Part 5

Gunshot wounds vary in gravity from the simplest laceration of cuticle to the instantaneous destruction of life. Death may take place primarily from direct causes already alluded to, viz.: from the destruction of vital organs, from extreme shock to the vital forces through the nervous system, or from hemorrhage; or it may ensue indirectly from secondary hemorrhage, gangrene, erysipelas, hectic fever, pyemia, or from the results of operations necessarily required in consequence of the original injury. In estimating the probable issue of a particular wound, not only the state of health at the time, but, if a soldier, the previous service, and diseases under which he has labored during it, must be taken into account, and the circumstances in which he is placed with respect to opportunity of proper care and treatment must also be carefully weighed. The time which has elapsed after the receipt of the injury is another important matter in forming a prognosis. The difficulties which have been already enumerated in the way of arriving at a safe diagnosis of the true nature and extent of the injury, and the liabilities above mentioned to which a patient with a gunshot wound is exposed, should put a surgeon on his guard against giving a hasty judgment in any case that is not very plain and simple. Military surgery abounds with examples of wounds of such extent and gravity as apparently to warrant the most unfavorable prognosis, which have nevertheless terminated in cure; while others, regarded as proportionably trifling, have led to fatal results. Tables may be found in works showing statistically the nature and relative numbers of wounds and injuries received in various actions, with their immediate and remote consequences, as well as the results of the surgical operations they have led to; but these afford little aid toward the prognosis of particular cases, each of which must be estimated in its own individual circumstances. Such tables are chiefly of value where they afford indications of the effects of different modes of treatment in wounds of a corresponding nature, and then only in patients under like circumstances of age and condition. Even moral circumstances must not be disregarded. The probable issue in any given case will be very different in one soldier, who is supported by the stimulating reflection that he has received his wound in a combat which has been attended with victory, from what it will be in another, who labors under the depression consequent upon the circumstances of defeat.

TREATMENT OF GUNSHOT WOUNDS IN GENERAL.

When the circumstances of a battle admit of the arrangement, the wounded should receive surgical attention preliminary to their being transported to the regimental or general field hospitals in rear. A slight provisional dressing, a few judicious directions to the bearers, may occasionally prevent the occurrence of fatal hemorrhage, or avert serious aggravation of the original injury from malposition, shaking, and spasmodic muscular action, in the course of conveyance from the neighborhood of the scene of conflict to the hospital. In the siege operations before Sebastopol, this was accomplished by assistant surgeons in the trenches, or, according to the French system, by regular ambulance hospitals in the ravines leading to them. The provisional treatment should be of the simplest kind, and chiefly directed to the prevention of additional injury during the passage to the hospital, where complete and accurate examination of the nature of the wound can alone be made, and where the patient can remain at rest after being subjected to the required treatment. The removal of any missiles or foreign bodies which may be readily obvious; the application of a piece of lint to the wound; the arrangement of any available support for a broken limb; protection against dust, cold, or other objectionable circumstances likely to occur in the transit; if “shock” exist, the administration of a little wine, aromatic ammonia, or other restorative, in water,—need little time in their execution, and may prove of great service to the patient. If hemorrhage exist from injury to a large vessel, it must of course receive the surgeon’s first and most earnest care. He should not trust to the pressure of a tourniquet, but secure it at once by ligature. Without this safeguard during the transport, and while in the hands of uneducated attendants, the life of the wounded man might be endangered, either from debility consequent upon gradual loss of blood or from sudden fatal hemorrhage. It has been recommended by some surgeons that all attendants whose duties consist in carrying the wounded from a field of battle should be directed, when bleeding is observed, to place a finger in the wound, and keep it there during the transport until the aid of a surgeon is obtained. The precise spot where compression by the finger is wanted, and the degree of pressure necessary, will be quickly made manifest to the sight by the effects on the flow of blood. Such a practice seems to offer less objection than the use of tourniquets by men whose knowledge of their proper application must be exceedingly limited.

On arrival at the hospital, where comparative leisure and absence of exposure afford means of careful diagnosis and definitive treatment, the following are the points to be attended to by the surgeon: firstly, examination of the wound with a view to obtaining a correct knowledge of its nature and extent; secondly, removal of any foreign bodies which may have lodged; thirdly, adjustment of lacerated structures; and fourthly, the application of the primary dressings.

