CHAPTER V.

GUNSHOT WOUNDS OF THE CHEST.

SIMPLE flesh contusions or wounds from gunshot, bayonet, or sabre, &c., demand peculiar attention, only from the danger of inflammation being set up in the contained organs.

In some cases there is an injury of the bony or cartilaginous parietes without lesion of contents. A ball may strike the ribs and pass out a little posterior to the entrance; the patient may spit up blood at the time, or even afterwards; or the bone may become necrosed, and still the lung or pleura may not be directly injured, and these patients generally recover.

A ball sometimes runs round under the skin, leaving a dark, livid appearance along its track in the muscles or even between the ribs, and makes its exit on the opposite side, and where, to all appearance, it has gone right through the lung, and bloody sputa still further confirms this opinion.

Sometimes a ball strikes against the coat or shirt, and is withdrawn unperceived, and may thus be mistaken for a case of penetrating wound and the ball lodged.

In some cases of gunshot wounds penetrating the chest the ball is lodged, or apparently lodged. There are cases on record where balls and other extraneous bodies have been lodged in the lung, or lying loose in the cavity of the chest for years, without causing any serious disturbance to the patient; still this is far from the usual result, as death generally ensues unless the foreign body is removed, and when it does lodge, a cyst is formed by adhesive inflammation, and thus shuts it out from the rest of the system. A ball, a piece of cloth, or any other foreign substance which has been driven into the cavity of the pleura, generally gives rise to inflammation and suppuration, and ultimately death, unless removed by operation. A

ball rolling about in the chest and on the diaphragm can be ascertained (as also the presence of fluid) by percussion and auscultation, and decides the place where the opening into the chest should be made, which is generally between the eleventh and twelfth ribs, unless the original wound is in a dependent position, when it should be reopened.

In perforating gunshot wounds of the chest, the wound may or may not bleed, and there may be only slight expectoration. Although the presence of blood in the expectoration may be looked upon as pretty sure evidence of injury to the lung, still its absence is no proof that the lung has not been wounded; respiration may be difficult, extremities cold, pulse weak, and countenance pale, but much depends upon the extent or nature of the injury and the peculiar constitution of the patient.

When the wound is too small to admit of examination by the finger, it ought to be enlarged, so that the surgeon may ascertain whether the ribs have been injured, or whether any extraneous matter is lodged. The splintered portions of the rib and any foreign body should be removed, and the sharp ends of the fractured ribs rounded off, but all unnecessary probing should be avoided.

Wounds of the lung become more dangerous as they approach the root, on account of the vessels being larger. The bruised and lacerated tract of the ball bleeds more or less according to the size of the vessel injured. Generally, more or less blood is spit up, and when it is effused into the cavity of the chest it gravitates to the posterior part, or on to the diaphragm, according to the position of the patient. When the wound is closed and the effused blood accumulates, the lung becomes gradually compressed, until the hæmorrhage ceases from the pressure. Should the effusion take place to such an extent as to endanger life from asphyxia, the wound should be reopened or the chest should be punctured with a trochar.

When it becomes necessary to make an opening into the cavity of the chest for the evacuation of blood, purulent fluid, or air, the operation can be performed as follows:-The patient having been placed in a sitting position and the chest supported, an incision should be made, commencing about two inches from the spinous processes of the vertebræ, over the intercostal

space, between the eleventh and twelfth ribs, and continued obliquely downwards and outwards between them. The latissimus dorsi and serratus having been divided, the external and internal intercostal muscles are to be divided in the middle of the intercostal space, and the pleura exposed, when, if the cavity contains fluid, it will project between the ribs so as to be felt by the finger. An opening is to be made close to the margin of the mass of spinal muscles at the moment of inspiration. The opening can be enlarged, if necessary, by the introduction of a director during full inspiration. The diaphragm ascends as high as the sixth rib in full expiration, and might easily be wounded if this precaution was not adopted.

Emphysema. Fracture of the rib, which has inflicted a wound of the surface of the lung, is the most common cause of emphysema, and through the aperture thus made the air escapes into the pleural cavity, and also into the subcutaneous cellular tissue. It is seldom that emphysema follows a gunshot wound, but is somewhat more common immediately after sword or lance wounds, but not so frequent as was formerly supposed. When air is admitted into the cavity of the chest, the lung does not collapse to any great extent, but continues to do its duty, although rather imperfectly, and also in those cases where a ball passes directly through the substance of the lung. The lung can only be compressed by a fluid, as in empyema, pneumothorax, or by confined air. In some cases the patient cannot lie down, and appears to be on the point of suffocation, the face and lips purple, &c. An opening should at once be made into the chest, for the purpose of evacuating the compressed air or fluid, as the case may be. Percussion and auscultation is of great service in diagnosing these cases. When partial or general emphysema takes place, incisions should be made into the subcutaneous cellular tissue on different parts of the body.

