A Treatise on Gunshot Wounds

by Sir T. Longmore

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.