A Treatise on Gunshot Wounds

by Sir T. Longmore

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.

In the treatment of gunshot wounds of the face where the bones are splintered and torn, the surgeon should always retain and replace as many of the broken portions as possible. It is often surprising how small connections with neighboring soft parts will suffice to maintain vitality and lead to restored union in this region. A case which occurred to the writer in August, 1855, in a private of the 19th Regiment, is detailed in the Lancet, p. 436, of that year. The wound was caused by a fragment of shell. The right half of the arch of the palate was jammed in and fixed at right angles to the other half, and the upper maxillary bone was so comminuted that it was scarcely possible to note the directions of the lines of fracture. The lower maxilla was broken in three places, and there was extensive laceration of the soft parts. Great difficulty was met with at first in unlocking the parts of the palate which had been driven into each other, and, when they were separated, the right half hung down loosely in the mouth; yet favorable union was obtained between all these fractures, the broken portions being adjusted so that the man recovered with both the upper and lower maxillæ consolidated in their normal relations to each other. No teeth had been driven out of their sockets, and they were very useful as points of support in the steps taken to procure coaptation of the disunited fragments. In the Lancet of February 24th, 1855, may be found the description of a series of wounds of the face, from the Crimea, which were examined by Mr. Samuel Solly, and described by him, some of them illustrating how wonderfully the larger arteries often escape in these injuries. In one, loss of the sense of taste on one side of the tongue had resulted; in two, there was partial paralysis of the portio dura; in another, impaired action of the jaw. In one, where a ball entered at the junction of the malar bone and os frontis on the left side, and descended and escaped at the posterior border of the sterno-mastoid muscle, the sight of the left eye was destroyed, and that of the right weakened; and constant headache, dullness of intellect, and incapacity for mental application remained. The injury had originally been followed by symptoms of cerebral concussion. In another case, the man came home with an iron shot firmly wedged and lodged in the center of the vomer. When extracted, at Chatham, by Staff-Surgeon Parry, it was found to weigh nearly four ounces. The returns of the Crimean campaign, from the 1st of April, 1855, to the end of the war, show 533 wounds of the face, of which number 445 returned to duty, 74 were invalided, and 14 died. Bones were penetrated in 107 of these cases, one eye was injured in 42, and both eyes in 2 cases. Mr. Guthrie has recorded that he several times saw both eyes destroyed by one ball, without much other mischief, and one, and even both, rendered amaurotic by balls which had passed behind the eyes. Of 21 cases of wounds of the face, with injuries to bones, returned to England from the late Indian mutiny, and recorded by Dr. Williamson, 11 had lost the sight of one eye, and 1 of both eyes; 6 cases were complicated with fracture of the lower jaw, and in 3 of these the fracture remained ununited.

GUNSHOT WOUNDS OF THE CHEST.