A young man, aged fifteen, was wounded by small shot in the chest, between the first and second ribs, and near the sternum, at the distance of about forty-eight paces. He ran about six hundred paces, fell, and died thirty-eight hours afterward. On opening the injured cavity of the thorax, it was found to contain twenty-eight ounces of blood, the lung having collapsed to one-fourth its natural size. An opening on its upper part corresponded to the external one in the paries; but the track of the shot could not be traced into its substance for more than two inches and three-quarters; a lacerated spot was, however, perceived at the lower edge of the sixth rib, about two inches from its head, at which part the intercostal artery was found to be torn through; the shot could not be found, and there was no opening in the skin behind.
The discussions which took place on this case led to the statement of an anatomical fact—that when a man is standing erect, a line drawn horizontally from the upper border of the second rib in front would touch the upper edge of the fifth rib behind, and that very little inclination, viz., an inch and a half, was necessary to make the shot wound the intercostal artery of the sixth. Auscultation would have made known the extravasation, and relief might have been given by an incision over the spot where uneasiness was felt; for the loss of blood was not sufficient of itself to destroy life, unless some other injury had been sustained, which was not perceived.
364. Wounds of the neck which are made with swords, or by knives or razors, by persons attempting to destroy themselves, are to be treated on two great principles. The first is, not to place the parts in contact until all hemorrhage has ceased, lest the patient be suffocated. In the mean time, while any oozing continues, a soft sponge should be placed between the edges of the cut. When the larynx or trachea is obstructed by a quantity of blood, it may be sucked out, or drawn up by an exhausting pump, and it may be advisable in some cases to introduce a tube. If the trachea be cut across, a stitch will be necessary to keep the ends in contact. The second is, to keep the divided parts in contact afterward, by position and bandage, but not by suture. If the œsophagus be wounded, nourishment should be administered by a gum-elastic tube introduced through the nares into the stomach. It is almost unnecessary to add that the artery, if wounded, should be secured by ligature. A hole in the internal jugular vein may be closed by a thread passed around it when raised by a tenaculum.
Captain Hall, of the 43d Regiment, was wounded by a ball which passed between the upper part of the back of the larynx and the termination of the pharynx, without causing much further inconvenience than the loss of voice. In this instance it must have been the superior laryngeal nerve that was injured, and not the recurrent, yet the voice could only be heard in a whisper, and was not completely recovered for years. If a ball should lodge in the trachea, it must be removed by the operation of laryngotomy or tracheotomy, if the original wound cannot be enlarged; although Birch, says Christopher Wren, hung up a man wounded in this way by the heels, when the ball dropped out through the glottis and mouth. General Sir E. Packenham, who was killed at New Orleans by a ball which went through the common iliac artery, had been twice shot through the neck in earlier life. The first shot, which went through high up from right to left, turned his head a little to the right. The second shot, from left to right, brought it straight. My kind and excellent friend had ever afterward a great respect and regard for the doctors and a strong feeling for the wounded. The recollection of that regard, and the advantages derived from it, have made me sometimes think it might be advantageous for the unfortunate as well as for the doctors if every general could be at least shot once through the neck or the body, before he was raised to the command of an army in the field; for there is nothing like actual experience of suffering to make men feel for their fellow-creatures in distress. A Minister at War would not perhaps be the worse for a little personal experience in this matter.
365. Wounds of the face made by swords or sharp-cutting instruments should be always retained in contact by sutures. When the cut is of small extent, and not deep, the skin only should be included by the thread, and that in the slightest possible manner, and the part supported by adhesive plaster and bandage. When the cheek is divided into the mouth, one, two, or more sutures may require to be inserted more deeply, but the deformity of a broad cicatrix will in general be avoided, by carefully sewing up the whole line, taking the very edge of skin only; and a cut in the bone or bones of the cheek should not prevent the attempt being made to unite the external wound over it.