The diagnosis should be established as early as possible after the arrival at hospital. An examination can then be made with more ease to the patient and more satisfactorily to the surgeon than at a later period. Not only is the sensibility of the parts adjoining the track of the ball numbed, but there is less swelling to interfere with the examination, so that the amount of disturbance effected among the several structures is more obviously apparent.

One of the earliest rules for examining a gunshot wound is to place the patient, as nearly as can be ascertained, in a position similar to that in which he was, in relation to the missile, at the time of being struck by it. In almost every instance the examination will be facilitated by attention to this precept. Occasionally it will at once indicate the probable injury to vessels or other important structures, in cases where the mutual relations of the wounds of entrance and exit, in the erect or horizontal posture of the body, would lead to no such information. Even in the direct course taken by a rifle–ball in a simple flesh wound, an erroneous opinion of the line in which the ball has moved may be formed from the first view, in consequence of the ready mobility of the several structures among themselves and their varying degrees of elasticity. Injury to nerves inducing paralysis, contusions of blood–vessels leading to secondary hemorrhage or gangrene, may thus, without sufficient circumspection, be overlooked on the first admission to hospital.

When only one opening has been made by a ball, it is to be presumed that it is lodged somewhere in the wound, and search must be made for it accordingly. But even where two openings exist, and evidence is afforded that these are the apertures of entrance and exit of one projectile, examination should still be made to detect the presence of foreign bodies. Portions of clothing, and, as has already been shown, other harder substances, are not unfrequently carried into a wound by a ball; and, though it itself may pass out, these may remain behind either from being diverted from the straight line of the wound or from becoming caught and impacted in the fibrous tissue through which the ball has passed. The inspection of the garments worn over the part wounded may often serve as a guide in determining whether foreign bodies have entered or not, and, if so, their kind, and thus save time and trouble in the examination of the wound itself.

Of all instruments for conducting an examination of a gunshot wound, the finger of the surgeon is the most appropriate. By its means the direction of the wound can be ascertained with least disturbance of the several structures through which it takes its course. If bones are fractured, the number, shape, length, position, and degree of looseness of the fragments may be more readily observed. In case of lodgment of foreign bodies, not only is their presence more obvious to the finger direct than through the agency of a probe or other metallic instrument, but by its means intelligence of their qualities is also communicated. A piece of cloth lying in a wound is recognized at once by a finger, while, saturated with clot as it is under such circumstances, it would probably be confounded among the other soft parts by any other mode of examination. The index finger naturally occurs as the most convenient for this employment; but the opening through the skin is sometimes too contracted to admit its entrance, and in this case the substitution of the little finger will usually answer all the purposes intended. When the finger fails to reach sufficiently far, owing to the depth of the wound, the examination is often facilitated by pressing the soft parts from an opposite direction toward the finger–end.

It was formerly the custom to enlarge the external orifice of all gunshot wounds by incision, and not merely the opening, but the walls of the wound itself, as soon after the injury as possible. This was not done as a means of rendering the examination easier, but as a prophylactic measure. Dilatation was also employed by tents and various other means with a view to secure the escape of sloughs and discharges. The opinions held by the older surgeons respecting the nature of these injuries, already briefly adverted to in the historical remarks on the subject, sufficiently explain their object in making incisions—namely, to convert what they regarded as a poisoned into a simple wound, and to obviate tension, and prevent strangulation of neighboring tissues by tumefaction or inflammation arising in its track. Even so late as 1792, Baron Percy, in his Manuel du Chirurgien d’Armée, writes: “The first indication of cure is to change the nature of the wound as nearly as possible into an incised one.” English surgeons have, however, generally discarded the practice since the arguments used by John Hunter against it, just about the same date as Baron Percy wrote, excepting only in cases where it is required to allow of the extraction of some extraneous body to secure a wounded artery, to replace parts in their natural situation, as in protrusion of viscera in wounds of the abdomen, or, “in short, when anything can be done to the part wounded after the opening is made for the present relief of the patient or the future good arising from it.” It does not often happen that it is necessary to enlarge the openings of wounds to remove balls, although a certain amount of constriction of the skin may be expected from the addition of the instrument employed in the extraction; but if much resistance is offered to their passage out, it is better to divide the edges of the fascia and skin to the amount of enlargement required than to use force. In removing fragments of shells or detached pieces of bone, the fascia and skin have almost invariably to be divided to a considerable extent.

