GUNSHOT WOUNDS. (continued 2)

As soon as the presence of a ball or other foreign body is ascertained it should be removed. If it be lying within reach from the wound of entrance, it should be extracted through this opening by means of some of the various instruments devised for the purpose. In case of a leaden bullet, Coxeter’s Extractor, corresponding with Baron Percy’s instrument for the same purpose, and consisting of a scoop for holding and central pin for fixing the bullet, has been found a very convenient appliance, from the comparatively limited space required for its action. Instruments of two blades, or scoops, with ordinary hinge action, dilate the track of the wound injuriously before the ball can be grasped by them. The way to the removal of a bullet may often be smoothed by judiciously clearing away the fibers, among which it is lodged, during the examination, by the finger; and sometimes, by means of the finger in the wound, and external pressure of the surrounding parts, the projectile may be brought near to the aperture of entrance, so that its extraction is still further facilitated. Such foreign substances as pieces of cloth can usually be brought out by the finger alone, or by pressing them between the finger and a silver probe inserted for the purpose. Sometimes a long pair of dressing forceps, guided by the finger, is found necessary for effecting this object. Caution must be used in employing forceps, where the foreign substance is out of sight and of such a quality that the soft tissues may be mistaken for it.

In instances where the foreign body has not completely penetrated, but is found lying beneath the skin away from the wound of entrance, an incision must be made for its extraction. Before using the knife, the substance to be removed should be fixed in situ, by pressure on the surrounding parts. In the instance of a round ball, the incision should be carried beyond the length of its diameter; an addition of half a diameter is usually sufficient to admit of the easy extraction of the ball. In removing conical balls, slugs, fragments of shells, stones, and other irregularly-shaped bodies, the surgeon cannot be too guarded in arranging that the fragment is drawn away with its long axis in line with the track of the wound. By proper care in this respect, much injury to adjoining structures may be avoided.

If balls are impacted in bone, as happens in the spongy heads of bones, in bones of the pelvis, and occasionally, though rarely, in other parts of long bones, they should be removed. This can be effected by means of a steel elevator, of convenient size; or, should this fail from the ball being too firmly impacted, a thin layer of the bone on one side of the ball may be gouged away, so that a better purchase may be obtained for the elevator, in effecting its removal. The fact is now fully established that, although in a few isolated cases balls remain lodged in bones without sensible inconvenience, in the majority the lodgment leads to such disease of the bony structure as often to entail troublesome abscesses, and in some instances eventually to necessitate amputation. The lodgment of balls will not often occur without extensive fracture in warfare where rifled arms of such force as the Minié or Enfield are the chief weapons employed, but will not unfrequently be met with in such campaigns as have lately happened in India.

Should there be reason for concluding that a ball or other foreign body has lodged, but after manual examination, and observation as well by varied posture of the part of the body supposed to be implicated as by indications derived from the patient’s sensations, effects of pressure or injury to nerves, and all other circumstances which may lead to information, should the site of the lodgment not be ascertained, the search should not be persevered in to the distress of the patient. Neither, although the site of lodgment be ascertained, if extensive incisions are required, or if there is danger of wounding important organs, should the attempts at extraction be continued. Either during the process of suppuration, by some accidental muscular contraction, or by gradual approach toward the surface, its escape may be eventually effected; or, if of a favorable form, and if not in contact with nerve, bone, or other important organ, it may become encysted, and remain without causing pain or mischief. When John Hunter wrote on gunshot wounds, he remarks, the practice of searching after a ball, broken bones, or any other extraneous bodies, had been in a great measure given up, from experience of the little harm caused by them when at rest, and not in a vital part; and he himself advises, even when a ball can be felt beneath skin that is sound, that it should be let alone, chiefly on the ground that two wounds are more objectionable than one, and that the extent of inflamed surface is proportionably increased by incision. More extensive experience has, however, shown that not only is the risk of subsequent ill results greater in those cases where foreign bodies remain lodged than when they have been cut out, but also that the advantages of a second opening for the escape of the necessary sloughs and discharges greatly preponderate over the disadvantages connected with it, as regards the additional extent of injured surface. The advantage also of the satisfaction to the mind of a patient from whom a ball has been removed must not be overlooked; for men suffering from gunshot wounds are invariably rendered uneasy by a vague apprehension of danger, for some time after the injury, if the missile has remained undiscovered.