Incised or even lacerated wounds of the eyelids and brows should be united by suture, as far as can possibly be done in the first instance, by which a subsequent painful operation may be avoided; great care should be taken in doing this; the suture must be inserted through the eyelid, and a leaden thread is often the best, the first being introduced at the very edge of the lid, and two, or as many more afterward as may be necessary. They may remain for three or more days, as circumstances seem to require. If the eye be wounded, any part protruding beyond the sclerotic coat should be cut off with scissors; but the eye, however injured, should not be removed unless the ball be detached in every direction, or destroyed. The treatment should be strictly antiphlogistic, in order to prevent suppuration of the eyeball, which may in general be effected, if too much injury have not been done to it, and if the treatment be sufficiently decided and well continued. These observations apply to the nose and ears, and all parts not actually separated—or, if separated, for a short time only—should be replaced in the manner directed, and every attempt made to procure reunion. If this should fail, surgery may yet be able to yield assistance by replacing the loss by a piece of integument dislodged from the neighboring parts—a proceeding requiring a separate consideration. Injuries from musket-balls are often attended by considerable laceration, particularly when near the eyelids. Whenever this occurs, the parts likely to adhere should be brought together by suture, after any splinters of bone which may present themselves, or can be seen or felt, have been removed from the holes made by the ball. If the bones should be broken, and not splintered, they will frequently reunite under proper management.
366. Wounds of the eye from small shot are remediable when these small bodies lodge in the cornea or sclerotica, whence they may be removed by any sharp-pointed instrument. When a shot or piece of a copper cap is driven through the cornea, into the iris, or lies in the anterior chamber, it should be removed by an incision to the extent of about one-fourth or one-fifth of the cornea, near its junction with the sclerotica, but in these cases a cataract, if not amaurosis, frequently results. When the shot passes through all the coats of the eye, it can neither be seen nor removed with safety; vision will be lost, much pain may be endured, and the eye will frequently be destroyed by suppuration, or by a gradual softening, and ultimate diminution in size. A contused wound from a large shot which only injures the coats of the eye, but does not perforate them, will oftentimes be cured by a proper antiphlogistic treatment, which in all cases should be most strictly enforced, although loss of sight is a frequent consequence after such injuries.
When a ball lodges behind the eye, it usually causes protrusion, inflammation, and suppuration of that organ. If it be not discovered by the usual means, its lodgment may be suspected from the gradual protrusion and inflammation of the eye itself. If it be discovered, it should be removed together with the eye, if such proceeding be necessary for its exposure. If suppuration have commenced in the eye, a deep incision into the organ will arrest, if not prevent, the horrible sufferings about to take place, and allow of the removal of the offending cause. If the eye remain in a state of chronic disease and suffering, a similar incision will give the desired relief. If the chronic state of irritation affect the other eye, the incision and sinking of the ball of the one first affected or injured is urgently demanded, and should not be delayed. If the back part of the eye be left with the muscles attached to it, a stump remains, against which an artificial eye may be fitted, so as sometimes to render the loss of the natural one almost unobservable.
367. I have several times seen both eyes destroyed and sunk by one ball, with little other inconvenience to the patient; one eye sunk, the other amaurotic, and both even amaurotic, almost without a sign of injury, by balls which had passed from side to side through both orbits, but behind the eyes. When the eye becomes amaurotic from a lesion of the first branch of the fifth pair of nerves, the pupil does not become dilated; the iris retains its usual action, although the retina may be insensible and vision destroyed. This was well shown in the case of the late Major-General Sir A. Leith, who was wounded by a sword in the forehead, this nerve being divided. It has so often occurred as to leave no doubt of the fact, and of the error formerly existing on this point.
368. Penetrating wounds implicating the bones of the face are always distressing. When the bones of the nose are carried away, there must always be some deformity remaining, although there is oftentimes but little suffering. When these bones are merely splintered and depressed, great pains should be taken to keep them properly elevated. If the duct of the parotid gland be implicated by an incised wound, care should be taken to divide the cheek into the mouth, if it should not have been already done, and to keep the incised wound open until the external one is closed. If a salivary fistula have formed externally, from inattention or otherwise, it must be treated according to the ordinary methods adopted in such cases. When a wound of the gland itself becomes fistulous, and weeps, which is a rare occurrence, it will be best treated by actual or potential cauterization, if moderate pressure should fail. When these wounds are of some extent, they are often followed by partial paralysis, in consequence of the seventh pair of nerves being injured, when the mouth is drawn somewhat to the other side. When the lachrymal bones or sac are injured by balls or swords, the tears usually continue through life to run over, and give inconvenience, although much good may be done by early attention to the injuries of this part. Wounds injuring the upper jaw are oftentimes followed by much suffering, and by permanent inconvenience.