Part 7

GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY.

The circumstances connected with wounds in particular situations of the body, or in particular organs, are in many respects common to injuries from other causes than gunshot; and in the following remarks the attention is chiefly drawn only to those leading peculiarities which constantly demand the consideration of the army surgeon, and which spring either from the nature of gun projectiles, or the circumstances under which this branch of military practice has for the most part to be pursued.

GUNSHOT WOUNDS OF THE HEAD.

No injuries met with in war require more earnest observation and caution in their treatment than wounds of the head. The vital importance of the brain; the varied symptoms which accompany the injuries to which this organ may be subjected, directly or indirectly; the difficulty in tracing out their exact causes; the many complications which may arise in consequence of them; the sudden changes in condition which not unfrequently occur without any previous warning,—all these circumstances will keep a prudent surgeon who has charge of such wounds continually on the alert. Injuries of this class, the most slight in appearance at their onset, not unfrequently prove most grave as they proceed, from encephalitis and its consequences, or from plugging of the sinuses by coagula, leading to coma, paralysis, or pyemia; and the converse sometimes holds good with injuries presenting at first the most threatening aspects, where care is taken to avert these serious results. Much will depend on the part of the head struck, both as regards the thicker and stronger processes or portions of the skull, and the situation of the sinuses and parts of the cerebrum within; on the force and shape of the projectile; the angle at which it strikes; the age and condition of the patient; and other matters already referred to in the general remarks on gunshot wounds. Mr. Guthrie has laid down as a rule that injuries of the head, of apparently equal extent, are more dangerous on the forehead than on the side or middle portion, and still more so than those on the back part; and that a fracture of the vertex is infinitely less important than one at the base of the cranium. When the injuries are caused by rifle–balls, however, these considerations are rarely of much avail, for the power of injury is such that it can scarcely ever be confined to the immediate neighborhood of the part directly struck.

Wounds of the head may be divided, for convenience of description, into wounds of the scalp and pericranium, without fracture of bone; similar wounds complicated with fracture of the outer or of both tables, without pressure on the encephalon; wounds with fracture and depression; and lastly, wounds in which the encephalon itself has been penetrated. Severe contusion of the bones of the cranium, followed by necrosis, and even fracture, with or without depression, may occur without an open wound of the superficial investments. The case of an officer is mentioned in Dr. Macleod’s Notes of the Crimean War, who was thus killed by a round shot. The scalp was not cut, almost uninjured, but the skull was most extensively comminuted.

=Wounds of the scalp and pericranium.=—These wounds are usually inflicted by projectiles which are brought into contact at a very acute angle, so that little direct injury to the brain or its membranes is inflicted, and the surgeon’s attention need only be directed to the same considerations as must occur in any contused wounds of the scalp from other causes than gunshot. But even in these accidents, though appearing to be simple flesh wounds, serious cerebral concussion and other lesions are occasionally met with. The usual stupor and other signs of concussion may be very evanescent, or may last for several days, disappearing gradually and wholly, or entailing subsequent evils at more or less remote periods. It must not be forgotten that when the pericranium is removed by a musket–ball, however superficial the injury may seem, there is always a certain degree of injury and bruising to the bone from which it is torn, and necessary laceration of the vessels which inosculate with the nutritive capillaries of the diploë, and through them of the vessels of the meninges with which they are connected. The injury to this vascular system almost invariably leads to necrosis of the portion of the skull from which the coverings are carried away; and sometimes, even when the pericranium is not torn off, sufficient injury is inflicted to lead to a like result. The death of bone is generally limited to a thin layer of the outer table, which in due time exfoliates. The injury to the vessels ramifying between the inner surface of the cranium and dura mater may lead to serious results. There may be rupture of a sinus, leading to compression, or fatal results may ensue from inflammation and suppuration. The case of a young soldier in whom the longitudinal sinus was thus ruptured occurred to the writer. In this instance a rifle–ball had divided the scalp and pericranium about four inches in length obliquely across the skull, just anterior to the angle of the lambdoidal suture, the posterior end of the sagittal suture being exposed midway in the line of the wound. The patient vomited at the instant of the blow, and symptoms of compression, mixed with some of concussion, soon followed. He died eleven hours after the injury. At a post–mortem examination, the superior longitudinal sinus was found to be ruptured, and about four ounces of coagulated blood were lying on the brain. Two darkly–congested spots were observed in the cerebrum, one on each hemisphere, corresponding with the line of direction in which the ball had passed, and these, when cut into, presented the usual characters of ecchymoses. There was no fracture of bone. The case may be found detailed at some length in the Lancet, vol. i., 1855. When inflammation follows the passage of a ball, whether terminating in resolution or leading to abscess, the symptoms and treatment required will be the same as in similar affections from other causes. In like manner, the occurrence of erysipelas, or other complications to which these wounds of the scalp are liable, will be found treated elsewhere. (See INJURIES OF THE HEAD.)

