The simplest method of administering chloroform is upon an ordinary

mask, the covering of which should be thin in order to permit of easy

play of air. By this method a patient can always be anesthetized, but

with a waste of the anesthetic and with absolute uncertainty as to

the proportion of chloroform vapor in the inspired air. A variety of

expedients have been suggested in time past, and chloroform inhalers of

various patterns are constantly upon the market. The Junker inhaler,

introduced some twenty-five years ago, was a great improvement upon

its predecessors, but only recently has a really scientific measuring

inhaler been placed before the profession. This is the one devised for

and introduced by a committee of the British Medical Association, and

is the result of the study and ingenuity of Prof. Vernon Harcourt. It

has already been stated that more than 2 per cent. of chloroform vapor

in the inhaled air is dangerous. The Harcourt apparatus consists of

a two-necked bottle, nearly filled with chloroform, into which are

dropped two colored glass beads, which serve to indicate when the

temperature is between 55° and 59° F. If the temperature be below 55°

F., both beads will float; if it be above 50° F. both will sink. If

the former, the proportion of chloroform will be below that indicated

by the pointer; if the latter, it will be greater. Inasmuch as during

inhalation the chloroform is cooled by evaporation, it is necessary to

occasionally place the warm hand over the bottle until the blue bead

has sunk and the red bead is beginning to sink, indicating that the

temperature is again approaching 59° F. A stopcock is so constructed

that when the pointer is at one end of the arc the maximum amount of

chloroform which may be taken up is 2 per cent.; when the pointer is at

the opposite end, the patient breathes only pure air. There are valves

which prevent the entrance of expired air into the apparatus, and which

show whether the stopcock is working. They also show the character of

the respiration. Administration is begun with the pointer at 0.2, and

while it may require 2 per cent. of vapor to produce narcosis; _i. e._,

the complete and final stage of anesthesia, it will take scarcely more

than 1 per cent. to maintain it. The mouth-piece has an expiratory

valve, and the apparatus can be held in any position, but should be

kept nearly vertical. The mask is fitted with an air cushion, which can

be molded in hot water so as to fit the patient’s face. Buxton, who is

the leading authority on anesthetics in London, has abandoned all other

apparatus for this. While he is a most skilled expert, he has shown

that by means of this apparatus chloroform can be given with almost

absolute safety.

Aside from the danger and discomfort pertaining to the use of

chloroform in apartments lighted or heated with natural gas, there is

another similar danger in connection with ordinary city illuminating

gas. In the presence of a flame produced by the latter the vapor of

chloroform is broken up not only into chlorine and hydrochloric acid,

but into a carbon oxychloride, known also as _phosgene_, which is

toxic and produces a sense of suffocation by producing decomposition

within the blood. A fatal occurrence of this kind led to experiments

on animals by an Italian observer, which showed that the substance

produced rapid disintegration of hemoglobin, which fell rapidly to 40

per cent., and that accompanying this there was suppression of urine

with convulsions.

Unless chloroform be given by one familiar with its use, it is best

given from a dropping bottle. If this be so arranged that it will

discharge but one drop at a time, and the anesthetizer so administer

it as to allow perhaps one drop to fall each second, the patient will

at no time get an overdose, nor will there be struggling or choking.

Irregularity of breathing is usually the result of insufficient air,

and the mask should be at once removed, so that the patient may take

one or two deep inspirations. When the cornea is insensitive the

patient will stand almost any manipulation except, perhaps, stretching

of the sphincters. When the sphincter can be stretched without

provoking any effect except a prolonged inspiration, then the patient

is, in all probability, completely relaxed and ready for any procedure.

When the breath becomes stertorous the mask should be removed even

though the cornea be sensitive. It will quickly lose its sensitiveness

again within a few seconds. _Proper breathing must be maintained._ Free

supply of air is important above all other things, and it is better

that the surgeon should wait rather than the anesthetizer.

Additional safety in the use of chloroform may be afforded by the

simultaneous use of oxygen gas, by which cyanosis is usually avoided

and vomiting often prevented. It may be safely used with chloroform,

but not with ether. If ozonized air be conducted into anhydrous ether

it forms a thick liquid, probably ethyl peroxide, which explodes if

heated (Hare). It is a mistake to so manage the administration of

chloroform with oxygen that the patient receives no pure air. Oxygen

is of great value, but it is not physiologically breathed in its

pure state. When the gas is allowed to bubble through a bottle of

chloroform, carrying with it the vapor, no idea can be formed as to

relative percentages. A better way is to administer the chloroform upon

a mask, and the oxygen by a tube from a wash-bottle filled with water

and passed into the nostril under the edge of the inhaler (Hare).

Gwathmey has introduced a modification of the well-known standard

Junker inhaler, by which oxygen and chloroform, or nitrous oxide and

ether, may be given together, or by which any desired combination

can be effected. Its special advantage is the same as the Harcourt

apparatus, that the percentage of chloroform or ether vapor can be

estimated or controlled. So far as the administration of chloroform

with oxygen is concerned, Roth has shown that oxygen does not decompose

the chloroform, but diminishes the danger of its administration.

Gwathmey refers to the advantage of keeping an open airway by turning

the head a little to one side and pressing the jaw well forward; he

also advises that when the anesthetic is removed from the face it

is well to replace its odor by some other perfume, such as cologne

or smelling salts, as it is presumed that the olfactory nerve is

responsible for the initial symptoms of nausea and gastric distress.

In some States natural gas is used as fuel, usually in open fireplaces

or stoves. When chloroform is administered in a room thus heated, or

even lighted by natural gas, formaldehyde gas is the result of a mutual

decomposition, and this is exceedingly pungent and irritating, and

will soon produce violent coughing in all who are present in the room.

It may be impossible to avoid this, but natural gas flames should be

extinguished and some other source of illumination should be depended

upon when practicable.

A. C. E. MIXTURE.

Under this term are known various mixtures of alcohol, chloroform,

and ether, the intent being to counteract the depressing influence

of chloroform by alcohol and ether. It may be said of every mixture

of anesthetics that it is no less dangerous than its strongest

constituent. Thus a mixture of chloroform and ether should be given

with as much precaution as pure chloroform.

Mixtures of this kind should be made fresh for each administration, as

the most volatile ingredient may evaporate in unknown amount and thus

change the proportions. This is true of the mixture even after it is

poured upon the inhaler, and the patient will thus be subjected to a

chloroform mixture of varying strength.

The administration of ether for a few seconds during chloroform

anesthesia will often prove beneficial in regulating or deepening

inspiration, but it would be best to have the two drugs separate, and

use the ether as it may seem called for, rather than to rely upon any

such mixture. Moreover the vapor of alcohol is of itself irritating and

undesirable.

ETHYL BROMIDE.

