Gunshot wounds then and now: how did John Hunter get away with it?

R P Craig QHS MD FRCS Commander Medical United Kingdom Land Forces

Gunshot wounds are increasingly becoming a speciality in Hunter's time with the present day, taking changes in the their own right. interim into account. Many others have addressed this J A Hunter 1794 issue in the past, including Lieutenant-General Sir Robert Drew, who was Director General of Army Medical Services at the time the author entered the In an increasingly violent and unstable world, the Hunter RAMC. His 1966 oration was followed by scholarly quotation chosen to introduce this paper may possibly be depositions by Mr George Qvist in 1979 and Mr as true today as it was two centuries ago. Kingsley-Brown in 1985. With such distinguished May I begin by expressing my gratitude for the honour predecessors, is it possible to add something original? of participating in this meeting on behalf of the Royal Well, perhaps it is. Army Medical Corps (RAMC). On Belle Ile, Hunter was faced with wounds caused by As you know, John Hunter served initially in what was cannon, muskets, bayonets, swords and knives, plus then the Army Medical Department between 1761 and secondary missiles of stone, bone or wood generated by 1763, which were the last two years of the Seven Years the first two. True bullets which emerge at high speed War. During this time, he saw action on Belle Ile and in from rifles, in which a gas seal is achieved between the Portugal, but it was during the occupation of the island bullet wall and the rifling, had not been invented, nor had that he appears to have gained much of his experience of projectiles which explode and fragment on impact. Thus, gunshot wounds. the gunshot wounds were restricted to ball and shot and it Belle Ile or Belle Isle, lies in the Bay of Biscay, some is on musket balls that I should like to concentrate, as did 9 miles off the French coast and is strategically placed to Hunter in his Treatise, Blood, Inflammation and Gun Shot control the egress of ships from the vital French ports of Wounds, published the year after his death. I was Saint Nazaire and Lorient. privileged to be allowed to inspect a few of those It should be remembered that there remained a real risk specimens in the Hunterian Museum which survived the at that time of invasion from France, and the control of bombing of the College in 1941. Belle Ile was part of a blockade by the Royal Navy which The first was a scapula (Fig. 1). At the inferior pole can extended from Dunkirk all the way round to Toulon. be seen the impression of a musket ball which then Hunter's second period of Army service occurred appears to have travelled up the lateral border. From this shortly before his death. In the splendid entrance hall of one may conclude that the recipient was probably almost the RAMC Headquarters Officers' Mess at Millbank, prone when shot and this specimen may represent one of hang a series of boards which list the names of its most the first examples of a blue on blue incident, so senior doctors. Although the Surgeon General is, today, controversial during Operation GRANBY in the Gulf the head of the Tri-service Medical Organisation, in the 3 years ago, as the shot must have been fired from behind. late eighteenth century, the title referred to the officer in Of course, it is not inconceivable that the victim was administrative charge ofthe regimental surgeons and their fleeing. mates. The most senior doctor, in keeping with the The next specimen (Fig. 2), provoked particular precedence of the time, was a physician. interest. It is a parietal bone showing two separate Along one of the corridors hang the portraits of the spherical depressions, both presumably the result of most recent Surgeons and Directors General. Once a new musket balls. One has just breached the inner table and one is added, that furthest away is then removed and hung the other almost so. The fact that there are two suggests elsewhere in the mess. Just to the left of the fireplace, in that they were the result of two different weapons as the mess anteroom, the RAMC have their own portrait of reloading used to take a minimum of 20 s. The Hunterian John Hunter, which is unsigned but in the Reynolds style. Institute very kindly took casts of the depressions which From the above, the strong and proud links which exist were measured. From these it has proved possible to between the RAMC and John Hunter can be appreciated. estimate the diameter of the original balls. As all were The author was asked to compare the surgery of war in made of lead, as opposed to iron, and were roughly 16 R P Craig

