Gunshot wounds are essentially contused, punctured, or lacerated wounds, differing from those produced by other means only in their potentialities. The modern army bullet is small caliber, jacketed with steel, has a high initial velocity, and long range. At close range, such missiles are destructive to tissues, producing crushed or lacerated conditions. On the skin at medium or long range, the wound of entrance is small, less than the diameter of the ball; likely dirty. The wound of exit is larger, more irregular, and bleeds more freely. Pain in skin wounds is often moderate, usually a burning sensation, with shock not severe. Fascia presents a smaller opening than the skin, fibers being split rather than cut, tending to close and interfering with drainage. Muscles are contused or lacerated, likely infiltrated; tendons may be pushed out of the way but can also be divided. Blood vessels may be torn, causing death due to hemorrhage.
Bone lesions vary widely: mere puncture, extensive comminution, or any grade in between. Soft and cancellous bone tends toward perforation; hard and compact bone towards comminution. Long bones are likely shattered at close range but not transversely fractured. Skull injuries can result in gutter fractures with two scalp openings connected by a trench through the outer table and diploe.
The brain itself is torn to pieces at short range, while long-range bullets traverse the brain producing areas of contusion and diffuse hemorrhage. Most gunshot fractures of the skull are accompanied by symptoms of brain injury: paresis, paralysis, loss or impairment of special senses, epilepsy, twitching, signs of brain irritation.
Spine injuries depend on cord damage; slight spinal concussion causes temporary loss of cutaneous sensibility, motor paralysis, and vesical and rectal incompetence. Severe concussion results in symmetrical abolition of sensation and motility with no sign of irritation in the paralyzed area and loss of patellar reflex. Thoracic wounds may or may not penetrate, but those traversing longitudinally often involve abdominal cavity.
Penetrating wounds of the heart are certainly fatal due to sudden stoppage of heart action; thoracic injuries involving great vessels lead to rapid internal hemorrhage. Abdominal wounds typically cause peritonitis and multiple small intestine perforations with pain, collapse, vomiting, and widespread peritonitis. Shock is nearly always present in abdominal wounds.
<Callout type="important" title="Bone Injury Severity">The severity of bone injury depends on the bullet's range and the bone's hardness: soft bones tend to be perforated while hard ones are shattered.</Callout>
Flesh wounds heal without difficulty if infection is avoided. First-aid dressing is applied, and in simpler cases, it need not be disturbed until field hospital treatment.
<Callout type="risk" title="Bullet Retention">If a bullet lodges, under no circumstances should it be probed for; if superficial, it may be removed at the time of first dressing.</Callout>
Treatment varies depending on injury severity: simple perforating fractures require skin wound treatment and immobilization. Extensive comminution with great laceration and destruction of soft parts requires careful sterilization and immobilization.
<Callout type="gear" title="Splints">Plaster-of-Paris splints are suitable for most requirements except the thigh; wire splints and Dutch cane folding splints are also effective.</Callout>
Key Takeaways
- Gunshot wounds vary in severity based on bullet characteristics and range.
- Bone injuries can be severe, ranging from simple puncture to extensive comminution.
- Proper sterilization and immobilization are crucial for treating gunshot fractures.
Practical Tips
- Use sterile water or antiseptic solutions for wound cleaning when sterile water is unavailable.
- Avoid probing for retained bullets as it can cause further injury.
- Apply appropriate splints to ensure proper immobilization of fractured limbs.
Warnings & Risks
- Do not underestimate the severity of gunshot wounds, especially those involving vital organs or extensive soft tissue damage.
- Retained bullets should never be probed without proper medical guidance to avoid additional injuries.
Modern Application
While modern medicine has advanced significantly since 1915, understanding historical techniques remains valuable. Key principles such as sterilization and immobilization are still crucial today. Knowledge of these methods can provide a foundation for improvising emergency care in situations where conventional medical supplies may be limited.
Frequently Asked Questions
Q: What is the typical size difference between entrance and exit wounds from a modern army bullet?
The wound of entrance is small, less than the diameter of the ball, while the wound of exit is larger, more irregular, and bleeds more freely.
Q: How does the hardness of bone affect gunshot injuries?
Soft bones tend to be perforated by bullets, whereas hard bones are more likely to shatter. This variation influences the severity and type of injury sustained.
Q: What is a 'gutter fracture' in the context of gunshot wounds?
A gutter fracture involves two scalp openings connected by a trench through the outer table and diploe, with extensive comminution and possible depression of the inner table.