A Treatise on Gunshot Wounds

by Sir T. Longmore

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.