A siege engine is a device that is designed to break or circumvent heavy castle doors, thick city walls and other fortifications in siege warfare.
Some are immobile, constructed in place to attack enemy fortifications
from a distance, while others have wheels to enable advancing up to the
enemy fortification. There are many distinct types, such as siege towers that allow foot soldiers to scale walls and attack the defenders, battering rams that damage walls or gates, and large ranged weapons (such as ballistae, catapults/trebuchets and other similar constructions) that attack from a distance by launching projectiles. Some complex siege engines were combinations of these types.
Siege engines are fairly large constructions – from the size of a small house to a large building. From antiquity up to the development of gunpowder,
they were made largely of wood, using rope or leather to help bind
them, possibly with a few pieces of metal at key stress points. They
could launch simple projectiles using natural materials to build up force by tension, torsion, or, in the case of trebuchets, human power or counterweights coupled with mechanical advantage. With the development of gunpowder and improved metallurgy, bombards and later heavy artillery became the primary siege engines.
Siege
engine in Assyrian relief of attack on an enemy town during the reign
of Tiglath-Pileser III 743-720 BC from his palace at Kalhu (Nimrud)
The earliest siege engines appear to be simple movable roofed towers
used for cover to advance to the defenders' walls in conjunction with scaling ladders, depicted during the Middle Kingdom of Egypt. Advanced siege engines including battering rams were used by Assyrians, followed by the catapult in ancient Greece.
In Kush siege towers as well as battering rams were built from the 8th century BC and employed in Kushite siege warfare, such as the siege of Ashmunein in 715 BC.
The Spartans used battering rams in the Siege of Plataea
in 429 BC, but it seems that the Greeks limited their use of siege
engines to assault ladders, though Peloponnesian forces used something
resembling flamethrowers.
The first Mediterranean people to use advanced siege machinery were the Carthaginians, who used siege towers and battering rams against the Greek colonies of Sicily. These engines influenced the ruler of Syracuse, Dionysius I, who developed a catapult in 399 BC.
The first two rulers to make use of siege engines to a large extent were Philip II of Macedonia and Alexander the Great. Their large engines spurred an evolution that led to impressive machines, like the Demetrius Poliorcetes' Helepolis
(or "Taker of Cities") of 304 BC: nine stories high and plated with
iron, it stood 40 m (130 ft) tall and 21 m (69 ft) wide, weighing 180 t
(400,000 lb). The most used engines were simple battering rams, or tortoises,
propelled in several ingenious ways that allowed the attackers to reach
the walls or ditches with a certain degree of safety. For sea sieges or
battles, seesaw-like machines (sambykē or sambuca)
were used. These were giant ladders, hinged and mounted on a base
mechanism and used for transferring marines onto the sea walls of
coastal towns. They were normally mounted on two or more ships tied
together and some sambykē included shields at the top to protect the
climbers from arrows. Other hinged engines were used to catch enemy
equipment or even opposing soldiers with opposable appendices which are
probably ancestors to the Romancorvus. Other weapons dropped heavy weights on opposing soldiers.
Roman siege engines.
The Romans preferred to assault enemy walls by building earthen ramps (agger) or simply scaling the walls, as in the early siege of the Samnite city of Silvium (306 BC). Soldiers working at the ramps were protected by shelters called vineae, that were arranged to form a long corridor. Convex wicker shields were used to form a screen (plutei or plute in English) to protect the front of the corridor during construction of the ramp. Another Roman siege engine
sometimes used resembled the Greek ditch-filling tortoise of Diades,
this galley (unlike the ram-tortoise of Hegetor the Byzantium) called a musculus
("muscle") was simply used as cover for sappers to engineer an
offensive ditch or earthworks. Battering rams were also widespread. The Roman Legions first used siege towers c. 200 BC; in the first century BC, Julius Caesar accomplished a siege at Uxellodunum in Gaul using a ten-story siege tower.
Romans were nearly always successful in besieging a city or fort, due
to their persistence, the strength of their forces, their tactics, and
their siege engines.
The first documented occurrence of ancient siege engine pieces in Europe was the gastraphetes
("belly-bow"), a kind of large crossbow. These were mounted on wooden
frames. Greater machines forced the introduction of pulley system for
loading the projectiles, which had extended to include stones also.
Later torsion siege engines appeared, based on sinew springs. The onager was the main Roman invention in the field.
The earliest documented occurrence of ancient siege-artillery pieces
in China was the levered principled traction catapult and an 8 ft
(2.4 m) high siege crossbow from the Mozi (Mo Jing), a Mohist text written at about the 4th – 3rd century BC by followers of Mozi who founded the Mohist school of thought during the late Spring and Autumn period and the early Warring States period.
Much of what we now know of the siege technology of the time comes from
Books 14 and 15 (Chapters 52 to 71) on Siege Warfare from the Mo Jing.
Recorded and preserved on bamboo strips, much of the text is now
extremely corrupted. However, despite the heavy fragmentation, Mohist
diligence and attention to details which set Mo Jing apart from other
works ensured that the highly descriptive details of the workings of
mechanical devices like Cloud Ladders, Rotating Arcuballistas and
Levered Catapults, records of siege techniques and usage of siege
weaponry can still be found today.
Elephant
Indian, Sri Lankan, Chinese and Southeast Asian kingdoms and empires used war elephants as battering rams.
Medieval designs include a large number of catapults such as the mangonel, onager, the ballista, the traction trebuchet
(first designed in China in the 3rd century BC and brought over to
Europe in the 4th century AD), and the counterweight trebuchet (first
described by Mardi bin Ali al-Tarsusi
in the 12th century, though of unknown origin). These machines used
mechanical energy to fling large projectiles to batter down stone walls.
Also used were the battering ram and the siege tower,
a wooden tower on wheels that allowed attackers to climb up and over
castle walls, while protected somewhat from enemy arrows.
A typical military confrontation in medieval times was for one side to lay siege to an opponent's castle.
When properly defended, they had the choice whether to assault the
castle directly or to starve the people out by blocking food deliveries,
or to employ war machines specifically designed to destroy or
circumvent castle defenses. Defending soldiers also used trebuchets and
catapults as a defensive advantage.
Other tactics included setting fires
against castle walls in an effort to decompose the cement that held
together the individual stones so they could be readily knocked over.
Another indirect means was the practice of mining,
whereby tunnels were dug under the walls to weaken the foundations and
destroy them. A third tactic was the catapulting of diseased animals or
human corpses over the walls in order to promote disease which would
force the defenders to surrender, an early form of biological warfare.
The development of specialized siege artillery, as distinct from field artillery, culminated during World War I and World War II. During the First World War, huge siege guns such as Big Bertha were designed to see use against the modern fortresses of the day. The apex of siege artillery was reached with the German Schwerer Gustav gun, a huge 80 cm (31 in) caliber railway gun, built during early World War II. Schwerer Gustav was initially intended to be used for breaching the French Maginot Line
of fortifications, but was not finished in time and (as a sign of the
times) the Maginot Line was circumvented by rapid mechanized forces
instead of breached in a head-on assault. The long time it took to
deploy and move the modern siege guns made them vulnerable to air attack
and it also made them unsuited to the rapid troop movements of modern warfare.
Legal prohibition of non-consensual medical interventions
Regulatory suspension of non-consensual medical interventions
Physical integrity and bodily autonomy on intersex not legislated
Intersex medical interventions, also known as intersex genital mutilations (IGM), are surgical, hormonal and other medical interventions performed to modify atypical or ambiguous genitalia and other sex characteristics, primarily for the purposes of making a person's appearance more typical and to reduce the likelihood of future problems. The history of intersex surgery
has been characterized by controversy due to reports that surgery can
compromise sexual function and sensation, and create lifelong health
issues.
