, constitute very important differences between gunshot injuries on the one side, and others caused by instru- ments 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 70 GUNSHOT WOUNDS. injuries occurred in a severe form, they invariably proved fatal. Of seventy-six cases treated, where depression only, without penetration or perforation, existed, fifty-five proved fatal, twelve were invalided, and nine only were discharged to duty. In the twenty-one survivors, the amount of de- pression is stated in the history of the campaign to have been slight, though unmistakable, and all except one recov- ered without any bad symptom. Of eighty-six other cases where perforation or penetration of the cranium occurred, all died. 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 sur- geons off their guard in making a prognosis, from supposi- tion 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 after- ward 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, TREPHINING. 71 when coma came on, and death shortly followed. The ball w.is found iu a sac, in which pus also was contained, at the base of the left anterior lobe of the brain. Treatment.—The treatment of the various kinds of frac- tures from gunshot, and their complications, may be con- sidered 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 sur- geons 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 pmnaiu-nt interruption of cerebral function, or that an abscess had formed within reach, and was capable of evacua- tion. Preventive trephining has been proved to be useless, as well as dangerous, and is no longer an admissible opera- tion. 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 diag- nosis in these cases is considered,—whether as to the dis- tinguishing 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 prc>sure 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 tre- phine was only successfully applied in four cases (and none of these were from rifle-balls) during the whole war; and 72 GUNSHOT AVOUNDS. that in these instances the patients were subsequently sub- ject to occasional headache and vertigo; and in the French report, by Dr. Scrive, it is stated that trephiniug was for the most part fatal in its results in the French army. In siege operations, the experience as regards wounds of the head is always very extensive, the lower parts of the body being so much more protected in the trenches. According to Dr. Scrive's returns, one of every three men killed in the trenches before Sebastopol, and one in every 3*4 wounded, was injured in this region. In the English returns, wounds of the head and face in the men are shown as 19-3 per cent.; in the officers, as 15 per cent.; but this is of the total wounded in the field as well as in the trenches. There was, therefore, as extensive a range for observation of the effects of trephining in the siege of Sebastopol as is likely to hap- pen in any war. Dr. Stromeyer, who in the early part of his professional career resorted to trephining in complicated fractures of the skull, records, in his Principles of Military Surgery, that he has abandoned the practice. After the battle of Kolding, in Sleswick, in 1849, there were eight gunshot fractures of the skull, with depression, and more or less cerebral symptoms. In all these, with one exception, the detachment of the fractures was left to nature, and all recovered. One patient, from whom some fragments were removed on the seventh day, was placed in considerable danger by the treatment, and Dr. Stromeyer resolved never to adopt it again." In 1850, in Sleswick, two young sur- geons came under Dr. Stromeyer's care with gunshot wounds of the head, accompanied by deep depression; they were both treated without trephining, and both recovered. Throughout the three campaigns of the Sleswick-Holstein war, there was only one case of trephining which gave a favorable result. Military experience makes it difficult to understand the frequent and successful performance of tre- panning by the older surgeons for such slight causes as they performed it, excepting that the patients labored under TREPHINING. 73 little el5 : " De tous les inoyens therapeutiques em- ployes par l'art chirurgicale, aucun n'a eie aussi efficace et n'a r6ussi avec un succes aussi complct que le chloroforme; jamais, dans aucune circonstance, son manieinent sur des milliers de blesses n'a cause" le moindre accident serieux;" and, more recently, Surgeon-Major M. Armand has .written: " During the Italian war, chloroform was as extensively used and was as harmless as in the Crimea. I never heard of an accident from its use." At the commencement of the Crimean war, the Inspector- General at the head of the British Medical Department cir- culated 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 lar as chloroform was available, it was used by many med- ical officers from the commencement of the campaign, and its employment became more general as the campaign ad- vanced. 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 ampu- tation for extensive gunshot wounds, and restoration to con- sciousness, calmly subside into natural and refreshing sleep. 