Where the finger is not sufficiently long to reach the bottom of the wound, even when the soft parts have been approximated by pressure from an opposite direction, and when the lodgment of a projectile is suspected, a long silver probe, that admits of being bent by the hand if required, is the best substitute. Elastic bougies or catheters are apt to become curled among the soft parts, and do not convey to the sense of touch the same amount of information as metallic instruments do. The probe should be employed with great nicety and care, for it may inflict injury on vessels or other structures which have escaped from direct contact with the ball, but have returned, by their elasticity, to the situations from which they had been pushed or drawn aside during its passage. The above directions for examining wounds apply more particularly to such as penetrate the extremities, or extend superficially in other parts of the body; where a missile has entered any of the important cavities, search for it is not to be made, but the surgeon’s attention is to be directed to matters of more vital importance to be hereafter noticed.

As soon as the presence of a ball or other foreign body is ascertained it should be removed. If it be lying within reach from the wound of entrance, it should be extracted through this opening by means of some of the various instruments devised for the purpose. In case of a leaden bullet, Coxeter’s Extractor, corresponding with Baron Percy’s instrument for the same purpose, and consisting of a scoop for holding and central pin for fixing the bullet, has been found a very convenient appliance, from the comparatively limited space required for its action. Instruments of two blades, or scoops, with ordinary hinge action, dilate the track of the wound injuriously before the ball can be grasped by them. The way to the removal of a bullet may often be smoothed by judiciously clearing away the fibers, among which it is lodged, during the examination, by the finger; and sometimes, by means of the finger in the wound, and external pressure of the surrounding parts, the projectile may be brought near to the aperture of entrance, so that its extraction is still further facilitated. Such foreign substances as pieces of cloth can usually be brought out by the finger alone, or by pressing them between the finger and a silver probe inserted for the purpose. Sometimes a long pair of dressing forceps, guided by the finger, is found necessary for effecting this object. Caution must be used in employing forceps, where the foreign substance is out of sight and of such a quality that the soft tissues may be mistaken for it.

In instances where the foreign body has not completely penetrated, but is found lying beneath the skin away from the wound of entrance, an incision must be made for its extraction. Before using the knife, the substance to be removed should be fixed _in situ_, by pressure on the surrounding parts. In the instance of a round ball, the incision should be carried beyond the length of its diameter; an addition of half a diameter is usually sufficient to admit of the easy extraction of the ball. In removing conical balls, slugs, fragments of shells, stones, and other irregularly–shaped bodies, the surgeon cannot be too guarded in arranging that the fragment is drawn away with its long axis in line with the track of the wound. By proper care in this respect, much injury to adjoining structures may be avoided.

If balls are impacted in bone, as happens in the spongy heads of bones, in bones of the pelvis, and occasionally, though rarely, in other parts of long bones, they should be removed. This can be effected by means of a steel elevator, of convenient size; or, should this fail from the ball being too firmly impacted, a thin layer of the bone on one side of the ball may be gouged away, so that a better purchase may be obtained for the elevator, in effecting its removal. The fact is now fully established that, although in a few isolated cases balls remain lodged in bones without sensible inconvenience, in the majority the lodgment leads to such disease of the bony structure as often to entail troublesome abscesses, and in some instances eventually to necessitate amputation. The lodgment of balls will not often occur without extensive fracture in warfare where rifled arms of such force as the Minié or Enfield are the chief weapons employed, but will not unfrequently be met with in such campaigns as have lately happened in India.