When a gunshot wound has been accompanied with much laceration and disturbance of the parts involved in the injury, it is necessary, after the removal of all foreign substances that can be detected, to readjust and secure the disjointed structures as nearly as possible in their normal relations to each other. The simplest means—strips of adhesive plaster, light pledgets of moist lint, a linen roller, favorable position of the limb or part of the body wounded—should be adopted for this purpose. Pressure, weight, and warmth should be avoided as much as possible in these applications, consistent with the end in view. It must not be forgotten, in thus bringing the parts together, that the purpose is not to obtain union by adhesion, which cannot be looked for, but simply to prevent avoidable irritation and malposition of parts, during the subsequent stages of cure by granulation and cicatrization. In all gunshot wounds, much discomfort to the patient is prevented by carefully sponging away all blood and clot from the surface adjoining the wound, and by adopting measures to prevent its spreading again in consequence of oozing. This can be readily done with the aid of a little warm water, and arrangement when the wound is first dressed, but can only be accomplished with considerable inconvenience after the thin clots have become hard and firmly adherent to the skin.

When the parts of a lacerated gunshot wound have been brought into apposition, as in simple penetrating wounds, the only dressing necessary is moistened lint. It should be kept moist either by the renewed application of water dropped upon it, or by preventing evaporation by covering it with oiled silk. The sensations of the patient may be consulted in the selection of either of these, and climate and temperature will be often found to determine the choice. In hot climates cold applications are the more grateful, and by checking the amount of inflammatory action and circumscribing its extent are usually the more advantageous. M. Velpeau and other French surgeons have strongly recommended the use of linseed-meal poultices, above all wet linen applications. Charpie is still extensively employed in French military hospitals.[5] M. Baudens and Dr. Stromeyer have strongly recommended the topical application of ice placed in bladders; others, the continued irrigation of the wound with tepid water. The means of applying such remedies are rarely available in the military hospitals where gunshot wounds are ordinarily treated in their early stages. When much local inflammation has set in, and when there is much constitutional fever even without unusual local irritation, the non-evaporating or warm applications will be found to be the most advantageous.

When suppurative action has been fully established, the surgeon must be guided by the general rules applicable to all other such cases. Care must be taken to prevent the accumulation of pus, lest it burrow, and sinuses become established—not an unfrequent result of want of sufficient caution in this regard. If much tumefaction of muscular tissues beneath fasciæ occurs, or abscesses form in them, free incisions should be at once made for their relief. In wounds where the communication between the apertures of entrance and exit is tolerably direct, occasional syringing with tepid water may be useful, by removing discharges and any fibers of cloth which may be lying in the course of the wound. Weak astringent solutions are occasionally employed in a similar way, with a view to improving the tone of the exhalents and exciting a more vigorous action in the process of granulation. The strictest attention to cleanliness and the complete removal of all foul dressings are essentially necessary, not merely for the comfort of the patient, but to prevent the accumulation of noxious effluvia, and also to obviate the access of flies to the wounds. In tropical climates, and in field-hospitals in mild weather, where many wounded are congregated, flies propagate with wonderful rapidity, and the utmost care is necessary to prevent the deposit of ova and generation of larvæ in the openings of gunshot wounds, especially while sloughs are in process of separation. Cloths dipped in weak solutions of creasote or disinfecting fluids, laid over the wound, are found necessary for this purpose when the insects abound in great numbers.