The treatment of an ordinary gunshot wound of the scalp should be very simple. Cleansing the surface of the wound, removing the hair from its neighborhood for the easier application of dressings, lint moistened with clean water, very spare diet, and careful regulation of the excretions are the only requirements in most cases. The patient must be closely watched, so that measures may be taken to counteract inflammatory symptoms in their earliest stages. Even after one of these wounds has healed, and the patient to all appearance has quite recovered, it is necessary to enjoin continued abstinence from excesses of all kinds. Instances are frequently quoted where intoxication, a long time after the date of injury, has induced symptoms of apoplexy and death. In the Surgical History of the Crimean Campaign, the case of a soldier of the 31st Regiment, thirty–eight years old, who received a contused wound at the back of the head from a piece of shell, without section of the scalp and without lesion of the bone, is related. In this instance a small abscess formed under the scalp, and was evacuated. After the wound was healed the man suffered from constant headaches, and was invalided to England. Soon after landing he drank freely, coma followed, and he died shortly afterward. The post–mortem examination showed traces of inflammatory action in the dura mater, and “just anterior and superior to the corpora quadrigemina was a tumor the size of a walnut, composed of organized fibrin and some clotted blood.”

=Wounds complicated with fracture, but without depression on the cerebrum.=—These are very uncertain in their effects, and often apt to mislead the surgeon, from the absence of urgent symptoms in their early stages. The occurrence of fracture is, however, sufficient to show the force with which the projectile has struck the head, and to indicate the mischief which the brain and its immediate coverings have not improbably sustained.

In these injuries there may be a simple furrowing of the outer table, without injury to the inner; or there may be fissure extending to a greater or less degree of length, or radiating in several lines; or both tables may be comminuted in the direction the ball has traversed in such small portions that they lie loosely on the dura mater without much alteration in the general outline of the cranial curve. The chief and only means, in many cases, of concluding that no depression upon the cerebrum has taken place is the absence of the usual symptoms of compression; for it is well known that simple observation of the injury to the outer table, whether by sight or touch, will by no means necessarily lead to a knowledge of the amount of injury or change of position in the inner table.

When simple removal of a portion of the outer surface of the skull has been caused by the passage of the ball or other missile, the wound will sometimes heal, under judicious treatment, without any untoward symptom. A layer of the exposed surface of bone will probably exfoliate, and the wound granulate and become closed without further trouble. But such injuries, for reasons before named, are very likely to be followed by inflammation, and not improbably abscess, between the internal table and dura mater; and further, as a consequence of the vascular supply being stopped, and perhaps also partly from the effects of the original contusion by necrosis of the inner table itself. Care must be taken not to mistake one of these injuries for a depressed fracture, as is not unlikely to happen when the excavation effected by the projectile is rather deep and the edges of the bone bordering the excavation are sharp.

Fissured fractures, when the fissure extends through the skull, usually result from injuries by shell. The passage of a ball may fracture and very slightly depress a portion of the outer table of the cranium, and then the line of fracture will very closely simulate fissured fracture extending through both tables, and the diagnosis between them be excessively doubtful. When fissured fracture exists, the distance to which it may be prolonged is often quite unindicated by symptoms, and its extent is very uncertain. Fissures often extend to long distances. They may occur at a part remote from the spot directly injured. In the case of a lieutenant of the 11th Hussars, who was apparently slightly wounded at Balaklava in the middle of the forehead by a piece of shell, a fissured fracture was found, after death, across the base of the skull, quite unconnected with the primary wound, and seemingly from contre–coup. Death resulted from inflammation and suppuration set up near this indirectly–injured part. Fissured fracture of the inner table may also occur from the action of a ball without external evidence of the fracture. Such a case occurred in the 55th Regiment, in the Crimea. The soldier had a wound of the scalp along the upper edge of the right parietal bone. The ball in passing had denuded the bone; but there was no depression. The man walked to camp from the trenches without assistance, and there were no cerebral symptoms on his arrival at hospital; but five days afterward there was general edema of the scalp and right side of face, the wound became unhealthy, and slight paralysis appeared on the left side. The next day hemiphlegia was more marked, convulsion and coma followed, and he died on the thirteenth day after the injury. Pressure from a large clot of coagulum and extensive inflammatory action were the immediate causes of death; but a fissure, confined to the inner table, running in line with the course of the ball, was also discovered. A preparation of the calvarium in this case was presented by Dr. Cowan, 55th Regiment, to the museum at Fort Pitt.

