inflicted by projectiles which are brought into contact at a very acute
angle, so that little direct injury to the brain or its membranes is
inflicted, and the surgeon’s attention need only be directed to the
same considerations as must occur in any contused wounds of the scalp
from other causes than gunshot. But even in these accidents, though
appearing to be simple flesh wounds, serious cerebral concussion and
other lesions are occasionally met with. The usual stupor and other
signs of concussion may be very evanescent, or may last for several
days, disappearing gradually and wholly, or entailing subsequent
evils at more or less remote periods. It must not be forgotten that
when the pericranium is removed by a musket–ball, however superficial
the injury may seem, there is always a certain degree of injury and
bruising to the bone from which it is torn, and necessary laceration
of the vessels which inosculate with the nutritive capillaries of
the diploë, and through them of the vessels of the meninges with
which they are connected. The injury to this vascular system almost
invariably leads to necrosis of the portion of the skull from which the
coverings are carried away; and sometimes, even when the pericranium
is not torn off, sufficient injury is inflicted to lead to a like
result. The death of bone is generally limited to a thin layer of
the outer table, which in due time exfoliates. The injury to the
vessels ramifying between the inner surface of the cranium and dura
mater may lead to serious results. There may be rupture of a sinus,
leading to compression, or fatal results may ensue from inflammation
and suppuration. The case of a young soldier in whom the longitudinal
sinus was thus ruptured occurred to the writer. In this instance a
rifle–ball had divided the scalp and pericranium about four inches
in length obliquely across the skull, just anterior to the angle of
the lambdoidal suture, the posterior end of the sagittal suture being
exposed midway in the line of the wound. The patient vomited at the
instant of the blow, and symptoms of compression, mixed with some of
concussion, soon followed. He died eleven hours after the injury. At a
post–mortem examination, the superior longitudinal sinus was found to
be ruptured, and about four ounces of coagulated blood were lying on
the brain. Two darkly–congested spots were observed in the cerebrum,
one on each hemisphere, corresponding with the line of direction in
which the ball had passed, and these, when cut into, presented the
usual characters of ecchymoses. There was no fracture of bone. The case
may be found detailed at some length in the _Lancet_, vol. i., 1855.
When inflammation follows the passage of a ball, whether terminating in
resolution or leading to abscess, the symptoms and treatment required
will be the same as in similar affections from other causes. In like
manner, the occurrence of erysipelas, or other complications to which
these wounds of the scalp are liable, will be found treated elsewhere.
(See INJURIES OF THE HEAD.)
The treatment of an ordinary gunshot wound of the scalp should be
very simple. Cleansing the surface of the wound, removing the hair
from its neighborhood for the easier application of dressings, lint
moistened with clean water, very spare diet, and careful regulation of
the excretions are the only requirements in most cases. The patient
must be closely watched, so that measures may be taken to counteract
inflammatory symptoms in their earliest stages. Even after one of
these wounds has healed, and the patient to all appearance has quite
recovered, it is necessary to enjoin continued abstinence from excesses
of all kinds. Instances are frequently quoted where intoxication, a
long time after the date of injury, has induced symptoms of apoplexy
and death. In the Surgical History of the Crimean Campaign, the case of
a soldier of the 31st Regiment, thirty–eight years old, who received a
contused wound at the back of the head from a piece of shell, without
section of the scalp and without lesion of the bone, is related.
In this instance a small abscess formed under the scalp, and was
evacuated. After the wound was healed the man suffered from constant
headaches, and was invalided to England. Soon after landing he drank
freely, coma followed, and he died shortly afterward. The post–mortem
examination showed traces of inflammatory action in the dura mater, and
“just anterior and superior to the corpora quadrigemina was a tumor the
size of a walnut, composed of organized fibrin and some clotted blood.”
=Wounds complicated with fracture, but without depression on the
cerebrum.=—These are very uncertain in their effects, and often apt to
mislead the surgeon, from the absence of urgent symptoms in their early
stages. The occurrence of fracture is, however, sufficient to show the
force with which the projectile has struck the head, and to indicate
the mischief which the brain and its immediate coverings have not
improbably sustained.
