Harvey Cushing, “Surgery of the Head”

Gunshot fractures.—In their simplest form these are perforating fractures which produce a circular loss of substance. When the result of a wound at short range from the modern small-arm, we have seen that the skull may be burst outward by the explosive action of hydrodynamic pressure.[…] We have learned, too, that these are compound or open fractures; that they are almost always comminuted ones with some depression of fragments; and, finally, that they often lead to sepsis, hemorrhage, or other intracranial lesions, which make of them a particularly dangerous and crippling form of injury. […]

The gunshot fractures which are seen in civil life are more apt to result from revolver shots and in orderly communities to be self-inflicted wounds, whether by accident or intent. Here again the character of the injury depends upon the nature of the weapon and the initial velocity of the projectile. Most of the wounds which one sees to-day are produced by soft bullets fired from the ordinary revolver with no great initial momentum; the heavier army pistols, on the other hand, fire a projectile which at near range has the explosive effect of a rifle. The soft, deforming revolver bullets are apt to lodge either in the bone at the site of entrance or somewhere within the cranial cavity, either at some point in the direct line of their flight or, in the case the missile has rebounded, at some point in a line determined by the angle of deflection from the opposite inner surface. […]It may be said, however, that, as a rule, there is no particular reason for its extraction, for in the absence of immediate complications it becomes encapsulated and, unless the missile chance to lie near the surface, the damage already done will only be increased by meddlesome attempts to locate and extract it.

The complications which result from penetrating bullet wounds may be classified as immediate, or those due to hemorrhage, compression, and destruction of tracts; intermediate, or those due to sepsis; and late symptomsv (irritative and paralytic), giving evidence of the permanent damage done to cerebral tissues. Hemorrhage, of all the immediate symptoms, is especially to be dreaded, as it may lead to rapid death from compression. In all cases in which there is an increase in intracranial tension from effused blood, the pressure forces the disorganized nervous tissue through the wounds of entrance and exit, and the extruded particles of white tissue are found mingled with the blood which oozes from the opening. It is not uncommon for cranial nerves to be injured, either by direct section or by implication in a basal fracture.

It is notorious that suicides often fail to accomplish their purpose. Brun has recorded 32 cases, of which number 16 recovered. Of these cases the wound of entrance was in the right temporal region sixteen times, in the left twice, in the forehead nine times, and in the mouth twice. The “temple” is regarded by the laity as a particularly vulnerable spot, which accounts for the preponderance of attempts in this situation. In them oftentimes the bullet merely passes extracranially from temporal fossa to temporal fossa, through the back of both orbits, cutting the optic nerves and leading to blindness—a sad penalty for a criminal act. […]

Treatment.—The fracture itself is the least of the ills following cranial gunshot wounds and cannot be considered apart from the other complications. If there is a clean-cut perforation and no serious immediate symptoms the wound may be left with a simple drain and healing may take place without incident; for unless septic foreign particles have been carried in with the missile, its track quickly cicatrizes and the bullet itself becomes encapsulated. […]The temptation to probe for, to locate, and to extract deep-lying fragments of the bullet should be resisted by the surgeon; for even if successful in their object these procedures usually serve merely to increase the damage already done by the missile without conferring any benefit whatever from its removal.

Source: William Williams Keen, ed., Surgery: Its Principles and Practice (Philadelphia and London: W.B. Saunders Company, 1908), 75-81

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