For operations of but short duration ethyl bromide offers some

advantages, in that its effects quickly pass away and that there are

few unpleasant sequels. Indeed, patients may take it for a few minutes

with almost as little disturbance as is produced by nitrous oxide;

nevertheless it cannot be regarded as being as free from danger as was

originally claimed. Only a pure preparation should be used. When given

as ether is usually given, upon a cone or mask, complete anesthesia may

often be produced within one minute. It can hardly be relied upon to

produce muscular relaxation and it frequently causes great congestion

of the face and head, consequently it is not as convenient for short

operations on the nasopharynx as its other good qualities might render

it. It is not unpleasant to take, and ordinary ether anesthesia may

well be begun with it.

METHYLENE BICHLORIDE.

For a number of years this anesthetic agent was in favor, especially

in Great Britain, where it was warmly advocated by Spencer Wells. Its

odor is agreeable, its action rapid, and recovery from its effects is

usually prompt. But it proved to be unsafe, since it was found that

the substance commonly used under this name was really chloroform

diluted with one-fifth of methyl alcohol, while the genuine methylene

bichloride was found by experiment to be a dangerous substance, and its

use has been discarded.

ETHYL CHLORIDE.

This, like every other drug used for the purpose, should be used in

perfectly pure form. While this can be obtained from manufacturers in

this country, there seems to be a tendency to rely upon the imported

preparation sold here under the name of Kelene. For certain short

operations, such as those upon the eye, nose, and throat, and for

children, it has many advantages and appears to be a reasonably safe

drug for the purpose. Consciousness is quickly recovered after its use,

and the after-effects are slight. It is in general use preparatory

to one of the stronger anesthetics, like ether or chloroform, and

affords a means of putting patients under the relaxing effect of either

of these drugs. It should be administered upon a cone or mask, from

which evaporation should not occur too easily, because it is extremely

volatile. In the hands of one accustomed to its use, operations of

considerable magnitude and duration may be successfully maintained.

A special valveless mask has been devised for its use, consisting of

a rubber mouth-piece which can be snugly fitted to the face, and a

movable tube over which two or three layers of gauze may be stretched,

upon which the ethyl chloride is allowed to drop or is ejected from the

tube in which it is sold. Sometimes the expired air will freeze upon

this gauze. This is of no disadvantage.

=Local Use.=--On account of its extreme volatility, chloride of ethyl

affords a ready means of producing local anesthesia. It boils at 50°

F., and when the tube containing it is held in the hands and its

capillary tip is opened it issues in the form of a fine spray, which

being directed upon the part to be desensitized first chills and then

freezes it. Whether this part be skin or mucous membrane the effect

is the same. As soon as the desired area is covered with a thin layer

of small frozen crystals, looking like hoar-frost, the surface is

anesthetized and the necessary instruments may be used. Blowing on the

part to be anesthetized will favor evaporation and shorten the time

necessary for the purpose.

The purposes to which this drug may thus be used are numerous and

obvious. For instance, in dentistry it will do much to allay the pain

of tooth extraction; in genito-urinary surgery such operations as

incision of the prepuce, the cauterization of venereal ulcers, and

circumcision may be done with little or no pain. The small operations

required in various skin diseases, the incision of small abscesses, the

use of caustics wherever they may be needed, may all be made easy under

its effect; while in cases of neuralgia, stings, bites, etc., it will

often alleviate the symptoms. The skin may also be anesthetized in this

way before the introduction of the needle through which antitoxins are

injected or hypodermoclysis practised. Before venesection or before

exploratory puncture it may also be used.

=Somnoform.=--This agent, composed of ethyl bromide 5 parts methyl

chloride 35 parts, and ethyl chloride 60 parts, was introduced by

Rowland, of Bordeaux, as a convenient means of producing an analgesic

condition, _i. e._, something between complete anesthesia and conscious

sensibility. The dose is about 5 Cc., to be sprayed upon a tightly

fitting mask. The patient should be told to breathe and swallow as

naturally as possible, and the effect is obtained within a few seconds.

The agent is so speedy in producing its effects that it is sometimes

difficult to tell when the proper degree of unconsciousness has been

secured. A patient may be directed to hold up an arm in order that

when it drops the surgeon may proceed. There is neither cyanosis nor

corneal reflex, and nausea does not usually occur. The essential

point of administration is the exclusion of air. Twenty seconds of

administration will give from one to two minutes of anesthetic effect,

during which various brief operations can be performed. By proper

management this period can be lengthened many times.

=Petroleum Ether.=--Petroleum ether was introduced by Schleich for the

purpose of diluting chloroform. By itself it has a weak anesthetic

power, and seems to possess some dangers of its own in the way of

depressing the heart’s action and producing convulsions.

OTHER VOLATILE ANESTHETICS.

Schleich was among the first to demonstrate that the retention of

an anesthetic within the body depends upon its boiling point. W.

Meyer carried Schleich’s views still farther and showed the at least

theoretical value of an anesthetic mixture whose boiling point was

that of the normal blood temperature. If the evaporating point be much

higher than the blood it is volatilized too easily, while if it be

lower it reduces body temperature as it evaporates. After considerable

experimentation Meyer recommended a mixture by volume of chloroform 3

parts, ether 2 parts, and ethyl chloride 1 part, and introduced this

mixture under the name of _anesthol_. This composition does not seem

to have met with great favor as yet, although it has theoretically

much to commend it, as it seems slower in action and but little more

satisfactory in other respects.

NITROUS OXIDE GAS.

This is by all means the most rapid general anesthetic in use. Patients

can be placed under its influence in from twenty-five to sixty seconds.

For a long time its employment was confined to dental practice, but

it is now in general use by surgeons, as a preliminary to the use of

ether or as the sole anesthetic agent. When managed properly patients

can be kept for a half-hour or even an hour under its influence.

Two disadvantages attend its administration: (1) It is difficult to

completely relax the muscles and so maintain them that no difficulties

are placed in the operator’s way, _e. g._, in certain operations upon

the abdomen where muscle rigidity delays and makes difficult the

operation. (2) The use of nitrous oxide alone so far impairs proper

oxygenation of the blood that this fluid becomes dark or almost black

and frequently obscures the field of operation. These difficulties,

especially the latter, can be overcome by the skilful _simultaneous

use of oxygen gas_, by which the blood is kept well oxygenated, and by

which the deep stupor of nitrous oxide poisoning can be made so safe

that it can be prolonged to the degree necessary to afford relaxation.

Nitrous oxide anesthesia is thus proved to be something more than mere

asphyxia, or it would be completely counteracted by oxygen. Suitable

apparatus can now be procured by which both gases can be blended

together as desired; considerable experience, however, is necessary

for their successful use. It is generally stated that nitrous oxide

alone should not be given to persons with fatty hearts or atheromatous

vessels. From a brief period of nitrous oxide anesthesia patients

usually recover within a few minutes and without after-effects; still,

relaxation of the sphincters may occur. After its prolonged use there

may be considerable headache and vertigo.