In these injuries there may be a simple furrowing of the outer table,
without injury to the inner; or there may be fissure extending to a
greater or less degree of length, or radiating in several lines; or
both tables may be comminuted in the direction the ball has traversed
in such small portions that they lie loosely on the dura mater without
much alteration in the general outline of the cranial curve. The chief
and only means, in many cases, of concluding that no depression upon
the cerebrum has taken place is the absence of the usual symptoms
of compression; for it is well known that simple observation of the
injury to the outer table, whether by sight or touch, will by no means
necessarily lead to a knowledge of the amount of injury or change of
position in the inner table.
When simple removal of a portion of the outer surface of the skull
has been caused by the passage of the ball or other missile, the
wound will sometimes heal, under judicious treatment, without any
untoward symptom. A layer of the exposed surface of bone will probably
exfoliate, and the wound granulate and become closed without further
trouble. But such injuries, for reasons before named, are very likely
to be followed by inflammation, and not improbably abscess, between the
internal table and dura mater; and further, as a consequence of the
vascular supply being stopped, and perhaps also partly from the effects
of the original contusion by necrosis of the inner table itself. Care
must be taken not to mistake one of these injuries for a depressed
fracture, as is not unlikely to happen when the excavation effected by
the projectile is rather deep and the edges of the bone bordering the
excavation are sharp.
Fissured fractures, when the fissure extends through the skull, usually
result from injuries by shell. The passage of a ball may fracture and
very slightly depress a portion of the outer table of the cranium, and
then the line of fracture will very closely simulate fissured fracture
extending through both tables, and the diagnosis between them be
excessively doubtful. When fissured fracture exists, the distance to
which it may be prolonged is often quite unindicated by symptoms, and
its extent is very uncertain. Fissures often extend to long distances.
They may occur at a part remote from the spot directly injured. In the
case of a lieutenant of the 11th Hussars, who was apparently slightly
wounded at Balaklava in the middle of the forehead by a piece of
shell, a fissured fracture was found, after death, across the base of
the skull, quite unconnected with the primary wound, and seemingly
from _contre–coup_. Death resulted from inflammation and suppuration
set up near this indirectly–injured part. Fissured fracture of the
inner table may also occur from the action of a ball without external
evidence of the fracture. Such a case occurred in the 55th Regiment, in
the Crimea. The soldier had a wound of the scalp along the upper edge
of the right parietal bone. The ball in passing had denuded the bone;
but there was no depression. The man walked to camp from the trenches
without assistance, and there were no cerebral symptoms on his arrival
at hospital; but five days afterward there was general edema of the
scalp and right side of face, the wound became unhealthy, and slight
paralysis appeared on the left side. The next day hemiphlegia was more
marked, convulsion and coma followed, and he died on the thirteenth day
after the injury. Pressure from a large clot of coagulum and extensive
inflammatory action were the immediate causes of death; but a fissure,
confined to the inner table, running in line with the course of the
ball, was also discovered. A preparation of the calvarium in this case
was presented by Dr. Cowan, 55th Regiment, to the museum at Fort Pitt.
The cases where comminution has resulted from the track of a ball
across the skull generally present less unfavorable results than those
where a single fissured fracture, extending through both tables,
exists. The small, loose fragments can be removed; and if the dura
mater be intact, the case, with proper care to prevent inflammatory
action, may not improbably be attended with a favorable recovery.
=Wounds complicated with fracture and depression on the cerebrum.=—Such
wounds are most serious, and the prognosis must be very unfavorable.
They must not be judged of by comparison with cases of fracture with
depression caused by such injuries as are usually met with in civil
practice. The severe concussion of the whole osseous sphere by the
stroke of the projectile, the bruising and injury to the bony texture
immediately surrounding the spot against which it has directly
impinged, as well as the contusion of the external soft parts, so
that the wound cannot close by the adhesive process, constitute very
important differences between gunshot injuries on the one side, and
others caused by instruments impelled solely by muscular force on the
other. So, also, the injury to the brain within, and its investments,
is proportionably greater in such injuries from gunshot. The experience
of the Crimean campaign shows that, when these injuries occurred in
a severe form, they invariably proved fatal. Of seventy–six cases
treated, where depression only, without penetration or perforation,
existed, fifty–five proved fatal, twelve were invalided, and nine
only were discharged to duty. In the twenty–one survivors, the amount
of depression is stated in the history of the campaign to have been
slight, though unmistakable, and all except one recovered without any
bad symptom. Of eighty–six other cases where perforation or penetration
of the cranium occurred, all died.
