ARTICLE XVIII. GUNSHOT WOUNDS OF THE HEAD AND CRANIUM. BY LOUIS A. LAGARDE, MAJOR AND SURGEON U. S. ARMY. THE introduction of steel-armored projectiles of reduced calibre for the military rifle of the civilized nations has modified the subject of gunshot wounds in nearly all the tissues, the head included. The experimenters with this new high-velocity bullet that does not deform on impact noticed in the beginning that the amount of destruction conferred by it at close range was very great, and that this destruction was generally proportional to the velocity and the resistance encountered on impact. When these conditions of velocity and resistance obtained, the destruction. took the character of what is often designated as explosive effects. These so-called explosive effects were especially noted in fluid or semifluid tissues enclosed in rigid walls, of which the brain and skull are the most typical examples. Such a lesion is usually characterized by a wound of entrance corresponding in size to the calibre of the projectile inflicting it, and a wound of exit varying in diameter from one to several inches. The channel track between the exit and entrance wounds is much lacerated and marked by the presence of bony sand and spicule of bone varying in size from one-fourth to one-half inch. The latter are usually found to have been driven into the tissues, not only in the line of flight of the projectile, but at right angles to it, as if an internal force had exerted itself in all directions. Many theories have been advanced to explain explosive effects, but it is now pretty generally attributed to the transmission of the energy of the projectile to the particles of bone and other tissues that become detached and then act as secondary projectiles. In the middle and remote ranges where the remaining energy has become very much, less, the destructive effects in wounds of the head by the new bullet are very much less than those inflicted by the old large leaden bullet that was apt to deform on impact. Gunshot wounds of the head are usually divided into flesh wounds and fractures. The latter are necessarily very fatal. In the Civil War the fatality among all head wounds that reached the hospitals was 28.93%. The fatality of the same class under similar conditions in the Spanish-American War was about the same, 26.09%. The figures concerning the relative number of the two are shown in the following table.* Head: Civil War...... Flesh wounds. 7,739 64 3.14 4.9 6,573 2,676 2,480 28.93 Fractures. Spanish-Ameri- 4,350 36 1.76 40 56 2.74 4.86 42 18 2 26.09 The figures illustrate the frequency of glancing shots with the slow-velocity leaden bullet of the Civil War as compared to their infrequency with the high-velocity steel *Extract from Borden's Military Surgery, Prize Essay, Proceedings Association Military Surgery, 1900. jacketed bullet in use at present. The latter, as a rule, travels in a straight line from the point of impact, being seldom deflected from its course by resistant bone. The relative increase in the number of fractures from the use of the modern rifle augments the fatality in head wounds, so that the humane features attributed to this weapon, already referred to, do not apply to wounds of this region. These results were foretold by the experimenters before the opportunity to observe the effects of the new arm in the actual conditions in war had presented themselves. Stevenson, writing in 1897 upon the proportion of flesh to fractured wounds of the skull, states as follows: "In future wars the proportion will be very different. Omitting indirect and grazing hits, almost every bullet which hits the skull, up to a range of 2,200 yards, will perforate it, and at about 2,900 yards they will penetrate and remain lodged. The destruction produced in the skull and brain by modern bullets is so extreme, even at long ranges, that comparatively few patients will survive long enough to reach the field hospital for treatment, and for the large majority of those who do, treatment will be unavailing." Concerning the results in the Anglo-Boer War, Makin† states: "Injuries to the head formed one of the most fruitful sources of death both upon the battlefield and in field hospitals." He mentions some "sensational immediate recoveries" among head wounds, and they doubtless were of the character of those noted by us in the Santiago campaign, namely, oblique perforations of the skull cap involving the brain tissue to a limited depth. The gunshot fractures about the base and those running deeply through the brain from base to vertex, or vice versa, were uniformly fatal. Of sixty-eight cases of gunshot fracture which were reported in the Surgeon-General's Report for 1900, and • Wounds in War, W. F. Stevenson, Colonel-Surgeon, British Army. + Experiences in South Africa, 1901. which occurred during the two preceding years, 54.4% ended fatally as against 59.2% out of 2,514 cases noted in the Civil War. Unlike wounds of other regions, those of the head, unless properly treated at once, undergo suppuration, a fact which is not surprising when the amount of dirt overlying the scalp is considered. The surgeons in the Cuban and South African campaigns are unanimous in recommending early and free exploration of all cases of fracture of the skull by gunshot. The aim should be to relieve pressure and to rid the wound of all dirt and loose. pieces of bone as soon as possible. DISCUSSION. Dr. F. A. HARRIS, of Boston: Naturally a great many factors enter into the production of the results of gunshot wounds of the head:-the calibre of the weapon; the charge of powder; the age of the powder; the distance from which the shot is fired and also the direction. Moreover a decided influence must be exerted by the part of the skull which receives the first impact of the ball. I have seen a case where a man fired a bullet of twentytwo calibre into his head at such short range that the hair was scorched. The base of the ball was flush with the external surface of the cranium, but as the ball had entered the petrous portion it had not penetrated the cavity of the cranium and did no more than annoy the would-be suicide, who many hours after firing the shot fulfilled his original intention by drowning himself. On the other hand I have seen a case where a man fired a twenty-eight calibre ball into his head, holding the weapon so far away that there was no brand and yet the top of the skull was utterly shattered, there being as many as thirty fragments, and the ball had buried itself in the wall of the room. This case, to be sure, was that of a Jew, a race whose skulls, according to my personal experience, (whatever may be the general fact) are of most unusual thinness. There is no sure way of determining the direction of a ball after it has entered the skull. As is well known even so thin a membrane as the pericardium may deflect a ball, and how much more likely is such deflection to be caused by the tables of the skull. To localize a bullet in the head is a task of extreme difficulty, inasmuch as the ragged track made through the cerebral tissue serves to obscure signs which might avail in an injury to the brain of a different sort. I have found that as a rule the ball is more or less mushroomed in its passage through the bone and from this flattenned and ragged condition far greater injury is done to the cerebral tissue than would be done by the passage of a smooth ball. I have found the track of the ball through the brain marked not only by disorganized brain substance but also by spicule of bone of greater or less size, as well as by fragments of lead scraped from the ball by the sharp edges of the tables of the skull. Even if the bullet could be successfully located and removed, it would be almost practically impossible to cleanse the wound through its entire extent, and remove all these foreign particles which together with the countless punctate-hemorrhages would be foci for the starting of an undoubtedly fatal inflammation, allowing that the shock of the original wound was not sufficient to cause death. I have never observed extensive hemorrhage to result from gunshot wounds of the head doubtless because in those cases where life has been prolonged for any considerable time no important vessel has been wounded, the death resulting later from acute inflammation. A few remarkable cases like that of Dr. Harlow and that of Dr. Morton demonstrate the miraculous toleration of severe injury to the brain substance, but my own observation of what occurs in consequence of the penetration of the cranium by a bullet makes me in the highest degree pessimistic as to the results of a possible operative procedure with a view to saving life. |