Timing, evidence, necessity and indications for surgeries in infancy,
adolescence or adult age have been controversial, associated with issues
of consent.
Interventions on intersex infants and children are increasingly recognized as human rights
issues. Intersex organizations, and human rights institutions
increasingly question the basis and necessity of such interventions. In 2011, Christiane Völling won the first successful case brought against a surgeon for non-consensual surgical intervention. In 2015, the Council of Europe recognized, for the first time, a right for intersex persons not to undergo sex-assignment treatment and Malta became the first country to prohibit involuntary or coerced modifications to sex characteristics.
Purposes of genital reconstructive surgery
The goals of surgery vary with the type of intersex condition but usually include one or more of the following:
to alleviate parental distress over the atypical genital appearance.
to make the appearance more normal for the person's sex of rearing
to reduce effects of atypical genitalia on psychosexual development and gender identity
to improve the potential for adult sexual relationships
Both sets of rationales may be the subject of debate, particularly as
the consequences of surgical interventions are lifelong and
irreversible. Questions regarding physical health include accurately
assessing risk levels, necessity and timing. Psychosocial rationales are
particularly susceptible to questions of necessity as they reflect
parental, social, and cultural concerns. There remains no clinical
consensus or clear evidence regarding surgical timing, necessity, type
of surgical intervention, degree of difference warranting intervention
and evaluation method. Such surgeries are the subject of significant contention, including community activism, and multiple reports by international human rightsand health institutions and national ethics bodies.
Types of intervention
Interventions include:
surgical treatment
hormone treatment
genetic selection and terminations
treatment for gender dysphoria
psychosocial support
Surgical interventions can broadly be divided into masculinizing surgical procedures intended to make genitalia more like those of typical XY-males, and feminizing surgical procedures
intended to make genitalia more like those of typical XX-females. There
are multiple techniques or approaches for each procedure. Some of these
are needed for variations in degrees of physical difference. Techniques
and procedure have evolved over the last 60 years. Some of the
different techniques have been devised to reduce complications
associated with earlier techniques. There remains a lack of consensus on
surgeries, and some clinicians still regard them as experimental.
Some children receive a combination of procedures. For example, a child regarded as a severely undervirilized boy with a pseudovaginal perineoscrotal hypospadias may have midline urogenital closure, third degree hypospadias repair, chordee release and phalloplasty, and orchiopexy performed. A child regarded as a severely virilized girl with congenital adrenal hyperplasia (CAH) may undergo both a partial clitoral recession and a vaginoplasty.
Masculinizing surgical procedures
Orchiopexy
and hypospadias repair are the most common types of genital corrective
surgery performed in infant boys. In a few parts of the world 5-alpha-reductase deficiency or defects of testosterone synthesis, or even rarer forms of intersex
account for a significant portion of cases but these are rare in North
America and Europe. Masculinizing surgery for completely virilized
individuals with XX sex chromosomes and CAH is even rarer. An early procedure was performed by London surgeon Thomas Brand in 1779.
Orchiopexy for repair of undescended testes (cryptorchidism) is the second most common surgery performed on infant male genitalia (after circumcision). The surgeon moves one or both testes, with blood vessels, from an abdominal or inguinal position to the scrotum. If the inguinal canal is open it must be closed to prevent hernia.
Potential surgical problems include maintaining the blood supply. If
vessels cannot be stretched into the scrotum, or are separated and
cannot be reconnected, a testis will die and atrophy.
Hypospadias repair may be a single-stage procedure if the hypospadias is of the first or second degree (urethral opening on glans or shaft respectively) and the penis is otherwise normal. Surgery for third-degree hypospadias (urethral opening on perineum
or in urogenital opening) is more challenging, may be done in stages,
and has a significant rate of complications and unsatisfactory outcomes.
Potential surgical problems: For severe hypospadias (3rd degree, on
perineum) constructing a urethral tube the length of the phallus is not
always successful, leaving an opening (a "fistula") proximal to the
intended urethral opening. Sometimes a second operation is successful,
but some boys and men have been left with chronic problems with
fistulas, scarring and contractures that make urination or erections
uncomfortable, and loss of sensation. It is increasingly recognized that
long-term outcomes are poor.
Epispadias repair
may involve comprehensive surgical repair of the genito-urinary area,
usually during the first seven years of life, including reconstruction
of the urethra, closure of the penile shaft and mobilisation of the
corpora.
Urogenital closure closure of any midline opening at the base of the penis. In severe undervirilization a boy may have a "pseudovaginal pouch" or a single urogenital opening in the midline of the perineum.
Potential surgical problems: The most complicated aspect of closure
involves moving the urethra to the phallus if it is not already there
(i.e., repairing a perineal hypospadias). Fistulas, scarring, and loss
of sensation are the main risks.
Gonadectomy (also referred to as "orchiectomy") removal of the gonads. This is done in three circumstances. (1) If the gonads are dysgenetic testes or streak gonads and at least some of the boy's cells have a Y chromosome, the gonads or streaks must be removed because they are nonfunctional but have a relatively high risk of developing gonadoblastoma. (2) In rare instances when an XX child has completely virilizing congenital adrenal hyperplasia (Prader stage 5), the ovaries can be removed before puberty to stop breast development and/or menstruation. (3) Gonadectomy can be performed in the equally rare instance of a child with true hermaphroditism virilized enough to raise as male, in which ovaries or ovotestes can be removed. A lifetime of hormone replacement will be required, to avoid osteoporosis and enable sexual functioning.
Chordee release
is the cutting of ventral penile skin and connective tissue to free and
straighten the penis. A mild chordee, manifest as a well-formed penis
"bent" downward by subcutaneous connective tissue, may be an isolated
birth defect easily repaired by releasing some of the inelastic
connective tissue on the ventral side of the shaft. In a complete
chordee the phallus is "tethered" downward to the perineum by skin. A
more severe chordee is often accompanied by a hypospadias and sometimes
by severe undervirilization: a perineal "pseudovaginal pouch" and bifid
("split") scrotum with an undersized penis. This combination, referred
to as pseudovaginal perineoscrotal hypospadias,
is in the spectrum of ambiguous genitalia due to a number of
conditions. Scarring and contracture are occasional complications, but
most unsatisfactory outcomes occur when a severe hypospadias needs to be
repaired as well. Long-term complications can include fistulas between colon or upper rectum and skin or other cavities, or between urethra and perineum. Loss of sensation.
Cloacal repair is among the most complex of the surgeries described here. Bladder exstrophy or more severe cloacal exstrophy
is a major birth defect involving inadequate closure and incomplete
midline fusion of multiple pelvic and perineal organs as well as the
front of the pelvis and lower abdominal wall. The penis and scrotum are often widely bifid
(the two embryonic parts unjoined). The penis often cannot be salvaged,
although the testes can be retained. Repair may involve closure of the
bladder, closure of the anterior abdominal wall, colostomy
(temporary or permanent) with reconstruction of the rectum. If the
halves of the phallus cannot be joined, they may be removed. The
smallest defect in this spectrum is an epispadias. Surgical repair for this is primarily a phalloplasty.
Potential surgical problems: Surgery for the more severe degrees of
cloacal exstrophy is extensive and usually multistage. A variety of
potential problems and complications can occur, including need for
long-term colostomy or vesicostomy.
In many cases a functional penis cannot be created. Scarring is often
extensive and the lower torso severely disfigured even with fairly good
outcomes.
