The neck is often penetrated, but if the spine and the important vessels and nerve trunks escape, little apparent damage may be done. If infection occur and suppuration take place resulting abscesses should be opened promptly, as they might migrate into the thorax or axilla. Even in the neck bullets which are producing no disturbance need not be disturbed; but if positive irritation or paralysis be caused by them they should be removed. Wounds of the larynx or trachea, by involving the parts in subsequent stricture, may call for tracheotomy.
Gunshot wounds of the spinal column below the neck are often complicated by perforations of the thorax or of the abdomen. So far as the spine is concerned the principal question is regarding the injury to the cord itself. In rare instances cerebrospinal fluid escapes from the wound; hemorrhage, or even the possibility of air entering the canal, is a more common possibility. I have seen perforation of the spinal canal, in connection with penetration of the thorax and lung, so that, after the operation of laminectomy, air escaped through the bullet wound in the spine with each inspiration and expiration. Infection in spinal injuries is always to be feared and caution should be observed regarding the maintenance of asepsis. The indications for laminectomy scarcely differ from those in other injuries to the cord. (See chapter on the [Spine].)
Wounds of the thorax are more likely to be penetrating than formerly, owing to the conical shape and greater velocity of even small-arm bullets. Emphysema does not necessarily imply perforation of the lung, as air may enter through the external wound with each respiratory effort. When an imaginary line connecting the wounds of entrance and exit would naturally pass through the lung, it may be assumed that this viscus has been perforated. Signs indicating such lung injuries are peculiar pain, disorder of the respiration, more or less cough, usually with raising of blood; when the pleural cavity is more or less filled with blood there will be signs of pressure on the lung from presence of fluid. In other words a bullet wound of the lung will usually lead to a more or less complete picture of traumatic hydropneumothorax. Sometimes external hemorrhage is severe, even though it come from an intercostal or internal mammary vessel; usually the blood from these vessels escapes within the thorax. I have known an intercostal artery to be divided by a small pistol bullet which scarcely penetrated the thorax of a man, who died in consequence, when the insertion of a small tampon would have checked the hemorrhage and saved his life. Lung tissue rarely bleeds seriously. When hemorrhage is from the lung it comes from a divided vessel of some size. A collection of blood in the chest is subject to the danger of infection, and empyema is a frequent but somewhat delayed consequence of gunshot wounds of the chest; while abscesses in the lung or mediastinum occasionally result.
To the primary occlusion, which should be the first attention given to every bullet wound of the thorax, there may be added complete immobilization of the chest. Fluid already present, unless it be clotted blood, may be withdrawn by aspiration. Traumatic, not to say septic pneumonia, is a serious complication. Should any operation be called for, like removal of fragments of rib or the checking of hemorrhage, it is best to make a free opening and a liberal removal of all particles or fragments, with ample provision for drainage. Hernia of any of the viscera through such wounds occasionally occurs.
Fig. 57[12]
Result of frostbite without gunshot. After battle of Mukden. (Major Lynch.)
[12] [Figs. 57], [58] and [59], as well as the others preceding credited to Major Lynch, are due to the courtesy of Major Charles Lynch, now of the United States Army General Staff, who was attached to the Russian Army as our Military Attaché, and who took them himself.
Fig. 58
