Part 9

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.

Perineal wounds are not unfrequently caused by shells bursting and projecting fragments upward; but they are generally mixed with lesions of viscera of the pelvis, or fracture of its structure, or injuries about the upper parts of the thighs or buttocks. In one such case, a portion of the scrotum, the whole of one testicle, and the greater part of the other were carried away. This wound healed without fungous growth from the remaining portion of the testis. Separate wounds of the external organs of generation are usually caused by bullets. In two cases in the Crimea, a bullet entered between the glans penis and prepuce, and traversed upward without penetrating the erectile tissue. M. Appia records a case where the ball entered the summit of the glans, traversed the whole length of the corpus cavernosum, passed under the pubic arch, and went out by the right buttock. The urethra was not opened. Double orchitis and scrotal abscesses followed; but favorable cure took place. In another case, a ball carried away the inferior part of the glans but did not wound the urethra. A soldier of the Rifle Brigade was wounded in the Crimea by a musket–ball, which entered the right buttock and came out by the body of the penis, just below the glans, having ruptured the urethra about four inches from the meatus. The wound of the penis closed favorably. Mr. C. Hutchinson has recorded the case of a soldier of the 42d Regiment, treated at the Deal Naval Hospital, who was wounded in the upper part of the thigh by a musket–ball, which lodged. Three weeks afterward, the ball was found imbedded in the pubes, the urethra being stretched around the convex surface; and this explained the cause of a distressing distention of the penis and dribbling of urine which had existed without intermission from the time of the injury, but ceased at once on the removal of the bullet.

GUNSHOT WOUNDS OF THE EXTREMITIES.

These injuries, always very numerous in warfare, offer many subjects of consideration for the military surgeon. No class of wounds includes so many cases that fall under his prolonged care as this. A large proportion of wounds of the head and trunk are immediately fatal, or from the commencement contain the elements of fatal results; while wounds of the extremities, if those of the thigh be excepted, are free from this extremely serious character. The treatment to be pursued, including questions of conservation, resection, amputation, and the proper time for the adoption of these latter if determined upon, often demands the closest attention of the surgeon. These subjects will be considered in their general bearing in other parts of this work, and only those points especially connected with the circumstances of warfare will be here referred to.

Gunshot wounds of the extremities divide themselves into flesh wounds and contusions, and those complicated with fracture of one or more bones. Flesh wounds may be simple, and these offer few peculiarities, whatever their site; or they may be accompanied with lesion to nerves, or blood–vessels, or both, and these usually increase in gravity in proportion as they approach the trunk.

When complicated with fracture, the lesion is usually rendered compound by the direct contact of the projectile with the bone injured; but the fracture is sometimes simple, when caused by indirect projectiles, such as stones or splinters, or by spent balls. These injuries are liable to become further aggravated by the fracture extending into or being complicated with an opening of one of the joints. Joints may be contused or opened by projectiles, without apparent lesion of any portion of the bones entering into their composition; but these are exceptions to the usual order of such cases from gunshot.

Simple flesh wounds have already been referred to both in respect to their nature and treatment in the commencement of this essay. It is in connection with fractures of bones and their proper treatment that the interest of surgeons is chiefly attracted in gunshot wounds of the extremities. From the nature of the injuries, already described, to which bones are subjected by the modern weapons of war, together with the irreparable nature of the wound in the softer structures, except after a long process of suppuration and granulation, as well as from the usual circumstances of military life, it might be anticipated that difficulty would often arise in determining which of the double set of risks and evils—those attending amputation, and those connected with attempts to preserve the limb with a profitable result—would be least likely to prove disadvantageous to the patient. Experience in such injuries has established certain rules which are now generally acted upon; some still remain _sub judice_.

Although the subject of pyemia is considered in its general bearings elsewhere, it is right to mention here that this serious complication, as met with in gunshot wounds, appears to be especially induced by injuries of bones, particularly those of long bones in which the medullary canal has been laid open and extensively splintered. Several circumstances probably conduce to this result: the prolonged suppurative action during the removal of sequestra, the irritation caused by sharp points and edges, sometimes increased by transport from primary to secondary hospitals, the patulous condition of veins in bones leading to thrombosis, being its chief local sources; while depressed vital power from any cause, and continued exposure to an impure atmosphere from the congregation of numerous patients with suppurating wounds, are the principal agents in producing the state of constitution favorable to its development and progress. Unless the hospital miasmata engendered in this way are constantly removed as they arise, or very greatly diluted by proper ventilation, it is almost impossible that patients laboring under severe wounds of the extremities with comminuted bony fractures can be long saved from septicemia and pyemia; and these, when they supervene, rarely lead to any but a fatal termination. The different conditions of hospital air, which in one set of cases lead to the appearance of hospital gangrene, in another set of pyemia, are not properly understood; but from the frequency with which the latter complication follows wounds of bones, it would seem that an especial influence is exerted by the local peculiarities of these injuries already mentioned. However, observation would also lead to the belief that certain individuals are much more predisposed to pyemic action than others placed under similar circumstances. Occasionally, in gunshot injuries of bones, where no splintering has occurred, but only a small portion of the periosteum has been torn off and the shaft contused by the stroke of a bullet, severe inflammation will follow, the medullary canal become filled with pus, and death ensue from pyemia. The attention of surgeons has been particularly called to the various circumstances producing inflammation and suppuration of the medullary tissues—osteo–myelitis—in long bones after gunshot injuries by M. Jules Roux of Toulon.[10]

=Upper Extremity.=—Fractures of the bones of the arm are well known to be very much less dangerous than like injuries in the corresponding bones of the lower extremity. Unless extremely injured by a massive projectile, or longitudinal comminution exist to a great extent, especially if also involving a joint, or the state of the patient’s health be very unfavorable, attempts should always be made to preserve the upper extremity after a gunshot wound. In the Director–General’s History of the Crimean Campaign, the recoveries without amputation are shown to be, in the humerus, 26·6; radius and ulna, 35·0; radius only, 70·0; ulna only, 70·0 per cent. of cases treated. The proportion of deaths in these cases was only 2·3 per cent. Although not the result of gunshot, a remarkable case, published by Staff–Surgeon Dr. Williamson, by whom the operation was performed, serves to illustrate how extensively bone may be removed from the upper arm, and a useful member be still retained. The details will be found in his Notes on the Wounded from the Mutiny in India. The whole of the ulna, (not merely sequestra, but also the new bone which had formed around them, the object of which proceeding is not stated,) two inches of the humerus, and the head and neck of the radius were removed; and, four months after the operation, the man could “bend his forearm, raise his hand behind his head, lift a 28–lb. weight from the ground, pronate and supinate the hand, and use his fingers well.” Of 194 wounds and injuries of the upper extremity among men returned from the late mutiny in India, 100 are recorded by Dr. Williamson to have been sent to duty regular or modified, 67 invalided from the service, 1 died, and 26 were still under treatment.