=With penetration of the cerebrum.=—It is obvious that, where a
projectile has power not only to fracture, but also to penetrate the
cranium, it will rarely be arrested in its progress near the wound of
entrance. Either splinters of bone, or the ball, or a portion of it
will be carried through the membranes into the cerebral mass. Sometimes
a ball, if not making its exit by a second opening in the cranium, will
lodge at the point of the cerebral substance opposite to that of its
place of entrance; but the course a projectile may follow within the
cranium is very uncertain.
Instances have occurred where balls have lodged in the cerebrum without
giving rise to serious symptoms of danger for a long time. Such cases
might lead to throwing surgeons off their guard in making a prognosis,
from supposition that the ball by some accident had not lodged. The
case of a soldier wounded by a ball in the posterior part of the side
of the head is mentioned by Mr. Guthrie. The wound healed, and the man
returned to duty; a year afterward he got drunk, and died suddenly.
The ball was found in a sac lying in the corpus callosum. Another
soldier wounded at Waterloo had a similar recovery, and also died
after intoxication. The ball was found deeply lodged in a cyst in the
posterior part of the brain. An artillery soldier was wounded, in the
Crimea, by a rifle–ball, which entered near the inner angle of the left
superciliary ridge. The wound progressed without a bad symptom until a
month afterward, when coma came on, and death shortly followed. The
ball was found in a sac, in which pus also was contained, at the base
of the left anterior lobe of the brain.
=Treatment.=—The treatment of the various kinds of fractures from
gunshot, and their complications, may be considered together. Formerly,
a gunshot wound of the head was supposed to be in itself a sufficient
indication for the use of the trephine; indeed, even where no fracture
was caused, an opening was recommended by comparatively recent surgeons
to be made in the cranium, to meet symptoms which might be expected
to result. Modern surgeons, however, generally have made use of the
trephine only when there was reason for concluding that depressed bone
was leading to _permanent_ interruption of cerebral function, or that
an abscess had formed within reach, and was capable of evacuation.
Preventive trephining has been proved to be useless, as well as
dangerous, and is no longer an admissible operation. The tendency
of the most recent experience has been to limit the practice of
trephining to the narrowest sphere; and when the very great difficulty
of making accurate diagnosis in these cases is considered,—whether
as to the distinguishing signs of compression; the precise seat of
its cause, if the compression exist; the space over which this cause,
when ascertained, may extend; its persistent or temporary character;
its complications; and certain dangers connected with the operation
itself,—no wonder need be excited that this tendency should exist.
Besides, the numerous cases which have now been noted where bone
has evidently been depressed, but the brain has accommodated itself
to the pressure without serious disability being caused, or where
compression from effusion has been removed by absorption under proper
constitutional treatment, are further causes of hesitation in respect
to trephining. In the Surgical Report of the Crimean Campaign, it
is stated that the trephine was only successfully applied in four
cases (and none of these were from rifle–balls) during the whole war;
and that in these instances the patients were subsequently subject
to occasional headache and vertigo; and in the French report, by Dr
Scrive, it is stated that trephining was for the most part fatal in
its results in the French army. In siege operations, the experience as
regards wounds of the head is always very extensive, the lower parts
of the body being so much more protected in the trenches. According to
Dr. Scrive’s returns, one of every three men killed in the trenches
before Sebastopol, and one in every 3·4 wounded, was injured in this
region. In the English returns, wounds of the head and face in the men
are shown as 19·3 per cent.; in the officers, as 15 per cent.; but this
is of the total wounded in the field as well as in the trenches. There
was, therefore, as extensive a range for observation of the effects of
trephining in the siege of Sebastopol as is likely to happen in any
war. Dr. Stromeyer, who in the early part of his professional career
resorted to trephining in complicated fractures of the skull, records,
in his Principles of Military Surgery, that he has abandoned the
practice. After the battle of Kolding, in Sleswick, in 1849, there were
eight gunshot fractures of the skull, with depression, and more or less
cerebral symptoms. In all these, with one exception, the detachment
of the fractures was left to nature, and all recovered. One patient,
from whom some fragments were removed on the seventh day, was placed in
considerable danger by the treatment, and Dr. Stromeyer resolved never
to adopt it again. In 1850, in Sleswick, two young surgeons came under
Dr. Stromeyer’s care with gunshot wounds of the head, accompanied by
deep depression; they were both treated without trephining, and both
recovered. Throughout the three campaigns of the Sleswick–Holstein war,
there was only one case of trephining which gave a favorable result.
