A Treatise on Gunshot Wounds

by Sir T. Longmore

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.