A Treatise on Gunshot Wounds

by Sir T. Longmore

Simple flesh wounds have already been referred to both in respect to their nature and treatment in the commencement of this essay. It is in connection with fractures of bones and their proper treatment that the interest of surgeons is chiefly attracted in gunshot wounds of the extremities. From the nature of the injuries, already described, to which bones are subjected by the modern weapons of war, together with the irreparable nature of the wound in the softer structures, except after a long process of suppuration and granulation, as well as from the usual circumstances of military life, it might be anticipated that difficulty would often arise in determining which of the double set of risks and evils—those attending amputation, and those connected with attempts to preserve the limb with a profitable result—would be least likely to prove disadvantageous to the patient. Experience in such injuries has established certain rules which are now generally acted upon; some still remain sub judice.

Although the subject of pyemia is considered in its general bearings elsewhere, it is right to mention here that this serious complication, as met with in gunshot wounds, appears to be especially induced by injuries of bones, particularly those of long bones in which the medullary canal has been laid open and extensively splintered. Several circumstances probably conduce to this result: the prolonged suppurative action during the removal of sequestra, the irritation caused by sharp points and edges, sometimes increased by transport from primary to secondary hospitals, the patulous condition of veins in bones leading to thrombosis, being its chief local sources; while depressed vital power from any cause, and continued exposure to an impure atmosphere from the congregation of numerous patients with suppurating wounds, are the principal agents in producing the state of constitution favorable to its development and progress. Unless the hospital miasmata engendered in this way are constantly removed as they arise, or very greatly diluted by proper ventilation, it is almost impossible that patients laboring under severe wounds of the extremities with comminuted bony fractures can be long saved from septicemia and pyemia; and these, when they supervene, rarely lead to any but a fatal termination. The different conditions of hospital air, which in one set of cases lead to the appearance of hospital gangrene, in another set of pyemia, are not properly understood; but from the frequency with which the latter complication follows wounds of bones, it would seem that an especial influence is exerted by the local peculiarities of these injuries already mentioned. However, observation would also lead to the belief that certain individuals are much more predisposed to pyemic action than others placed under similar circumstances. Occasionally, in gunshot injuries of bones, where no splintering has occurred, but only a small portion of the periosteum has been torn off and the shaft contused by the stroke of a bullet, severe inflammation will follow, the medullary canal become filled with pus, and death ensue from pyemia. The attention of surgeons has been particularly called to the various circumstances producing inflammation and suppuration of the medullary tissues—osteo-myelitis—in long bones after gunshot injuries by M. Jules Roux of Toulon.[10]

Upper Extremity.—Fractures of the bones of the arm are well known to be very much less dangerous than like injuries in the corresponding bones of the lower extremity. Unless extremely injured by a massive projectile, or longitudinal comminution exist to a great extent, especially if also involving a joint, or the state of the patient’s health be very unfavorable, attempts should always be made to preserve the upper extremity after a gunshot wound. In the Director-General’s History of the Crimean Campaign, the recoveries without amputation are shown to be, in the humerus, 26·6; radius and ulna, 35·0; radius only, 70·0; ulna only, 70·0 per cent. of cases treated. The proportion of deaths in these cases was only 2·3 per cent. Although not the result of gunshot, a remarkable case, published by Staff-Surgeon Dr. Williamson, by whom the operation was performed, serves to illustrate how extensively bone may be removed from the upper arm, and a useful member be still retained. The details will be found in his Notes on the Wounded from the Mutiny in India. The whole of the ulna, (not merely sequestra, but also the new bone which had formed around them, the object of which proceeding is not stated,) two inches of the humerus, and the head and neck of the radius were removed; and, four months after the operation, the man could “bend his forearm, raise his hand behind his head, lift a 28-lb. weight from the ground, pronate and supinate the hand, and use his fingers well.” Of 194 wounds and injuries of the upper extremity among men returned from the late mutiny in India, 100 are recorded by Dr. Williamson to have been sent to duty regular or modified, 67 invalided from the service, 1 died, and 26 were still under treatment.