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Figure 1. Scapula showing the entry of a ball at the Figure 3. Shaft of femur showing a cavity caused by a inferior pole with a tunnel running up the lateral edge. ball, with surrounding long-standing osteomyelitis. The hole seen in the blade is an artefact. The final specimen (Fig. 3), is of an upper femur injured by a ball. The deformation of the bone and spherical, their extrapolated weight comes to 23.7 g. The evidence of osteomyelitis which so commonly followed French muskets of the 1760s fired balls weighing 23.8 g, such wounds is well shown. However, it serves to whereas, the British equivalent, the famous 'Brown Bess' introduce the theme of this paper, which relates to a ball of 31.5 g. It would seem likely, therefore, that the energy transfer in military wounds. The trauma section weapon which inflicted these parietal bone wounds was a of the Chemical, Biological and Defence Establishment precursor the of French 'Charleville' musket. (CBDE) at Porton Down have studied this subject over many years. Much of the data used in this study stems from that establishment and the author is keen to acknowledge formally the contributions of a generation of staff, but specifically Lieutenant-Colonel S G Mellor, Major G Bowyer and Dr G Cooper. In order to establish a baseline for comparison with the weapons of today, CBDE were asked to estimate the energy transfer needed to inflict the femoral injury shown in 3. Their answer 4: Fig. came to something over 100 joules. The standard teaching advocated today for the surgical management of war injuries to the limbs, is debridement and delayed primary suture. This debridement or unbridling was described in the sixteenth century by Ambroise Pare and then largely forgotten until World War I. In the early 1760s, surgical doctrine in the Army Medical Department, included the enlargement and Figure 2. Parietal bone-the effects of two different dilatation of wounds produced by musket balls, with the musket balls. extraction of debris and the ball if possible. During his Gunshot wounds then and now 17

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Figure 4. The cavitational effects of an AK47 bullet on the vastus lateralis are evident. tour of duty on Belle Ile, Hunter was the subject of much possibly manure, from which contamination of the wound criticism from his more senior military surgical colleagues tracks during dilatation must have been almost inevitable. for questioning this doctrine and for, as he describes it, Qvist concluded that: 'being very quiet' in his management of such injuries. In In the surgical environment ofhis time, Hunter's management of other words, he let nature take its course. In his treatise, gun shot wounds was justified. he describes with great accuracy the development of quite slough, suppuration and discharge, followed in many Hanging in the National Gallery is a dramatic picture of cases by healing and minimal morbidity. This radically the 1792 Battle of Valmy, in the Argonne near Chalons different management appears to have stemmed from his Sur Mane. In the bottom left-hand corner is depicted a extraordinary powers of observation and deduction. dressing station in a stable. The awful prevailing The difference between the wounds caused by musket conditions, with dirt, mud and horse manure everywhere balls with those of a modem bullet are shown well in Fig. are shown starkly. 4. At presentation, the quite innocuous entry and exit There is, however, a second very important reason wounds, caused by a Russian made AK47 bullet, were why the conservative approach advocated by Hunter seen. Only when the wounds were explored did the proved so successful. It relates to the wound tracks severity of the injury become apparent. The gross muscle themselves which were very different from those seen damage is evident as is the tension to which the tissues today. have been subjected, revealed by the bulging of the vastus The wounding effects of missiles are directly propor- lateralis out of the wound. Debridement of all the dead tional to the transfer of energy. The salient message here muscle was performed and delayed primary suture at 5 is the kinetic energy available at the point of impact. This days resulted in rapid recovery. is not only a function of the mass of the missile but also, In the light of this present knowledge, how, therefore, more importantly, half the square of its velocity. Balls did Hunter get away with it? Why were his results were, admittedly, heavy, but equally they were relatively apparently so good? slow. What has happened over the last two centuries is a There are two probable explanations. The first was dramatic increase in the velocity ofmissiles, due firstly, to superbly expounded by Mr George Qvist in his 1979 the effects of efficient rifling and, secondly to the Hunterian Oration. He quoted Wellington's surgeon, G J development of missiles which themselves explode and Guthrie: produce fragments which travel at very high speed. A military surgeon should never be taught to expect any Bullets are designed to achieve stability in flight and, in convenience; his field pannier for a seat for the patient and a consequence, have become extremely accurate over much dry piece of ground to spread his dressings and instruments longer ranges. upon, are all that are required. Loss of velocity in flight occurs down range due to wind resistance, with the effects of gravity producing However, a total lack of asepsis would have caused the characteristic trajectory. A lot of work was under- instruments to have become caked in blood, mud and taken in the 1960s to study the retardation of bullets 18 RPCraig and balls using gelatin blocks, with a density equal to invasive infection could be postponed, using antibiotics, that of human soft tissue. From this work came the by the team at Porton Down. concept of temporary cavitation surrounding missile Casualties have always been an encumbrance on the tracks which not only caused collateral damage, but also battlefield and their presence tends to lower the morale of caused pulsation, with alternating positive and negative uninjured colleagues. Their evacuation is manpower pressures, and this was shown to be capable of sucking intensive, all stretcher cases requiring at least two others skin, clothing and bacteria into the cavity from both to transport them to medical care. Helmets and body entry and exit wounds. armour tend to reduce the likelihood of death but, Among the weapons tested was the NATO Self- paradoxically, increase the resources needed to treat Loading Rifle (SLR) which fired a 7.62 mm diameter those wounded. Antibiotics which reduce the chance of bullet weighing 9.3 g at a muzzle velocity of 850 m/s. The streptococcal and clostridial infection have a place if energy transferred to the gelatin produced a dramatic administered early, and benzyl penicillin has been shown demonstration of cavitation and allowed young surgeons to remain the most effective agent. to appreciate the events which produced the effects shown The bacteriology of fragment wounds has been studied in Fig 4. The AK47 bullet achieved energies ofmagnitude using pigs' thighs, into which a preformed fragment comparable to that of the SLR. Weapons such as mortars weighing 2.7 g travelling at approximately 250 m/s is and shells are used to produce fragments with a very wide fired, coincidentially producing an energy transfer of range of both size and velocity. Many of the newer around 85 joules, very similar to that of a 'Brown Bess' weapons, however, are specifically designed to produce musket ball fired from 75 m (Fig. 5). preformed fragments. Each of these weighs around A controlled group which did not receive antibiotics 300 mg or roughly one-hundredth of the old musket had the tracks excised at 7 days. Slough and suppuration ball. Despite this, the increased velocity imparted by the was evident but it was felt that the wounds would not have explosion results in an energy of around 300 joules, proven fatal unless an invasive infection such as gas roughly equivalent to that of the British musket ball at a gangrene were to have supervened. These wounds are range of less than 30 m (Fig. 5). likely, therefore, to be similar in severity to the limb The wounds seen in World War I confirmed the wounds which presented to Hunter on Belle Ile. dangers of potentially lethal streptococcal and clostridial The 'Brown Bess' fired balls weighing 31.5 g at a infection if surgery was delayed. Because evacuation from muzzle velocity of around 180 m/s, whereas the lighter the battlefield to a surgical facility takes time, most French 'Charleville' ball (23.8 g) was a good deal faster at recently evident in the Gulf War, where it averaged 12 h, 300 m/s. research has been directed to ways in which the onset of Figure 5 clearly demonstrates the rapid down-range Energy Down Range 600 Musket balls circa 1760