The constitutional treatment in an ordinary gunshot wound, uncomplicated with injury to bone or structures of first importance, should be very simple. The avoidance of all irregularity in habits tending to excite febrile symptoms or to aggravate local inflammation, attention to the due performance of the excretory functions, and support of the general strength, are chiefly to be considered. Bleeding, with a view to prevent the access of inflammation in such cases, is now never practiced, as formerly, by English surgeons. The diet should be nutritious, but not stimulating. A pure fresh atmosphere is a very important ingredient in the means of recovery. If from previous habits of the patient, or from circumstances to which he is unavoidably exposed, the local inflammation has become aggravated,—indicated by pain, increased swelling, and redness about the wound,—topical depletion by leeches or cupping, bleeding from the arm, saline and antimonial medicines, and strict rest in the recumbent position, must be had recourse to, the extent being regulated by the circumstances of each case. In instances such as these, when the inflammation has become diffused, the purulent secretion is not confined to the track of the wound, but is liable to extend among the areolar connections of the muscles; and if the cure be protracted, attention will be necessary to prevent the formation of sinuses. If stiffness or contractions result, attempts must be made to counteract them by passive motion and friction, with appropriate liniments; if a tendency to edema and debility remain in a limb after the wound is healed, the cold-water douche will be found to be one of the most efficient topical remedies. In French practice, the administration of a chalybeate tincture,[6] as a tonic, or diluted as an injection, in wounds threatening to assume an unhealthy character, is very highly praised. It is stated that under the conjoined employment of this remedy internally and externally, in wounds of a pallid, unhealthy aspect, accompanied by nervous irritability and symptoms of approaching pyemia, the granulations have resumed a red and healthy appearance, and the general state of health become rapidly favorable.

Progress of cure.—Simple flesh wounds from gunshot usually heal in five or six weeks. In the course of the first day the part wounded becomes stiff, slightly swelled, tender, a slight inflammatory blush surrounds the apertures through which the missile has passed, and a slight serous exudation escapes from them. Suppuration commences on the third or fourth day, and in about ten days or a fortnight the sloughs are thrown off. Granulation now progresses, more or less quickly according to the health and vigor of the patient’s constitution. The opening of exit is usually the first closed. When the wound is complicated with unfavorable circumstances, whether inducing in the patient a condition of asthenia or leading to excess of inflammatory action, the progress of the cure may be extended over as many months as, under favorable circumstances, weeks are occupied in the process.

GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY.

The circumstances connected with wounds in particular situations of the body, or in particular organs, are in many respects common to injuries from other causes than gunshot; and in the following remarks the attention is chiefly drawn only to those leading peculiarities which constantly demand the consideration of the army surgeon, and which spring either from the nature of gun projectiles, or the circumstances under which this branch of military practice has for the most part to be pursued.

GUNSHOT WOUNDS OF THE HEAD.

No injuries met with in war require more earnest observation and caution in their treatment than wounds of the head. The vital importance of the brain; the varied symptoms which accompany the injuries to which this organ may be subjected, directly or indirectly; the difficulty in tracing out their exact causes; the many complications which may arise in consequence of them; the sudden changes in condition which not unfrequently occur without any previous warning,—all these circumstances will keep a prudent surgeon who has charge of such wounds continually on the alert. Injuries of this class, the most slight in appearance at their onset, not unfrequently prove most grave as they proceed, from encephalitis and its consequences, or from plugging of the sinuses by coagula, leading to coma, paralysis, or pyemia; and the converse sometimes holds good with injuries presenting at first the most threatening aspects, where care is taken to avert these serious results. Much will depend on the part of the head struck, both as regards the thicker and stronger processes or portions of the skull, and the situation of the sinuses and parts of the cerebrum within; on the force and shape of the projectile; the angle at which it strikes; the age and condition of the patient; and other matters already referred to in the general remarks on gunshot wounds. Mr. Guthrie has laid down as a rule that injuries of the head, of apparently equal extent, are more dangerous on the forehead than on the side or middle portion, and still more so than those on the back part; and that a fracture of the vertex is infinitely less important than one at the base of the cranium. When the injuries are caused by rifle-balls, however, these considerations are rarely of much avail, for the power of injury is such that it can scarcely ever be confined to the immediate neighborhood of the part directly struck.

Wounds of the head may be divided, for convenience of description, into wounds of the scalp and pericranium, without fracture of bone; similar wounds complicated with fracture of the outer or of both tables, without pressure on the encephalon; wounds with fracture and depression; and lastly, wounds in which the encephalon itself has been penetrated. Severe contusion of the bones of the cranium, followed by necrosis, and even fracture, with or without depression, may occur without an open wound of the superficial investments. The case of an officer is mentioned in Dr. Macleod’s Notes of the Crimean War, who was thus killed by a round shot. The scalp was not cut, almost uninjured, but the skull was most extensively comminuted.