In the latter part of the Crimean campaign, when the health of the troops and means of treatment were favorable, it was often remarkable what extensive injuries of the upper extremity, even where the joints were involved, were repaired without amputation. The following cases are examples: Sergeant Bacon, 7th Fusileers, aged thirty-six, at the attack on the Redan on the 8th of September, 1855, was wounded by a rifle-ball, which entered the head of the left humerus, shattered the bone very much, and was extracted from below the left scapula. Dr. Moorhead determined to try to preserve the limb. The head of the humerus required to be removed in small, broken fragments; and the shaft, being found to be split down between three and four inches, was to that distance removed by the saw. The case progressed favorably, and in 1857 this man was in London with a most useful arm. A young soldier of the 23d Regiment was wounded, on the 15th August, 1855, by a large grape-shot, which passed through the right arm near the shoulder, comminuting the bone for three inches and extensively destroying the soft parts. Staff-Surgeon Williams, in medical charge, despairing of saving the limb, proposed to amputate, but, at the suggestion of the late Director-General Alexander, then principal medical officer of the Light Division, arranged to allow some days to elapse to watch symptoms. The case progressed so well that the idea of amputation was abandoned, and the man recovered with a very serviceable arm. In another regiment of the Light Division, the 77th, a healthy young soldier, under the care of Surgeon Franklin, was wounded at the last assault of the Redan, and sustained a comminuted fracture of the humerus, had the elbow-joint opened, both bones of the forearm broken about two inches below the joint, and the soft parts widely opened, by a piece of shell. Here no excision was practiced, but fragments removed as they became loose; the arm, with its dressings, was supported on a zinc-wire cradle, hollowed out and bent at the elbow to the desired angle; and nourishment, with malt liquor, were freely given from the first day. Anchylosis was established, and he left for England with a useful limb. The fractures above and below the joint prevented the application of passive motion.

In these injuries, where the bone is much splintered, the detached portions, and any fragments which are only retained by very partial periosteal connections, should be removed; projecting spiculæ sawn or cut off;[11] the wound being extended at the most dependent opening where two exist, or fresh incisions being made for this purpose, if necessary; light water-dressing applied; the limb properly supported; and the case proceeded with as in cases of compound fracture from other causes. (See Fracture.) The same general rules also apply in preserving as much of the hand as possible, in gunshot injuries. If the shoulder or elbow joint be much injured, but the principal vessels have escaped, the articulating surfaces and broken portions should be excised. Care should be taken to see that the projectile has wholly passed out, or been removed. In a case of comminuted fracture of the humerus, in the 88th Regiment, no union having taken place a month after the injury, and some dead bone requiring removal, an incision was made for this purpose, when half the bullet was found between the fractured ends. Good union, with free motion of the arm, resulted, after this foreign body and the necrosed bone were taken away. The results of excision practiced in the shoulder and elbow joints, especially the former, after gunshot wounds, have been exceedingly satisfactory. Especial attention was directed to the practice of resections of joints after gunshot injuries in the Sleswick-Holstein campaigns between 1848 and 1851; and Dr. Friedrich Esmarch has published the results in a valuable essay on the subject. Of nineteen patients in whom the shoulder-joint was resected, in twelve a more or less useful arm was preserved; and seven died. Complete anchylosis did not occur in any one instance; and in several the power of motion became so great as to enable the men to perform heavy work. Of forty patients for whom resection of the elbow-joint was performed six died, thirty-two recovered with a more or less useful arm, one remained unhealed at the time Dr. Esmarch wrote, (1851,) and in one mortification ensued and amputation was performed. These operations present no peculiarities in the mode of performance or their after-treatment, as compared with similar resections in civil practice.

