Chapter XXXVI

.) Septic complications are more likely to occur in proportion to disregard of antiseptic precautions in the first treatment. Usually the most serious head injuries are those connected with penetrating bullets. Sometimes the skull undergoes extensive shattering, and occasionally the base is fractured. Instantaneous death, such as occurs when a soldier is beheaded by a cannon ball, sometimes causes a peculiar cataleptic rigidity, which is a species of immediate postmortem rigidity, by which a body may be maintained in the position it occupied when struck. Obviously, lesions at the base are still more serious than those of the vertex, and wounds of the cerebrum are nearly always fatal. I have seen a number of men who had been shot entirely through the head--by Mauser or smaller bullets--who, nevertheless, recovered more or less completely. In one soldier, I recall, the bullet traversed an orbit in such a way as to divide the optic nerve. He was blinded, but recovered most of his other functions; he remained well for some years, and then developed symptoms of insanity. Epilepsy and other psychical disturbances are all more or less frequent after head injuries. Plate XIII illustrates how a bullet may be, apparently, harmlessly embedded in the interior of the cranium. Sometimes years after such injuries

## active symptoms make their first appearance. There can be no question

as to the value of the information usually afforded in such cases by the aid of the _x_-rays.

The same necessity exists here as elsewhere for primary antiseptic occlusion, including careful shaving and cleansing of the scalp. Inasmuch as nearly every gunshot wound of the skull calls for subsequent operation--just as does almost every compound fracture--the parts should be prepared for it early, and everything else should be left until the time when the surgeon is ready to make a complete operation and meet all the indications. In such a case hemorrhage may be temporarily checked by tampon. The surgeon should not omit to take advantage of all the information which a study of cerebral localization may afford him, since localizing symptoms may reveal not only the course of a bullet, but something regarding its location.

_Penetrating wounds of the face_ are less serious than those of the cranium proper. Occasionally a bullet striking a tooth will displace it and drive it in some other portion of the face, _e. g._, the tongue. Bullets and loose pieces of bone should be removed in wounds of the face. Hemorrhage can usually be controlled by tampons. Interdental splints may often be used to advantage, and in every case where the mouth has been injured antiseptic mouth-washes should be frequently used; in the case of the nose, an antiseptic spray should be employed.

The _neck_ is often penetrated, but if the spine and the important vessels and nerve trunks escape, little apparent damage may be done. If infection occur and suppuration take place resulting abscesses should be opened promptly, as they might migrate into the thorax or axilla. Even in the neck bullets which are producing no disturbance need not be disturbed; but if positive irritation or paralysis be caused by them they should be removed. Wounds of the larynx or trachea, by involving the parts in subsequent stricture, may call for tracheotomy.

_Gunshot wounds of the spinal column_ below the neck are often complicated by perforations of the thorax or of the abdomen. So far as the spine is concerned the principal question is regarding the injury to the cord itself. In rare instances cerebrospinal fluid escapes from the wound; hemorrhage, or even the possibility of air entering the canal, is a more common possibility. I have seen perforation of the spinal canal, in connection with penetration of the thorax and lung, so that, after the operation of laminectomy, air escaped through the bullet wound in the spine with each inspiration and expiration. Infection in spinal injuries is always to be feared and caution should be observed regarding the maintenance of asepsis. The indications for laminectomy scarcely differ from those in other injuries to the cord. (See chapter on the Spine.)

_Wounds of the thorax_ are more likely to be penetrating than formerly, owing to the conical shape and greater velocity of even small-arm bullets. Emphysema does not necessarily imply perforation of the lung, as air may enter through the external wound with each respiratory effort. When an imaginary line connecting the wounds of entrance and exit would naturally pass through the lung, it may be assumed that this viscus has been perforated. Signs indicating such lung injuries are peculiar pain, disorder of the respiration, more or less cough, usually with raising of blood; when the pleural cavity is more or less filled with blood there will be signs of pressure on the lung from presence of fluid. In other words a bullet wound of the lung will usually lead to a more or less complete picture of traumatic hydropneumothorax. Sometimes external hemorrhage is severe, even though it come from an intercostal or internal mammary vessel; usually the blood from these vessels escapes within the thorax. I have known an intercostal artery to be divided by a small pistol bullet which scarcely penetrated the thorax of a man, who died in consequence, when the insertion of a small tampon would have checked the hemorrhage and saved his life. Lung tissue rarely bleeds seriously. When hemorrhage is from the lung it comes from a divided vessel of some size. A collection of blood in the chest is subject to the danger of infection, and empyema is a frequent but somewhat delayed consequence of gunshot wounds of the chest; while abscesses in the lung or mediastinum occasionally result.

To the _primary occlusion_, which should be the _first attention given to every bullet wound of the thorax_, there may be added complete immobilization of the chest. Fluid already present, unless it be clotted blood, may be withdrawn by aspiration. Traumatic, not to say septic pneumonia, is a serious complication. Should any operation be called for, like removal of fragments of rib or the checking of hemorrhage, it is best to make a free opening and a liberal removal of all particles or fragments, with ample provision for drainage. Hernia of any of the viscera through such wounds occasionally occurs.

[Illustration: FIG. 57[12]

Result of frostbite without gunshot. After battle of Mukden. (Major Lynch.)]

