splintered and torn, the surgeon should always retain and replace
as many of the broken portions as possible. It is often surprising
how small connections with neighboring soft parts will suffice to
maintain vitality and lead to restored union in this region. A case
which occurred to the writer in August, 1855, in a private of the
19th Regiment, is detailed in the _Lancet_, p. 436, of that year. The
wound was caused by a fragment of shell. The right half of the arch of
the palate was jammed in and fixed at right angles to the other half,
and the upper maxillary bone was so comminuted that it was scarcely
possible to note the directions of the lines of fracture. The lower
maxilla was broken in three places, and there was extensive laceration
of the soft parts. Great difficulty was met with at first in unlocking
the parts of the palate which had been driven into each other, and,
when they were separated, the right half hung down loosely in the
mouth; yet favorable union was obtained between all these fractures,
the broken portions being adjusted so that the man recovered with both
the upper and lower maxillæ consolidated in their normal relations to
each other. No teeth had been driven out of their sockets, and they
were very useful as points of support in the steps taken to procure
coaptation of the disunited fragments. In the _Lancet_ of February
24th, 1855, may be found the description of a series of wounds of
the face, from the Crimea, which were examined by Mr. Samuel Solly,
and described by him, some of them illustrating how wonderfully the
larger arteries often escape in these injuries. In one, loss of the
sense of taste on one side of the tongue had resulted; in two, there
was partial paralysis of the portio dura; in another, impaired action
of the jaw. In one, where a ball entered at the junction of the malar
bone and os frontis on the left side, and descended and escaped at
the posterior border of the sterno–mastoid muscle, the sight of the
left eye was destroyed, and that of the right weakened; and constant
headache, dullness of intellect, and incapacity for mental application
remained. The injury had originally been followed by symptoms of
cerebral concussion. In another case, the man came home with an
iron shot firmly wedged and lodged in the center of the vomer. When
extracted, at Chatham, by Staff–Surgeon Parry, it was found to weigh
nearly four ounces. The returns of the Crimean campaign, from the 1st
of April, 1855, to the end of the war, show 533 wounds of the face,
of which number 445 returned to duty, 74 were invalided, and 14 died.
Bones were penetrated in 107 of these cases, one eye was injured in
42, and both eyes in 2 cases. Mr. Guthrie has recorded that he several
times saw both eyes destroyed by one ball, without much other mischief,
and one, and even both, rendered amaurotic by balls which had passed
behind the eyes. Of 21 cases of wounds of the face, with injuries to
bones, returned to England from the late Indian mutiny, and recorded by
Dr. Williamson, 11 had lost the sight of one eye, and 1 of both eyes;
6 cases were complicated with fracture of the lower jaw, and in 3 of
these the fracture remained ununited.
GUNSHOT WOUNDS OF THE CHEST.
These always form a large proportion of the injuries from warfare,
both in the open field and more especially in sieges, where the upper
part of the body is chiefly exposed. Dr. Scrive’s returns show that
the proportion of chest to other wounds was 1 in 12 in the trenches,
and 1 in 20 in ordinary engagements. In the British forces they are
returned as 1 in 10 among the officers during the whole war, and nearly
1 in 17 among the men, from 1st April, 1855, to the end of the war.
The ample space of this region, and the exposed surface it offers as a
target toward the enemy, would lead to an anticipation of such results.
The serious complications which ensue when the cavity of the chest is
penetrated, and the dangerous consequences of wounds of its viscera,
cause the proportionate mortality to be very great. The British returns
show that among the officers treated for these wounds 31–1/2 per cent.
and among the men 28–1/10 per cent. died. Out of 603 wounded men who
returned to England from the late Indian mutiny, the number who had
received wounds of the chest was only 19. In many instances men thus
wounded do not live long enough to come under treatment, but die on the
field of action from penetration of the heart, hemorrhage, suffocation,
or shock; and the proportion of chest wounds returned as “killed in
action,” or as “died under treatment,” will constantly vary according
to circumstances connected with the nature of the military operations,
and the opportunities of early removal from the field to hospital.
