anticipated from the large vessels and important canals leading to the
thorax and abdomen, which at first sight appear to be so exposed and
unprotected. In no region are so many examples offered of large vessels
meeting but escaping from balls in their passage as in this; because
the cause which operates elsewhere—ready mobility among long and
yielding structures—exists in a greater degree in the neck than in any
other part. Where the large vessels happen to be divided, death must
follow almost immediately.
Superficial wounds of the neck offer no peculiarities. The larynx and
trachea being the organs most prominent, and most frequently injured,
are those which chiefly attract the surgeon’s notice in warfare; but
a consideration of the anatomical structure will at once show what
numerous other complications, whether from direct injury or consequent
inflammation, projectiles are likely to cause when driven deeply into
or perforating this region.
A brief abstract of some wounds of the neck, which occurred during the
Crimean campaign, will serve to exhibit the leading symptoms connected
with them when the larynx, or larynx and œsophagus, are involved.
Four cases may be found in the _Lancet_ of January 19th, 1856, to
which journal they were communicated by the late Mr. Guthrie, as
“very interesting.” In the Surgical History of the War it is stated
that only three wounds of the neck, other than simple flesh wounds,
occurred among the officers, from the commencement to the end of the
war; of which two proved fatal, and one led to invaliding. The case
of an officer of the 19th Regiment, however, fell under the care of
the writer, which is not included in that number; and in this instance
the neck was completely traversed, the œsophagus perforated from side
to side, and the larynx injured. It is detailed among the cases by
Mr. Guthrie. After the shock had subsided, the leading symptoms were
aphonia, dysphagia, numbness of one arm, edema and stiffness of the
neck, distressing accumulation of mucus about the fauces, and slight
pyrexia. Recovery progressed favorably, and on the twenty–second day
after the injury both external wounds in the neck were healed, and the
two in the œsophagus appeared to be closed also. The patient referred
to still suffers from a certain amount of aphonia, but not enough
to prevent him from performing his duties as a captain, though want
of sufficient power of voice would probably disable him for a more
extensive command. Another of these cases, in which emphysema of the
neck, edema of the glottis, great dyspnœa, and threatened suffocation
gradually supervened in a superficial gunshot wound of the neck, with
fracture of the thyroid cartilage, is related by Assistant–Surgeon
Cowan, 55th Regiment, who performed tracheotomy, and thereby saved the
patient’s life. In another, the ball passed through the thyro–hyoid
membrane, fractured the thyroid cartilage, and tore the lining membrane
of the glottis. Tracheotomy was performed on the day after the injury,
without benefit. Liquids could not be prevented from passing into the
trachea through the wound made by the projectile. The fourth case above
referred to was in a private of the 97th Regiment. The ball entered
at the pomum Adami, and passed out by the anterior edge of the right
sterno–mastoid muscle. Loss of voice, frequent cough, bloody sputa,
slight emphysema at the wound of entrance, and nausea, were the leading
symptoms. When the man attempted to drink, some of the fluid escaped by
the wound of exit. After five days this occurrence ceased; and after
the twelfth day, air no longer passed out of the wound of entrance.
Both wounds gradually healed; but aphonia—the voice being reduced to a
whisper—existed when the man left the regimental hospital. A soldier of
the Rifle Brigade, under the care of Deputy Inspector–General Fraser,
C.B., then surgeon of the battalion, was shot through the trachea, and
respiration was for some time carried on by the wound; it, however,
gradually and completely healed, and a favorable recovery ensued.
Another interesting case, hitherto unrecorded, occurred in a soldier
of the same battalion, at the last assault of the Redan. A rifle–ball
entered this man’s neck at the lower part of the left sterno–mastoid
muscle, passed across under the skin, wounding the anterior surface
of the trachea, severed some fibers of the right sterno–mastoid, and
effected its exit. The man was wounded at the same time by two other
rifle–balls, both flesh wounds, one through the left forearm, the other
through the upper part of the right thigh; while a shell exploding
near him, caused his left eye to be penetrated with particles of stone
and earth. Vision was lost; but in other respects, excepting a little
lameness from the wound in the thigh, he was discharged cured, after
fifty–six days’ hospital treatment.
