D • GUNSHOT INJURIES AND STAB WOUNDS
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haemorrhages in brain and spinal cord as a result of exposure to explosions. These were
confirmed by animal experiments (Whitteridge, Krahn & Zuckerman, 1942). In dis-
accordance with these authors Greenfield & Russell (1963) have taken the view that blast
(Vent d'obus or Vent explosiv of French authors) by itself had little effect on the brain
or spinal cord and that lesions in these organs following bomb explosions were due to
other factors, especially CO poisoning in the case of the brain and subluxation of the
spine in the case of the spinal cord. Wolman (1967) described a case who in 1917 at
Passchendale following explosion sustained a paraplegia, which, however, improved
within 18 months and who died in 1960. From his histological results of the spinal cord
(small cavity in C8 surrounded by dense gliosis and small areas of demyelination in the
posterior and lateral tracts of C4 and T5), Wolman concluded that these pathological
changes were compatible with an old contusion rather than with a direct effect of the
blast.
Various theories have been advanced regarding the mechanism of blast on the spinal
cord. Guillain (1920) believed on account of his experiences during the First World War
that the pathological changes are the result of the sudden air pressure. Other authors
compare the changes following explosion with the effects following Caisson-disease
(decompression sickness). In their opinion the mechanism of blast is the development
of air bubbles due to sudden reduction in atmospheric pressure followed immediately
by increase of atmospheric pressure (Rothman, 1915; Chatelin, 1917; Sollier, 1918).
Leri (1918), Foerster (1929) and others assume a contusional effect on the spinal cord as
a result of enormous pressure with high speed, and Foerster found the anatomical
changes identical with those produced by acute pressure to the cord as a result of gunshot
—or blast violence. There is, however, general agreement that death occurs as a result of
damage to the lungs.
INITIAL TREATMENT OF GUNSHOT INJURIES
There is general agreement of all authors that as soon as possible an adequate debride-
ment of the wound should be carried out in combination with local and systemic anti
biotic therapy. This is of particular importance if the missile has first perforated the
bowels before penetrating the spine and spinal cord. The wound should be excised
to its depths and all tissues contaminated with pieces of clothing and other external
material removed. Early larninectomy may under certain circumstances be necessary to
perform a thorough and complete debridement, especially if the missile or bone splinters
lying outside the dura appear to be contaminated. This is particularly necessary if the
dura is found to be perforated and cerebro-spinal fluid leaks through the wound. Pro
vided that immediate systemic antibiotic therapy is employed, a laminectomy should not
be hurriedly performed with inadequate equipment and personnel and the patient should
be immediately evacuated as an emergency—if possible, by helicopter—to a place where
satisfactory preparations for this procedure exist. The wound should be sprinkled with
sulfanomide-penicillin powder but kept open before the transportation.
With regard to the indications for decompressive laminectomy in cases of gunshot
injuries, there has been great controversy amongst neurosurgeons (Pool, 1945; Haynes,