Gunshot wounds of the chest may conveniently be divided for study into
two classes, viz., _non–penetrating_ and _penetrating_. NON–PENETRATING
wounds become subdivided into simple contused wounds of the soft
parietes; contused and lacerated wounds; the same accompanied with
injury to bones or cartilage; and, lastly, those complicated with
lesion of some of the contents of the chest, the pleura remaining
unopened, or, if opened, without a superficial wound. PENETRATING
wounds may exist without wound, or with wounds of one or more of the
viscera of this cavity. Among the more serious complications with which
the latter may be accompanied is the lodgment of the projectile or
other foreign bodies, as of fragments of bone, within the chest. As
wounds of the heart and great vessels are almost invariably at once
fatal, and as the organs of respiration occupy the greater part of
the cavity of this region, it is in reference to the latter that the
treatment of chest wounds is chiefly concerned.
=Non–penetrating wounds.=—Of the simpler wounds in which the soft
parietes only are involved little need be observed, excepting that the
healing process is often prolonged by the natural movements of the
ribs to which the wounded structures are attached, especially when
the ball has taken a circuitous course beneath the skin, and that
the surgeon must be on his guard to watch for pleuritis arising as
an occasional consequence of these injuries. In two deaths recorded
in the Director–General’s History of the Crimean War, under simple
flesh wounds, without fracture or pleural opening, from bullets, the
fatal termination arose from pleuro–pneumonia. When the force has been
great, as when fragments of shell or rifle–balls strike at full speed
against a man’s breast–plate, not only may troublesome superficial
abscesses and sinuses follow, but the lungs may have been compressed
and ecchymosed at the time of the injury, and hemoptysis be one of the
symptoms presented.
When the projectile has been of large size, although no opening of the
parietes or fracture exists, death sometimes ensues by suffocation as
the direct result of pulmonary engorgement. The danger of pleuritis
or pneumonia will be greater when the injury has been so severe as to
cause division of bone or cartilage, and the subsequent suppuration and
process of exfoliation will not unfrequently prove very tedious and
troublesome. Although the pleura has not been opened, the lung may be
lacerated either by the force of contusion or, as in a case recorded by
Dr. Macleod, by the edges of the fractured ribs, which may afterward
return to their normal relative positions, so as to leave no indication
during life of the means by which the lung had been wounded. Such an
injury would be rendered much more probable by the existence of old
adhesions, connecting the pulmonary and costal pleuræ opposite to the
site of injury.
Notwithstanding a projectile has not penetrated the parietes of the
chest, a pleural cavity may be opened, as in injuries from other
causes, and the lung wounded by the sharp edges of fractured ribs. This
will be indicated by emphysema, pneumothorax, hemoptysis, probably
signs of internal hemorrhage, and inflammation. Such wounds will
generally be the result of injuries from fragments of shell.
=Penetrating wounds.=—These wounds, especially when the lung is
perforated or the projectile lodges, are necessarily exceedingly
dangerous. Fatal consequences are to be feared, either from hemorrhage,
leading to exhaustion or suffocation; from inflammation of the
pulmonary structure or pleuræ; from irritative fever accompanying
profuse discharges; or from fluid accumulations in one or both of the
pleural sacs.
In gunshot injuries a penetrating wound of the chest is in most
instances readily obvious to the sense of sight or touch; but it will
be found by no means easy always to decide whether a lung has been
penetrated or otherwise. The train of symptoms usually described as
characterizing wounds of the lung must not be expected to be all
constantly present; they are each liable to be modified by a great
variety of circumstances, and may each severally exist in penetrating
wounds of the chest where the lung has escaped perforation. Nor is
it always easy to determine whether the ball has lodged or not; or,
the ball having passed through, whether fragments of bone, or other
substances, have remained behind.