128 GUNSHOT WOUNDS. One reason for not using chloroform in the Inspector-Gen- eral's caution was, that the smart of the knife is a powerful stimulant; but " pain," it has been remarked by a great sur- geon, "when amounting to a certain degree of intensity and duration, is itself destructive;" and there can be little doubt that the acute pain of surgical operations, superadded to the pain which has been endured in consequeuce of severe gunshot fractures, has often, where chloroform has not been used, intensified the shock, and led to fatal results. In civil surgery, statistical evidence has demonstrated that the mor- tality after surgical operations has lessened since the use of chloroform ; and it is believed the same result would be shown, if opportunity existed, in army practice. In the report of a case in the Crimea, instancing, perhaps, the greatest compli- cation of injuries from gunshot of any which recovered, Dr. Macleod remarks casually in his Notes, p. 265: " This am- putation was of course done under chloroform, otherwise it is questionable whether the operation could have been per- formed at all, the patient was so much depressed." Mr. Guthrie, in the Addenda to his Commentaries, remarked, from the reports aud cases which had reached him, that chlo- roform had been administered in all the divisions of the army save the second, and had been generally approved; and that the evidence was sufficient to authorize surgeons to admin- ister it even in such wounds as those requiring amputation at the hip-joint. The late Director-General amputated in three instances at the hip-joint, after the battle of the Alma, under chloroform—two on the 21st and one on the 22d Sep- tember—and all these lived to be carried on board ship on the latter-named day, and two, as before stated, lived several weeks. The absence of increased shock from pain during the amputation very probably enabled these patients to with- stand the fatigue of removal to the coast and embarkation on board ship. With regard to the objection of occasional bad results, a recent estimate has shown that the probable proportion of all the deaths which have occurred from chlo- ANESTHESIA. 129 rofonn to the operations performed under its influence, ex- elusive of its use in midwifery, dental surgery, and private pnietice, has been one in 16,000; and as these accidents may equally occur during "minor operations," in army prac- tice as in civil life, it should be used or not at the option of the patient. In respect to the danger of anesthetics in the secondary operations connected with gunshot wounds, Dr. Scrive's ex- perience has led him to remark: "When consecutive ampu- tation is rendered necessary by the gradually increasing debility of a wounded man from purulent discharges, chloro- formization takes place with the most perfect calm on the part of the patient;" and he classes its use under "chloro- formization de n6cessitc." 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 in- stances, the use of chloroform, by diminishing pain and pre- venting shock, and thus giving the opportunity of more accurate examination of parts, becomes particularly valuable in army practice. After the battles of Alma aud lnkerman, 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 3Ir. Guthrie. This officer had both feet completely destroyed by round shot at lnkerman, 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 am- putations were done by the late Director-General of the Army Medical Department. In illustration of the second 130 GUNSHOT WOUNDS. casualty, the following, which happened to the writer at Alma, may be named. A man of the Grenadier company of the 19th Regiment had a leg smashed by round shot. It was a question whether the fracture of bone extended into the knee-joint. Two superior staff-surgeons were near; a hasty consultation was held, and it was decided that the probabilities were in favor of the joint being intact. Ampu- tation was performed, and the tibia sawn off close to the tubercle. It was then rendered evident that there was fissured fracture into the joint. As soon as the man had recovered from the state of anesthesia, the necessity of am- putation above the knee was explained to him, and he readily assented. This was shortly afterward done, and the man recovered without any unusual symptoms, and was invalided to England. It is not likely, without chloroform, in a doubt- ful case of this kind, that the chance of saving the knee would have been conceded. In the British army in the Crimea chloroform was gener- ally 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 appa- ratus, 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 Reuiew, October, 1859, Dr. Hayward, of Boston, has strongly advo- cated 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. 