Wounds of the scalp and pericranium.—These wounds are usually inflicted by projectiles which are brought into contact at a very acute angle, so that little direct injury to the brain or its membranes is inflicted, and the surgeon’s attention need only be directed to the same considerations as must occur in any contused wounds of the scalp from other causes than gunshot. But even in these accidents, though appearing to be simple flesh wounds, serious cerebral concussion and other lesions are occasionally met with. The usual stupor and other signs of concussion may be very evanescent, or may last for several days, disappearing gradually and wholly, or entailing subsequent evils at more or less remote periods. It must not be forgotten that when the pericranium is removed by a musket-ball, however superficial the injury may seem, there is always a certain degree of injury and bruising to the bone from which it is torn, and necessary laceration of the vessels which inosculate with the nutritive capillaries of the diploë, and through them of the vessels of the meninges with which they are connected. The injury to this vascular system almost invariably leads to necrosis of the portion of the skull from which the coverings are carried away; and sometimes, even when the pericranium is not torn off, sufficient injury is inflicted to lead to a like result. The death of bone is generally limited to a thin layer of the outer table, which in due time exfoliates. The injury to the vessels ramifying between the inner surface of the cranium and dura mater may lead to serious results. There may be rupture of a sinus, leading to compression, or fatal results may ensue from inflammation and suppuration. The case of a young soldier in whom the longitudinal sinus was thus ruptured occurred to the writer. In this instance a rifle-ball had divided the scalp and pericranium about four inches in length obliquely across the skull, just anterior to the angle of the lambdoidal suture, the posterior end of the sagittal suture being exposed midway in the line of the wound. The patient vomited at the instant of the blow, and symptoms of compression, mixed with some of concussion, soon followed. He died eleven hours after the injury. At a post-mortem examination, the superior longitudinal sinus was found to be ruptured, and about four ounces of coagulated blood were lying on the brain. Two darkly-congested spots were observed in the cerebrum, one on each hemisphere, corresponding with the line of direction in which the ball had passed, and these, when cut into, presented the usual characters of ecchymoses. There was no fracture of bone. The case may be found detailed at some length in the Lancet, vol. i., 1855. When inflammation follows the passage of a ball, whether terminating in resolution or leading to abscess, the symptoms and treatment required will be the same as in similar affections from other causes. In like manner, the occurrence of erysipelas, or other complications to which these wounds of the scalp are liable, will be found treated elsewhere. (See Injuries of the Head.)

The treatment of an ordinary gunshot wound of the scalp should be very simple. Cleansing the surface of the wound, removing the hair from its neighborhood for the easier application of dressings, lint moistened with clean water, very spare diet, and careful regulation of the excretions are the only requirements in most cases. The patient must be closely watched, so that measures may be taken to counteract inflammatory symptoms in their earliest stages. Even after one of these wounds has healed, and the patient to all appearance has quite recovered, it is necessary to enjoin continued abstinence from excesses of all kinds. Instances are frequently quoted where intoxication, a long time after the date of injury, has induced symptoms of apoplexy and death. In the Surgical History of the Crimean Campaign, the case of a soldier of the 31st Regiment, thirty-eight years old, who received a contused wound at the back of the head from a piece of shell, without section of the scalp and without lesion of the bone, is related. In this instance a small abscess formed under the scalp, and was evacuated. After the wound was healed the man suffered from constant headaches, and was invalided to England. Soon after landing he drank freely, coma followed, and he died shortly afterward. The post-mortem examination showed traces of inflammatory action in the dura mater, and “just anterior and superior to the corpora quadrigemina was a tumor the size of a walnut, composed of organized fibrin and some clotted blood.”

Wounds complicated with fracture, but without depression on the cerebrum.—These are very uncertain in their effects, and often apt to mislead the surgeon, from the absence of urgent symptoms in their early stages. The occurrence of fracture is, however, sufficient to show the force with which the projectile has struck the head, and to indicate the mischief which the brain and its immediate coverings have not improbably sustained.