THE CHOICE OF AN ANESTHETIC.

This will depend upon who is to be the anesthetizer as well as upon

the actual condition of the patient. If an inexperienced person is

to administer the anesthetic, ether is safer than chloroform, though

slower. On the other hand, when given by an expert, and after due

preparation of the patient, chloroform is ordinarily preferable. The

latter is especially indicated in the young and aged, as well as in

those who have bronchitis or chronic cough, and those who have advanced

renal diseases or atheroma, because it is not likely to produce such

high arterial tension.

Ether should never be given near an unprotected flame, and lamps or

gas-jets should be held above the level of the operating table, as

the vapor of ether is heavier than air and will tend to sink. The

disadvantages of chloroform where natural gas is in use have already

been mentioned.

Efforts should be made to prevent struggling, as in the violence of

this unconscious act an overtaxed heart might yield, or at least

undergo dilatation. Chloroform is notably less likely to be followed

by nausea and vomiting than ether, and yet nausea cannot always be

prevented. There can be no doubt that morphine, alone or with atropine,

may be given with advantage to most patients before administration

of a general anesthetic. The treatment of postanesthetic nausea has

been referred to in the chapter on the Preparation and After-care of

Patients. By general consent, chloroform is the anesthetic of choice

during labor.

THE DANGERS OF AND ACCIDENTS FROM ANESTHETICS.

The principal dangers from any of the volatile anesthetics come

from interference with circulation and with respiration. The heart

may give rise to alarm by gradual _failure in strength_, while the

pulse becomes more rapid and irregular, or by sudden and apparently

complete _cessation of activity_. _When the pupils suddenly dilate_

and do not react to light danger is close at hand, if it have not

already manifested itself, and then is the time to discontinue the

anesthetic and resort to vigorous methods, which may include artificial

respiration, but must include attention to the heart. It is customary

to use injections of strychnine, which are often too weak or too small

to be of service, nothing less than ¹⁄₂₀ Gr., which may be repeated

in a few moments, will be of any service. If ¹⁄₁₅₀ to ¹⁄₁₀₀ Gr. of

atropine be given with the strychnine it will prove a much more

effective stimulus. It is right and proper to administer these drugs in

this emergency, but still more reliable measures are at hand.

_Sudden stoppage of the heart_, being the most disastrous accident

during or after anesthesia, has attracted no small amount of attention

on the part of experimenters. An active _massage of the heart_ seems

to furnish the basis for all the newer methods of treating it, all of

which are accompanied by artificial respiration. Some of Crile’s work

in this connection was alluded to in the chapter on Blood Pressure and

Shock.

[Illustration: FIG. 41

Showing how proper traction on the tongue pulls on the epiglottis.

(Hare.)]

Numerous investigators have revived the hearts of experimental animals

by massage and saline injections, and Crile has shown the advantage of

adding adrenalin to the latter. It is better to begin the efforts while

the heart is still feebly beating than to wait until it has ceased.

Ordinarily this massage should be made through the intact thorax, but

the time is coming when it will be esteemed life-saving either to open

the abdomen and massage the heart through the diaphragm, or to open

the thorax and do it directly. The former can be done during almost

any abdominal operation. The greatest obstacle to success has been the

formation of clots in the cardiac cavities. These are formed within a

few moments after the heart has ceased to act.

_Massage of the heart, coupled with the use of adrenalin_, will prove

of service.

_Approaching cardiac weakness_ is always indicated by failure of

capillary circulation, which may be easily and instantly estimated

by making pressure upon the finger-nails. The rapidity with which

the blood will return to give them a natural appearance, after such

pressure is made, will be the index as to whether or no stimulation

is necessary. Tardiness in return of color, or absence, is a better

indication of the approach of shock than is coldness of the nose or

moisture of the skin. It often precedes acceleration of the pulse.

_Respiration may be interfered with by a variety of causes._ Not

infrequently the tongue is allowed to drop backward into the pharynx

as the patient lies upon his back, which, by its pressure, causes the

epiglottis to fall backward upon and close the glottis. The indication

here is to lift the tongue forward and carry the epiglottis upward so

as to restore the air channel. Extension of the head and neck will

accomplish much in this direction, as well as holding the lower jaw

forward and upward by well-regulated pressure exerted behind the angle

and at the same time by upward and forward traction upon the hyoid

bone. But when it is necessary in cases of emergency to carry out this

maneuver forcibly and extensively, then the _tongue should be drawn

upward and forward_ in the direction indicated in Figs. 41 and 42.

Tongue forceps are often resorted to for this purpose, and can be

procured in various forms and shapes. To the writer their employment

has always seemed far more barbarous than the much simpler expedient

of passing a curved needle, armed with silk, through the tongue in

either direction, 3 to 5 Cm. back of its tip. The suture thus drawn

through is knotted and made into a loop, and may be employed through

a long operation to make all the traction that will be required. This

really makes the tongue less sore and produces _less swelling and

after-discomfort_ than does the use of forceps.

[Illustration: FIG. 42

Showing how dragging the tongue over the teeth fails to pull on the

epiglottis. (Hare.)]

Respiration may also be impeded or suddenly checked by the presence of

a foreign body. This may possibly be a plate which the anesthetizer

has failed to require the patient to remove, or it may be material

ejected from the stomach; this latter is especially likely to happen

when emergency has required anesthesia without due preparation. When

this happens the fingers should be passed behind the epiglottis and

the obstructing body removed. In rare instances some portion of food

may have been so impacted in the glottis as to completely obstruct it.

If such an emergency arise the trachea should be opened and relief

thus afforded. Only in this way can life be saved. Embarrassment

of respiration is caused at other times by the patient apparently

“forgetting to breathe” or by his taking such shallow inspirations

that nothing is accomplished. This may be combated in several ways. In

the former instance the use of ether or injections of atropine will

frequently afford the necessary stimulus to the respiratory centres.

In the latter class of cases especially the most valuable expedient is

the _dilatation of the sphincter ani_, which may be stretched with a

speculum, or with the fingers. Long-drawn, even gasping inspirations

may follow this expedient.

Finally in certain cases artificial respiration will be required,

combined with rhythmical traction upon the tongue. The tongue should

be grasped, or controlled by a suture, and _retracted from the mouth

at the rate of at least sixteen times a minute, while the chest is

compressed at the same rate_, the traction being made at the moment

of relaxation of chest pressure. Tongue traction alone will sometimes

renew respiratory movements in extreme cases.[9] Figs. 43 and 44 from

Hare, show the combined manipulation of inverting the patient in

order that the brain may not lack for blood supply, and carrying out

artificial respiration.

