Part 7

=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.

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.

These always form a large proportion of the injuries from warfare, both in the open field and more especially in sieges, where the upper part of the body is chiefly exposed. Dr. Scrive’s returns show that the proportion of chest to other wounds was 1 in 12 in the trenches, and 1 in 20 in ordinary engagements. In the British forces they are returned as 1 in 10 among the officers during the whole war, and nearly 1 in 17 among the men, from 1st April, 1855, to the end of the war. The ample space of this region, and the exposed surface it offers as a target toward the enemy, would lead to an anticipation of such results. The serious complications which ensue when the cavity of the chest is penetrated, and the dangerous consequences of wounds of its viscera, cause the proportionate mortality to be very great. The British returns show that among the officers treated for these wounds 31–1/2 per cent. and among the men 28–1/10 per cent. died. Out of 603 wounded men who returned to England from the late Indian mutiny, the number who had received wounds of the chest was only 19. In many instances men thus wounded do not live long enough to come under treatment, but die on the field of action from penetration of the heart, hemorrhage, suffocation, or shock; and the proportion of chest wounds returned as “killed in action,” or as “died under treatment,” will constantly vary according to circumstances connected with the nature of the military operations, and the opportunities of early removal from the field to hospital.

Gunshot wounds of the chest may conveniently be divided for study into two classes, viz., _non–penetrating_ and _penetrating_. NON–PENETRATING wounds become subdivided into simple contused wounds of the soft parietes; contused and lacerated wounds; the same accompanied with injury to bones or cartilage; and, lastly, those complicated with lesion of some of the contents of the chest, the pleura remaining unopened, or, if opened, without a superficial wound. PENETRATING wounds may exist without wound, or with wounds of one or more of the viscera of this cavity. Among the more serious complications with which the latter may be accompanied is the lodgment of the projectile or other foreign bodies, as of fragments of bone, within the chest. As wounds of the heart and great vessels are almost invariably at once fatal, and as the organs of respiration occupy the greater part of the cavity of this region, it is in reference to the latter that the treatment of chest wounds is chiefly concerned.

=Non–penetrating wounds.=—Of the simpler wounds in which the soft parietes only are involved little need be observed, excepting that the healing process is often prolonged by the natural movements of the ribs to which the wounded structures are attached, especially when the ball has taken a circuitous course beneath the skin, and that the surgeon must be on his guard to watch for pleuritis arising as an occasional consequence of these injuries. In two deaths recorded in the Director–General’s History of the Crimean War, under simple flesh wounds, without fracture or pleural opening, from bullets, the fatal termination arose from pleuro–pneumonia. When the force has been great, as when fragments of shell or rifle–balls strike at full speed against a man’s breast–plate, not only may troublesome superficial abscesses and sinuses follow, but the lungs may have been compressed and ecchymosed at the time of the injury, and hemoptysis be one of the symptoms presented.

When the projectile has been of large size, although no opening of the parietes or fracture exists, death sometimes ensues by suffocation as the direct result of pulmonary engorgement. The danger of pleuritis or pneumonia will be greater when the injury has been so severe as to cause division of bone or cartilage, and the subsequent suppuration and process of exfoliation will not unfrequently prove very tedious and troublesome. Although the pleura has not been opened, the lung may be lacerated either by the force of contusion or, as in a case recorded by Dr. Macleod, by the edges of the fractured ribs, which may afterward return to their normal relative positions, so as to leave no indication during life of the means by which the lung had been wounded. Such an injury would be rendered much more probable by the existence of old adhesions, connecting the pulmonary and costal pleuræ opposite to the site of injury.

Notwithstanding a projectile has not penetrated the parietes of the chest, a pleural cavity may be opened, as in injuries from other causes, and the lung wounded by the sharp edges of fractured ribs. This will be indicated by emphysema, pneumothorax, hemoptysis, probably signs of internal hemorrhage, and inflammation. Such wounds will generally be the result of injuries from fragments of shell.

=Penetrating wounds.=—These wounds, especially when the lung is perforated or the projectile lodges, are necessarily exceedingly dangerous. Fatal consequences are to be feared, either from hemorrhage, leading to exhaustion or suffocation; from inflammation of the pulmonary structure or pleuræ; from irritative fever accompanying profuse discharges; or from fluid accumulations in one or both of the pleural sacs.

In gunshot injuries a penetrating wound of the chest is in most instances readily obvious to the sense of sight or touch; but it will be found by no means easy always to decide whether a lung has been penetrated or otherwise. The train of symptoms usually described as characterizing wounds of the lung must not be expected to be all constantly present; they are each liable to be modified by a great variety of circumstances, and may each severally exist in penetrating wounds of the chest where the lung has escaped perforation. Nor is it always easy to determine whether the ball has lodged or not; or, the ball having passed through, whether fragments of bone, or other substances, have remained behind.