In these injuries there may be a simple furrowing of the outer table, without injury to the inner; or there may be fissure extending to a greater or less degree of length, or radiating in several lines; or both tables may be comminuted in the direction the ball has traversed in such small portions that they lie loosely on the dura mater without much alteration in the general outline of the cranial curve. The chief and only means, in many cases, of concluding that no depression upon the cerebrum has taken place is the absence of the usual symptoms of compression; for it is well known that simple observation of the injury to the outer table, whether by sight or touch, will by no means necessarily lead to a knowledge of the amount of injury or change of position in the inner table.

When simple removal of a portion of the outer surface of the skull has been caused by the passage of the ball or other missile, the wound will sometimes heal, under judicious treatment, without any untoward symptom. A layer of the exposed surface of bone will probably exfoliate, and the wound granulate and become closed without further trouble. But such injuries, for reasons before named, are very likely to be followed by inflammation, and not improbably abscess, between the internal table and dura mater; and further, as a consequence of the vascular supply being stopped, and perhaps also partly from the effects of the original contusion by necrosis of the inner table itself. Care must be taken not to mistake one of these injuries for a depressed fracture, as is not unlikely to happen when the excavation effected by the projectile is rather deep and the edges of the bone bordering the excavation are sharp.

Fissured fractures, when the fissure extends through the skull, usually result from injuries by shell. The passage of a ball may fracture and very slightly depress a portion of the outer table of the cranium, and then the line of fracture will very closely simulate fissured fracture extending through both tables, and the diagnosis between them be excessively doubtful. When fissured fracture exists, the distance to which it may be prolonged is often quite unindicated by symptoms, and its extent is very uncertain. Fissures often extend to long distances. They may occur at a part remote from the spot directly injured. In the case of a lieutenant of the 11th Hussars, who was apparently slightly wounded at Balaklava in the middle of the forehead by a piece of shell, a fissured fracture was found, after death, across the base of the skull, quite unconnected with the primary wound, and seemingly from contre-coup. Death resulted from inflammation and suppuration set up near this indirectly-injured part. Fissured fracture of the inner table may also occur from the action of a ball without external evidence of the fracture. Such a case occurred in the 55th Regiment, in the Crimea. The soldier had a wound of the scalp along the upper edge of the right parietal bone. The ball in passing had denuded the bone; but there was no depression. The man walked to camp from the trenches without assistance, and there were no cerebral symptoms on his arrival at hospital; but five days afterward there was general edema of the scalp and right side of face, the wound became unhealthy, and slight paralysis appeared on the left side. The next day hemiphlegia was more marked, convulsion and coma followed, and he died on the thirteenth day after the injury. Pressure from a large clot of coagulum and extensive inflammatory action were the immediate causes of death; but a fissure, confined to the inner table, running in line with the course of the ball, was also discovered. A preparation of the calvarium in this case was presented by Dr. Cowan, 55th Regiment, to the museum at Fort Pitt.

The cases where comminution has resulted from the track of a ball across the skull generally present less unfavorable results than those where a single fissured fracture, extending through both tables, exists. The small, loose fragments can be removed; and if the dura mater be intact, the case, with proper care to prevent inflammatory action, may not improbably be attended with a favorable recovery.

Wounds complicated with fracture and depression on the cerebrum.—Such wounds are most serious, and the prognosis must be very unfavorable. They must not be judged of by comparison with cases of fracture with depression caused by such injuries as are usually met with in civil practice. The severe concussion of the whole osseous sphere by the stroke of the projectile, the bruising and injury to the bony texture immediately surrounding the spot against which it has directly impinged, as well as the contusion of the external soft parts, so that the wound cannot close by the adhesive process, constitute very important differences between gunshot injuries on the one side, and others caused by instruments impelled solely by muscular force on the other. So, also, the injury to the brain within, and its investments, is proportionably greater in such injuries from gunshot. The experience of the Crimean campaign shows that, when these injuries occurred in a severe form, they invariably proved fatal. Of seventy-six cases treated, where depression only, without penetration or perforation, existed, fifty-five proved fatal, twelve were invalided, and nine only were discharged to duty. In the twenty-one survivors, the amount of depression is stated in the history of the campaign to have been slight, though unmistakable, and all except one recovered without any bad symptom. Of eighty-six other cases where perforation or penetration of the cranium occurred, all died.