[9] Freudenthal has called attention to the extreme irritability of

both surfaces of the epiglottis, and advises to pass the index finger

down upon it, irritating it by friction. This causes a powerful

reflex effect, as the glossopharyngeal supplies its anterior surface

and the inner branch of the superior laryngeal its posterior surface.

While these measures are to be regarded as emergency expedients, they

will often need to be supplemented by others, the use of adrenalin and

of salt solution, either beneath the skin or in the veins, and the use

of the Crile pneumatic rubber suit described in the chapter on Shock.

[Illustration: FIG. 43

Showing inversion of patient and method of performing artificial

respiration simultaneously. (Hare.)]

[Illustration: FIG. 44

Same as Fig. 43.]

There is a delay in the management of the patient after the conclusion

of an operation which is too often neglected--namely, prevention of

such exposure as shall produce a sudden checking of perspiration. The

patient should be wrapped in several thicknesses of blanket, leaving

only the face exposed; and only when fully conscious should he be

uncovered gradually and well dried with a bath towel. Such procedure

takes away much of the danger of congestion of the lungs, or of the

kidneys, which may cause serious disturbance should they occur.[10]

[10] The following is quoted from a recent journal article by an

unknown writer:

_Acid Intoxication after Anesthetics._--Occasionally some surgeon

reports a case of peculiar rapid fatal toxemia after a prolonged

operation, the cause of which is obscure. We have also heard of this

trouble after parturition, during which chloroform was given for a

prolonged period, and the ultimate cause of the violent symptoms

has been unknown. Now we are beginning to believe that anesthetics,

especially chloroform, can produce a destructive effect on the liver

and kidney cells very similar to phosphorus poisoning. In many cases

a peculiar idiosyncrasy seems necessary to explain the toxic effect,

but certain predisposing causes have been noted, _e. g._, hemorrhage.

The symptom-complex makes its appearance from a few hours to a few

days after the anesthesia, and consists of vomiting, restlessness,

delirium, convulsions, coma, irregular breathing, cyanosis, and

icterus in varying degree. The disease as described by Bevan and

Favill is a hepatic toxemia, resulting from acute fatty degeneration

of the liver, and seems to be a clinical entity. It is characterized

by an acid intoxication, acetone, diacetic acid, and beta-oxybutyric

acid being found in the blood and urine. Several clinical varieties

must receive renewed interest in the light of this investigation.

First is acute yellow atrophy of the liver, many cases of which occur

after chloroform anesthesia. Next, the rapid death after abdominal

operations, which have hitherto been attributed to intestinal

toxemia; and lastly, certain fatal cases of nephritis after operation

need a more careful study.

ARTIFICIAL RESPIRATION.

All foreign bodies should be removed from the mouth and pharynx. If

the patient have been in water he should be suspended head downward,

in order that the water may escape by gravity from the lungs. In all

of these methods _rhythmical traction_ upon the tongue will be found a

valuable aid in the procedure.

_Sylvester’s method_ utilizes the arms as levers by which to expand

the thorax, by means of the muscles which pass between them and the

chest. The patient is laid on his back, the shoulders somewhat elevated

and the head thrown backward. The forearms are seized just below the

elbows and carried upward over his head, by which movement the chest

is expanded; here they are held about two seconds, and then brought

down to the side of the chest and actual compression of the thorax made

with them, for the same period of time. When the chest is compressed,

an assistant may also press the liver upward and thus help to empty

the lungs. The intent is to make from sixteen to eighteen of these

movements in a minute. In children the movements are made more rapidly,

and in infants considerably more. It is usually necessary that traction

be made upon the feet to prevent pulling the body upward when the arms

are moved to expand the thorax. If the manipulations can be carried out

upon a table whose feet can be somewhat elevated this will also help,

as the blood is thereby induced to enter the cranium.

_Marshall Hall’s method_ is to roll the patient from his back on to his

side, the uppermost arm being utilized to make pressure upon the side

of the thorax in order to expel air. Then the body is rolled over on to

the back, by which movement the chest is expanded. This method is not

nearly as efficient as that mentioned above.

[Illustration: FIG. 45

Fell’s apparatus for forced or artificial respiration.]

In case of drowning _Howard’s method_ is quite applicable. The

maneuvers are as follows:

1. Turning the patient upon the face, with a large firm roll under the

stomach and chest, and protecting his mouth from the surface upon which

he is lying, press with full weight two or three times, for four or

five seconds, each time upon his back, so that the water is expelled

from his lungs and stomach.

2. Then quickly turn him face upward with the roll beneath his back,

with his head hanging downward and his hands above his head. The

operator then kneels astride over the patient, with the hips between

his knees, and grasps the lower part of the patient’s chest firmly,

bracing his own hands with his elbows firmly against his own hips.

With his full weight he then makes pressure upon the patient’s chest,

compressing it laterally for two or three seconds, gradually leaning

forward while doing this, and then with a sudden jerk pushing himself

backward. The intent here is to imitate the ordinary respiration rate

as above, or perhaps a little less often. This may be continued for a

half-hour or even for an hour, sometimes with eventual success.

There should be also massage of the heart, in addition to traction

upon the tongue. Artificial assistance should not be discontinued

until the patient is breathing regularly and sufficiently without

help. In Fig. 45 is represented the Fell apparatus for making forced

artificial respiration, this being a great improvement on the so-called

mouth-to-mouth inflation. The essential feature of it is a bellows, by

which the air is forced into the lungs, through a mouth-piece made to

fit tightly over the face, or through a tracheotomy tube. In accident

cases other measures, such as artificial warmth, etc., should be

employed.

MORPHINE AND SCOPOLAMINE.

Morphine offers no little aid in the production of anesthesia in many

cases. Those patients who are terrified by the thought of operation,

and who are in a semihysterical state when anesthesia is begun, may

be greatly tranquillized by a hypodermic injection of 0.01 to 0.015

of morphine, fifteen or twenty minutes previously. Given in this way

it acts as a heart tonic and general equalizer to the circulation.

If a small dose of atropine be added the effect upon the respiratory

centres is much enhanced. Again, in those cases where anesthesia is

begun without it, and patients prove very rebellious, it will have the

same happy effect. The only objection to its use is the nausea which

may thereby be produced. There is no way by which to dissociate this

from the nausea due to the anesthetic, elsewhere considered under the

heading of the After-care of Patients.

Patients can rarely be so completely put under the influence of

morphine as to justify its use alone.

=Scopolamine.=--The Germans sell under this name an alkaloid made from

the Solanaceæ, which seems to be identical with the _hyoscyamine_ of

the U.S. Pharmacopœia. Schneiderlin, in 1900, published a method of

producing anesthesia with little discomfort by using it combined with

morphine. The mixture seems more effective than either alkaloid alone,

but is rather slow in action. On the day preceding the operation a

trial dose of 0.02 of morphine and 0.008 to 0.01 of scopolamine may

be given. This will demonstrate the susceptibility of the patient to

the mixture. One hour and a half before the operation this dose, or a

larger one, should be administered, and, if necessary, another one of

smaller size fifteen minutes before the time of operation.