131 AFTER-USEFULNESS OF WOUNDED SOLDIERS. The results of wounds uufit 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 in cases where resections of the joints have been per- formed, 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 re- tained 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 em- ployment 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 132 GUNSHOT WOUNDS. than circumstances have ever previously admitted. Hitherto, the majority of the younger medical officers of the army have found themselves, on the occasion of war, suddeuly in possession of a large number of wounded officers and soldiers to treat, with only those general principles of surgery to guide them which they had originally obtained in their studies in civil hospitals and schools; but this knowledge, essential and absolutely necessary above all other as it is, has been long admitted in the first-class powers of the Con- tinent, whose military experience is necessarily greatest, to be incomplete for this purpose. Now that an Army Medi- cal School has been established in England, and that in it the large number of sick and wounded who annually return from all parts of the world—serving to illustrate, among other subjects, the consequences of wounds and of the surgi- cal operations performed for them in all their varieties—will be turned to account, as well as the great collection of pre- parations in the museum of the Army Medical Department, it is only reasonable to hope that the opportunities of study in these specialties which will be afforded to every medical officer at his entrance into the army will cause each indi- vidual, not only to be ready to apply at any moment all the improvements derived from experience and observation, up to the most advanced period, in this branch of the profession of surgery, but will also best prepare the members of the department for extending still further the sphere of useful- ness which has been cultivated by their predecessors. THE END. MEDICAL WORKS PUBLISHED BY J. B. LIPPINCOTT & Co., PHILADELPHIA. -------!fcs3------- Will be sent by mail, post paid, on receipt of the price by tlie ^Publishers. Leidy's Anatomy. Human Anatomy: An Elementary Text-book for Students. By Joseph Leidy, M.D., Professor of Anatomy in the University of Pennsylvania. Elegantly illustra ted from nurae- rous original drawings. One vol. 8vo. $5.00 Vl«W of tho Ucart, with the anterior portions of the Tentriclea removed. Dorsal Vertebra. J. B. LIPPINCOTT & Co.'B PUBLICATIONS. Beck's Medical Jurisprudence. Elements of Medical Jurisprudence. Eleventh edition. By Theodrio Romeyn Beck, M.D., LL.D., Professor of Materia Medica in the Albany Medical College, etc.; and John B. Beck, M.D., Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons of the City of New York, etc. With notes by an association of the friends of Drs. Beck. The whole revised by C. R. Gilman, M.D., Professor of Medical Jurisprudence in the College of Physicians and Surgeons of New York. Two vols. 8vo. $10.00. Beck's Medical Jurisprudence has so fully established its character as a Btandard on that subject, by its numerous editions, both in England and this country, that it is unnecessary to speak of its merits. Mr. Warren, the distinguished English legal writer, in his introduction to Law Studies, says of it:— "The best work, by far, upon the subject of forensic medicine, of all those which have come under the author's notice, is the Medical Jurispru- dence of Dr. Beck, which is not only an instructive, but, a highly interest- ing work." The eleventh American edition, which you have afforded me the oppor- tunity of examining, is evidently a very great improvement upon all pre- vious editions. The large amount of new matter accumulated by Dr. T. R. Beck before his death, has been judiciously introduced by his able pro- fessional friends, to whom it was intrusted, and has rendered the work as complete as it is invaluable. Very truly, yours, GEO. SHARSWOOD. Louisville, Ky., Dec. 24, 1859. I am glad to have the opportunity to read the last edition (1860) of Beck's Medical Jurisprudence. This is the best work on the subject of general medical jurisprudence ever published; and the labors of Dr. Gil- man have contributed much to the value of the present edition. Very respectfully, HENRY PIRTLE. Rosltn, N. Y., Jan.13, 1860. I am well acquainted with the great merits of Dr. Beck's work, which I have been in the habit of considering as the only real cyclopedia of medi- cal jurisprudence in our language.....It is so invaluable both to law and medical practitioners, that I cannot conceive of any work extant which will, in all particulars, furnish such orthodox opinions. Respectfully yours, JNO. ORDRONAUX. J. B. LIPPINCOTT & Co.'s PUBLICATIONS. Kolliker's Anatomy. Manual of Human Microscopical Anatomy. Professor of Anat- By A. Kollikeb, omy and Physiol- ogy in Wurzburg. Translated by Geo. Bush, F.R.S., and Thomas Huxley, F. R. S. Edited, with notes and ad- ditions, by J. Da Costa, M.D. Il- lustrated by 313 en- gravings on wood. One vol. 8vo. $3.75. It would be useless for us to attempt a re- viow of this work, for tho text is so fully il- lustrated by engrav- ings, and is so inti- mately associated with them, that we cannot extract any part as a sample of the style, without weakening its force, for the want of its nrrompanying il- lustration. The book must be read and studied before an adequate idea can be formed of ita value and excellence. The book comas from such high authority, and is indorsed by such competent judges, as to make it at once indispensable to the student of microscopic anatomy. We hope it will have an extensive circulation.