With penetration of the cerebrum.—It is obvious that, where a projectile has power not only to fracture, but also to penetrate the cranium, it will rarely be arrested in its progress near the wound of entrance. Either splinters of bone, or the ball, or a portion of it will be carried through the membranes into the cerebral mass. Sometimes a ball, if not making its exit by a second opening in the cranium, will lodge at the point of the cerebral substance opposite to that of its place of entrance; but the course a projectile may follow within the cranium is very uncertain.

Instances have occurred where balls have lodged in the cerebrum without giving rise to serious symptoms of danger for a long time. Such cases might lead to throwing surgeons off their guard in making a prognosis, from supposition that the ball by some accident had not lodged. The case of a soldier wounded by a ball in the posterior part of the side of the head is mentioned by Mr. Guthrie. The wound healed, and the man returned to duty; a year afterward he got drunk, and died suddenly. The ball was found in a sac lying in the corpus callosum. Another soldier wounded at Waterloo had a similar recovery, and also died after intoxication. The ball was found deeply lodged in a cyst in the posterior part of the brain. An artillery soldier was wounded, in the Crimea, by a rifle-ball, which entered near the inner angle of the left superciliary ridge. The wound progressed without a bad symptom until a month afterward, when coma came on, and death shortly followed. The ball was found in a sac, in which pus also was contained, at the base of the left anterior lobe of the brain.

