Chapter IV: Part 4

=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]

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

In the latter part of the Crimean campaign, when the health of the troops and means of treatment were favorable, it was often remarkable what extensive injuries of the upper extremity, even where the joints were involved, were repaired without amputation. The following cases are examples: Sergeant Bacon, 7th Fusileers, aged thirty–six, at the attack on the Redan on the 8th of September, 1855, was wounded by a rifle–ball, which entered the head of the left humerus, shattered the bone very much, and was extracted from below the left scapula. Dr. Moorhead determined to try to preserve the limb. The head of the humerus required to be removed in small, broken fragments; and the shaft, being found to be split down between three and four inches, was to that distance removed by the saw. The case progressed favorably, and in 1857 this man was in London with a most useful arm. A young soldier of the 23d Regiment was wounded, on the 15th August, 1855, by a large grape–shot, which passed through the right arm near the shoulder, comminuting the bone for three inches and extensively destroying the soft parts. Staff–Surgeon Williams, in medical charge, despairing of saving the limb, proposed to amputate, but, at the suggestion of the late Director–General Alexander, then principal medical officer of the Light Division, arranged to allow some days to elapse to watch symptoms. The case progressed so well that the idea of amputation was abandoned, and the man recovered with a very serviceable arm. In another regiment of the Light Division, the 77th, a healthy young soldier, under the care of Surgeon Franklin, was wounded at the last assault of the Redan, and sustained a comminuted fracture of the humerus, had the elbow–joint opened, both bones of the forearm broken about two inches below the joint, and the soft parts widely opened, by a piece of shell. Here no excision was practiced, but fragments removed as they became loose; the arm, with its dressings, was supported on a zinc–wire cradle, hollowed out and bent at the elbow to the desired angle; and nourishment, with malt liquor, were freely given from the first day. Anchylosis was established, and he left for England with a useful limb. The fractures above and below the joint prevented the application of passive motion.

In these injuries, where the bone is much splintered, the detached portions, and any fragments which are only retained by very partial periosteal connections, should be removed; projecting spiculæ sawn or cut off;[11] the wound being extended at the most dependent opening where two exist, or fresh incisions being made for this purpose, if necessary; light water–dressing applied; the limb properly supported; and the case proceeded with as in cases of compound fracture from other causes. (See FRACTURE.) The same general rules also apply in preserving as much of the hand as possible, in gunshot injuries. If the shoulder or elbow joint be much injured, but the principal vessels have escaped, the articulating surfaces and broken portions should be excised. Care should be taken to see that the projectile has wholly passed out, or been removed. In a case of comminuted fracture of the humerus, in the 88th Regiment, no union having taken place a month after the injury, and some dead bone requiring removal, an incision was made for this purpose, when half the bullet was found between the fractured ends. Good union, with free motion of the arm, resulted, after this foreign body and the necrosed bone were taken away. The results of excision practiced in the shoulder and elbow joints, especially the former, after gunshot wounds, have been exceedingly satisfactory. Especial attention was directed to the practice of resections of joints after gunshot injuries in the Sleswick–Holstein campaigns between 1848 and 1851; and Dr. Friedrich Esmarch has published the results in a valuable essay on the subject. Of nineteen patients in whom the shoulder–joint was resected, in twelve a more or less useful arm was preserved; and seven died. Complete anchylosis did not occur in any one instance; and in several the power of motion became so great as to enable the men to perform heavy work. Of forty patients for whom resection of the elbow–joint was performed six died, thirty–two recovered with a more or less useful arm, one remained unhealed at the time Dr. Esmarch wrote, (1851,) and in one mortification ensued and amputation was performed. These operations present no peculiarities in the mode of performance or their after–treatment, as compared with similar resections in civil practice.

=Lower extremity.=—Gunshot wounds of the lower extremity vary much more greatly in the gravity of their results, as well as in the treatment to be adopted, according to the part of the limb injured, than happens in those of the upper extremity. As a general rule, ordinary fractures below the knee, from rifle–balls, should never cause primary amputation; while, excepting in certain special cases, in fractures above the knee, from rifle–balls, amputation is held by most military surgeons to be a necessary measure. The special cases are gunshot fractures of the upper third of the femur, especially where the hip–joint is implicated; for in these the danger attending amputation itself is so great that the question is still open, whether the safety of the patient is best consulted by excision of the injured portion of the femur, by simple removal of detached fragments and trusting to natural efforts for union, or by resorting to amputation. The decision of the surgeon must generally rest upon the extent of injury to the surrounding structures, the condition of the patient, and other circumstances of each particular case. If the femoral artery and vein have been lacerated, any attempt to preserve the limb will certainly prove fatal.

The femur—the earliest formed, the longest, most powerful, and most compact in structure of all the long bones of the body—can only be shattered by a ball striking it with immense force. Attention was specially directed in the late Crimean campaign to the question of the proper treatment of these injuries, and expectations were generally held that the advanced experience in conservative surgery would lead to many such cases terminating favorably with preservation of the limb, which previously would have been subjected to amputation. Toward the latter part of the war, all the circumstances of the patients were as favorable for testing this practice as they have been in the various _émeutes_ in Paris, with the advantages of immediate attention and all the appliances of the best hospitals close at hand. Yet, in the Surgical History of the Campaign, it is stated that only fourteen out of 174 cases of compound fracture of the femur among the men, and five out of twenty among the officers recovered without amputation being performed; that those selected for the experiment of preserving the limb were patients where the amount of injury done to the bone and soft parts was comparatively small; that where recovery ensued, it always proved tedious, and the risks during a long course of treatment numerous and grave; and that the proportion of recoveries would not appear even so large as the above, if the deaths of those who after long treatment were subjected to amputation as a last resource were included. Amputations of the thigh, however, were very fatal in their results also, the recoveries being stated to be, among the men, in the upper third 12–9/10, in the middle third 40, in the lower third 43–3/10, per cent. of cases treated. Among the officers the proportion was rather more favorable. But this percentage includes those cases in which attempts had been made to preserve the limb, and failure resulting, amputation was resorted to as a last chance of saving the patient, so that they ought to have been excluded from the lists of amputations, both primary and secondary, as commonly interpreted. On account of this comparatively indifferent success of amputation, resection of portions of the shaft of the femur was sometimes practiced; but the records state that no success attended the experiment, every case, without exception, having proved fatal.