500 to 0 O British 'Brown Bess' 400 A French 'Charleville' A

I- 300 v French Charleville' B

200 .0 : 100

0 0 50 100 150 200 Range (m)

Figure 5. The down range energy of the "Brown Bess" and both models of the "Charleville" musket is shown. Gunshot wounds then and now 19

3500 Energy Down Range

(0 3000 G) 0 0 2500

2000 0) w 1500 L. :) * SLR 1000 * M16

v SA80 500 A AK74 * AK47 0 0 100 200 300 400 500 Range (m) Figure 6. In comparison with Figure 5, the relatively massive energies of modem bullets can be seen. drop in energy. By 50 m less than one-third of the initial themselves weighing less but, more importantly, the available energy remains. In order to achieve maximum ammunition was much lighter and far greater quantities effect, range had to be kept to a minimum. The bravery of could be carried by a soldier. What the development of troops of the line and their officers can only be imagined. rifling achieved was the capacity to widen the distance To hold fire until the advancing enemy came to within 40 between combatants, a philosophy now taken much to 50 paces must have been extraordinarily difficult. further with the use of long range artillery, surface-to- Assuming that it does indeed take more than 100 joules to surface and air-to-surface missiles. fracture a femur, it will be appreciated that the ball which Retuming to Hunter's time, right down in the bottom resulted in Hunter's femoral specimen must have been left comer of Fig. 6 is the relatively minute energy of fired from a range of certainly less than 75 m. musket balls. It is contended, therefore, that the second How do these energies compare with modem weapons? reason why the management advocated by Hunter proved Frankly, there is hardly a comparison. Figure 6 shows so successful, was that the energy imparted was so low, the down-range energies of the previous standard little if any cavitation could have occurred, tissue damage NATO rifle, the SLR, which fires a 7.62 mm bullet and being limited to the wound track only. its Russian equivalent the AK47, and also their In conclusion, it is hoped that this thesis conceming replacements, the US M16 or Armalite; the new NATO energy transfer further exonerates Hunter from criticism. SA80, and the Russian AK74, all of which fire a bullet It may also serve to emphasise the importance of measuring 5-6 mm. The rationale for reducing the observation and logical deduction, in the practice of diameters of these bullets stemmed from the rifles surgery.