Military experience makes it difficult to understand the frequent
and successful performance of trepanning by the older surgeons for
such slight causes as they performed it, excepting that the patients
labored under little else than the effects of the operation itself,
while very fatal mischief has existed in addition in those instances in
which the operation has been resorted to for accidents from gunshot. A
circumstance quoted by Sir G. Ballinghall particularly illustrates the
favorable results of abstaining from trephining in some cases. After
the battle of Talavera, a hospital which had been established in the
town had to be suddenly abandoned, and an order was given for all the
wounded who could march to leave it. There was no time for selection,
and among those who marched were twelve or fourteen men with wounds
of the head, in which the cranium was implicated, four or five having
both tables fractured, and two having the globe of one eye destroyed
along with fracture of the os frontis. All these men recovered, though
they were sixteen days on the march, harassed and exposed to a burning
sun, and had no other application than water–dressing. Of eight cases
of contusion or fracture of the cranium, with displacement of both
tables, recorded by Dr. Williamson, among men who were sent from India
to Chatham, during the late mutiny, none had been trephined. In all
these there was a depressed cicatrix, the wound having contracted and
become closed by a strong fibrous investment. In one case—a wound by
a musket–ball, in the center of the forehead—the ball was supposed to
be still lodged within the skull. In the Fort Pitt museum are several
preparations, showing depressed fracture of the inner table of the
skull from gunshot, taken from patients who had recovered without
trephining, and died years afterward from other causes. The edges of
the depressed portions of bone had become smooth, and united by new
osseous matter, and the cerebrum must have accommodated itself to the
new form of the inner cranial surface. Two or three instances are
known in which the course of a ball has been traced from the sight
of entrance across the brain, and trephining resorted to for its
extraction, with success; but there are also many others in which the
mere operation of the extraction of a foreign body has apparently led
to the immediate occurrence of fatal results. Moreover, splinters of
bone are not unfrequently carried into the brain by balls, and these
may elude observation; or the ball itself may be divided and enter the
brain in different directions, as was observed in the Crimea; when
the operation of trephining can only be an additional complication to
the original injury, without any probable advantage. Where irregular
edges, points, or pieces of bone are forced down and penetrate—not
merely press upon—the cerebral substance, or where abscess manifestly
exists in any known site, or a foreign substance has lodged near the
surface, and relief cannot be afforded by the wound, trephining may be
resorted to for the purpose; but the application of the operation, even
in these cases, will be very much limited if certainty of diagnosis
be insisted upon. In all other cases, it seems now generally admitted
that much harm will be avoided, and benefit more probably effected,
by employing long–continued constitutional treatment, viz., all the
means necessary for controlling and preventing the diffusion of
inflammation over the surface of the brain and its membranes,—the most
careful regimen, very spare diet, strict rest, calomel and antimonials,
occasional purgatives, cold application locally, so applied as to
exclude the air from the wound, and free depletion by venesection, in
case of inflammatory symptoms arising. Similar remarks will apply in
case of lodgment of a projectile within the brain; if the site of its
lodgment is obvious, it should be removed with as little disturbance
as possible, but trephining for its extraction on simple inference is
unwarrantable.
GUNSHOT WOUNDS OF THE SPINE.
Gunshot wounds of the spine are closely associated with similar
injuries of the head. In both classes corresponding considerations
must be entertained by the surgeon in reference to the important
nerve–structures, with their membranes, which are likely to be
involved in the injury to their osseous envelope; in both, the effects
of concussion, compression, laceration of substance, or subsequent
inflammatory action, chiefly attract attention. In the Surgical History
of the Crimean Campaign, twenty–seven cases are noted in which vertebræ
were fractured, eight being without apparent lesion of the spinal
cord, and nineteen with evident lesion. Of these, twenty–five died;
and two, in which the fractures were confined to the processes of the
vertebræ, survived to be invalided. The gunshot wounds affecting the
spinal column have not been separated from injuries in other regions
in the French returns. Six men only wounded in the spine, during the
late mutiny in India, arrived in Chatham. In all, they were the results
of musket–balls. Two were wounds of the sacrum; in the remainder,
the portions of the vertebræ fractured were the spinous processes.