Phalloplasty
is a general term for any reconstruction of the penis itself,
especially for more unusual types of injuries, deformities, or birth
defects. The principal difficulty is that erectile tissue is not easily
constructed and this limits the surgeon's ability to make more than
minor size changes. Construction of a narrow tube lined with mucosa (a
urethra) is a similar challenge. Minor revisions of the skin are rarely
followed by problems. More complicated reconstruction may result in
scarring and contracture, which can distort the shape or curvature of
the penis, or interfere with erections or make them painful.
Hysterectomy is removal of a uterus. It is rare that a uterus or Müllerian duct derivatives would need to be removed from a child being raised as a boy: see persistent Müllerian duct syndrome.
The most common scenario is accidental discovery of persistent
Müllerian derivatives or a small uterus during abdominal surgery of a
normal boy for cryptorchidism, appendectomy,
or bowel disease. Removal would not involve genital surgery. A rarer
indication would be that of a completely virilized XX child with congenital adrenal hyperplasia (Prader stage 5) being raised as a male; ovaries and uterus must be removed to prevent breast development and menstruation by early adolescence. Risks are simply those of abdominal surgery.
Testicular prostheses
are saline-filled plastic ovoids implanted in the scrotum. They have no
function except to provide the appearance and feel of testes. Several
sizes are available, but most are implanted in adolescence to avoid
repeated procedures to implant larger sizes at puberty. Prostheses made
of silastic
are no longer available due to safety and perception-of-safety
concerns. Potential surgical problems: Foreign body reactions, rarely
with infection or erosion of scrotal skin, are minimal but constitute
the most significant complication.
Penile augmentation surgery
is surgery intended to enlarge a small penis. Early attempts in the
1950s and 1960s involved constructing a tube of non-erectile flesh
extending a small penis but the penis did not function. In recent years a
small number of urologists have been offering an augmentation
procedure that involves moving outward some of the buried components of
the corpora so that the penis protrudes more. The girth is augmented
with transplantation of the patient's fat. This procedure is designed to
preserve erectile and sexual function without surgically altering the
urethra. This type of surgery is not performed on children and primarily
produces a small increase in the size of a normal penis, but would be
less likely to produce a major functional change in a severe micropenis.
Potential surgical problems include reabsorption of the fat, scarring
resulting in interference with erectile function, and issues with
physical sensation.
Concealed penis
where a normal penis is buried in suprapubic fat. In most cases, when
the fat is depressed with the fingers, the penis is seen to be of normal
size. This is common in overweight boys before the penile growth of
puberty. Surgical techniques have been devised to improve it. The most common problems post-surgery are recurrence with continued weight gain and scarring.
Feminizing surgical procedures
In
the last 50 years, the following procedures were most commonly
performed to make the genitalia more typically female: virilization due
to congenital adrenal hyperplasia; genital variations due, for example, to cloacal exstrophy; genital variations in infants with XY or mixed chromosomes to be raised as girls, such as gonadal dysgenesis, partial and complete androgen insensitivity syndrome, micropenis, cloacal and bladder exstrophy.
In the 21st century, feminizing surgery to support reassignment of XY
infants with non-ambiguous micropenis has been largely discontinued, and
surgical reassignment of XY infants with exstrophy or other significant
variations or injuries is diminishing. See history of intersex surgery.
Licence to Lie and to Mutilate: "even the most enthusiastic proponents of prophylactic castration" - treatment of androgen insensitivity syndrome in 1963
Clitorectomy amputation or removal of most of the clitoris, including glans, erectile tissue, and nerves.
This procedure was the most common clitoral surgery performed prior to
1970, but was largely abandoned by 1980 because it usually resulted in
loss of clitoral sensation. Potential surgical problems: The primary
effect of this surgery is a drastic reduction in ability to experience orgasm. The appearance is not very normal. Regrowth of unwanted erectile tissue has sometimes presented problems.
Clitoroplasty,
like phalloplasty, is a term that encompasses any surgical
reconstruction of the clitoris, such as removal of the corpora. Clitoral
recession and reduction can both be referred to as clitoroplasty.
Potential surgical problems: Major complications can include scarring,
contractures, loss of sensation, loss of capacity for orgasm, and
unsatisfactory appearance.
Clitoral recession
involves the repositioning of the erectile body and glans of the
clitoris farther back under the symphysis pubis and/or skin of the
preputium and mons. This was commonly done from the 1970s through the
1980s to reduce protrusion without sacrificing sensation. Outcomes were
often unsatisfactory, and it fell into disfavor in the last 15 years.
Potential surgical problems: Unfortunately the subsequent sensations
were not always pleasant, and erection could be painful. Adults who had a
clitoral recession in early childhood often report reduced capacity for
enjoyment of sexual intercourse, though similar women who had not had
surgery also report a high rate of sexual dysfunction.
Clitoral reduction
was developed in the 1980s to reduce size without reducing function.
Lateral wedges of the erectile tissue of the clitoris are removed to
reduce the size and protrusion. The neurovascular tissue is carefully
spared to preserve function and sensation. Nerve stimulation and sensory
responses are now often performed during the surgery to confirm
function of the sensory nerves.
Clitoral reduction is rarely done except in combination with
vaginoplasty when substantial virilization is present. Potential
problems: The degree to which the goal of preserving sexual sensations
is attained is a subject of controversy regarding the necessity of such
treatments, and lack of firm evidence of good outcomes.
The success of more contemporary approaches was challenged by Thomas in
2004: "confidence in the superiority of modern surgery is almost
certainly misplaced as the crucial components of current clitoral
reduction surgery are not fundamentally different from those used in
specialist centres 20 years ago".
Vaginoplasty, the construction or reconstruction of a vagina,
can be fairly simple or quite complex, depending on the initial
anatomy. If a normal internal uterus, cervix and upper vagina (the Müllerian derivatives)
exist, and the outer virilization is modest, surgery involves
separating the fused labia and widening the vaginal introitus. With
greater degrees of virilization, the major challenge of the procedure is
to provide a passage connecting the outer vaginal opening to the cervix
which will stay wide enough to allow coitus. XY girls or women with
partial androgen insensitivity syndrome
will have a blind vaginal pouch of varying degrees of depth. Sometimes
this can be dilated to a usable depth. Sometimes surgery is performed to
deepen it.
The most challenging surgery with the highest complication rate
is construction of an entirely new vagina (a "neovagina"). The most
common instance of this is when a child will be assigned and raised as a
female despite complete virilization, as with Prader 5 CAH, or (in the past) when a genetic male infant with a severely defective penis was reassigned
as a female. One method is to use a segment of colon, which provides a
lubricated mucosal surface as a substitute for the vaginal mucosa.
Another is to line the new vagina with a skin graft.
Potential surgical problems: Stenosis (narrowing) of the constructed
vagina is the most common long-term complication and the chief reason
that a revision may be required when a girl is older. When a neovagina
is made from a segment of bowel, it tends to leak mucus; when made with a
skin graft, lubrication is necessary. Less common complications include
fistulas, uncomfortable scarring, and problems with urinary continence.
Gonadectomy is removal of the gonads. If the gonads are dysgenetic testes or streak gonads and at least some of the cells have a Y chromosome, the gonads or streaks must be removed because they are nonfunctional but have a relatively high risk of developing gonadoblastoma.
If the gonads are relatively "normal" testes, but the child is to be
assigned and raised as female, (e.g., for intersex conditions with
severe undervirilization, or major malformations involving an absent or
unsalvageable penis) they must be removed before puberty to prevent
virilization from rising testosterone.