Lower extremity.—Gunshot wounds of the lower extremity vary much more greatly in the gravity of their results, as well as in the treatment to be adopted, according to the part of the limb injured, than happens in those of the upper extremity. As a general rule, ordinary fractures below the knee, from rifle-balls, should never cause primary amputation; while, excepting in certain special cases, in fractures above the knee, from rifle-balls, amputation is held by most military surgeons to be a necessary measure. The special cases are gunshot fractures of the upper third of the femur, especially where the hip-joint is implicated; for in these the danger attending amputation itself is so great that the question is still open, whether the safety of the patient is best consulted by excision of the injured portion of the femur, by simple removal of detached fragments and trusting to natural efforts for union, or by resorting to amputation. The decision of the surgeon must generally rest upon the extent of injury to the surrounding structures, the condition of the patient, and other circumstances of each particular case. If the femoral artery and vein have been lacerated, any attempt to preserve the limb will certainly prove fatal.

The femur—the earliest formed, the longest, most powerful, and most compact in structure of all the long bones of the body—can only be shattered by a ball striking it with immense force. Attention was specially directed in the late Crimean campaign to the question of the proper treatment of these injuries, and expectations were generally held that the advanced experience in conservative surgery would lead to many such cases terminating favorably with preservation of the limb, which previously would have been subjected to amputation. Toward the latter part of the war, all the circumstances of the patients were as favorable for testing this practice as they have been in the various émeutes in Paris, with the advantages of immediate attention and all the appliances of the best hospitals close at hand. Yet, in the Surgical History of the Campaign, it is stated that only fourteen out of 174 cases of compound fracture of the femur among the men, and five out of twenty among the officers recovered without amputation being performed; that those selected for the experiment of preserving the limb were patients where the amount of injury done to the bone and soft parts was comparatively small; that where recovery ensued, it always proved tedious, and the risks during a long course of treatment numerous and grave; and that the proportion of recoveries would not appear even so large as the above, if the deaths of those who after long treatment were subjected to amputation as a last resource were included. Amputations of the thigh, however, were very fatal in their results also, the recoveries being stated to be, among the men, in the upper third 12-9/10, in the middle third 40, in the lower third 43-3/10, per cent. of cases treated. Among the officers the proportion was rather more favorable. But this percentage includes those cases in which attempts had been made to preserve the limb, and failure resulting, amputation was resorted to as a last chance of saving the patient, so that they ought to have been excluded from the lists of amputations, both primary and secondary, as commonly interpreted. On account of this comparatively indifferent success of amputation, resection of portions of the shaft of the femur was sometimes practiced; but the records state that no success attended the experiment, every case, without exception, having proved fatal.