When the chest has been opened by a projectile, the following signs
may be expected in addition to the external physical evidences of
the injury: a certain amount of constitutional shock; collapse from
loss of blood; and, if the lung be wounded, effusion into the pleural
cavity, hemoptysis, dyspnœa, and an exsanguine appearance. These will
generally, but not invariably, be followed, after twenty–four hours or
later, by the usual signs of inflammation in some of the structures
injured.
The shock of penetrating wounds of the chest, apart from the collapse
consequent on hemorrhage, is not generally so great as happens in
extensive injuries to the extremities or in penetrating wounds of
the abdomen. There is often much more “shock” when a ball has not
penetrated; but, having met with something to oppose its course, has
nevertheless inflicted a violent percussion of the whole chest and its
contents.
When loss of blood occurs without the lung being wounded, the
hemorrhage is probably proceeding from a wound of one of the
intercostal arteries, which has been torn by the sharp ends of
fractured bone. Serious hemorrhage, however, is exceedingly rare from
vessels external to the cavity of the chest.
When blood is effused in any large quantity into the pleural sac—as
indicated by the exsanguine appearance of the patient, increasing
dyspnœa, occasional hemoptysis, and the stethoscopic signs on
auscultation,—the inference is, that the lung has been opened, and
that it is from its structure the blood is flowing. The amount of
hemorrhage in wounds of the lungs will greatly vary according to the
direction of the track of the ball; for the large vessels cannot here
glide away from the action of the projectile, as they may in the neck
or extremities of the body. Wounds, therefore, near the root of each
lung, where the pulmonary arteries and veins are largest, are attended
with the greatest amount of hemorrhage; and as coagula can hardly form
sufficiently to suppress the flow of blood, are generally fatal.
Hemoptysis indicates injury to the lung, but does not give assurance
that this organ has been penetrated. It generally accompanies gunshot
wounds of the lung in a greater or less degree, no doubt always when a
bronchial tube of large size is penetrated; but, as may be ascertained
by careful perusal of recorded cases, is sometimes wholly absent, even
though the patient may be troubled by cough. Dr. Fraser, in a recent
monograph on Wounds of the Chest, states that out of nine fatal cases
observed by him in the Crimea in which the lungs were wounded, only
one had hemoptysis; and out of seven in which the lungs were found not
to be wounded, two had hemoptysis. This, however, from the writer’s
observation, would appear to be an unusual proportion of cases in which
hemoptysis was not present after wounds of the lungs.
Dyspnœa is a frequent accompaniment of wounds penetrating the lung,
but not a constant symptom before inflammatory action has set in.
When dyspnœa is great in the early period, it will often be found to
depend upon the injuries to the parietes, and to the pain caused on
taking a full inspiration; as a sign of subsequent mischief in the
progress of the case, it is, of course, very constantly present. It is
now known that the opening of the pleura does not necessarily induce
collapse of the lung, even though unfettered by adhesions, during life.
It was formerly supposed that the escape of air by the wound was a
sufficient proof that the lung had been opened by the projectile; but
it is evident that it is not so, as the air may enter by the wound
and be forced out again by the expansion of the lung in inspiration,
or by the action of the chest on expiration. If air and frothy mucus
with blood, as noticed in one of the cases recorded in the Crimean
campaign, escape by the wound, there can be no doubt of the nature of
the injury. Emphysema is not common in penetrating gunshot wounds,
but occasionally happens. The free opening generally made by the
projectile sufficiently explains this fact.
It is not necessary to refer at any length in this place to the
inflammations which may supervene. Diffused inflammation of the
lung after wounds is not so common as might perhaps be expected. In
unfavorable cases, the pleural cavity is generally found to be the seat
of extensive inflammatory action or unhealthy accumulations, especially
where irritation has been kept up by the presence of foreign bodies or
the patient’s constitution has become from any cause debilitated.