The cases where comminution has resulted from the track of a ball across the skull generally present less unfavorable results than those where a single fissured fracture, extending through both tables, exists. The small, loose fragments can be removed; and if the dura mater be intact, the case, with proper care to prevent inflammatory action, may not improbably be attended with a favorable recovery.

=Wounds complicated with fracture and depression on the cerebrum.=—Such wounds are most serious, and the prognosis must be very unfavorable. They must not be judged of by comparison with cases of fracture with depression caused by such injuries as are usually met with in civil practice. The severe concussion of the whole osseous sphere by the stroke of the projectile, the bruising and injury to the bony texture immediately surrounding the spot against which it has directly impinged, as well as the contusion of the external soft parts, so that the wound cannot close by the adhesive process, constitute very important differences between gunshot injuries on the one side, and others caused by instruments impelled solely by muscular force on the other. So, also, the injury to the brain within, and its investments, is proportionably greater in such injuries from gunshot. The experience of the Crimean campaign shows that, when these injuries occurred in a severe form, they invariably proved fatal. Of seventy–six cases treated, where depression only, without penetration or perforation, existed, fifty–five proved fatal, twelve were invalided, and nine only were discharged to duty. In the twenty–one survivors, the amount of depression is stated in the history of the campaign to have been slight, though unmistakable, and all except one recovered without any bad symptom. Of eighty–six other cases where perforation or penetration of the cranium occurred, all died.

=With penetration of the cerebrum.=—It is obvious that, where a projectile has power not only to fracture, but also to penetrate the cranium, it will rarely be arrested in its progress near the wound of entrance. Either splinters of bone, or the ball, or a portion of it will be carried through the membranes into the cerebral mass. Sometimes a ball, if not making its exit by a second opening in the cranium, will lodge at the point of the cerebral substance opposite to that of its place of entrance; but the course a projectile may follow within the cranium is very uncertain.

Instances have occurred where balls have lodged in the cerebrum without giving rise to serious symptoms of danger for a long time. Such cases might lead to throwing surgeons off their guard in making a prognosis, from supposition that the ball by some accident had not lodged. The case of a soldier wounded by a ball in the posterior part of the side of the head is mentioned by Mr. Guthrie. The wound healed, and the man returned to duty; a year afterward he got drunk, and died suddenly. The ball was found in a sac lying in the corpus callosum. Another soldier wounded at Waterloo had a similar recovery, and also died after intoxication. The ball was found deeply lodged in a cyst in the posterior part of the brain. An artillery soldier was wounded, in the Crimea, by a rifle–ball, which entered near the inner angle of the left superciliary ridge. The wound progressed without a bad symptom until a month afterward, when coma came on, and death shortly followed. The ball was found in a sac, in which pus also was contained, at the base of the left anterior lobe of the brain.