According to this method an interval of sixty to eighty minutes should

elapse between the first dose and the operation itself. When anesthesia

is thus produced it lasts from three to several hours. Others have

advised to divide the dose into three injections, giving the first

about two and one-half hours, the second one and one-half hours, and

the third one-half hour before operating. In some cases this has

produced complete and satisfactory anesthesia; in some it has not

been complete, while in others serious symptoms have been produced.

The statement that each alkaloid counteracts the dangerous effects

of the other is not substantiated; it is probable that the combined

effect is greater than would be that of either used alone. This mixture

should rarely be used, save in those cases where general anesthesia

is inadvisable, and where there are difficulties, even about the

employment of local anesthetics.

LOCAL ANESTHESIA.

The use of ethyl chloride, as the most volatile of the ordinary drugs,

by which chilling or freezing of the skin may be produced, has been

already mentioned. Other agents which chill or freeze may be used, _e.

g._, a spray of common ether or of rhigolene, or the local application

of ice and salt.

=Liquid Air.=--Liquid air, when available, affords an excellent means

of benumbing sensibility, since one or two very light applications, two

or three minutes apart, admirably serve the purpose. It is, however,

rarely available and should be used with great caution.

=Cocaine.=--Of the local anesthetics _cocaine_, or some of its

compounds or substitutes, will give the best results; although it

is said that injections of pure water, if sufficiently bulky, will

also answer the purpose of a local anesthetic. Cocaine has marvellous

properties upon mucous surfaces or in the tissues, but none upon the

unbroken skin. Where the parts to be operated are covered with skin

it is necessary to inject the drug with a hypodermic syringe, as in

the case of all deeper tissues. About the eye, the drug is used in

from 1 to 4 per cent. strength; in the nasopharynx, from 2 to 4 for

ordinary purposes; about the genitals, 2 to 5 per cent.; beneath the

skin, ordinarily in strength of 1 to 2 per cent. In operations upon

the nasopharynx and larynx it is often advisable to make a local

application of a small amount of an almost saturated solution, by which

a more complete effect is gained.

_Cocaine is not without dangerous toxic properties_, to which some

persons are peculiarly susceptible. It will seriously disturb heart

action in some; in others produce vertigo and mild delirium, and in

still others peculiar erotic symptoms. Warm solutions are more quickly

absorbed than cold ones. The use of more than 0.06 (1 grain) should be

avoided.

When the skin alone is to be anesthetized the injection should be made

into and not beneath. The nearer the cocaine solution is deposited to

the principal nerve trunk or branches the more promising will be its

effect.

The use of cocaine in operations, under general anesthesia, for the

prevention of those depressing influences which cause lowered blood

pressure and shock, has been alluded to in the chapter on Shock. For

instance, it is well to spray the larynx after opening it and before

making further operation upon it; while in all major operations in

which large nerve trunks are exposed or divided, _e. g._, amputations,

etc., the injection into the nerve trunks of a few drops of 2 or 3 per

cent. cocaine solution prevents this kind of disturbance.

For small and localized operations the direct injection of cocaine

into and around the area involved will prove sufficient. It is rarely

necessary to use for this purpose a solution stronger than 1 or 2 per

cent., especially if it is deposited drop by drop around the entire

margin of the area and if the part have been previously made bloodless

by pressure, as by the Esmarch rubber bandage. But when extensive

operations are to be undertaken the method of “_blocking_,” so called,

should be carried out. This consists in cocainizing the principal nerve

trunks which supply the part, for which purpose an accurate knowledge

of regional neural anatomy is necessary, with the intent to inject into

or closely around the nerve trunks a few drops of a 1 or 2 per cent.

solution. Working in this way by combination of injection, then of

incision, by which the nerve trunks are better exposed and more fully

protected in order to be more completely injected, and then proceeding

farther with the operative part, extensive operations have been and may

be done; such for instance as amputations, not alone of the limbs but

even of the shoulder girdle, removal of large tumors, etc. In this way,

for example, Kocher now removes most of the goitres which he attacks.

The essential feature of this work is to first get the cocaine inside

of the nerve sheaths. In this way a minimum of the drug is used with a

maximum of effect. Nevertheless when a large nerve trunk is thus to be

paralyzed temporarily it is best to inject the solution directly _into

it as well as around it inside the sheath_. Cocaine is a temporary

protoplasmic poison, and for the time being shuts off the afferent

power of the nerve. One advantage of this method is the avoidance of

shock as well as of pain. Another method, devised by Schleich, is to be

preferred. He uses three different solutions, of which the second is

commonly used. Tablets for making these solutions can now be obtained.

In order to secure the best effect with them the parts should be made

bloodless. The solution is deposited subcutaneously in a series of

drops around the margin of the area, and then massage may be made to

distribute the fluid more uniformly in the tissues. When the tissue to

be operated upon is inflamed the injections should be made first into

the healthy area on the proximal side.

Schleich’s formulas are as follows:

No. 1.

Cocainæ hydrochloridi .200 (gr. iij).

Morphinæ hydrochloridi .025 (gr. ²⁄₅).

Sodii chloridi .200 (gr. iij).

Aquæ destillatæ ad 100.000 (f ℥ iiiss).

No. 2.

Cocainæ hydrochloridi .100 (gr. iss).

Morphinæ hydrochloridi .025 (gr. ²⁄₅).

Sodii chloridi .200 (gr. iij).

Aquæ destillatæ ad 100.000 (f ℥ iiiss).

No. 3.

Cocainæ hydrochloridi .010 (gr. ¹⁄₆).

Morphinæ hydrochloridi .005 (gr. ²⁄₅).

Sodii chloridi .200 (gr. iij).

Aquæ destillatæ ad 100.000 (f ℥ iiiss).

Various substitutes for cocaine are now on the market. Some of these

are soluble and some insoluble. _Eucaine_ is most commonly used,

especially in form known as _eucaine B._, or _beta-eucaine_. It is

weaker than cocaine, especially so in toxic properties, and solutions

of twice the strength can be used, often with satisfaction, and almost

always without danger. For urethral and eye work, _e. g._, it answers

the purpose; nevertheless, it will sometimes prove disappointing.