=Treatment.=—The object of the surgeon’s care must be in the first
place to arrest hemorrhage; afterward, to remove pieces or jagged
projections of bone, or any other sources of local irritation; and to
adopt means to prevent interference with the natural process of cure,
which takes place by adhesion of the opposite pleural surfaces near
the wound in the first instance, and subsequently by cicatrization of
the wound itself, or, as shown in an interesting preparation in the
museum of the Army Medical Department at Fort Pitt, by contraction
into a narrow sinus lined with a distinct adventitious membrane into
which the small bronchial tubes open. Although the shock may happen
to be considerable, attempts to rally the patient, if any be made,
should be conducted very cautiously; the prolongation of the depressed
condition may be valuable in enabling the injured structures to assume
the necessary state for preventing hemorrhage. Hemorrhage from vessels
belonging to the costal parietes should be arrested by ligature, as in
other parts, if the source from which it proceeds can be ascertained,
and if the flow of blood be so free as not to be controlled by the
ordinary styptics. Operative interference of this kind is chiefly
called for on account of secondary, not primary, hemorrhage. Hemorrhage
from the lung itself must be treated on the general principles adopted
in all such cases; the application of cold to the chest, perfect quiet,
the administration of opium, and, if the patient be sufficiently
strong, bleeding from a large opening until syncope supervenes. When
blood has accumulated in any large quantity, and the patient is much
oppressed, the wound should be enlarged, if necessary, so as, with the
assistance of proper position, to facilitate its escape. If the effused
blood, from the situation of the wound, cannot be thus evacuated,
and the patient be in danger of suffocation, then the performance of
paracentesis, as directed for the relief of empyema, must be resorted
to.
The extensive bleedings formerly recommended in all penetrating
gunshot wounds of the chest are now practiced with much greater
limitations—indeed, should never be employed simply with a view to
prevent mischief from arising. Venesection carried to a great extent
does harm by lessening the restorative powers of the frame. It appears
to interrupt the process of adhesion between the pleural surfaces and
the steps taken by nature to repair the existing mischief, while it
leads the injured structures into a condition favorable for gangrene,
or encourages the formation of ill–conditioned purulent effusions. When
inflammation has arisen, venesection may be joined with other means to
control its excessive action, and to give relief, which it certainly
does, to the patient; and where hemorrhage is manifestly going on
internally, it may be practiced with a view of draining the blood from
the system and more speedily inducing faintness, to give an opportunity
to the pulmonic vessels to become closed; but, even when thus applied,
the general state of the patient will not be unconsidered by a
judicious surgeon, nor caution neglected, lest the venesection cause
him to sink more rapidly from the additional shock to the system and
abstraction of restorative force. Taking away blood certainly does not
prevent pneumonia from supervening, but occasionally seems to give the
inflammation, when it arises, more power over the weakened structures,
or even to cause it to be accompanied with typhoid symptoms. Many
cases will be found in the various published records derived from the
Crimean campaign, where favorable recovery has taken place after wounds
of the lung without venesection being at all resorted to as part of the
treatment.
The case of an officer of the 19th Regiment, who was shot at the
assault of the Great Redan, and under the care of the writer, will
serve to illustrate some of the points before named. In this instance,
a rifle–ball passed through the upper part of the left scapula near
its superior posterior angle, comminuting the bone and entering the
chest. The ball, together with a piece of cloth, was excised in
front, two inches above and internal to the fold of the axilla. The
mouth was filled with blood immediately after the injury; bloody
expectoration continued for three days; there was hacking cough on
increased inspiration; the respiratory murmur was accompanied with
slight crepitating _ráles_ in the upper part of the lung; there was
weakness, but not much shock. The small degree of the latter symptom,
and the absence of evidence of effusion of blood into the pleural
cavity, led at the time to a suspicion that the ball had glanced round
the costal pleura and had only contused the lung; but the fact of the
absence of vessels of large size at this part of the lung, especially
if there were pleural adhesions, may have been the cause of these
results. This officer had been much weakened in frame by scorbutic
diarrhœa in the winter of 1854–55, and though the cure was protracted
by occasional attacks of diarrhoea subsequently to the injury, by
profuse discharge from the wounds, and separation from time to time
of spiculæ of bone, he left for England two months afterward with his
recovery nearly completed, and no inconvenience has been experienced in
the discharge of his duties since. No venesection was practiced in this
case; but tonics, nourishing diet, and port wine were given as soon as
suppurative action had been established.
