When suppurative action has been fully established, the surgeon must be guided by the general rules applicable to all other such cases. Care must be taken to prevent the accumulation of pus, lest it burrow, and sinuses become established—not an unfrequent result of want of sufficient caution in this regard. If much tumefaction of muscular tissues beneath fasciæ occurs, or abscesses form in them, free incisions should be at once made for their relief. In wounds where the communication between the apertures of entrance and exit is tolerably direct, occasional syringing with tepid water may be useful, by removing discharges and any fibers of cloth which may be lying in the course of the wound. Weak astringent solutions are occasionally employed in a similar way, with a view to improving the tone of the exhalents and exciting a more vigorous action in the process of granulation. The strictest attention to cleanliness and the complete removal of all foul dressings are essentially necessary, not merely for the comfort of the patient, but to prevent the accumulation of noxious effluvia, and also to obviate the access of flies to the wounds. In tropical climates, and in field-hospitals in mild weather, where many wounded are congregated, flies propagate with wonderful rapidity, and the utmost care is necessary to prevent the deposit of ova and generation of larvæ in the openings of gunshot wounds, especially while sloughs are in process of separation. Cloths dipped in weak solutions of creasote or disinfecting fluids, laid over the wound, are found necessary for this purpose when the insects abound in great numbers.
The constitutional treatment in an ordinary gunshot wound, uncomplicated with injury to bone or structures of first importance, should be very simple. The avoidance of all irregularity in habits tending to excite febrile symptoms or to aggravate local inflammation, attention to the due performance of the excretory functions, and support of the general strength, are chiefly to be considered. Bleeding, with a view to prevent the access of inflammation in such cases, is now never practiced, as formerly, by English surgeons. The diet should be nutritious, but not stimulating. A pure fresh atmosphere is a very important ingredient in the means of recovery. If from previous habits of the patient, or from circumstances to which he is unavoidably exposed, the local inflammation has become aggravated,—indicated by pain, increased swelling, and redness about the wound,—topical depletion by leeches or cupping, bleeding from the arm, saline and antimonial medicines, and strict rest in the recumbent position, must be had recourse to, the extent being regulated by the circumstances of each case. In instances such as these, when the inflammation has become diffused, the purulent secretion is not confined to the track of the wound, but is liable to extend among the areolar connections of the muscles; and if the cure be protracted, attention will be necessary to prevent the formation of sinuses. If stiffness or contractions result, attempts must be made to counteract them by passive motion and friction, with appropriate liniments; if a tendency to edema and debility remain in a limb after the wound is healed, the cold-water douche will be found to be one of the most efficient topical remedies. In French practice, the administration of a chalybeate tincture,[6] as a tonic, or diluted as an injection, in wounds threatening to assume an unhealthy character, is very highly praised. It is stated that under the conjoined employment of this remedy internally and externally, in wounds of a pallid, unhealthy aspect, accompanied by nervous irritability and symptoms of approaching pyemia, the granulations have resumed a red and healthy appearance, and the general state of health become rapidly favorable.
Progress of cure.—Simple flesh wounds from gunshot usually heal in five or six weeks. In the course of the first day the part wounded becomes stiff, slightly swelled, tender, a slight inflammatory blush surrounds the apertures through which the missile has passed, and a slight serous exudation escapes from them. Suppuration commences on the third or fourth day, and in about ten days or a fortnight the sloughs are thrown off. Granulation now progresses, more or less quickly according to the health and vigor of the patient’s constitution. The opening of exit is usually the first closed. When the wound is complicated with unfavorable circumstances, whether inducing in the patient a condition of asthenia or leading to excess of inflammatory action, the progress of the cure may be extended over as many months as, under favorable circumstances, weeks are occupied in the process.
GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY.
The circumstances connected with wounds in particular situations of the body, or in particular organs, are in many respects common to injuries from other causes than gunshot; and in the following remarks the attention is chiefly drawn only to those leading peculiarities which constantly demand the consideration of the army surgeon, and which spring either from the nature of gun projectiles, or the circumstances under which this branch of military practice has for the most part to be pursued.
GUNSHOT WOUNDS OF THE HEAD.