Concussion of the spinal column, leading to paralysis more or less
persistent, is usually occasioned by fragments of shell, or stones
from parapets; and in these cases the accidents are mostly accompanied
by extensive lesions of the neighboring structures. In one fatal
case in the Crimea, the ball passed through the spine rather below
the first dorsal vertebra, leading to complete loss of sensation and
voluntary motion below the seat of injury, and death on the sixteenth
day afterward; in another, a rifle–bullet entered the right side of
the second lumbar vertebra, traversed the spinal canal at that part,
and lodged in the body of the bone. In this latter case, violent pain
was complained of in the lower extremities, shooting along the groins.
The patient was paraplegic, and death ensued thirty–three hours
after admission. In another fatal case, a rifle–bullet passed through
the right cheek, and lodged near the base of the skull. There was no
paralysis, but delirium and coma supervened, and the patient died five
days after receiving the wound. The bullet was found after death,
lying just below the basilar process, and a large piece of the atlas
was broken off and almost detached. The spinal cord did not appear to
have been primarily injured, but acute inflammation had been set up,
and had extended to the membranes of the brain. There is a preparation
in the museum at Fort Pitt which shows fracture both of the atlas and
axis, without lodgment of the ball. The patient survived thirty days.
It is curious that, in a case under the care of the writer, before
referred to, where a rifle–ball passed through the right loin, entered
the spinal canal between the third and fourth lumbar vertebræ, breaking
the laminæ, passed upward within the column, between it and the cord,
and made its exit through the left intervertebral foramen between the
second and third vertebræ, as shown after death, no paralysis occurred
at the time of the injury, nor subsequently, nor was any evidence
afforded post mortem of thecal inflammation having been excited. (See
Guy’s Reports, vol. v., 1859.)
In injuries of the vertebral column and spinal cord occurring in
military practice, the mischief is usually so complicated and
extensive, and the medulla itself so bruised, that the cases must be
very rare indeed in which the operation of trephining, if justifiable
in any case, can offer the slightest prospect of benefit. M. Baudens
extracted, with an elevator supplied with a canula, a ball which had
lodged in the eleventh dorsal vertebra and was causing compression with
complete paraplegia. The paralysis disappeared immediately after the
extraction of the bullet; but tetanus came on four days afterward, and
proved speedily fatal. Balls have been known to pass through the bodies
of vertebræ, and apparent cure follow; but as such patients in military
practice are usually invalided out of the service as soon as they are
fit to leave hospital, no opportunity is afforded of observing the
consequences which ulteriorly ensue.
GUNSHOT WOUNDS OF THE FACE.
Wounds of the face from musket–shot, grape, and small fragments of
shell are usually more distressing from the deformity they occasion
than dangerous to life. The absence of vital organs, the natural
divisions among the bones, and their comparatively soft structure,
rendering them less liable to extensive splitting; the copious vascular
reticulation and supply rendering necrosis so much less likely and
repair so much easier than in other bones; the limited amount of space
occupied by the osseous structure between their respective periosteal
investments, and the opportunities from the number of cavities and
passages connected with this region for the escape of discharges, lead
to this result. On the other hand, the vascularity of this region
leads to danger both of primary and especially secondary hemorrhage—a
circumstance which, in all deep wounds of this region, must be looked
for as a not improbable complication. The other complications of these
gunshot wounds are lesions of the organs of special sense, injury to
the base of the skull, paralysis from injury to nerves, wounds of
glands, their ducts, and of the lachrymal apparatus; but it is scarcely
necessary to do more than allude to them, as the considerations
connected with their treatment will be found elsewhere.
Wounds from cannon–shot occasionally illustrate what terrible injuries
may be borne in this region without life being at once extinguished.
They are the more distressing because the patient lives conscious of
his sufferings without possibility of surgical alleviation. The case of
an officer of Zouaves, wounded in the Crimea, is recorded, who had his
whole face and lower jaw carried away by a ball, the eyes and tongue
included, so that there remained only the cranium, supported by the
spine and neck. This unfortunate being lived twenty hours after the
injury, breathing by the laryngeal opening at the pharynx, while his
gestures left no doubt that he was conscious of his condition. Mr.
Guthrie has recorded a similar case which occurred in an officer during
the assault of Badajos. This patient suffered distressingly from want
of water to moisten his throat, but could not swallow when some was
brought. One eye was left hanging in the orbit, the floor of which was
destroyed, and this enabled him to write thanks for attention paid him.
He did not die till the second night after the injury.