— Western Lancet. The reputation of Frofessor Kolliker, acquired by hip former and larger work on microscopical anatomy, will be enhanced by this text book on Histology, for such it is destined to be pre eminently. The text is fully illustrated by engravings, greatly adding to the value of the work, and accompanied by explicit explanations of the figures. We commend it to khc profession, and to students especially, as worthy of their patronage.— .V. Y. Medical Gazette Cartilage cells from a fibrous, velvety, articular cartila.se of the eon dyle of the femur of man, magnified 360 diameters. J. B. LIPPINCOTT & Co.'s PUBLICATIDI. J. Wood's Practice of Medicine. A Treatise on the Practice of Medicine. By Geo. B. Wood, M.D., Professor of the Theory and Practice of Medicine in the University of Pennsylvania. Fourth edition, improved. Two vols. 8vo. $f.00. This is far the best work on the practice of medicine in the English lan- guage, and we recommend it strongly to the attention of our readers. It is much fuller than Dr. Watson's admirable lectures, while it is less lengthy than the Library or Cyclopaedia of Medicine; and it has this further ad- vantage over the two last-named works—that while they are far behind, it is a fair reflex of the actual state of knowledge.—London Medical Time* and Gazette. Wood and Bache's Dispensatory. The Dispensatory of the United States: Consisting of—* 1. A treatise on Materia Medica, or the natural, commercial, chemical, and medical history of the substances employed in medicine, and recognized by the Pharmacopoeias of the United States and Great Britain; 2. A treatise on Pharmacy: Comprising an account of the preparations directed by the American and British Pharma- copoeias, and designed especially to illustrate the Pharma- copoeia of the United States; and 3. A copious Appendix, embracing an account of all sub- stances not contained in the official catalogues, which are used in medicine, or have any interest for the physician or apothecary. By Geo. B. Wood, M.D., Professor of the Theory and Practice of Medicine in the University of Penn- sylvania, etc. etc., and Franklin Bache, M.D., Professor of Chemistry in the Jefferson Medical College of Philadel- phia, etc. etc. Eleventh edition, much enlarged. One vol. 8vo. $6.00. This work has been thoroughly revised, with many alterations and addi- tions, so as to bring it fully up to the level of the present state of materia medica and pharmacy. It embraces the substance of the recently revised United States and British Pharmacopoeiiis, with a commentary on all that is new in those publications. Nothing, indeed, has been omitted in the revision which could render it worthy of the confidence it has enjoyed. J. B. LIPPINCOTT & Co.'s PUBLICATIONS. Wood's Therapeutics. A Troatise on Therapeutics and Pharmacology, or Materia Medica. By Geo. B. Wood, M.D., Professor of the The ory and Practice of Medicine in the University of Penn- sylvania, Senior Physician of the Pennsylvania Hospital, one of the authors of the United States Dispensatory, author of a Treatise on the Practice of Medicine, etc. etc Two vols. 8vo. $7.00. In his preface Dr. Wood gives the following account of his opportunities for acquiring knowledge and forming just views on the subjects embraced In this treatise: — "Almost from the commencement of his professional life the author has given peculiar attention to this branch of medical knowledge. For a period of about thirty years, before 1850, when he was transferred to the professorship which he now occupies, he was engaged in teaching materia medica, first as a private lecturer, and afterwards successively in the Phil- adelphia College of Pharmacy and the University of Pennsylvania. His position, therefore, rendered constant investigations into the properties, effects, and uses of remedies necessary in order at once to do justice to his pupils and avoid discredit to himself. Most of those whom he now addresses are probably aware that he is one of the authors of the United States Dispensatory. To provide the original materials for his portion of that work, and to gather from time to time the knowledge requisite for its maintenance upon a level with the progressive condition of medical science, unremitting diligence was essential in prosecuting in- quiry and investigation in the whole field of pharmacology. In addition to the ordinary professional opportunities, he has for about twenty years held the office of one of the physicians of the Pennsylvania Hospital, which has given him facilities for testing the value of remedies greater than any amount of private practice could afford. Few persons have had greater advantages or stronger inducements than himself for acquiring the knowledge requisite for the production of a work of this kind." Wood's Lectures and Addresses. Introductory Lectures and Addresses on Medical Subjects. Delivered