Seven cases of gunshot wounds of the neck returned to England from the
late mutiny in India. They were all simple flesh wounds. In one the
musket–ball had not been discovered, and its position remained unknown.
The man was wounded at Lucknow, and the ball entered the left side of
the neck, close to the thyroid cartilage. Baron Percy reports a similar
wound and case of lodgment in his _Army Surgeon’s Manual_; in this
instance, the ball was known to pass away by the bowels, a fortnight
after the injury was received.
The liability to concussion of the cervical portion of the vertebral
column, and to injury of the deep cervical and other nerves, must not
be overlooked. Wounds of the neck are often accompanied by more or
less loss of power in one of the upper extremities; and more extensive
paralysis occasionally succeeds, although there was no primary evidence
of the spine being implicated in the injury.
GUNSHOT WOUNDS OF THE ABDOMEN.
Gunshot wounds of the abdomen, like those of the chest, are, for the
sake of convenience, divided into _non–penetrating_ and _penetrating_.
The NON–PENETRATING may be either simple flesh wounds, or may be
accompanied with fracture of some of the pelvic bones, or with injury
to some of the contained viscera. In PENETRATING wounds, the peritoneum
only, or, together with it, one or more of the abdominal viscera, may
be wounded; or, in comparatively rare cases, a viscus may be penetrated
without the peritoneum being involved. It is in the regional cavity
of the abdomen that the proportion of penetrating wounds is the
greatest. The cranium, from its form, structure, and coverings, serves
as a strong defense even against gunshot; the osseous yet elastic and
movable ribs, the sternum, and muscular parietes greatly protect the
contents of the cavity which they inclose; but the extensively exposed
surface of the abdomen, anteriorly and laterally, has no power of
resistance to offer against a projectile directly impinging it; and
when this important cavity is once penetrated by these means, death
is the almost inevitable result. Even the chances of a favorable
termination which may exist in wounds from other causes are generally
wanting; and much of their treatment, such as the use of sutures, and
other means to insure the apposition of cut edges, is inapplicable,
from the parts to a certain distance being almost necessarily deprived
of their vitality, to injuries from gunshot.
=Non–penetrating= wounds require but few remarks in this place. The
fatal injuries which occasionally occur from masses of shell or round
shot, in which the liver, spleen, or other viscera are ruptured without
penetration of parietes, and where death ensues from shock, hemorrhage,
or peritonitis, have already been alluded to. If, although the viscera
have been contused, the injury does not amount to being mortal, the
patient should be subjected to perfect quiet, extreme abstinence,
and, only when inflammation arises, to the necessary treatment for
its control. If the parietes have been much contused, abscess or
sloughing may be expected; and a tendency to visceral protrusion must
be afterward guarded against.
When portions of the pelvic parietes are fractured by heavy
projectiles, very protracted abscesses generally arise, connected with
necrosed bone; and the vital powers of the patient are greatly tried
by the necessary restraint and long confinement. The great force by
which these wounds must be produced, and the general contusion of the
surrounding structures, cause a large proportion sooner or later to
prove fatal, notwithstanding the peritoneal cavity may have escaped.
Of twenty–nine such cases which came under treatment in the Crimea,
sixteen died. Even apparently slight cases, as where a portion of the
crest of the ilium is carried away by shell, or ball lodged in one of
the pelvic bones, often prove very tedious, from the long–continued
exfoliations and abscesses which result.
=Penetrating wounds.=—A penetrating wound of the abdomen, whether
viscera be wounded or not, is usually attended with a great amount
of “shock.” The prognosis will be extremely unfavorable, if there
is reason to fear the projectile has lodged in the cavity of the
peritoneum; and in all cases the danger will be very great from
inflammation of this serous investment. The liability to accumulation
of blood in the cavity, from some vessel of the abdominal wall being
involved in the wound, must not be forgotten.