_Orthoform_ is a crystalline, sparingly soluble artificial product,

which is too light and too coherent to be generally serviceable. It

often gives satisfaction mixed with other powders or in ointments,

and it is usually free from toxic properties. _Nervanin_ is another

laboratory product, not equal in activity to cocaine, but almost free

from unpleasant properties. _Anesthesin_ is another similar product,

which is practically free from physiological properties save that it

acts as a local anesthetic. The latter may be employed for infiltration

anesthesia in the following proportion, recommended by Dunbar:

Anesthesin hydrochloride 0.250

Sodium chloride 0.150

Morphine hydrochloride 0.005 to 0.015

Water 100.000 Cc.

_Stovaine_ and _alypin_ are among the latest synthetic substitutes for

cocaine. The latter seems to offer promise of usefulness.

Adrenalin may be added to any of these solutions in proportion of 1 per

cent. of a 1 to 1000 solution, and will have a beneficial effect in all

cases.

INTRASPINAL COCAINIZATION.

The intraspinal injection of remedies was first suggested by Corning,

of New York, in 1885; it remained, however, for Bier to perfect the

technique in 1899, and to make it so popular that the same maneuver

has been practised for various other purposes; as, for instance, for

withdrawal of cerebrospinal fluid in cases of hydrocephalus, etc., or

the injection of tetanus antitoxin. (See chapter on Tetanus.)

The intent in this use of cocaine is to spread the solution over the

surface of the cord and beneath the arachnoid. For this purpose a

needle about 4 inches in length, with a point not too sharp, preferably

gold or platinum plated, is used; with this also a syringe which will

hold 2 to 4 Cc., which can be firmly, yet easily, attached to the

needle. The accompanying illustration (Fig. 46) will give an idea of

the technique. The patient should be seated leaning forward so as to

curve the back and open the intervertebral spaces. A sterilized towel

is stretched tightly across the back from one iliac crest to the other;

its upper edge should then pass just over the spinous process of the

fourth lumbar vertebra. The injection is usually practised between

the second and third lumbar spines, or between the third and fourth;

the latter having been identified, the former are easily made out.

The needle is entered about 1 Cm. to the right of the middle line and

passed forward, inward, and upward, to a depth of 7 or 8 Cm. in the

ordinary adult, until the resistance offered by the tissues is felt to

have been passed and the point to have entered a cavity. If the needle

has been passed alone the escape of a drop or two of cerebrospinal

fluid will indicate that the spinal canal has been entered; if the

syringe is attached to the needle the piston should be withdrawn

in order to show the same result. It is possible to practise this

operation with a patient in the recumbent position, but it is done more

easily as above outlined. The skin may be frozen by the freezing spray,

or may be anesthetized by the local injection of cocaine solution with

the ordinary hypodermic syringe.

It is astonishing what beneficial effects can be gained from the use of

a small amount of cocaine. It is rarely necessary to use more than 0.03

(¹⁄₂ grain) of pure cocaine in order to procure analgesia of the entire

lower part of the body.

_Beta-cocaine_ or _tropacocaine_ may be used for the same purpose, in

double this amount, but they do not give as reliable results. Morton,

of San Francisco, has suggested that ¹⁄₂ Gr. powders of cocaine be

wrapped in such a way that they can be repeatedly sterilized by a

heat of 200° F., and that one of these be dropped into the syringe

barrel, that this be attached to the needle, and the cocaine itself

be dissolved in the cerebrospinal fluid withdrawn through the latter,

and then thrown back again. This is probably the neatest and most

serviceable method yet devised, and its originator has assured the

writer that with 1 Gr. of tropacocaine used in this way, thrown into

the spinal canal with considerable force, _i. e._, in such a way as to

more completely distribute it, he has been able to practise operations

even upon the tongue with little or no pain to the patient. The

solution used for this purpose should be sterilized, also the needle,

the syringe, the patient’s skin, and the operator’s hands. The water

with which the cocaine solution is made should be first pure, then

measured, and the solution made in such strength that not more than

the amount indicated above will be used. This should then be again

heated, but not quite to the boiling point, since cocaine solutions are

impaired by too much heat.

[Illustration: FIG. 46

Technique of intraspinal injection.]

The advantages of intraspinal anesthesia are many and obvious, and

were it not for disadvantages this method would have supplanted all

others for certain work. It is, however, by no means free from danger,

both from the maneuver and from the drug itself. Carelessness in its

introduction may lead to septic meningitis, while the drug itself may

produce considerable and even serious or fatal disturbance, though

these cases are rare. It has been claimed that 2 per cent. of the

cases in which this method has been employed have, in consequence,

terminated fatally. The immediate effects are largely confined to the

stomach and the nervous system, and include nausea, intense headache,

and profound depression. The remote effects are less positive, but

have been stated to include serious changes in the cord itself. It is

often a disadvantage to have the patient mentally conscious of what is

going on, even though oblivious to pain. Inasmuch as cocaine produces

analgesia rather than anesthesia, nervous patients will be likely to

mistake the general sensation of lifting a limb, or manipulating it,

for actual pain. There are not a few cases where chloroform and ether

are so plainly contra-indicated that if it were possible to use any

other agent with safety this would offer a valuable substitute.

The effect desired is not produced immediately, but comes on slowly,

after the expiration of ten to twelve minutes. As ordinarily used,

anesthesia of the surface will be produced up to the height of about

the waist. Should it be desired, however, to increase or enhance

the effect the solution might be injected between some of the dorsal

vertebræ, although at this point it will require more skill to

introduce the needle, and the operator should be cautious not to injure

the cord. Below the second lumbar vertebra the cord breaks up into its

segments and the patient would be almost exempt from this danger. It

is occasionally necessary to tranquillize the patient’s fear by using

morphine subcutaneously at the same time. It is a question whether this

can be safely combined with cocaine for the subarachnoid injection.

Failing in this it may be necessary to supplement the use of cocaine

with ether or chloroform.

The intraspinal injection of normal saline solution, or even of pure

water, has been shown by Eden to be almost as effective in some cases

as the cocaine solutions. Bier has largely modified his statements

about the value of intraspinal cocaine injections, and speaks of them

as more dangerous than he had first appreciated.[11]

[11] _Magnesium Salts as Local Anesthetics._--Six years ago Meltzer

discovered that magnesium salts have the property of inhibiting

functional activity in nerve tissue, and in December, 1899, he

announced that the intracerebral injection of magnesium sulphate

in a rabbit caused paralysis without previous convulsions. He has

recently announced the local anesthetic effect of small doses of a

25 per cent. solution of magnesium sulphate, an effect which lasts

from one to two hours. It is the magnesium “ion” which possesses the

anesthetic property, since the chloride and the bromides give the

same effects.

These salts have this advantage over other local anesthetics that

there is no primary period of excitation. Moreover, applied locally

to nerve trunks they have the effect of “blocking” them; and when

applied to the sciatic, pneumogastric, and other nerves, temporarily

abolish their power of conducting influences, either motor or

sensory. This effect is apparently due to the fact that the magnesium

normally present in the tissues constantly exercises an inhibitory

power over them, and that when thus applied from without they merely

exaggerate the condition already present; thus, if this be true,

affording an ideal anesthetic.

