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.
The constitutional treatment in an ordinary gunshot wound,
uncomplicated with injury to bone or structures of first importance,
should be very simple. The avoidance of all irregularity in habits
tending to excite febrile symptoms or to aggravate local inflammation,
attention to the due performance of the excretory functions, and
support of the general strength, are chiefly to be considered.
Bleeding, with a view to prevent the access of inflammation in such
cases, is now never practiced, as formerly, by English surgeons.
The diet should be nutritious, but not stimulating. A pure fresh
atmosphere is a very important ingredient in the means of recovery.
If from previous habits of the patient, or from circumstances to
which he is unavoidably exposed, the local inflammation has become
aggravated,—indicated by pain, increased swelling, and redness about
the wound,—topical depletion by leeches or cupping, bleeding from
the arm, saline and antimonial medicines, and strict rest in the
recumbent position, must be had recourse to, the extent being regulated
by the circumstances of each case. In instances such as these, when
the inflammation has become diffused, the purulent secretion is not
confined to the track of the wound, but is liable to extend among the
areolar connections of the muscles; and if the cure be protracted,
attention will be necessary to prevent the formation of sinuses. If
stiffness or contractions result, attempts must be made to counteract
them by passive motion and friction, with appropriate liniments; if
a tendency to edema and debility remain in a limb after the wound is
healed, the cold–water douche will be found to be one of the most
efficient topical remedies. In French practice, the administration of
a chalybeate tincture,[6] as a tonic, or diluted as an injection, in
wounds threatening to assume an unhealthy character, is very highly
praised. It is stated that under the conjoined employment of this
remedy internally and externally, in wounds of a pallid, unhealthy
aspect, accompanied by nervous irritability and symptoms of approaching
pyemia, the granulations have resumed a red and healthy appearance, and
the general state of health become rapidly favorable.
=Progress of cure.=—Simple flesh wounds from gunshot usually heal in
five or six weeks. In the course of the first day the part wounded
becomes stiff, slightly swelled, tender, a slight inflammatory blush
surrounds the apertures through which the missile has passed, and a
slight serous exudation escapes from them. Suppuration commences on the
third or fourth day, and in about ten days or a fortnight the sloughs
are thrown off. Granulation now progresses, more or less quickly
according to the health and vigor of the patient’s constitution.
The opening of exit is usually the first closed. When the wound is
complicated with unfavorable circumstances, whether inducing in the
patient a condition of asthenia or leading to excess of inflammatory
action, the progress of the cure may be extended over as many months
as, under favorable circumstances, weeks are occupied in the process.
GUNSHOT WOUNDS IN SPECIAL REGIONS OF THE BODY.
The circumstances connected with wounds in particular situations of the
body, or in particular organs, are in many respects common to injuries
from other causes than gunshot; and in the following remarks the
attention is chiefly drawn only to those leading peculiarities which
constantly demand the consideration of the army surgeon, and which
spring either from the nature of gun projectiles, or the circumstances
under which this branch of military practice has for the most part to
be pursued.
GUNSHOT WOUNDS OF THE HEAD.
No injuries met with in war require more earnest observation and
caution in their treatment than wounds of the head. The vital
importance of the brain; the varied symptoms which accompany
the injuries to which this organ may be subjected, directly or
indirectly; the difficulty in tracing out their exact causes; the
many complications which may arise in consequence of them; the sudden
changes in condition which not unfrequently occur without any previous
warning,—all these circumstances will keep a prudent surgeon who has
charge of such wounds continually on the alert. Injuries of this class,
the most slight in appearance at their onset, not unfrequently prove
most grave as they proceed, from encephalitis and its consequences, or
from plugging of the sinuses by coagula, leading to coma, paralysis,
or pyemia; and the converse sometimes holds good with injuries
presenting at first the most threatening aspects, where care is taken
to avert these serious results. Much will depend on the part of the
head struck, both as regards the thicker and stronger processes or
portions of the skull, and the situation of the sinuses and parts of
the cerebrum within; on the force and shape of the projectile; the
angle at which it strikes; the age and condition of the patient; and
other matters already referred to in the general remarks on gunshot
wounds. Mr. Guthrie has laid down as a rule that injuries of the head,
of apparently equal extent, are more dangerous on the forehead than on
the side or middle portion, and still more so than those on the back
part; and that a fracture of the vertex is infinitely less important
than one at the base of the cranium. When the injuries are caused by
rifle–balls, however, these considerations are rarely of much avail,
for the power of injury is such that it can scarcely ever be confined
to the immediate neighborhood of the part directly struck.
Wounds of the head may be divided, for convenience of description,
into wounds of the scalp and pericranium, without fracture of bone;
similar wounds complicated with fracture of the outer or of both
tables, without pressure on the encephalon; wounds with fracture and
depression; and lastly, wounds in which the encephalon itself has been
penetrated. Severe contusion of the bones of the cranium, followed by
necrosis, and even fracture, with or without depression, may occur
without an open wound of the superficial investments. The case of
an officer is mentioned in Dr. Macleod’s Notes of the Crimean War,
who was thus killed by a round shot. The scalp was not cut, almost
uninjured, but the skull was most extensively comminuted.