=Treatment.=—The treatment of the various kinds of fractures from gunshot, and their complications, may be considered together. Formerly, a gunshot wound of the head was supposed to be in itself a sufficient indication for the use of the trephine; indeed, even where no fracture was caused, an opening was recommended by comparatively recent surgeons to be made in the cranium, to meet symptoms which might be expected to result. Modern surgeons, however, generally have made use of the trephine only when there was reason for concluding that depressed bone was leading to permanent interruption of cerebral function, or that an abscess had formed within reach, and was capable of evacuation. Preventive trephining has been proved to be useless, as well as dangerous, and is no longer an admissible operation. The tendency of the most recent experience has been to limit the practice of trephining to the narrowest sphere; and when the very great difficulty of making accurate diagnosis in these cases is considered,—whether as to the distinguishing signs of compression; the precise seat of its cause, if the compression exist; the space over which this cause, when ascertained, may extend; its persistent or temporary character; its complications; and certain dangers connected with the operation itself,—no wonder need be excited that this tendency should exist. Besides, the numerous cases which have now been noted where bone has evidently been depressed, but the brain has accommodated itself to the pressure without serious disability being caused, or where compression from effusion has been removed by absorption under proper constitutional treatment, are further causes of hesitation in respect to trephining. In the Surgical Report of the Crimean Campaign, it is stated that the trephine was only successfully applied in four cases (and none of these were from rifle–balls) during the whole war; and that in these instances the patients were subsequently subject to occasional headache and vertigo; and in the French report, by Dr Scrive, it is stated that trephining was for the most part fatal in its results in the French army. In siege operations, the experience as regards wounds of the head is always very extensive, the lower parts of the body being so much more protected in the trenches. According to Dr. Scrive’s returns, one of every three men killed in the trenches before Sebastopol, and one in every 3·4 wounded, was injured in this region. In the English returns, wounds of the head and face in the men are shown as 19·3 per cent.; in the officers, as 15 per cent.; but this is of the total wounded in the field as well as in the trenches. There was, therefore, as extensive a range for observation of the effects of trephining in the siege of Sebastopol as is likely to happen in any war. Dr. Stromeyer, who in the early part of his professional career resorted to trephining in complicated fractures of the skull, records, in his Principles of Military Surgery, that he has abandoned the practice. After the battle of Kolding, in Sleswick, in 1849, there were eight gunshot fractures of the skull, with depression, and more or less cerebral symptoms. In all these, with one exception, the detachment of the fractures was left to nature, and all recovered. One patient, from whom some fragments were removed on the seventh day, was placed in considerable danger by the treatment, and Dr. Stromeyer resolved never to adopt it again. In 1850, in Sleswick, two young surgeons came under Dr. Stromeyer’s care with gunshot wounds of the head, accompanied by deep depression; they were both treated without trephining, and both recovered. Throughout the three campaigns of the Sleswick–Holstein war, there was only one case of trephining which gave a favorable result. Military experience makes it difficult to understand the frequent and successful performance of trepanning by the older surgeons for such slight causes as they performed it, excepting that the patients labored under little else than the effects of the operation itself, while very fatal mischief has existed in addition in those instances in which the operation has been resorted to for accidents from gunshot. A circumstance quoted by Sir G. Ballinghall particularly illustrates the favorable results of abstaining from trephining in some cases. After the battle of Talavera, a hospital which had been established in the town had to be suddenly abandoned, and an order was given for all the wounded who could march to leave it. There was no time for selection, and among those who marched were twelve or fourteen men with wounds of the head, in which the cranium was implicated, four or five having both tables fractured, and two having the globe of one eye destroyed along with fracture of the os frontis. All these men recovered, though they were sixteen days on the march, harassed and exposed to a burning sun, and had no other application than water–dressing. Of eight cases of contusion or fracture of the cranium, with displacement of both tables, recorded by Dr. Williamson, among men who were sent from India to Chatham, during the late mutiny, none had been trephined. In all these there was a depressed cicatrix, the wound having contracted and become closed by a strong fibrous investment. In one case—a wound by a musket–ball, in the center of the forehead—the ball was supposed to be still lodged within the skull. In the Fort Pitt museum are several preparations, showing depressed fracture of the inner table of the skull from gunshot, taken from patients who had recovered without trephining, and died years afterward from other causes. The edges of the depressed portions of bone had become smooth, and united by new osseous matter, and the cerebrum must have accommodated itself to the new form of the inner cranial surface. Two or three instances are known in which the course of a ball has been traced from the sight of entrance across the brain, and trephining resorted to for its extraction, with success; but there are also many others in which the mere operation of the extraction of a foreign body has apparently led to the immediate occurrence of fatal results. Moreover, splinters of bone are not unfrequently carried into the brain by balls, and these may elude observation; or the ball itself may be divided and enter the brain in different directions, as was observed in the Crimea; when the operation of trephining can only be an additional complication to the original injury, without any probable advantage. Where irregular edges, points, or pieces of bone are forced down and penetrate—not merely press upon—the cerebral substance, or where abscess manifestly exists in any known site, or a foreign substance has lodged near the surface, and relief cannot be afforded by the wound, trephining may be resorted to for the purpose; but the application of the operation, even in these cases, will be very much limited if certainty of diagnosis be insisted upon. In all other cases, it seems now generally admitted that much harm will be avoided, and benefit more probably effected, by employing long–continued constitutional treatment, viz., all the means necessary for controlling and preventing the diffusion of inflammation over the surface of the brain and its membranes,—the most careful regimen, very spare diet, strict rest, calomel and antimonials, occasional purgatives, cold application locally, so applied as to exclude the air from the wound, and free depletion by venesection, in case of inflammatory symptoms arising. Similar remarks will apply in case of lodgment of a projectile within the brain; if the site of its lodgment is obvious, it should be removed with as little disturbance as possible, but trephining for its extraction on simple inference is unwarrantable.