Testes in androgen insensitivity
are a special case: if there is any degree of responsiveness to
testosterone, they should be removed before puberty. On the other hand,
if androgen insensitivity is complete, the testes may be left to produce
estradiol (via testosterone) to induce breast development, but there is
a slowly increasing risk of cancer in adult life. Streak gonads without
a Y chromosome cell line need not be removed but will not function.
Finally, the gonads in true hermaphroditism
must be directly examined; atypical gonads with Y line or potential
testicular function should be removed but in rare instances a surgeon
may try to preserve the ovarian part of an ovotestis. Potential surgical problems: A lifetime of hormone replacement will be required, to avoid osteoporosis and enable sexual functioning.
Cloacal exstrophy and bladder exstrophy repair is needed regardless of the sex of assignment or rearing. Simple bladder exstrophy in a genetic female does not usually involve the vagina. Cloacal exstrophy in a genetic female usually requires major surgical reconstruction of the entire perineum, including bladder, clitoris, symphysis pubis, and both the vaginal introitus and urethra. However, the uterus and ovaries
are normally formed. Severe bladder exstrophy or cloacal exstrophy in
genetic males often renders the phallus widely split, small, and
unsalvageable. The scrotum is also widely split, though testes
themselves are usually normal. From the 1960s until the 1990s, many of
these infants were assigned and raised as females, with fashioning of a
vagina and gonadectomy as part of the perineal reconstruction.
Potential surgical problems: Surgery for the more severe degrees
of cloacal exstrophy is extensive and usually multistage. A variety of
potential problems and complications can occur, including need for
long-term colostomy or vesicostomy.
Creating a functional urethra is difficult and poor healing, with
scarring, stricture, or fistula can require a vesicostomy to prevent
urinary incontinence. Construction of a functional internal and external anal sphincter
can be equally difficult when this has been disrupted as well.
Functional problems can warrant a temporary or long-term colostomy. The
added challenge for the most severely affected genetic females, and for
genetic males who are being raised as females, is construction of a
neovagina. Scarring is extensive and the lower torso disfigured even
with the best outcomes. Finally, it has become apparent that some XY
males (without intersex conditions) who are reassigned and raised as females have not developed a female gender identity and have sought reassignment back to male.
Hormone treatment
There is widespread evidence of prenatal testing and hormone treatment to prevent intersex traits. In 1990, a paper by Heino Meyer-Bahlburg titled Will Prenatal Hormone Treatment Prevent Homosexuality?
was published in the Journal of Child and Adolescent
Psychopharmacology. It examined the use of "prenatal hormone screening
or treatment for the prevention of homosexuality" using research
conducted on foetuses with congenital adrenal hyperplasia (CAH). Dreger, Feder, and Tamar-Mattis
describe how later research constructs "low interest in babies and men –
and even interest in what they consider to be men's occupations and
games – as "abnormal", and potentially preventable with prenatal dex
[amethasone]".
In April 2014, Organisation Intersex International Australia made a submission on genetic selection via preimplantation genetic diagnosis to the National Health and Medical Research Council
recommending that deselection of embryos and foetuses on grounds of
intersex status should not be permitted. It quoted research by
Professors Morgan Holmes, Jeff Nisker, associate professor Georgiann Davis, and by Jason Behrmann and Vardit Ravitsky. It quotes research showing pregnancy termination rates of up to 88% in 47,XXY even while the World Health Organization describes the trait as "compatible with normal life expectancy", and "often undiagnosed".
Behrmann and Ravitsky find social concepts of sex, gender and sexual
orientation to be "intertwined on many levels. Parental choice against
intersex may thus conceal biases against same-sex attractedness and
gender nonconformity."
Gender dysphoria
The DSM-5 included a change from using gender identity disorder to gender dysphoria.
This revised code now specifically includes intersex people who do not
identify with their sex assigned at birth and experience clinically
significant distress or impairment, using the language of disorders of sex development. This move was criticised by intersex advocacy groups in Australia and New Zealand.
Psychosocial support
A
2006 clinician "Consensus Statement on Intersex Disorders and Their
Management" attempted to prioritise psychosocial support for children
and families, but it also supports surgical intervention with
psychosocial rationales such as "minimizing family concern and distress"
and "mitigating the risks of stigmatization and gender-identity
confusion".
In 2012, the Swiss National Advisory Commission on Biomedical
Ethics argued strongly in favour of improved psychosocial support,
saying:
The initial aim of counselling and
support is therefore to create a protected space for parents and the
newborn, so as to facilitate a close bond. In addition, the parents need
to be enabled to take the necessary decisions on the child's behalf
calmly and after due reflection. In this process, they should not be
subjected to time or social pressures. Parents' rapid requests for
medical advice or for corrective surgery are often a result of initial
feelings of helplessness, which need to be overcome so as to permit
carefully considered decision-making.
It is important to bear in mind and also to point out to the
parents that a diagnosis does not in itself entail any treatment or
other medical measures, but serves initially to provide an overview of
the situation and a basis for subsequent decisions, which may also take
the form of watchful waiting.
...interventions have lasting effects on the development of identity,
fertility, sexual functioning and the parent-child relationship. The
parents' decisions should therefore be marked by authenticity, clarity
and full awareness, and based on love for the child, so that they can
subsequently be openly justified vis-à-vis the child or young adult.
Recognition that medicalization and
stigmatisation of intersex people result in significant trauma and
mental health concerns.
In view of ensuring the bodily integrity and well-being of intersex
people, autonomous non-pathologising psycho-social and peer support be
available to intersex people throughout their life (as self-required),
as well as to parents and/or care providers.
Outcomes and evidence
Specialists
at the Intersex Clinic at University College London began to publish
evidence in 2001 that indicated the harm that can arise as a result of
inappropriate interventions, and advised minimising the use of childhood
surgical procedures.
A 2004 paper by Heino Meyer-Bahlburg and others examined outcomes from early surgeries in individuals with XY variations, at one patient centre.
The study has been used to support claims that "the majority of
women... have clearly favored genital surgery at an earlier age" but the
study was criticized by Baratz and Feder in a 2015 paper for neglecting
to inform respondents that:
(1) not having surgery at all might be an option; (2) they might have had lower rates of reoperation for stenosis
if surgery were performed later, or (3) that significant technical
improvements that were expected to improve outcomes had occurred in the
13 or 14 years between when they underwent early childhood surgery and
when it might have been deferred until after puberty.
Chicago consensus statement
In
2006, an invited group of clinicians met in Chicago and reviewed
clinical evidence and protocols, and adopted a new term for intersex
conditions: Disorders of sex development (DSD) in the journal article Consensus Statement on Intersex Disorders and their Management. The new term refers to "congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical."
The term has been controversial and not widely adopted outside clinical
settings: the World Health Organization and many medical journals still
refer to intersex traits or conditions. Academics like Georgiann Davis and Morgan Holmes, and clinical psychologists like Tiger Devore argue that the term DSD was designed to "reinstitutionalise" medical authority over intersex bodies. On surgical rationales and outcomes, the article stated that:
It is generally felt that surgery
that is carried out for cosmetic reasons in the first year of life
relieves parental distress and improves attachment between the child and
the parents. The systematic evidence for this belief is lacking. ...
information across a range of assessments is insufficient ... outcomes
from clitoroplasty identify problems related to decreased sexual
sensitivity, loss of clitoral tissue, and cosmetic issues ... Feminising
as opposed to masculinising genitoplasty requires less surgery to
achieve an acceptable outcome and results in fewer urological
difficulties... Long term data on sexual function and quality of life
among those assigned female as well as male show great variability.
There are no controlled clinical trials of the efficacy of early (less
than 12 months of age) versus late surgery (in adolescence and
adulthood), or of the efficacy of different techniques"
Changing practices?