Should there be reason for concluding that a ball or other foreign body has lodged, but after manual examination, and observation as well by varied posture of the part of the body supposed to be implicated as by indications derived from the patient’s sensations, effects of pressure or injury to nerves, and all other circumstances which may lead to information, should the site of the lodgment not be ascertained, the search should not be persevered in to the distress of the patient. Neither, although the site of lodgment be ascertained, if extensive incisions are required, or if there is danger of wounding important organs, should the attempts at extraction be continued. Either during the process of suppuration, by some accidental muscular contraction, or by gradual approach toward the surface, its escape may be eventually effected; or, if of a favorable form, and if not in contact with nerve, bone, or other important organ, it may become encysted, and remain without causing pain or mischief. When John Hunter wrote on gunshot wounds, he remarks, the practice of searching after a ball, broken bones, or any other extraneous bodies, had been in a great measure given up, from experience of the little harm caused by them when at rest, and not in a vital part; and he himself advises, even when a ball can be felt beneath skin that is sound, that it should be let alone, chiefly on the ground that two wounds are more objectionable than one, and that the extent of inflamed surface is proportionably increased by incision. More extensive experience has, however, shown that not only is the risk of subsequent ill results greater in those cases where foreign bodies remain lodged than when they have been cut out, but also that the advantages of a second opening for the escape of the necessary sloughs and discharges greatly preponderate over the disadvantages connected with it, as regards the additional extent of injured surface. The advantage also of the satisfaction to the mind of a patient from whom a ball has been removed must not be overlooked; for men suffering from gunshot wounds are invariably rendered uneasy by a vague apprehension of danger, for some time after the injury, if the missile has remained undiscovered.

When a gunshot wound has been accompanied with much laceration and disturbance of the parts involved in the injury, it is necessary, after the removal of all foreign substances that can be detected, to readjust and secure the disjointed structures as nearly as possible in their normal relations to each other. The simplest means—strips of adhesive plaster, light pledgets of moist lint, a linen roller, favorable position of the limb or part of the body wounded—should be adopted for this purpose. Pressure, weight, and warmth should be avoided as much as possible in these applications, consistent with the end in view. It must not be forgotten, in thus bringing the parts together, that the purpose is not to obtain union by adhesion, which cannot be looked for, but simply to prevent avoidable irritation and malposition of parts, during the subsequent stages of cure by granulation and cicatrization. In all gunshot wounds, much discomfort to the patient is prevented by carefully sponging away all blood and clot from the surface adjoining the wound, and by adopting measures to prevent its spreading again in consequence of oozing. This can be readily done with the aid of a little warm water, and arrangement when the wound is first dressed, but can only be accomplished with considerable inconvenience after the thin clots have become hard and firmly adherent to the skin.

When the parts of a lacerated gunshot wound have been brought into apposition, as in simple penetrating wounds, the only dressing necessary is moistened lint. It should be kept moist either by the renewed application of water dropped upon it, or by preventing evaporation by covering it with oiled silk. The sensations of the patient may be consulted in the selection of either of these, and climate and temperature will be often found to determine the choice. In hot climates cold applications are the more grateful, and by checking the amount of inflammatory action and circumscribing its extent are usually the more advantageous. M. Velpeau and other French surgeons have strongly recommended the use of linseed–meal poultices, above all wet linen applications. Charpie is still extensively employed in French military hospitals.[5] M. Baudens and Dr. Stromeyer have strongly recommended the topical application of ice placed in bladders; others, the continued irrigation of the wound with tepid water. The means of applying such remedies are rarely available in the military hospitals where gunshot wounds are ordinarily treated in their early stages. When much local inflammation has set in, and when there is much constitutional fever even without unusual local irritation, the non–evaporating or warm applications will be found to be the most advantageous.

When suppurative action has been fully established, the surgeon must be guided by the general rules applicable to all other such cases. Care must be taken to prevent the accumulation of pus, lest it burrow, and sinuses become established—not an unfrequent result of want of sufficient caution in this regard. If much tumefaction of muscular tissues beneath fasciæ occurs, or abscesses form in them, free incisions should be at once made for their relief. In wounds where the communication between the apertures of entrance and exit is tolerably direct, occasional syringing with tepid water may be useful, by removing discharges and any fibers of cloth which may be lying in the course of the wound. Weak astringent solutions are occasionally employed in a similar way, with a view to improving the tone of the exhalents and exciting a more vigorous action in the process of granulation. The strictest attention to cleanliness and the complete removal of all foul dressings are essentially necessary, not merely for the comfort of the patient, but to prevent the accumulation of noxious effluvia, and also to obviate the access of flies to the wounds. In tropical climates, and in field–hospitals in mild weather, where many wounded are congregated, flies propagate with wonderful rapidity, and the utmost care is necessary to prevent the deposit of ova and generation of larvæ in the openings of gunshot wounds, especially while sloughs are in process of separation. Cloths dipped in weak solutions of creasote or disinfecting fluids, laid over the wound, are found necessary for this purpose when the insects abound in great numbers.