No injuries met with in war require more earnest observation and caution in their treatment than wounds of the head. The vital importance of the brain; the varied symptoms which accompany the injuries to which this organ may be subjected, directly or indirectly; the difficulty in tracing out their exact causes; the many complications which may arise in consequence of them; the sudden changes in condition which not unfrequently occur without any previous warning,—all these circumstances will keep a prudent surgeon who has charge of such wounds continually on the alert. Injuries of this class, the most slight in appearance at their onset, not unfrequently prove most grave as they proceed, from encephalitis and its consequences, or from plugging of the sinuses by coagula, leading to coma, paralysis, or pyemia; and the converse sometimes holds good with injuries presenting at first the most threatening aspects, where care is taken to avert these serious results. Much will depend on the part of the head struck, both as regards the thicker and stronger processes or portions of the skull, and the situation of the sinuses and parts of the cerebrum within; on the force and shape of the projectile; the angle at which it strikes; the age and condition of the patient; and other matters already referred to in the general remarks on gunshot wounds. Mr. Guthrie has laid down as a rule that injuries of the head, of apparently equal extent, are more dangerous on the forehead than on the side or middle portion, and still more so than those on the back part; and that a fracture of the vertex is infinitely less important than one at the base of the cranium. When the injuries are caused by rifle-balls, however, these considerations are rarely of much avail, for the power of injury is such that it can scarcely ever be confined to the immediate neighborhood of the part directly struck.
Wounds of the head may be divided, for convenience of description, into wounds of the scalp and pericranium, without fracture of bone; similar wounds complicated with fracture of the outer or of both tables, without pressure on the encephalon; wounds with fracture and depression; and lastly, wounds in which the encephalon itself has been penetrated. Severe contusion of the bones of the cranium, followed by necrosis, and even fracture, with or without depression, may occur without an open wound of the superficial investments. The case of an officer is mentioned in Dr. Macleod’s Notes of the Crimean War, who was thus killed by a round shot. The scalp was not cut, almost uninjured, but the skull was most extensively comminuted.
Wounds of the scalp and pericranium.—These wounds are usually inflicted by projectiles which are brought into contact at a very acute angle, so that little direct injury to the brain or its membranes is inflicted, and the surgeon’s attention need only be directed to the same considerations as must occur in any contused wounds of the scalp from other causes than gunshot. But even in these accidents, though appearing to be simple flesh wounds, serious cerebral concussion and other lesions are occasionally met with. The usual stupor and other signs of concussion may be very evanescent, or may last for several days, disappearing gradually and wholly, or entailing subsequent evils at more or less remote periods. It must not be forgotten that when the pericranium is removed by a musket-ball, however superficial the injury may seem, there is always a certain degree of injury and bruising to the bone from which it is torn, and necessary laceration of the vessels which inosculate with the nutritive capillaries of the diploë, and through them of the vessels of the meninges with which they are connected. The injury to this vascular system almost invariably leads to necrosis of the portion of the skull from which the coverings are carried away; and sometimes, even when the pericranium is not torn off, sufficient injury is inflicted to lead to a like result. The death of bone is generally limited to a thin layer of the outer table, which in due time exfoliates. The injury to the vessels ramifying between the inner surface of the cranium and dura mater may lead to serious results. There may be rupture of a sinus, leading to compression, or fatal results may ensue from inflammation and suppuration. The case of a young soldier in whom the longitudinal sinus was thus ruptured occurred to the writer. In this instance a rifle-ball had divided the scalp and pericranium about four inches in length obliquely across the skull, just anterior to the angle of the lambdoidal suture, the posterior end of the sagittal suture being exposed midway in the line of the wound. The patient vomited at the instant of the blow, and symptoms of compression, mixed with some of concussion, soon followed. He died eleven hours after the injury. At a post-mortem examination, the superior longitudinal sinus was found to be ruptured, and about four ounces of coagulated blood were lying on the brain. Two darkly-congested spots were observed in the cerebrum, one on each hemisphere, corresponding with the line of direction in which the ball had passed, and these, when cut into, presented the usual characters of ecchymoses. There was no fracture of bone. The case may be found detailed at some length in the Lancet, vol. i., 1855. When inflammation follows the passage of a ball, whether terminating in resolution or leading to abscess, the symptoms and treatment required will be the same as in similar affections from other causes. In like manner, the occurrence of erysipelas, or other complications to which these wounds of the scalp are liable, will be found treated elsewhere. (See Injuries of the Head.)