Data presented in recent years suggests that little has changed in practice.
Creighton and others in the UK have found that there have been few
audits of the implementation of the 2006 statement, clitoral surgeries
on under-14s have increased since 2006, and "recent publications in the
medical literature tend to focus on surgical techniques with no reports
on patient experiences".
Patient outcomes
A 2014 civil society submission to the World Health Organization cited data from a large German Netzwerk DSD/Intersexualität study:
In a study in Lübeck conducted
between 2005 and 2007 ... 81% of 439 individuals had been subjected to
surgeries due to their intersex diagnoses. Almost 50% of participants
reported psychological problems. Two thirds of the adult participants
drew a connection between sexual problems and their history of surgical
treatment. Participating children reported significant disturbances,
especially within family life and physical well-being – these are areas
that the medical and surgical treatment was supposed to stabilize.
A 2016 Australian study of persons born with atypical sex
characteristics found that "strong evidence suggesting a pattern of
institutionalised shaming and coercive treatment of people". Large
majorities of respondents opposed standard clinical protocols.
2016 Global DSD Update
A 2016 follow-up to the 2006 Consensus Statement, termed a Global Disorders of Sex Development Update stated,
There is still no consensual
attitude regarding indications, timing, procedure and evaluation of
outcome of DSD surgery. The levels of evidence of responses given by the
experts are low (B and C), while most are supported by team
expertise... Timing, choice of the individual and irreversibility of
surgical procedures are sources of concerns. There is no evidence
regarding the effect of surgically treated or non-treated DSDs during
childhood for the individual, the parents, society or the risk of
stigmatization... Physicians working with these families should be aware
that the trend in recent years has been for legal and human rights
bodies to increasingly emphasize preserving patient autonomy.
A 2016 paper on "Surgery in disorders of sex development (DSD) with a
gender issue" repeated many of the same claims, but without reference
to human rights norms. A commentary to that article by Alice Dreger
and Ellen Feder criticized that omission, stating that issues have
barely changed in two decades, with "lack of novel developments", while
"lack of evidence appears not to have had much impact on physicians'
confidence in a standard of care that has remained largely unchanged."
Another 2016 commentary stated that the purpose of the 2006 Consensus
Statement was to validate existing practices, "The authoritativeness and
"consensus" in the Chicago statement lies not in comprehensive
clinician input or meaningful community input, but in its utility to
justify any and all forms of clinical intervention."
Management practices for intersex conditions have evolved over the
last 60 years. In recent decades surgical practices have become the
subject of public and professional controversy, and evidence remains
lacking.
Comparing early against late surgeries
Argued or putative advantages of infant surgery:
Tissue is more elastic and heals better according to many surgeons.
Genital surgery performed before the age of memory is less emotionally traumatic.
Surgery in infancy avoids asking adolescent to make a decision that is stressful and difficult even for adults.
Assuming infant surgery is successful, there is no barrier to engaging in normal sexual activities, and less distortion of psychosexual identity.
Argued or putative advantages of surgery in adolescence or later:
If outcome is less than satisfactory, early surgery leaves a person wondering if they would have been better off without it.
Any surgery not absolutely necessary for physical health should be
postponed until the person is old enough to give informed consent.
Genital surgery should be handled differently than other birth
defect surgery; this is a type of surgery that parents should not be
empowered to make decisions about because they will be under social
pressure to make "bad" decisions.
By mid-adolescence or later, persons may decide that their atypical genitalia do not need to be changed.
Infant vaginoplasties should not be done because most people who
have had them performed report some degree of difficulty with sexual
function; even though we have no evidence that adult sexual function
will be better if surgery is deferred, the outcomes couldn't be worse
than they currently are after infant surgery.
Others argue that the key questions are not ones of early or late surgery, but questions of consent and autonomy.
Parental consent
Parents
are frequently considered able to consent to feminizing or
masculinizing interventions on their child, and this may be considered
standard for the treatment of physical disorders. However this is
contested, particularly where interventions seek to address psychosocial
concerns. A BMJ
editorial in 2015 stated that parents are unduly influenced by
medicalized information, may not realize that they are consenting to
experimental treatments, and regret may be high.
Research has suggested that parents are willing to consent to
appearance-altering surgeries even at the cost of later adult sexual
sensation. Child rights expert Kirsten Sandberg states that parents have no right to consent to such treatments.
Sensation and sexual function
Reports published in the early 1990s state that 20-50% of surgical cases result in a loss of sexual sensation.
A 2007 paper by Yang, Felsen and Poppas provided what the authors
believe is the first study of clitoral sensitivity after clitoris
reduction surgery, but the research was itself the subject of ethical
debate. Postoperative patients aged older than five years were
"considered candidates" for clitoral sensitivity testing, and 10 of 51
patients were tested, with 9 undergoing extended vibratory sensory
testing. The initial tests were performed on the inner thigh, labia majora, labia minora, vaginal introitus
and clitoris, with a "cotton tip applicator" and extended tests with a
biothesiometer, a medical device used to measure sensitivity thresholds.
Values were recorded. The authors note that there are no control data
"for assessment of the viability and function of the clitoris in
unaffected women." The ethics of these tests have been criticized by bioethicists, and subsequently defended by the Office for Human Research Protections.
Loss of sexual function and sensation remains a concern in a
submission by the Australasian Paediatric Endocrine Group to the
Australian Senate in 2013.
Clinical decision-making has prioritized perceived advantages from
infant clitoral reduction surgery over the potential disadvantages of
reduced or distorted sexual sensation. Human rights institutions stress
the informed consent of the individual concerned.
Decision-making on cancer and other physical risks
Intersex banner reading "End Intersex Surgery," Berlin Pride 27 June 2020
In the cases where nonfunctional testes are present, or with partial
androgen insensitivity syndrome, there is a risk that these develop
cancer. They are removed by orchidectomy or monitored carefully.
In a major Parliamentary report in Australia, published in October
2013, the Senate Community Affairs References committee was "disturbed"
by the possible implications of current practices in the treatment of
cancer risk. The committee stated: "clinical intervention pathways
stated to be based on probabilities of cancer risk may be encapsulating
treatment decisions based on other factors, such as the desire to
conduct normalising surgery… Treating cancer may be regarded as
unambiguously therapeutic treatment, while normalising surgery may not.
Thus basing a decision on cancer risk might avoid the need for court
oversight in a way that a decision based on other factors might not. The
committee is disturbed by the possible implications of this..."
Gender identity issues
Gender
identity and sexuality in intersex children have been problematized,
and subjective judgements are made about the acceptability of risk of
future gender dysphoria.
Medical professionals have traditionally considered the worst outcomes
after genital reconstruction in infancy to occur when the person
develops a gender identity discordant with the sex assigned as an
infant. Most of the cases in which a child or adult has voluntarily
changed sex and rejected sex of assignment and rearing
have occurred in partially or completely virilized genetic males who
were reassigned and raised as females. This is the management practice
that has been most thoroughly undermined in recent decades, as a result
of a small number of spontaneous self-reassignments to male. Reducing
the likelihood of a gender "mismatch" is also a claimed advantage of
deferring reconstructive surgery until the patient is old enough to
assess gender identity with confidence.
Human rights institutions question such approaches as being "informed by redundant social constructs around gender and biology".
Stigma and normality
Parents may be advised that without surgery, their child will be stigmatized, but they may make different choices with non-medicalized information. However, there is no evidence that surgeries help children grow up psychologically healthy.