When, in addition to the cavity being opened, viscera are penetrated,
and death does not directly ensue from rupture of some of the larger
arteries, the shock is not only very severe, but the collapse attending
it is seldom recovered from up to the time of the fatal termination
of the case. This is sometimes the only symptom which will enable the
surgeon to diagnose that viscera are perforated. The mind remains
clear; but the prostration, oppressive anxiety, and restlessness are
intense; and, as peritonitis supervenes, pain, dyspnœa, diffused
tenderness, irritability of the stomach, distention, and the other
signs of this inflammation are superadded. In ordinary wounds from
musket–shot, scarcely any matter will escape from the opening of the
parietes, the margin of which becomes quickly tumefied; but if any
escape, it will probably indicate what viscus has been wounded. If
the stomach has been penetrated, there will probably be vomiting of
blood from the first. If the spleen or liver be wounded, death from
hemorrhage is likely to follow quickly. In some instances patients,
however, recover after gunshot wounds involving these viscera, and
examples in illustration may be found in various works on military
surgery. Two particularly manifest instances, where officers were shot
through the liver by musket–balls, occurred lately in India, one at
Lucknow, the other at the siege of Delhi: both recovered. The cases are
described in the _Indian Annals of Medical Science_ for January, 1859.
If the small intestines have been perforated, and death follows soon
after from peritonitis, the bowels usually remain unmoved, so that no
evidence is offered of the nature of the wound from evacuations; but
in any case of penetrating wound of the abdomen, when the opportunity
is offered, steps should be taken—a matter not unlikely to be omitted
under the circumstances of camp hospitals full of patients—to isolate
and examine all evacuations which may follow. By attending to this
direction, the writer had the satisfaction of ascertaining the passage
of a ball and piece of cloth, after a wound in the loin, in a case
already alluded to. If the kidneys or bladder are penetrated, the
escape of urine into the abdomen is almost a certain cause of fatal
result. The latter viscus may, however, be penetrated without the
peritoneal cavity being opened; and, as experience proves, the wound
is then by no means of a fatal character. Musket–balls sometimes lodge
in the bladder. This was ascertained to have happened in a soldier
of the 20th Regiment, in the Crimea; but the patient died from other
injuries, so that the information could not be turned to account. Mr.
Guthrie performed the usual operation of lithotomy, with success, to
remove a musket–ball which had struck a soldier just above the pubes,
at Waterloo, and lodged. He also records a similarly successful case
in a man wounded at the battle of Chillianwallah: this ball formed
the nucleus of a calculus. Baron Percy removed a ball and a portion
of shirt from the bladder. In all such cases, it is probable that the
bladder has been penetrated at some part uncovered by peritoneum,
so that the cavity of the abdomen has not been opened; or, if
otherwise, the foreign body has found its way in by ulceration, after
adhesions had been established, and thus circumscribed the openings of
communication. Small foreign bodies may also pass into the bladder by
the ureter. A case in which the kidney was wounded came under the care
of the writer, after the 8th of September, 1855. The patient survived
twelve days, and then died from pyemia. He had been taken prisoner, but
was found in Sebastopol, and brought to his regimental hospital on the
second day after the assault. There was only one wound in the right
loin, and the ball had lodged. Extensive abscesses formed among the
gluteal muscles on the left side, and down the left thigh; and though
free incisions were made, great constitutional irritation supervened,
and he sank. The substance of the right kidney had been perforated,
but the ureter had escaped. The ball had passed across the abdomen,
and lodged in the left buttock. Mr. Guthrie mentions some wounds of
the kidney where recovery took place; in one, seven months after the
wound, after an attack of retention of urine, a piece of cloth was
forced out by the urethra, which must have come down from the pelvis
of the kidney. When the abdominal parietes have been opened by shell
or passage of large shot, protrusion of omentum and intestines will
probably be one of the results. This does not always happen. In Dr.