[12] Figs. 57, 58 and 59, as well as the others preceding credited to Major Lynch, are due to the courtesy of Major Charles Lynch, now of the United States Army General Staff, who was attached to the Russian Army as our Military Attaché, and who took them himself.

[Illustration: FIG. 58

Result of frostbite after two days and nights of exposure. After battle of Mukden. (Major Lynch.)]

The subject of _injuries to the heart_ will be dealt with in the

## chapter devoted to the surgery of that organ. Not every perforation of

the heart substance is fatal, and there are enough successful cases on record of radical intervention by resection of the thoracic wall, and of exposure of the pericardium, even of the heart itself, to justify this method of attack in any case which will permit of it. Not the least of the dangers pertaining to heart injuries is the impediment to heart action caused by a collection of blood in the pericardial sac. Should anything further be called for it would be warrantable at any time to explore this sac and withdraw fluid through the aspirating needle, through a trocar, or even by incision and drainage.

In the _abdomen_ all conceivable forms of injury may be met with, from contusions produced possibly by a spent cannon ball, to lacerations from fragments of a bursting shell and multiple perforations produced by one or more bullets. A first requisite in all such injuries is immediate antiseptic occlusion. This will not prevent such prompt and further study of the case as may indicate suitable treatment. When shock is extreme, indicating the possible result of contusions or laceration, or when perforation of the stomach, intestines, or bladder is probable, laparotomy should be performed at once. According to De Nancrède the order of probable frequency of these injuries of the abdomen is small intestine, large intestine, liver, stomach, kidney, spleen, and pancreas. Multiple lesions are also common. The immediate dangers are those from shock and hemorrhage, to be supplemented later by imminent danger of septic peritonitis.

[Illustration: FIG. 59

## Scene in operating room in Second Field Hospital of Fifth Division of

Japanese Army, at Mukden Railway Station. (Major Lynch.)]

The modern small bullet causes few surface indications as to the amount of damage done within, as in the thorax. A careful consideration of the location of the wounds of entrance and exit will indicate the probability of perforation, especially of the hollow viscera. The appearance of blood, either in the mouth or from the rectum or urethra, the recognition of a rapidly accumulating amount of fluid, the presence of gas in the abdomen, are all significant indications of perforating injury. Several years ago Senn advised the insufflation of hydrogen gas into the colon, on the theory that its escape from the intestine into the abdominal cavity and thence out of one of the abdominal wounds, where it could be lighted as it passed through a small tube, would afford a certain and unmistakable test as to perforation of the bowel, and such is undoubtedly the case. Nevertheless, it is not one which is always easy or even possible of application, and no time should be wasted in waiting for a supply of hydrogen for this purpose.

The safest course and the most life-saving one is _exploration_ when there is any doubt as to the nature of the injury. This means an operator possessed of good judgment, a suitable environment, rigid antiseptic precautions, and a small incision to begin with, with the finger as the best of all probes. The escape of bloody fluid, bloody urine, or fecal matter will immediately justify a much more extended incision through which complete orientation may be obtained. The first incision may be best made as an enlargement of the bullet wound, but any extensive operation within the abdominal cavity can be made through a sufficiently long median incision. Only in this way can the source of hemorrhage be ascertained. Thus the intestines may be systematically gone over inch by inch. When perforations are found they may be either dealt with as they appear--each opening being closed transversely--or the entire intestinal canal may be exposed. Contused spots will eventually slough, and should be treated as if they were perforations. Injuries, therefore, of short portions of the intestines might justify the removal of several inches. Instead of making multiple resections, it would be better to remove _en masse_ the involved portion of the bowel, and then make lateral anastomosis or an end-to-end suture. Perforations of the mesentery as well as tears in the omentum should be carefully closed. Everything which is not vitally necessary and which has been injured should be removed. The posterior surface of the stomach, the lesser cavity of the omentum, the region of the gall-bladder and pancreas, the kidneys and ureters, and the bladder should be examined, in order that injury may be detected. After operations of this kind the abdominal cavity may be flushed with sterile salt solution; while the question of drainage should be decided upon the individual merits and indications of each case, as it is safer to drain the contaminated peritoneal cavity than to rely upon mere cleansing and drying.

If the _spleen or kidney_ be injured, it is safer to make a primary removal of them; if they are not removed, posterior drainage should be made.

In uncertain cases of abdominal wounds the back as well as the abdomen should be scrubbed in order that if posterior drainage be necessary it can be made without delay.

The _after-treatment_ of such patients does not differ from that of non-traumatic cases. Abstention from stomach feeding, the judicious use of salines, dependence upon hypodermoclysis and rectal nourishment, and the use of opiates are all matters of importance.

When the _bladder_ has been injured there is usually more or less injury of some of the other pelvic organs. An empty bladder will escape more often than one which is full; while the latter will nearly always leak into the peritoneal cavity or along the bullet track, thus infecting one or both. The appearance of blood in the urine is one of the indications of bladder injury, and sometimes the bladder will fill with blood clot, which will produce the phenomenon of retention. Such a case may rapidly succumb to infection if relief be not promptly afforded, and this may come through abdominal section or a combination of it with exploration through the perineum. Particles of clothing and bone and even the bullet itself have been removed from the cavity of the bladder. It is advisable to open the bladder from below and insert a self-retaining drainage tube, by which, especially when combined with the method of drainage by siphonage, as described in the chapter on Surgery of the Bladder, a satisfactory and continuous emptying of the organ may be maintained.

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