chiefly before the medical classes of the Univer- sity of Pennsylvania. By Geo. B. Wood, M.D., LL.D., President of the American Philosophical Society, Professor of the Theory and Practice of Medicine, and of Clinical Medicine, in the University of Pennsylvania, etc. etc. One vol. 8vo. $1 75. J. B. LIPPINCOTT & Co.'s PUBLICATIONS. Gerhard on the Chest. The Diagnosis, Pathology, and Treatment of Diseases of the Chest. By W. H. Gerhard, M.D., one of the Physicians to the Pennsylvania Hospital, Fellow of the College of Phy- sicians of Philadelphia, Member of the American Philo- sophical Society, etc. Fourth edition, revised and enlarged. One vol. 8vo. Cloth. $2.75; sheep, $3.00. This is the work of more than twenty years.....During the sale of the different editions, new mjuut^ius been incorporated, the result of experience and observation, or uia^Tlrom the valuable contributions of other writers. To this latest edition about one hundred pages of new matter have been added, bringing the work up to the present knowledge of diseases of the Chest. With the advantage of such constant revision, the volume takes rank among the most valuable medical standards.—North American. CostilTs Treatise on Poisons. A practical Treatise on Poisons, their Symptoms, Antidotes, anrl^klode of Treatment. By 0. H. Costill, M.D. One vol. 18mo. 50 cents. ■ * * '. \ The author claims for this work no originality except in design. He has collected and arranged the symptoms, post-mortem appearances, and the treatment of poisoning, from the best writers on the subject. Of these, the works of Christison, Beck, and Taylor have been principally consulted, as also the various medical periodicals. These publications the author has drawn upon freely, and has occasionally introduced cases illustrative of treatment. Practical utility has been the object aimed at throughout. Wanington's Obstetrics. ' Tho Obstetric Catechism: Containing two thousand three t undred and forty-seven questions and answers on obstetrics proper. By Joseph Warrington, M.D. 150 illustrations. One vol. 12mo. $1.50. An excellent compend of obstetric science and practice, in a very conve- nient form for purposes of instruction. The author is a very eminent professor, and the work was intended for the use of his own pupils, and Btudents of medicine generally. The illustrations of the work are very numerous, and of the most useful kind to the student. J. B. LIPPINCOTT & Co.'s PUBLICATIONS. Old Inter-Capsular Fracture, with considerable shortening. Malgaigne's Treatise on Fractures. A Treatise on Fractures. By Professor J. F. Malqaigne, of Paris. With over one huu dred Illustrations. Translated from the French, with notes and additions, by John H. Packard, M.D. One vol. 8vo. $4.00. Malgaigne's Treatise has en- joyed so wide a circulation and such well-deserved renown, that we must own to a feeling of sur- prise at learning that before the appearance of the present work no attempt has been made to pre- sent so popular an author in an English dress. The pititant book, a contribution to our^iterature from America, is th^wTTik of a gentleman whose name is not otherwise known to us, and is OH*^Riich we can conscientiously pronounce very valuable. . . A very usoljilfcook indeed, and one which we hope will have an extensive circulati«u-.—'British and Foreign Med. Chir. Review. Must be regarded as a monument, conspicuous and to be admired,-'even among the noble monuments of the medical literature of his [the dbthor's] country. As a solid, complete, substantial, highly-finished work, we know of none that is its superior; it can, with justice, be regarded as a model in scientific literature.—North American Med. Chir. Rev. It affords us sincere pleasure to be able to welcome the appearance, in an Bnglish dress, of this valuable treatise. The annotations which Dr. Packard has appended to it are numerous, and appear to us to be of much practical value, adapting, as they do, the treatment of fractures to the generally received and most approved American methods.—Journal of tht Medical Sciences. Bernard and Robin on the Blood. Notes of M. Bernard's Lectures on the Blood, with an Ap- pendix, giving an account of the latest studies of M. Robin, the celebrated microscopist. By Walter Franklin Atlek M.D. One vol. 12mo. Cloth, 75 cents. J. B. LIPPINCOTT & Co.'s PUBLICATIONS. Rush on the Voice. 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S 73 73 5 73 4 'A it*** '' • '■; i yfri'crtFt r--V.zz:z. yyr! ff ■ *$*-<<•■ *^ 'tttKtffi V--}}y,-Y,Yf, >;,; v trrrtfrf,fiif!(f,ff „^,i;V 'fffffftr. *.?£/, , rrff ■ frrj'r)}/) - r 11-ft' rft•/ rffi'ff r r >' < i .- ft*'?, t rtfttff^tt ■ f. yy\. ////< $trrrfrrffi>>r>rirrt . *i''*({}}tri ft tr , rtt(t .' f r y r r ,■ rrc:r ■\\rt r rr'.-'ti■'?: . tyy.y.tXt' ft ft: f}}ftr (VUV'i- - -. \ V ^ } \ \ \\ > X >, * \ * \ >,\ 1 . v,v \* ivv \\ ' vuvvvw V*\ SAVVT; ,vt>. v.V- **■**' . v \ v \.%S - \ ^ *' * • k vvv iluw.'W^iw \ v * * K \ * vvvws fu C * A V V VV\V WW v.v V.' '' ' - '• * \ V V \ w«, vvvA'yij vvvvyv^ v v! v v^ vi v '-- v \ v v yi\ UUMVlUitttlH ; * \ v * * ^VUVnU^v. VWiuv i\\*v\ >y\ vv\v > ^v \yiy> 524367