In December, 1905, Meltzer read a paper before the New York Academy

of Medicine, announcing success with intraspinal injection of

magnesium sulphate in 25 per cent. strength. Blake, of New York,

promptly made use of the suggestion in a child with tetanus. Two

injections of antitoxin had been made into the cervical cord on

successive days, with apparently no effect. He then made lumbar

puncture and a subdural injection of magnesium sulphate, giving 1 Cc.

of 25 per cent. solution for every twenty-five pounds of body weight,

administering it every thirty-six hours, employing four doses. The

effect was marked, in immediate control of convulsions, which,

however, was not permanent; hence the repetition of the doses. How

much influence the previous antitoxin had produced does not appear.

Meltzer suggests that the best time for an operation is three or

four hours after a spinal injection. He reports four cases thus

operated, in one of which, after the operation, the patient passed

into a period of deep general anesthesia, in which he remained for

five hours, the pulse keeping up, the respirations falling to ten

per minute. In this case another spinal puncture was made, some of

the spinal fluid let out, and the spinal cavity treated by repeated

irrigations with sterile salt solution.

Meltzer’s few but important experiences indicate that at least three

or four hours should be allowed to elapse after the introduction of

the magnesium solution. He advises 1 Cc. for every twenty-five pounds

of body weight, for intraspinal injection, which causes not only

_analgesia_ but temporary paralysis of the legs, sensation and motion

returning in from eight to fourteen hours, with possible retention of

urine for a day or two, requiring the use of the catheter.

Doses a little larger than the above, he thinks, would permit the

performance of extensive operations in the abdominal cavity, or even

higher up, without the aid of a general anesthesia. He is inclined

to think that it would be preferable not to wait four hours, but

to operate within about two hours after injection, with the aid

of a small amount of chloroform, the operation to be followed by

another puncture, with the removal of at least as much fluid as

was introduced, and irrigation with sterile salt solution, finally

leaving some of it within the canal.

PART IV.

INJURY AND REPAIR.

CHAPTER XXI.

WOUNDS AND THEIR REPAIR.

The old classification of wounds divides them into _contused_,

_lacerated_, _punctured_, and _incised_. For descriptive purposes these

adjectives are self-sufficient; they can be criticised only in case

the injuries differ in character. The adjectives thus employed allude

to the character of the injury as well as to its cause, but no meaning

should be conveyed by any of them other than to indicate a severance

of continuity in tissues. In either case cells are rudely torn apart.

But whether the injury be subcutaneous and the tearing make a ragged

surface; or whether the wound be an open one, with the possibility of

introduction of germ-laden air and grosser impurities, even though the

surfaces separated present an even plane, as in an incised wound; or a

channel or tunnel, as when made by a pointed instrument or a gunshot

missile, the principle is the same, and the same processes of repair

are brought to work to undo the harm. There is but one natural method

of repair, and that includes the exudate, or the utilization of the

fluid portion of the blood already poured out, and the activity of

cells, those which lie in the vicinity and those which are furnished

from a distance, _i. e._, leukocytes and wandering corpuscles. It is of

advantage to have the injury subcutaneous and protected from contact

with the air, yet extensive injuries of this kind are often much longer

in healing than those inflicted by the surgeon’s knife, when the parts

can be brought into complete apposition with each other by sutures.

It is the writer’s intent to simplify the description of the healing

processes and to insist that it is always the same, not modified in

character but in duration and extent, according to the nature of the

injury.

CONTUSION.

The term contusion implies a subcutaneous injury of varied extent,

in which laceration cannot be left out of consideration. Even in

the mildest contusion mechanical harm has been done, permitting a

dilatation of the vessels and the escape of fluid. Should this occur in

linear form, as by a whip-lash, there may be what is called a _wheal_.

In loose tissues swelling occurs more easily, as in the eyelid, the

scrotum, etc. Injuries of severity will produce laceration, at least

of capillaries if not of arterioles, and the result is the escape of

an amount of blood which will infiltrate the surrounding tissues and

discolor them and produce an _extravasation_ or _ecchymosis_. The blood

barely escapes and coagulates before its absorption begins. The fluid

portion disappears before the solid, and the pigment is usually the

last. There results a _black and blue spot_; the color when near the

surface is at first indigo or purple, and fades out through bluish and

greenish tints into a yellow, which may not disappear for two or three

weeks. Should blood collect in a cavity or in large amount the mass is

called a _hematoma_; this is especially common in the pelvis and in the

cranial cavity. Should a vessel wall give way from weakness caused by

disease instead of by accident the result is the same.

Contused wounds of the surface often cover excessive and even fatal

injuries within, as when a heavy object falls upon or injures the

abdomen or a limb. The skin is resistant, and the writer has seen a

limb pulpified by being run over by a heavy car, the skin being but

slightly torn. In such accidents exploratory incisions are imperative.

Better results will follow opening the abdomen in cases of severe

contusion, for the purpose of exploring the viscera, than will follow

the “let-alone” policy of waiting for something serious to appear.

An outpour of blood should be expected in every contusion, save the

most trifling, while clot formation may ensue. Whether the clot will be

absorbed or require the aid of the surgeon will depend upon its size,

its location, and its liability to infection. Clot in some locations,

_e. g._, pressing upon the brain or spinal cord, may justify extensive

operation for its removal.

_Pain produced by contusion_ is variable. When nerve trunks of

considerable size have been injured pain is frequently aggravated. In

general it is proportionate to the amount of swelling, _i. e._, to the

density or laxity of the injured tissue. When exudate occurs beneath

unyielding membranes, for instance the periosteum and the capsules of

certain organs, the pain may be severe. The appearance of discoloration

is proportionate to the depth of the injury and the amount of

hemorrhage. The time of its appearance will depend upon the distance

from the surface; after fracture of the neck of the femur it may not be

observed for several days. The general condition of the patient will

depend greatly upon his temperament. When there has been considerable

extravasation the release of the fibrin ferment may produce a mild rise

in temperature.

=Treatment.=--So long as air or other infection can be excluded the

treatment of contusions is simple. Cleanliness of the injured parts

should be enjoined; also physiological rest, by their confinement

within dressings or splints, or by placing the patient in bed. An

antiseptic application, dry, watery, or in ointment form, should be

applied upon a surface which has been abraded. Differences of opinion

exist as to the respective values of heat and cold. When the case is

seen early, before much swelling has occurred, the exudate may be

limited by the application of cold dressings; whereas if seen after

the swelling is at its height the use of moist heat may favor a more

speedy re-absorption. The effect of extremes, either of heat or cold,

is sedative, although hot applications afford more relief than do those

of ice. Of domestic remedies in use among the laity it may be said that

those which have any value owe it to the alcohol which they contain.

