Part 8

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.

Gunshot wounds of this region do not appear to be so fatal as might be anticipated from the large vessels and important canals leading to the thorax and abdomen, which at first sight appear to be so exposed and unprotected. In no region are so many examples offered of large vessels meeting but escaping from balls in their passage as in this; because the cause which operates elsewhere—ready mobility among long and yielding structures—exists in a greater degree in the neck than in any other part. Where the large vessels happen to be divided, death must follow almost immediately.

Superficial wounds of the neck offer no peculiarities. The larynx and trachea being the organs most prominent, and most frequently injured, are those which chiefly attract the surgeon’s notice in warfare; but a consideration of the anatomical structure will at once show what numerous other complications, whether from direct injury or consequent inflammation, projectiles are likely to cause when driven deeply into or perforating this region.

A brief abstract of some wounds of the neck, which occurred during the Crimean campaign, will serve to exhibit the leading symptoms connected with them when the larynx, or larynx and 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.