Macleod’s Notes, p. 237, is detailed a remarkable case of recovery,
which was witnessed by the writer, after the wall of the abdomen,
including the peritoneum, had been destroyed to the extent of five
inches long by three broad; and a coil of intestine laid bare without
protrusion, in the right iliac region. This patient had also a fracture
of the ileum, another of the great trochanter on the same side, and his
right forearm smashed. This case was treated in the general hospital
before Sebastopol, by Mr. Hooke. Sometimes a wound caused by a large
projectile, which was at first not penetrating, will indirectly become
so, from the severe contusion and consequent sloughing to such an
extent as to denude the viscera; and if, as is not unlikely, adhesion
has taken place in the mean time between a portion of the viscera and
peritoneal lining of the abdominal paries, the sloughing action may
extend more deeply and the bowel itself become opened.
Curious instances are recorded in which balls have passed directly
through the abdomen without perforating any important viscus, as proved
by examination after death. As an example, on the other hand, of the
number of wounds which may thus be inflicted, a soldier of the 19th
Regiment, on duty in the trenches before Sebastopol, who was shot
through the abdomen in the act of defecation, was found by the writer,
on post–mortem examination, to have had as many as sixteen openings
made in the small intestine. He survived the wound nineteen hours.
Gunshot wounds of the colon, especially of the sigmoid flexure,
appear to be less fatal, probably from structural causes as well as
circumstances of position, than wounds of the small intestine. In the
Museum of Fort Pitt, however, is a preparation of jejunum exhibiting
three constrictions, and supposed to have been perforated in three
places, from a private of the 80th Regiment, who was shot through the
abdomen at Ferozeshah, in 1845, and who died from cholera in 1851.
Inspector–General Taylor, C.B., then surgeon of the regiment, who
made the examination post mortem, thus described the injured part
of the intestine: “The intestines neither there nor elsewhere were
morbidly adherent; but the fold of intestines immediately opposed to
the cicatrix presented a line of contraction as if a ligature had been
tied round the gut. The same appearance existed in two other places.”
It seems more likely that the gut was contused than perforated, and
that contraction gradually supervened, especially as no adhesions were
found; and, when wounded, the symptoms were so slight as to have led to
the supposition that the ball had gone round the abdominal wall.
A gunshot wound of the intestine, more especially the colon, may lead
to fecal fistula, and life be thus saved for a time. One such case only
occurred in the Crimea, in the 19th Regiment, of which the writer was
then the surgeon; this case, which has been before casually mentioned,
subsequently passed under the care of his friend Mr. Birkett, of Guy’s
Hospital, in which institution the patient died, from the effects of
albuminuria, four years after the receipt of the wound referred to. The
surgical history of this case has been already published at some length
in the _Lancet_;[9] the medical history, together with the results
of the post–mortem inspection, have been detailed by Dr. Habershon,
in vol. v., Ser. III., of the _Guy’s Hospital Reports_. The fistula
became closed at intervals, and occasionally, before other disease
supervened, hopes were entertained that recovery might result. The
direction and depth of the wound precluded any of the usual operations
for attempting to effect a radical cure. Two cases of abnormal anus by
gunshot perforation are recorded by Dr. Williamson among the wounded
who have recently returned from India; in both instances the descending
colon was the part of the bowel implicated. A similar result is
recorded in a private of the 13th Regiment wounded at Cabul in 1840.
=Wounds of the diaphragm.=—Musket–balls occasionally pass through
the diaphragm; and Mr. Guthrie has remarked that these wounds, in
instances where the patients survive, only become closed under rare
and particular circumstances. Hence the danger of portions of some
of the viscera of the abdomen, as the stomach or colon, passing into
the chest, and thus forming diaphragmatic herniæ, and of these,
eventually, from some cause becoming strangulated. Two very interesting
preparations of these accidents from gunshot exist in the museum at
Fort Pitt. In both instances, the stomach, colon, and omentum form the
hernial protrusions. In one, death occurred, a year after the wound,
from strangulation induced suddenly after a full meal; in the other,
the soldier continued at duty twenty–two years after, and died from
other causes. All the cases which occurred in the Crimea in which
openings had thus been established between the cavities of the chest
and abdomen proved fatal. A case is detailed in the Surgical History
of the War where the patient survived a double perforation of the
diaphragm, together with a wound of the liver, six days; in another
instance, where the lung, diaphragm, liver, and spleen were wounded,
the soldier lived sixteen hours. The direction of the ball, hiccough,
dyspnœa accompanied with spasmodic inspiration, and inflammatory
signs more particularly connected with the chest will be the usual
indications of such a wound; and in case of recovery, the risk of
hernial protrusion and strangulation must be explained to the patient.