Unlike other aesthetic surgical procedures performed on infants, such as corrective surgery for a cleft lip (as opposed to a cleft palate),
genital surgery may lead to negative consequences for sexual
functioning in later life (such as loss of sensation in the genitals,
for example, when a clitoris
deemed too large or penis is reduced/removed), or feelings of
freakishness and unacceptability, which may have been avoided without
the surgery. Studies have revealed how surgical intervention has had
psychological effects, affecting well-being and quality of life. Genital
surgeries do not ensure a successful psychological outcome for the
patient and might require psychological support when the patient is
trying to distinguish a gender identity.
The Swiss National Advisory Commission on Biomedical Ethics states
that, where "interventions are performed solely with a view to
integration of the child into a family and social environment, then they
run counter to the child's welfare. In addition, there is no guarantee
that the intended purpose (integration) will be achieved."
Opponents of all "corrective surgery" on atypical sex
characteristics suggest to change social opinion regarding the
desirability of having genitalia that look more average, rather than
perform surgery to try to make them more like those of other people.
Medical photography and display
Photographs
of intersex children's genitalia are circulated in medical communities
for documentary purposes, and individuals with intersex traits may be
subjected to repeated genital examinations and display to medical teams.
Problems associated with experiences of medical photography of intersex
children have been discussed along with their ethics, control and usage.
"The experience of being photographed has exemplified for many people
with intersex conditions the powerlessness and humiliation felt during
medical investigations and interventions".
Secrecy and information provision
Additionally,
parents are not often consulted on the decision-making process when
choosing the sex of the child, and they may be advised to conceal
information from their child. The Intersex Society of North America
stated that "For decades, doctors have thought it necessary to treat
intersex with a concealment-centered approach, one that features
downplaying intersex as much as possible, even to the point of lying to
patients about their conditions."
Alternative pathways
In 2015, an editorial in the BMJ
described current surgical interventions as experimental, stating that
clinical confidence in constructing "normal" genital anatomies has not
been borne out, and that medically credible pathways other than surgery
do not yet exist.
The Council of Europe highlights several areas of concern in relation to intersex surgeries and other medical treatment:
unnecessary "normalising" treatment of intersex persons, and unnecessary pathologisation of variations in sex characteristics.
access to justice and reparation for unnecessary medical treatment, as well as inclusion in equal treatment and hate crime law.
access to information, medical records, peer and other counselling and support.
respecting self-determination in gender recognition, through expeditious access to official documents.
The Council of Europe argues that secrecy and shame have perpetuated
human rights abuses and a lack of social understanding of the reality of
intersex people. It calls for respect for "intersex persons' right not
to undergo sex assignment treatment".
Alice Dreger,
a US professor of Clinical Medical Humanities and Bioethics, argues
that little has changed in actual clinical practice in recent years.
Creighton and others in the UK have found that there have been few
audits of the implementation of the 2006 statement, clitoral surgeries
on under-14s have increased since 2006, and "recent publications in the
medical literature tend to focus on surgical techniques with no reports
on patient experiences".
In 2011, Christiane Völling
won the first successful case brought against a surgeon for
non-consensual surgical intervention. The Regional Court of Cologne,
Germany, awarded her €100,000.
In April 2015, Malta became the first country to recognize a
right to bodily integrity and physical autonomy, and outlaw
non-consensual modifications to sex characteristics. The Act was widely
welcomed by civil society organizations.
In June 2017, Joycelyn Elders, David Satcher, and Richard Carmona, three former Surgeons General of the United States published a paper at the Palm Center,
calling for a rethink of early genital surgeries on children with
intersex traits. The statement reflected on the history of such
interventions, their rationales and outcomes, stating:
When an individual is born with
atypical genitalia that pose no physical risk, treatment should focus
not on surgical intervention but on psychosocial and educational support
for the family and child. Cosmetic genitoplasty should be deferred
until children are old enough to voice their own view about whether to
undergo the surgery. Those whose oath or conscience says “do no harm”
should heed the simple fact that, to date, research does not support the
practice of cosmetic infant genitoplasty.
Factors that determine rates of gun violence vary by country. These factors may include the illegal drug trade, easy access to firearms, substance misuse including alcohol, mental health problems, firearm laws, social attitudes, economic differences, and occupations such as being a police officer. Where guns are more common, altercations more often end in death.
Before management begins, the area must be verified as safe. This is followed by stopping major bleeding, then assessing and supporting the airway, breathing, and circulation. Firearm laws, particularly background checks and permit to purchase, decrease the risk of death from firearms. Safer firearm storage may decrease the risk of firearm-related deaths in children.
In 2015, about a million gunshot wounds occurred from interpersonal violence. In 2016, firearms resulted in 251,000 deaths globally, up from 209,000 in 1990. Of these deaths, 161,000 (64%) were the result of assault, 67,500 (27%) were the result of suicide, and 23,000 (9%) were accidents. In the United States, guns resulted in about 40,000 deaths in 2017. Firearm-related deaths are most common in males between the ages of 20 and 24 years. Economic costs due to gunshot wounds have been estimated at US$140 billion a year in the United States.
Signs and symptoms
Trauma
from a gunshot wound varies widely based on the bullet, velocity, mass,
entry point, trajectory, affected anatomy, and exit point. Gunshot
wounds can be particularly devastating compared to other penetrating injuries
because the trajectory and fragmentation of bullets can be
unpredictable after entry. Moreover, gunshot wounds typically involve a
large degree of nearby tissue disruption and destruction caused by the
physical effects of the projectile correlated with the bullet velocity
classification.
The immediate damaging effect of a gunshot wound is typically severe bleeding with the potential for hypovolemic shock, a condition characterized by inadequate delivery of oxygen to vital organs.
In the case of traumatic hypovolemic shock, this failure of adequate
oxygen delivery is due to blood loss, as blood is the means of
delivering oxygen to the body's constituent parts. Devastating effects
can result when a bullet strikes a vital organ such as the heart, lungs,
or liver, or damages a component of the central nervous system such as
the spinal cord or brain.
Common causes of death following gunshot injury include bleeding, low oxygen caused by pneumothorax,
catastrophic injury to the heart and major blood vessels, and damage to
the brain or central nervous system. Non-fatal gunshot wounds
frequently have mild to severe long-lasting effects, typically some form
of major disfigurement such as amputation because of a severe bone fracture and may cause permanent disability. A sudden blood gush may take effect immediately from a gunshot wound if a bullet directly damages larger blood vessels, especially arteries.
The degree of tissue disruption caused by a projectile is related to the cavitation
the projectile creates as it passes through tissue. A bullet with
sufficient energy will have a cavitation effect in addition to the
penetrating track injury. As the bullet passes through the tissue,
initially crushing then lacerating, the space left forms a cavity; this
is called the permanent cavity.
Higher-velocity bullets create a pressure wave that forces the tissues
away, creating not only a permanent cavity the size of the caliber of
the bullet but a temporary cavity or secondary cavity, which is often many times larger than the bullet itself.
The temporary cavity is the radial stretching of tissue around the
bullet's wound track, which momentarily leaves an empty space caused by
high pressures surrounding the projectile that accelerate material away
from its path. The extent of cavitation, in turn, is related to the following characteristics of the projectile:
Kinetic energy: KE = 1/2mv2 (where m is mass and v is velocity).
This helps to explain why wounds produced by projectiles of higher mass
and/or higher velocity produce greater tissue disruption than
projectiles of lower mass and velocity. The velocity of the bullet is a
more important determinant of tissue injury. Although both mass and
velocity contribute to the overall energy of the projectile, the energy
is proportional to the mass while proportional to the square of
its velocity. As a result, for constant velocity, if the mass is
doubled, the energy is doubled; however, if the velocity of the bullet
is doubled, the energy increases four times. The initial velocity of a
bullet is largely dependent on the firearm. The US military commonly
uses 5.56-mm bullets, which have a relatively low mass as compared with
other bullets; however, the speed of these bullets is relatively fast.