Treatment.—The treatment of the various kinds of fractures from gunshot, and their complications, may be considered together. Formerly, a gunshot wound of the head was supposed to be in itself a sufficient indication for the use of the trephine; indeed, even where no fracture was caused, an opening was recommended by comparatively recent surgeons to be made in the cranium, to meet symptoms which might be expected to result. Modern surgeons, however, generally have made use of the trephine only when there was reason for concluding that depressed bone was leading to permanent interruption of cerebral function, or that an abscess had formed within reach, and was capable of evacuation. Preventive trephining has been proved to be useless, as well as dangerous, and is no longer an admissible operation. The tendency of the most recent experience has been to limit the practice of trephining to the narrowest sphere; and when the very great difficulty of making accurate diagnosis in these cases is considered,—whether as to the distinguishing signs of compression; the precise seat of its cause, if the compression exist; the space over which this cause, when ascertained, may extend; its persistent or temporary character; its complications; and certain dangers connected with the operation itself,—no wonder need be excited that this tendency should exist. Besides, the numerous cases which have now been noted where bone has evidently been depressed, but the brain has accommodated itself to the pressure without serious disability being caused, or where compression from effusion has been removed by absorption under proper constitutional treatment, are further causes of hesitation in respect to trephining. In the Surgical Report of the Crimean Campaign, it is stated that the trephine was only successfully applied in four cases (and none of these were from rifle-balls) during the whole war; and that in these instances the patients were subsequently subject to occasional headache and vertigo; and in the French report, by Dr Scrive, it is stated that trephining was for the most part fatal in its results in the French army. In siege operations, the experience as regards wounds of the head is always very extensive, the lower parts of the body being so much more protected in the trenches. According to Dr. Scrive’s returns, one of every three men killed in the trenches before Sebastopol, and one in every 3·4 wounded, was injured in this region. In the English returns, wounds of the head and face in the men are shown as 19·3 per cent.; in the officers, as 15 per cent.; but this is of the total wounded in the field as well as in the trenches. There was, therefore, as extensive a range for observation of the effects of trephining in the siege of Sebastopol as is likely to happen in any war. Dr. Stromeyer, who in the early part of his professional career resorted to trephining in complicated fractures of the skull, records, in his Principles of Military Surgery, that he has abandoned the practice. After the battle of Kolding, in Sleswick, in 1849, there were eight gunshot fractures of the skull, with depression, and more or less cerebral symptoms. In all these, with one exception, the detachment of the fractures was left to nature, and all recovered. One patient, from whom some fragments were removed on the seventh day, was placed in considerable danger by the treatment, and Dr. Stromeyer resolved never to adopt it again. In 1850, in Sleswick, two young surgeons came under Dr. Stromeyer’s care with gunshot wounds of the head, accompanied by deep depression; they were both treated without trephining, and both recovered. Throughout the three campaigns of the Sleswick-Holstein war, there was only one case of trephining which gave a favorable result. Military experience makes it difficult to understand the frequent and successful performance of trepanning by the older surgeons for such slight causes as they performed it, excepting that the patients labored under little else than the effects of the operation itself, while very fatal mischief has existed in addition in those instances in which the operation has been resorted to for accidents from gunshot. A circumstance quoted by Sir G. Ballinghall particularly illustrates the favorable results of abstaining from trephining in some cases. After the battle of Talavera, a hospital which had been established in the town had to be suddenly abandoned, and an order was given for all the wounded who could march to leave it. There was no time for selection, and among those who marched were twelve or fourteen men with wounds of the head, in which the cranium was implicated, four or five having both tables fractured, and two having the globe of one eye destroyed along with fracture of the os frontis. All these men recovered, though they were sixteen days on the march, harassed and exposed to a burning sun, and had no other application than water-dressing. Of eight cases of contusion or fracture of the cranium, with displacement of both tables, recorded by Dr. Williamson, among men who were sent from India to Chatham, during the late mutiny, none had been trephined. In all these there was a depressed cicatrix, the wound having contracted and become closed by a strong fibrous investment. In one case—a wound by a musket-ball, in the center of the forehead—the ball was supposed to be still lodged within the skull. In the Fort Pitt museum are several preparations, showing depressed fracture of the inner table of the skull from gunshot, taken from patients who had recovered without trephining, and died years afterward from other causes. The edges of the depressed portions of bone had become smooth, and united by new osseous matter, and the cerebrum must have accommodated itself to the new form of the inner cranial surface. Two or three instances are known in which the course of a ball has been traced from the sight of entrance across the brain, and trephining resorted to for its extraction, with success; but there are also many others in which the mere operation of the extraction of a foreign body has apparently led to the immediate occurrence of fatal results. Moreover, splinters of bone are not unfrequently carried into the brain by balls, and these may elude observation; or the ball itself may be divided and enter the brain in different directions, as was observed in the Crimea; when the operation of trephining can only be an additional complication to the original injury, without any probable advantage. Where irregular edges, points, or pieces of bone are forced down and penetrate—not merely press upon—the cerebral substance, or where abscess manifestly exists in any known site, or a foreign substance has lodged near the surface, and relief cannot be afforded by the wound, trephining may be resorted to for the purpose; but the application of the operation, even in these cases, will be very much limited if certainty of diagnosis be insisted upon. In all other cases, it seems now generally admitted that much harm will be avoided, and benefit more probably effected, by employing long-continued constitutional treatment, viz., all the means necessary for controlling and preventing the diffusion of inflammation over the surface of the brain and its membranes,—the most careful regimen, very spare diet, strict rest, calomel and antimonials, occasional purgatives, cold application locally, so applied as to exclude the air from the wound, and free depletion by venesection, in case of inflammatory symptoms arising. Similar remarks will apply in case of lodgment of a projectile within the brain; if the site of its lodgment is obvious, it should be removed with as little disturbance as possible, but trephining for its extraction on simple inference is unwarrantable.

GUNSHOT WOUNDS OF THE SPINE.