GUNSHOT WOUNDS OF THE SPINE.

Gunshot wounds of the spine are closely associated with similar injuries of the head. In both classes corresponding considerations must be entertained by the surgeon in reference to the important nerve–structures, with their membranes, which are likely to be involved in the injury to their osseous envelope; in both, the effects of concussion, compression, laceration of substance, or subsequent inflammatory action, chiefly attract attention. In the Surgical History of the Crimean Campaign, twenty–seven cases are noted in which vertebræ were fractured, eight being without apparent lesion of the spinal cord, and nineteen with evident lesion. Of these, twenty–five died; and two, in which the fractures were confined to the processes of the vertebræ, survived to be invalided. The gunshot wounds affecting the spinal column have not been separated from injuries in other regions in the French returns. Six men only wounded in the spine, during the late mutiny in India, arrived in Chatham. In all, they were the results of musket–balls. Two were wounds of the sacrum; in the remainder, the portions of the vertebræ fractured were the spinous processes. Concussion of the spinal column, leading to paralysis more or less persistent, is usually occasioned by fragments of shell, or stones from parapets; and in these cases the accidents are mostly accompanied by extensive lesions of the neighboring structures. In one fatal case in the Crimea, the ball passed through the spine rather below the first dorsal vertebra, leading to complete loss of sensation and voluntary motion below the seat of injury, and death on the sixteenth day afterward; in another, a rifle–bullet entered the right side of the second lumbar vertebra, traversed the spinal canal at that part, and lodged in the body of the bone. In this latter case, violent pain was complained of in the lower extremities, shooting along the groins. The patient was paraplegic, and death ensued thirty–three hours after admission. In another fatal case, a rifle–bullet passed through the right cheek, and lodged near the base of the skull. There was no paralysis, but delirium and coma supervened, and the patient died five days after receiving the wound. The bullet was found after death, lying just below the basilar process, and a large piece of the atlas was broken off and almost detached. The spinal cord did not appear to have been primarily injured, but acute inflammation had been set up, and had extended to the membranes of the brain. There is a preparation in the museum at Fort Pitt which shows fracture both of the atlas and axis, without lodgment of the ball. The patient survived thirty days. It is curious that, in a case under the care of the writer, before referred to, where a rifle–ball passed through the right loin, entered the spinal canal between the third and fourth lumbar vertebræ, breaking the laminæ, passed upward within the column, between it and the cord, and made its exit through the left intervertebral foramen between the second and third vertebræ, as shown after death, no paralysis occurred at the time of the injury, nor subsequently, nor was any evidence afforded post mortem of thecal inflammation having been excited. (See Guy’s Reports, vol. v., 1859.)

In injuries of the vertebral column and spinal cord occurring in military practice, the mischief is usually so complicated and extensive, and the medulla itself so bruised, that the cases must be very rare indeed in which the operation of trephining, if justifiable in any case, can offer the slightest prospect of benefit. M. Baudens extracted, with an elevator supplied with a canula, a ball which had lodged in the eleventh dorsal vertebra and was causing compression with complete paraplegia. The paralysis disappeared immediately after the extraction of the bullet; but tetanus came on four days afterward, and proved speedily fatal. Balls have been known to pass through the bodies of vertebræ, and apparent cure follow; but as such patients in military practice are usually invalided out of the service as soon as they are fit to leave hospital, no opportunity is afforded of observing the consequences which ulteriorly ensue.

GUNSHOT WOUNDS OF THE FACE.