In considering the results of gunshot fractures of the femur, the situation of the injury is a matter of great importance, whether as regards chances of recovery without or with amputation. In the Surgical History of the Crimean Campaign this fact is shown in the results of amputation; but the distinction is not made in regard to the recoveries without amputation. Dr. Macleod, in his Notes, remarks that he has only been able to discover three cases in which recovery followed a compound fracture in the upper third of the femur without amputation: one, that of an officer of the 17th Regiment; the second, of a soldier of the 62d; and a third, whose regiment is not named. A case, however, was under the care of the writer, not included in the above, nor appearing in the official history of the war; and one, judging from the results described in Dr. Macleod’s Notes, more fortunate in its issue than at least two of the number he mentions. With regard to the first patient, Dr. Macleod states he has been informed “that although his limb was in a very good condition when he left for England, the trouble it has since given him, and the deformed condition in which it remains, makes it by no means an agreeable appendage;”[12] in the second, the fracture was in the lower part of the upper third, and the injury was comparatively slight; in the third, a mass of callus was thrown out which connected the bone, but he died of purulent poisoning, and never left the Crimea. In the case which was under the writer, the fracture was within the upper third; there is no distortion, and shortening only of 1-1/2 inches; the officer is able to walk or ride without any inconvenience, and competent for all duty. All the circumstances were most favorable for recovery in this instance; and a consideration of these on the one hand, and the experience of the unfavorable results of amputation in this region on the other, led to the effort to save the limb. A short history of this case will be useful. Lieutenant D. M., 19th Regiment, aged seventeen, of sanguine temperament, healthy frame, was brought up to camp about 4 A.M. Sept. 9th, 1855. He had been wounded in the assault upon the Redan in the upper part of the left thigh, and had been lying by the side of the ditch where he fell thirteen hours. When discovered, he was carried carefully in a soldier’s greatcoat as far as the opening of the trenches, and thence on a stretcher to camp. He was very cold and prostrate on his arrival. The wound in his left thigh had been caused by a ball, which had passed out. It entered posteriorly at the fold between the left nates and thigh, three inches from the tuberosity of the ischium; passed forward, downward, and outward, and made its exit seven inches below the trochanter major. The femur was broken in the line of passage of the ball, which, from entrance to exit, appeared to be about six inches. From the trochanter major to the seat of fracture was four inches; to the external condyle on the same side was 15-1/2 inches. The amount of comminution appeared slight, but, from its vicinity to the joint, the great swelling about the limb, and desire to avoid aggravating pain, the precise condition of fracture was not further ascertained. The upper fragment projected forward, but any attempts at reduction caused great suffering; and some restoratives being given, wet compresses applied to the thigh, and the limb secured against additional movement, the patient was left to rest. At a consultation the following morning, from the patient’s age, so favorable for reparative action, very healthy constitution, and the fact that, the siege being over, full attention could be paid to the case, conservation of the limb was settled to be attempted, and the patient was therefore treated with this view. In addition to the wound just named, he had received an extensive contusion of the right thigh by the fall of some heavy substance from the explosion which occurred at one A.M., after the Russians left the Redan.

There is not space to follow the details of the treatment of this case. The cure was protracted by large and troublesome bed-sores; and attention to these, to the discharges from the wound, and preserving favorable position, occupied much time and care daily, and caused many changes in the appliances for these objects to be from time to time necessary. On November the 4th, union had so far taken place that he was able to raise his body from the knee upward while in bed, without apparent motion at the seat of fracture. On November 15th, in consequence of the great explosion at the right siege-train, he had to be carried to another division of the camp; this was effected without harm. In the middle of January he was able to sit in a chair without inconvenience; and on February 22d he left the Crimea for England, being able to walk with the assistance of crutches. Union was then firm; but a slight serous oozing continued from the wound of exit, and there was much stiffness of the ankle and knee joints from the long-continued constrained position to which he had been subjected. In July, 1856, after his arrival in Ireland, indications of pus collecting manifested themselves at the wound of exit; and Professor Tufnell, on passing a bougie about seven inches in the course of the wound, evacuated a small abscess, and felt a piece of bone trying to make its way to the surface. This was subsequently removed, and, under Mr. Tufnell’s able care, the stiffness of the joints gradually disappeared, and he was enabled to return to duty.

Dr. Macleod says that, after many inquiries respecting cases of this nature in the hospitals of the other armies engaged in the war, excepting one presented by Baron Larrey to the Société de Chirurgie in 1857, he never could hear of any other but that of a Russian whose greatly shattered and deformed limb he often examined.[13] It had united almost without treatment. Two cases of united fractures of the femur in the upper third have arrived from the late mutiny in India, and in both, Dr. Williamson records, a good and useful limb had resulted, one with shortening of 1-1/2, the other 3-1/2, inches. Still more recently, M. Jules Roux, of the St. Maudrier Hospital, at Toulon, has given a list of no less than twenty-one cases of gunshot injuries of the upper third of the femur, which he had examined on their return from the Italian war of 1859, in all of which consolidation of the fracture had taken place. We have no data by which we can estimate the proportion of these cases of union to those in which other results ensued.