Gunshot wounds of the spine are closely associated with similar injuries of the head. In both classes corresponding considerations must be entertained by the surgeon in reference to the important nerve-structures, with their membranes, which are likely to be involved in the injury to their osseous envelope; in both, the effects of concussion, compression, laceration of substance, or subsequent inflammatory action, chiefly attract attention. In the Surgical History of the Crimean Campaign, twenty-seven cases are noted in which vertebræ were fractured, eight being without apparent lesion of the spinal cord, and nineteen with evident lesion. Of these, twenty-five died; and two, in which the fractures were confined to the processes of the vertebræ, survived to be invalided. The gunshot wounds affecting the spinal column have not been separated from injuries in other regions in the French returns. Six men only wounded in the spine, during the late mutiny in India, arrived in Chatham. In all, they were the results of musket-balls. Two were wounds of the sacrum; in the remainder, the portions of the vertebræ fractured were the spinous processes. Concussion of the spinal column, leading to paralysis more or less persistent, is usually occasioned by fragments of shell, or stones from parapets; and in these cases the accidents are mostly accompanied by extensive lesions of the neighboring structures. In one fatal case in the Crimea, the ball passed through the spine rather below the first dorsal vertebra, leading to complete loss of sensation and voluntary motion below the seat of injury, and death on the sixteenth day afterward; in another, a rifle-bullet entered the right side of the second lumbar vertebra, traversed the spinal canal at that part, and lodged in the body of the bone. In this latter case, violent pain was complained of in the lower extremities, shooting along the groins. The patient was paraplegic, and death ensued thirty-three hours after admission. In another fatal case, a rifle-bullet passed through the right cheek, and lodged near the base of the skull. There was no paralysis, but delirium and coma supervened, and the patient died five days after receiving the wound. The bullet was found after death, lying just below the basilar process, and a large piece of the atlas was broken off and almost detached. The spinal cord did not appear to have been primarily injured, but acute inflammation had been set up, and had extended to the membranes of the brain. There is a preparation in the museum at Fort Pitt which shows fracture both of the atlas and axis, without lodgment of the ball. The patient survived thirty days. It is curious that, in a case under the care of the writer, before referred to, where a rifle-ball passed through the right loin, entered the spinal canal between the third and fourth lumbar vertebræ, breaking the laminæ, passed upward within the column, between it and the cord, and made its exit through the left intervertebral foramen between the second and third vertebræ, as shown after death, no paralysis occurred at the time of the injury, nor subsequently, nor was any evidence afforded post mortem of thecal inflammation having been excited. (See Guy’s Reports, vol. v., 1859.)

In injuries of the vertebral column and spinal cord occurring in military practice, the mischief is usually so complicated and extensive, and the medulla itself so bruised, that the cases must be very rare indeed in which the operation of trephining, if justifiable in any case, can offer the slightest prospect of benefit. M. Baudens extracted, with an elevator supplied with a canula, a ball which had lodged in the eleventh dorsal vertebra and was causing compression with complete paraplegia. The paralysis disappeared immediately after the extraction of the bullet; but tetanus came on four days afterward, and proved speedily fatal. Balls have been known to pass through the bodies of vertebræ, and apparent cure follow; but as such patients in military practice are usually invalided out of the service as soon as they are fit to leave hospital, no opportunity is afforded of observing the consequences which ulteriorly ensue.

GUNSHOT WOUNDS OF THE FACE.

Wounds of the face from musket-shot, grape, and small fragments of shell are usually more distressing from the deformity they occasion than dangerous to life. The absence of vital organs, the natural divisions among the bones, and their comparatively soft structure, rendering them less liable to extensive splitting; the copious vascular reticulation and supply rendering necrosis so much less likely and repair so much easier than in other bones; the limited amount of space occupied by the osseous structure between their respective periosteal investments, and the opportunities from the number of cavities and passages connected with this region for the escape of discharges, lead to this result. On the other hand, the vascularity of this region leads to danger both of primary and especially secondary hemorrhage—a circumstance which, in all deep wounds of this region, must be looked for as a not improbable complication. The other complications of these gunshot wounds are lesions of the organs of special sense, injury to the base of the skull, paralysis from injury to nerves, wounds of glands, their ducts, and of the lachrymal apparatus; but it is scarcely necessary to do more than allude to them, as the considerations connected with their treatment will be found elsewhere.

Wounds from cannon-shot occasionally illustrate what terrible injuries may be borne in this region without life being at once extinguished. They are the more distressing because the patient lives conscious of his sufferings without possibility of surgical alleviation. The case of an officer of Zouaves, wounded in the Crimea, is recorded, who had his whole face and lower jaw carried away by a ball, the eyes and tongue included, so that there remained only the cranium, supported by the spine and neck. This unfortunate being lived twenty hours after the injury, breathing by the laryngeal opening at the pharynx, while his gestures left no doubt that he was conscious of his condition. Mr. Guthrie has recorded a similar case which occurred in an officer during the assault of Badajos. This patient suffered distressingly from want of water to moisten his throat, but could not swallow when some was brought. One eye was left hanging in the orbit, the floor of which was destroyed, and this enabled him to write thanks for attention paid him. He did not die till the second night after the injury.

In the treatment of gunshot wounds of the face where the bones are 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.

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.

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]