A Treatise on Gunshot Wounds

by Sir T. Longmore

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.