Wounds of the face from musket–shot, grape, and small fragments of shell are usually more distressing from the deformity they occasion than dangerous to life. The absence of vital organs, the natural divisions among the bones, and their comparatively soft structure, rendering them less liable to extensive splitting; the copious vascular reticulation and supply rendering necrosis so much less likely and repair so much easier than in other bones; the limited amount of space occupied by the osseous structure between their respective periosteal investments, and the opportunities from the number of cavities and passages connected with this region for the escape of discharges, lead to this result. On the other hand, the vascularity of this region leads to danger both of primary and especially secondary hemorrhage—a circumstance which, in all deep wounds of this region, must be looked for as a not improbable complication. The other complications of these gunshot wounds are lesions of the organs of special sense, injury to the base of the skull, paralysis from injury to nerves, wounds of glands, their ducts, and of the lachrymal apparatus; but it is scarcely necessary to do more than allude to them, as the considerations connected with their treatment will be found elsewhere.

Wounds from cannon–shot occasionally illustrate what terrible injuries may be borne in this region without life being at once extinguished. They are the more distressing because the patient lives conscious of his sufferings without possibility of surgical alleviation. The case of an officer of Zouaves, wounded in the Crimea, is recorded, who had his whole face and lower jaw carried away by a ball, the eyes and tongue included, so that there remained only the cranium, supported by the spine and neck. This unfortunate being lived twenty hours after the injury, breathing by the laryngeal opening at the pharynx, while his gestures left no doubt that he was conscious of his condition. Mr. Guthrie has recorded a similar case which occurred in an officer during the assault of Badajos. This patient suffered distressingly from want of water to moisten his throat, but could not swallow when some was brought. One eye was left hanging in the orbit, the floor of which was destroyed, and this enabled him to write thanks for attention paid him. He did not die till the second night after the injury.

In the treatment of gunshot wounds of the face where the bones are splintered and torn, the surgeon should always retain and replace as many of the broken portions as possible. It is often surprising how small connections with neighboring soft parts will suffice to maintain vitality and lead to restored union in this region. A case which occurred to the writer in August, 1855, in a private of the 19th Regiment, is detailed in the Lancet, p. 436, of that year. The wound was caused by a fragment of shell. The right half of the arch of the palate was jammed in and fixed at right angles to the other half, and the upper maxillary bone was so comminuted that it was scarcely possible to note the directions of the lines of fracture. The lower maxilla was broken in three places, and there was extensive laceration of the soft parts. Great difficulty was met with at first in unlocking the parts of the palate which had been driven into each other, and, when they were separated, the right half hung down loosely in the mouth; yet favorable union was obtained between all these fractures, the broken portions being adjusted so that the man recovered with both the upper and lower maxillæ consolidated in their normal relations to each other. No teeth had been driven out of their sockets, and they were very useful as points of support in the steps taken to procure coaptation of the disunited fragments. In the Lancet of February 24th, 1855, may be found the description of a series of wounds of the face, from the Crimea, which were examined by Mr. Samuel Solly, and described by him, some of them illustrating how wonderfully the larger arteries often escape in these injuries. In one, loss of the sense of taste on one side of the tongue had resulted; in two, there was partial paralysis of the portio dura; in another, impaired action of the jaw. In one, where a ball entered at the junction of the malar bone and os frontis on the left side, and descended and escaped at the posterior border of the sterno–mastoid muscle, the sight of the left eye was destroyed, and that of the right weakened; and constant headache, dullness of intellect, and incapacity for mental application remained. The injury had originally been followed by symptoms of cerebral concussion. In another case, the man came home with an iron shot firmly wedged and lodged in the center of the vomer. When extracted, at Chatham, by Staff–Surgeon Parry, it was found to weigh nearly four ounces. The returns of the Crimean campaign, from the 1st of April, 1855, to the end of the war, show 533 wounds of the face, of which number 445 returned to duty, 74 were invalided, and 14 died. Bones were penetrated in 107 of these cases, one eye was injured in 42, and both eyes in 2 cases. Mr. Guthrie has recorded that he several times saw both eyes destroyed by one ball, without much other mischief, and one, and even both, rendered amaurotic by balls which had passed behind the eyes. Of 21 cases of wounds of the face, with injuries to bones, returned to England from the late Indian mutiny, and recorded by Dr. Williamson, 11 had lost the sight of one eye, and 1 of both eyes; 6 cases were complicated with fracture of the lower jaw, and in 3 of these the fracture remained ununited.

GUNSHOT WOUNDS OF THE CHEST.

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.