As a result, they produce a larger amount of kinetic energy, which is
transmitted to the tissues of the target.
The size of the temporary cavity is approximately proportional to the
kinetic energy of the bullet and depends on the resistance of the tissue
to stress. Muzzle energy, which is based on muzzle velocity, is often used for ease of comparison.
Yaw:
Handgun bullets will generally travel in a relatively straight line or
make one turn if a bone is hit. Upon travel through deeper tissue,
high-energy rounds may become unstable as they decelerate, and may
tumble (pitch and yaw) as the energy of the projectile is absorbed,
causing stretching and tearing of the surrounding tissue.
Fragmentation:
Most commonly, bullets do not fragment, and secondary damage from
fragments of shattered bone is a more common complication than bullet
fragments.
Low velocity wounds are typical of small caliberhandguns and display wound patterns like Gustilo Anderson Type 1 or 2 wounds
Medium-velocity: Between 1,200 ft/s (366 m/s) and 2,000 ft/s (610 m/s)
These are more typical of shotgun blasts or higher caliber handguns
like magnums. The risk of infection from these types of wounds can vary
depending on the type and pattern of bullets fired as well as the
distance from the firearm.
High-velocity: Between 2,000 ft/s (610 m/s) and 3,500 ft/s (1,067 m/s)
Usually caused by powerful assault or hunting rifles and usually
display wound pattern similar to Gustilo Anderson Type 3 wounds. The
risk of infection is especially high due to the large area of injury and
destroyed tissue.
Bullets from handguns
are sometimes less than 1,000 ft/s (300 m/s) but with modern pistol
loads, they usually are slightly above 1,000 ft/s (300 m/s), while
bullets from most modern rifles
exceed 2,500 ft/s (760 m/s). One recently developed class of firearm
projectiles is the hyper-velocity bullet, such cartridges are usually
either wildcats made for achieving such high speed or purpose-built
factory ammunition with the same goal in mind. Examples of hyper
velocity cartridges include the .220 Swift, .17 Remington and .17 Mach IV cartridges. The US military commonly uses 5.56mm
bullets, which have a relatively low mass as compared with other
bullets (40-62 grains); however, the speed of these bullets is
relatively fast (approximately 2,800 ft/s (850 m/s), placing them in the
high velocity category). As a result, they produce a larger amount of
kinetic energy, which is transmitted to the tissues of the target.
However, one must remember that high kinetic energy does not
necessarily equate to high stopping power, as incapacitation usually
results from remote wounding effects such as bleeding, rather than raw
energy transfer. High energy does indeed result in more tissue
disruption, which plays a role in incapacitation, but other factors such
as wound size and shot placement play as big of, if not a bigger role
in stopping power and thus, effectiveness. Muzzle velocity does not consider the effect of aerodynamic drag on the flight of the bullet for the sake of ease of comparison.
Kronlein shot
The "Kronlein shot" (German: Krönleinschuss) is a distinctive type of headshot wound that can only be created by a high velocity rifle bullet or shotgun slug. In a Kronlein shot, the intact brain is ejected from the skull and deposited some distance from the victim's body.
This type of wound is believed to be caused by a hydrodynamic effect.
Hydraulic pressure generated within the skull by a high velocity bullet
leads to the explosive ejection of the brain from the fractured skull.
Prevention
Medical
organizations in the United States recommend a criminal background
check being held before a person buys a gun and that a person who has
convictions for crimes of violence should not be permitted to buy a gun.
Safe storage of firearms is recommended, as well as better mental
health care and removal of guns from those at risk of suicide. In an effort to prevent mass shootings, greater regulations on guns that can rapidly fire many bullets is recommended.
Management
Initial assessment for a gunshot wound is approached in the same way as other acute trauma using the advanced trauma life support (ATLS) protocol. These include:
A) Airway - Assess and protect airway and potentially the cervical spine
B) Breathing - Maintain adequate ventilation and oxygenation
E) Exposure - Expose entire body and search for any missed injuries,
entry points, and exit points while maintaining body temperature
Depending on the extent of injury, management can range from urgent
surgical intervention to observation. As such, any history from the
scene such as gun type, shots fired, shot direction and distance, blood
loss on scene, and pre-hospital vitals signs can be very helpful in
directing management. Unstable people with signs of bleeding that cannot
be controlled during the initial evaluation require immediate surgical exploration in the operating room. Otherwise, management protocols are generally dictated by anatomic entry point and anticipated trajectory.
Initial assessment of a gunshot wound to the neck involves
non-probing inspection of whether the injury is a penetrating neck
injury (PNI), classified by violation of the platysma muscle.
If the platysma is intact, the wound is considered superficial and only
requires local wound care. If the injury is a PNI, surgery should be
consulted immediately while the case is being managed. Of note, wounds
should not be explored on the field or in the emergency department given
the risk of exacerbating the wound.
Due to the advances in diagnostic imaging, management of PNI has
been shifting from a "zone-based" approach, which uses anatomical site
of injury to guide decisions, to a "no-zone" approach which uses a
symptom-based algorithm.
The no-zone approach uses a hard signs and imaging system to guide next
steps. Hard signs include airway compromise, unresponsive shock,
diminished pulses, uncontrolled bleeding, expanding hematoma, bruits/thrill, air bubbling from wound or extensive subcutaneous air, stridor/hoarseness, neurological deficits.
If any hard signs are present, immediate surgical exploration and
repair is pursued alongside airway and bleeding control. If there are no
hard signs, the person receives a multi-detector CT angiography for better diagnosis. A directed angiography or endoscopy
may be warranted in a high-risk trajectory for the gunshot. A positive
finding on CT leads to operative exploration. If negative, the person
may be observed with local wound care.
Initial workup as outlined in the Workup section is particularly
important with gunshot wounds to the chest because of the high risk for
direct injury to the lungs, heart, and major vessels. Important notes
for the initial workup specific for chest injuries are as follows. In
people with pericardial tamponade or tension pneumothorax, the chest
should be evacuated or decompressed if possible prior to attempting tracheal intubation because the positive pressure ventilation can cause hypotention or cardiovascular collapse.
Those with signs of a tension pneumothorax (asymmetric breathing,
unstable blood flow, respiratory distress) should immediately receive a chest tube (> French 36) or needle decompression if chest tube placement is delayed. FAST exam should include extended views into the chest to evaluate for hemopericardium, pneumothorax, hemothorax, and peritoneal fluid.
Those with cardiac tamponade, uncontrolled bleeding, or a persistent air leak from a chest tube all require surgery.
Cardiac tamponade can be identified on FAST exam. Blood loss warranting
surgery is 1–1.5 L of immediate chest tube drainage or ongoing bleeding
of 200-300 mL/hr. Persistent air leak is suggestive of tracheobronchial injury which will not heal without surgical intervention. Depending on the severity of the person's condition and if cardiac arrest
is recent or imminent, the person may require surgical intervention in
the emergency department, otherwise known as an emergency department thoracotomy (EDT).
However, not all gunshot to the chest require surgery. Asymptomatic people with a normal chest X-ray can be observed with a repeat exam and imaging after 6 hours to ensure no delayed development of pneumothorax or hemothorax.[29]
If a person only has a pneumothorax or hemothorax, a chest tube is
usually sufficient for management unless there is large volume bleeding
or persistent air leak as noted above.[29]
Additional imaging after initial chest X-ray and ultrasound can be
useful in guiding next steps for stable people. Common imaging
modalities include chest CT, formal echocardiography, angiography, esophagoscopy, esophagography, and bronchoscopy depending on the signs and symptoms.