Should strangulation occur, it can hardly be expected that division of
the stricture could be performed without the operation itself leading
to equally certain fatal results.
=Treatment.=—In the general treatment of penetrating wounds of the
abdomen by gunshot, the surgeon can do little more than to soothe and
relieve the patient by the administration of opiates, and to treat
symptoms of inflammation when they arise on the same principles as in
all other cases. The usual directions to attempt agglutination of the
opposite portions of peritoneum by favorable posture cannot generally
be carried out, the attempts being defeated by the restlessness of
the patient. The collapse which attends such injuries may be useful
in checking hemorrhage; and the exhibition of stimulants is further
contra–indicated by the risk of exciting too much reaction, should the
wound not prove directly fatal. If the wound be caused by grape–shot
or a piece of shell, and intestine protrudes, it must be returned; if
the intestine be wounded, sutures are inapplicable, as in an incised
wound, without previously removing the contused edges. When the bladder
is penetrated, care must be taken to provide for the removal of the
urine, either by an elastic catheter, or, if this cannot be retained,
by perineal incision. A freely communicating external wound prevents
the employment of the catheter from being essential. A soldier of the
57th Regiment was wounded, on the 18th June, 1855, by a musket–ball,
which entered the left buttock, fractured the pelvis, and came out
about three inches above the os pubis and one inch to the right of
the median line. The bladder was perforated; urine escaped by both
openings, chiefly by the one in front. Here the catheter caused so much
irritation that it was withdrawn; but the posterior wound soon ceased
to discharge urine, and in eighteen days the anterior wound was free
from discharge also. Seven weeks after the date of injury symptoms
resembling those of stone in the bladder came on; these were relieved
on three spiculæ of bone making their escape by the urethra. About
the same time the anterior wound became again open, and some pieces of
bone were discharged. After ninety–seven days’ treatment in the Crimea,
the man was sent home—the anterior wound being still so far open that
distention of the bladder, as from accumulation at night–time, led to
a little oozing from it. This subsequently healed; and he was sent to
duty on the 22d of November, nearly six months after the date of injury.
GUNSHOT WOUNDS OF THE PERINEUM AND GENITOURINARY ORGANS.
From the position of these parts of the body, uncomplicated gunshot
wounds of them are comparatively rare. Throughout the whole of the
Crimean war, the number of cases treated amounted, among the men, to
70; among the officers, only to 4. The number of deaths which resulted
were 21 among the men, chiefly cases of extensive laceration involving
the urinary apparatus; among the officers, none. Three men only, out
of 603 who returned from the late mutiny in India to Chatham, are
recorded under this class. In one, the injury was from a spent shot,
which caused a bruise without laceration over the symphysis pubis, and
produced persistent incontinence of urine; in each of the other two,
a musket–ball wounded the left testicle, injured the urethra, and led
to urinary fistula, which was, however, afterward healed. In one, the
testicle was so much injured that it was removed on the day the wound
was received; in the other, it sloughed away shortly after. A corporal
of the 19th Regiment, wounded in this region on the 8th September,
1855, was under the care of the writer. A portion of the ascending
ramus of the ischium on the right side was driven into the perineum,
the soft parts were much injured, and the right testicle was destroyed.
The viscera of the pelvis escaped. He was doing well until nearly a
fortnight after the injury, when nervous irritation and trismus set in,
and he sank.