It is seldom that a HERNIA of the lung takes place after a gunshot wound. When a portion does protrude and is left uncovered, it soon becomes livid and shrivelled, without being gangrenous, and may be removed by the knife. Hernia of a portion of the lung is most likely to occur during expiration,

and when the wound is of considerable size and has been left open. The protruded portion should be returned and covered by the integuments, sutures inserted, and a pad and bandage applied if necessary.

When death takes place shortly after the receipt of the wound, the portion of lung immediately in close contact to the tract of the ball will be inflamed and consolidated. When, after the lapse of several years, at the entrance and exit of the ball, there will, in all probability, be pleuritic adhesions, with depressed and adherent cicatrices, and along the course of the ball there will be a firm, consolidated fibrinous substance, distinctly marking the course of the ball, or a narrow, thin line may be the only evidence to show that the lung was wounded.

A ball in passing through the substance of the lung destroys the life of the part, which suppurates, and either gradually heals, leaving a depressed cicatrix, usually, although not always, attached to the walls of the chest. During life, in many cases, it interferes so little with the respiratory murmur as not to be noticed by auscultation, as was very clearly observed in several of the cases from India. On other occasions the wound does not heal, nor the track of the ball close up, but remains open and fistulous, and becomes lined by a distinct membrane, as can be seen in preparation No. 3638. (See Plate II, fig. 1.)

The two cases from India which terminated fatally, viz., Doyle and Knox, particularly that of Doyle, is interesting, as furnishing an admirable illustration of a perforating gunshot wound through the lung, the track of the ball still remaining open and fistulous, and being lined by a distinct, firm, false membrane, having numerous bronchial tubes of moderate size entering it; it also shows gangrene taking place in the healthy lung, and the wounded one remaining almost perfectly free from disease.

It is stated in the Report on the Wounded from the Crimea, vol. ii, p. 321 :-"Occasionally small circumscribed collections of pus took place in the track of the ball, surrounded and cut off from the remainder of the lung by consolidated pulmonary tissue, but in no case did the wounds of the organs remain a fistulous passage."

It is a point well worthy of remark, that although, from the

position of the apertures of entrance and exit of the old round ball, it often appears as if it must have gone through the centre of the lung, still it will be found that the lung is only wounded superficially, or not through the thickest part, as is seen in the case of Doyle. This seems to be produced by the direction of the ball being deflected by striking the ribs, and then making its exit directly opposite. If a knife or piece of wire were put from one aperture to another, it would, in this case, pass directly through the thickest part of the lung. Preparations Nos. 3637, 3638, 3639, page 86, are from Private Owen Doyle.

Frequently very severe wounds are inflicted on the upper and back part of the chest without any injury to the contents, producing great laceration of the muscles, with splintered fracture of the scapula, followed by sloughing, with tedious, deep-seated suppuration and hectic, occasionally terminating fatally, and leading to secondary affections of the lungs.

The diagnosis of wounds of the lung in gunshot injuries is frequently very difficult, and none of the ordinary signs singly can be exclusively relied on, but taken collectively, we can, in most cases, come to a correct diagnosis. The symptoms indicating a wound of the lung are hæmoptysis, dyspnoea; the passage of air by the wound or tromatapnoea, emphysema, pneumonia, and pleuritis; also the supposed course or direction of the ball can, in many cases, assist us in coming to a conclusion as to whether the lung is really wounded or not. When the lung is injured, florid blood oozes from the external wound, and frothy, arterial blood is expectorated or brought up by coughing; the pulse is weak and fluttering, nostrils distended, and eyes staring, and extremities cold.

Treatment. In wounds of the lung the first dangerous effects are exhaustion from hæmorrhage, or suffocation from blood being poured into the air-cells or cavity of the chest. The secondary affections to be dreaded are violent inflammation of the pleura or lungs, or both combined, with long, tedious suppuration, causing cough, emaciation, and hectic, which frequently leads to a fatal termination.

When the contents of the chest have sustained a lesion by contusion from round shot, which has fractured the ribs, but without penetrating or causing any external wound, the case