But in discountenancing great bleeding, mention should not at the same
time be omitted that, in many cases, recorded by numerous authors,
and judging _post factum_, the successful issues appear to have been
owing to copious venesection. A remarkable case occurred in a young
soldier of the 33d Regiment, private Thomas Monaghan, under the care
of Deputy Inspector–General Dr. Muir, then surgeon of the regiment.
This man was wounded in August, 1855, through the left shoulder–joint
and chest, the glenoid cavity and head of the humerus being injured
and the lung implicated. In this instance complete recovery as to the
chest, and recovery with partial anchylosis of the shoulder, without
operative interference, followed, and appeared attributable chiefly
to inflammatory action being subdued by repeated depletion, the use
of antimonial medicines, and enforced abstinence. In two other cases,
hitherto unrecorded, which occurred during the same month in the same
regiment, successful terminations appeared to be attributable to
similar means. In one of these the ball entered the front of the chest,
between the third and fourth ribs, and passed out between the seventh
and eighth ribs below; in the other, after passing through the right
arm, it entered the chest at the posterior border of the axilla, and
emerged near the apex of the scapula.
To remove splinters of bone, and readjust indented portions of the
ribs, the finger should be introduced into the wound, and care taken
that in doing so no pieces of cloth or fragments be separated and
projected into the pleural sac. Notice must at the same time be taken
of any bleeding vessel requiring to be secured. A pledget of lint
should be laid over the wound, and a broad bandage placed round the
chest, just tight enough to support the ribs and in some degree to
restrain their movements, but with an opening over each wound large
enough to permit the ready access of the surgeon to it if necessary. If
the patient’s comfort admits of it, he should be laid with the wound
downward, with a view to prevent accumulation of fluid in the pleura;
and if there be two openings, as will be most frequently the case in
rifle–ball wounds, one wound should be thus placed, and the upper one
kept covered. In gunshot wounds, closure of the parietes by adhesion is
of course not to be looked for. The diet, beverages, and medicines must
constantly have reference to the avoidance of inflammatory action; and
should this occur it must be combated on general principles. It is by
such means we shall best assist the natural efforts toward recovery.
If the presence of a ball within the cavity be ascertained, efforts
should be made for its removal. But any attempt to determine where the
ball has lodged should be made very cautiously, as more harm may result
from the interference than from the lodgment of the foreign body. The
existence of old adhesions will modify the effects of a penetrating
wound, by excluding the track of the ball from the general pleural
cavity, and may influence the result of the injury, especially if there
be hemorrhage, or lodgment of foreign bodies, which may thus be brought
within the sphere of removal more readily.
=Wounds of the heart= seldom come to the military surgeon’s notice,
as they ordinarily prove fatal on the battlefield. Still it is right
to mention, that examples occur in which musket–balls are lodged in
the heart without immediately fatal results; and one case is recorded,
where a ball was found imbedded in its substance six years after the
injury was received, and death then ensued from causes unconnected
with the wound.[7] Cicatrices have also been discovered, showing that
a portion of this organ had been wounded with recovery. A private of
the 2d Foot, wounded in the chest, came to England in a transport,
and died sixteen days afterward in the military hospital at Plymouth.
On removing the heart, a ball was found in the pericardium. There was
a transverse opening in the right ventricle, near the origin of the
pulmonary artery, and the appearances led to the supposition that the
ball had, previous to death, been lying in the right auricle. There
was general inflammation of the heart and left side of the chest, but
no signs of inflammation on the right side. A preparation of this heart
is preserved.[8] These are only referred to as indications of what
cases may occur among chest injuries; such accidents are so rare as to
lead to little practical result.
GUNSHOT WOUNDS OF THE NECK.