Abdomen
Abdominal gunshot wound
Important anatomy in the abdomen includes the stomach, small bowel, colon, liver, spleen, pancreas, kidneys,
spine, diaphragm, descending aorta, and other abdominal vessels and
nerves. Gunshots to the abdomen can thus cause severe bleeding, release
of bowel contents, peritonitis, organ rupture, respiratory compromise, and neurological deficits.
The most important initial evaluation of a gunshot wound to the
abdomen is whether there is uncontrolled bleeding, inflammation of the peritoneum,
or spillage of bowel contents. If any of these are present, the person
should be transferred immediately to the operating room for laparotomy.
If it is difficult to evaluate for those indications because the person
is unresponsive or incomprehensible, it is up to the surgeon's
discretion whether to pursue laparotomy, exploratory laparoscopy, or alternative investigative tools.
Although all people with abdominal gunshot wounds were taken to
the operating room in the past, practice has shifted in recent years
with the advances in imaging to non-operative approaches in more stable
people.
If the person's vital signs are stable without indication for immediate
surgery, imaging is done to determine the extent of injury. Ultrasound (FAST) and help identify intra-abdominal bleeding and X-rays can help determine bullet trajectory and fragmentation.
However, the best and preferred mode of imaging is high-resolution
multi-detector CT (MDCT) with IV, oral, and sometimes rectal contrast. Severity of injury found on imaging will determine whether the surgeon takes an operative or close observational approach.
Diagnostic peritoneal lavage
(DPL) has become largely obsolete with the advances in MDCT, with use
limited to centers without access to CT to guide requirement for urgent
transfer for operation.
Extremities
Acute
penetrating trauma from a close-range shotgun blast injury to knee.
Birdshot pellets are visible in the wound, within the shattered patella.
The powder wad from the shotgun shell has been extracted from the
wound, and is visible at the upper right of the image.
The four main components of extremities are bones, vessels, nerves, and soft tissues. Gunshot wounds can thus cause severe bleeding, fractures,
nerve deficits, and soft tissue damage. The Mangled Extremity Severity
Score (MESS) is used to classify the severity of injury and evaluates
for severity of skeletal and/or soft tissue injury, limb ischemia, shock, and age. Depending on the extent of injury, management can range from superficial wound care to limb amputation.
Vital sign stability and vascular assessment are the most
important determinants of management in extremity injuries. As with
other traumatic cases, those with uncontrolled bleeding require
immediate surgical intervention. If surgical intervention is not readily available and direct pressure is insufficient to control bleeding, tourniquets or direct clamping of visible vessels may be used temporarily to slow active bleeding.
People with hard signs of vascular injury also require immediate
surgical intervention. Hard signs include active bleeding, expanding or
pulsatile hematoma, bruit/thrill, absent distal pulses and signs of
extremity ischemia.
For stable people without hard signs of vascular injury, an
injured extremity index (IEI) should be calculated by comparing the
blood pressure in the injured limb compared to an uninjured limb in
order to further evaluate for potential vascular injury.
If the IEI or clinical signs are suggestive of vascular injury, the
person may undergo surgery or receive further imaging including CT
angiography or conventional arteriography.
In addition to vascular management, people must be evaluated for
bone, soft tissue, and nerve injury. Plain films can be used for
fractures alongside CTs for soft tissue assessment. Fractures must be debrided and stabilized, nerves repaired when possible, and soft tissue debrided and covered. This process can often require multiple procedures over time depending on the severity of injury.
In 2015, about a million gunshot wounds occurred from interpersonal violence. Firearms, globally in 2016, resulted in 251,000 deaths up from 209,000 in 1990. Of these deaths 161,000 (64%) were the result of assault, 67,500 (27%) were the result of suicide, and 23,000 were accidents. Firearm related deaths are most common in males between the ages of 20 to 24 years.
The countries with the greatest number of deaths from firearms are Brazil, United States, Mexico, Colombia, Venezuela, Guatemala, Bahamas and South Africa which make up just over half the total. In the United States in 2015, about half of the 44,000 people who died by suicide did so with a gun.
As of 2016, the countries with the highest rates of gun violence
per capita were El Salvador, Venezuela, and Guatemala with 40.3, 34.8,
and 26.8 violent gun deaths per 100,000 people respectively. The countries with the lowest rates of were Singapore, Japan, and South Korea with 0.03, 0.04, and 0.05 violent gun deaths per 100,000 people respectively.
Canada
In 2016, about 893 people died due to gunshot wounds in Canada (2.1 per 100,000). About 80% were suicides, 12% were assaults, and 4% percent were accidents.
In 2017, there were 39,773 deaths in the United States as a result gunshot wounds.
Of these 60% were suicides, 37% were homicides, 1.4% were by law
enforcement, 1.2% were accidents, and 0.9% were from an unknown cause. This is up from 37,200 deaths in 2016 due to a gunshot wound (10.6 per 100,000).
With respect to those that pertain to interpersonal violence, it had
the 31st highest rate in the world with 3.85 deaths per 100,000 people
in 2016.
The majority of all homicides and suicides are firearm-related, and the
majority of firearm-related deaths are the result of murder and
suicide.
When sorted by GDP, however, the United States has a much higher
violent gun death rate compared to other developed countries, with over
10 times the number of firearms assault deaths than the next four
highest GDP countries combined.
Gunshot violence is the third most costly cause of injury and the
fourth most expensive form of hospitalization in the United States.
History
Until the 1880s, the standard practice for treating a gunshot wound called for physicians to insert their unsterilized fingers into the wound to probe and locate the path of the bullet. Standard surgical theory such as opening abdominal cavities to repair gunshot wounds, germ theory, and Joseph Lister's technique for antiseptic surgery using diluted carbolic acid, had not yet been accepted as standard practice. For example, sixteen doctors attended to President James A. Garfield after he was shot in 1881, and most probed the wound with their fingers or dirty instruments. Historians agree that massive infection was a significant factor in Garfield's death.
At almost the same time, in Tombstone, Arizona Territory, on 13 July 1881, George E. Goodfellow performed the first laparotomy to treat an abdominal gunshot wound. Goodfellow pioneered the use of sterile techniques in treating gunshot wounds, washing the person's wound and his hands with lye soap or whisky, and his patient, unlike the President, recovered. He became America's leading authority on gunshot wounds and is credited as the United States' first civilian trauma surgeon.
Mid-nineteenth-century handguns such as the Colt revolvers used
during the American Civil War had muzzle velocities of just 230– /s and
their powder and ball predecessors had velocities of 167 m/s or less.
Unlike today's high-velocity bullets, nineteenth-century balls produced
almost little or no cavitation and, being slower moving, they were
liable to lodge in unusual locations at odds with their trajectory.
Wilhelm Röntgen's discovery of X-rays in 1895 led to the use of radiographs to locate bullets in wounded soldiers.
Survival rates for gunshot wounds improved among US military personnel during the Korean and Vietnam Wars, due in part to helicopter evacuation, along with improvements in resuscitation and battlefield medicine. Similar improvements were seen in US trauma practices during the Iraq War. Some military trauma care practices are disseminated by citizen soldiers who return to civilian practice. One such practice is to transfer major trauma cases to an operating theater as soon as possible, to stop internal bleeding.
Within the United States, the survival rate for gunshot wounds has
increased, leading to apparent declines in the gun death rate in states
that have stable rates of gunshot hospitalizations.
Research
Research into gunshot wounds in the USA is hampered by lack of funding. Federal-funded research into firearm injury, epidemiology, violence, and prevention is minimal.
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