Elastic constriction will reduce the amount of exudate and assist in

the absorption of that already present. It is a measure, however, to be

used with great caution lest venous return be interfered with and edema

or gangrene be the consequence. A joint tensely distended with fluid as

a result of combined contusion and laceration, called a _sprain_, may

be emptied by aspiration, but this should be used only under antiseptic

precautions. Finally any collection of blood which fails to disappear

may be incised and cleaned, its cavity mopped out with compresses, and

its surface made to come in contact by pressure. In hematomas and large

extravasations of blood, sometimes in joints, but rarely in the pleural

or peritoneal cavities, this method may also be used.

LACERATED WOUNDS.

Lacerated wounds differ from contused in the character of the tears

in the tissues affected and in the exposure to infection by contact.

They vary in extent and severity. Not infrequently tissues or organs

of the greatest importance are lacerated, _e. g._, the globe of the

eye, the liver, the intestines. The term laceration itself implies

such open injury that part of it may be exposed to infection. The

first danger is from hemorrhage. This may subside spontaneously, or

may have been checked by some first aid, or may prove nearly fatal by

the time the patient is seen by the surgeon. The first measure will be

_hemostasis_ by the readiest and most effective measures at hand. This

may mean the application of compresses or of a tourniquet, or even of

manual pressure, until surgical procedures can be instituted. Shock

should be treated by lowering the head and raising the extremities, or

bandaging the latter, and the subcutaneous administration of morphine

or atropine. Emergency treatment of these cases should include removal

of foreign bodies, and such cleanliness and attention to antisepsis

as may be possible at the time. Support of the injured part should be

effected temporarily until dressings can be scientifically applied. If

cane sugar will keep fruit and meat from decomposition it will have the

same effect in human tissues, and a laceration with or without compound

fracture of bone may be filled with granulated sugar until a suitable

dressing can be applied.

The surgical treatment of laceration should include the following

measures: _Hemostasis_; the _removal of foreign bodies_, as well as

of tissue which is so injured as to make repair impossible or even

questionable; a careful _study of nerve supply_, in order to be sure

that no nerve suture should be made; a similar _study of muscles and

tendons_, in order that tendon suture may be promptly made; careful

_antisepsis_ throughout, asepsis being impossible; closure of the

wound by buried and superficial sutures, and such drainage tubes or

outlets as may permit free escape of whatever products of inflammation

or disintegration may result. There should also be provision for

physiological rest of the injured parts as well as of the patient’s

mind and body.

When large areas of skin or deep tissues are destroyed or torn away,

as in scalp wounds, avulsion of limbs or parts of limbs, it may be

necessary to retain that which can be saved and to remove that which

would slough if left to itself, thereby providing for flaps of skin by

which the wound may subsequently be covered, or leaving them in case

removal of a part must be made.

Everything which has vitality should be spared; on the other hand, that

which has lost its vitality should be removed at once. Thus amputations

may be sometimes called for because of extensive lacerations with

destruction of vascular and nerve supply, even though the bones be

uninjured.

In cases where the question of viability of tissues cannot be promptly

decided it is best to keep the injured part immersed in water as warm

as can be borne. In hospitals the entire body may be kept immersed for

days. By the use of warm water parts which have been seriously injured

may be restored. Ulcerations which are seen after the sloughing process

has begun can be best treated by immersion or by the application

of brewers’ yeast upon compresses or cotton. No other substance,

perhaps, will so quickly clear up an indolent or foul surface as this;

it hastens the time of separation of all that is dead or dying and

restores healthful activity to the surrounding tissues.

Extensive lacerations leave frequent opportunity for operations by

which function may be restored or improvement affected.

PUNCTURED WOUNDS.

The essential features of punctured wounds are sufficiently indicated

by the descriptive name; but harm may be done through a small external

opening. An important subvariety of punctured wounds is inflicted by

_gunshot_ missiles, which will receive consideration by themselves.

Injury to important vessels may lead to serious hemorrhage; while

injuries to nerve trunks may be followed by paralysis of sensation and

motion, or, as in the case of a sympathetic trunk, by the well-known

consequences of division of vasomotor nerves, _e. g._, in the neck.

When the punctured wound bleeds freely and externally it may be assumed

that some large vessel has been injured. When it bleeds into one of the

cavities of the body delay in recognition may occur. This is true of a

puncture of the skull by which the middle meningeal artery or one of

the sinuses is wounded, when the symptoms of brain pressure may tardily

or rapidly appear. In the chest the intercostal or internal mammary

artery may be so injured as to bleed into the pleural cavity and cause

death. A puncture of the heart frequently leads to fatal hemorrhage

into the pericardial cavity, and in the abdomen puncture of the various

viscera has led to consequences beyond help save when prompt relief

could be afforded.

The dangers attending punctures pertain to the introduction of

infectious material which may produce sepsis or may slowly produce

tetanus. No ordinary weapon or tool is clean in a surgical sense, while

a rusty nail is even less so. It will be seen, therefore, that the

danger inherent in such a case is not to be measured by either the size

or the depth of the wound.

In dealing with these cases the first attention is to be given to

_hemorrhage_. Obviously punctures in certain regions are much more

likely to be followed by hemorrhage, and any puncture in the vicinity

of one of the large vessels should be managed with caution, especially

if the surgeon ascertain that it had bled profusely when first

inflicted. Such a puncture, when seen a few hours later, may have

become occluded by clot, or a considerable hematoma may have formed

beneath the skin. It is safe to presume that there is more danger of

septic infection than can accrue from later attention, and it would be

advisable in such cases to anesthetize the patient and lay open the

parts freely under full aseptic precautions, in order that the clot be

turned out and any bleeding vessel secured. A brief study of such a

case will decide the question of injury to the principal nerve trunks.

A principal nerve which has been injured or divided should be carefully

sought for and its ends freshened and sutured. This is true also of

any tendon whose function is evidently lost. If the thorax have been

punctured and the physical signs indicate the presence of fluid, _i.

e._, blood in the pleural cavity, it should be incised and the blood

withdrawn. This method should also be applied to punctures of the

heart. These measures will be more completely dealt with in treating of

the surgery of the chest and its contents.

_Punctured wounds of the abdomen_ may give rise to great anxiety. If

none of the viscera have been injured they may be let alone, but if

doubt exists as to the safety or injury of any of them the abdomen

should be opened. (See Surgery of the Abdomen.)

=Treatment.=--For emergency purposes antiseptic occlusion is the

best procedure, and all punctures inflicted by ragged and infectious

materials, as rusty nails, should be treated by free incision, with

thorough cleansing and packing with antiseptic material, that the

wounds may heal by granulation.

INCISED WOUNDS.

Incised wounds are those inflicted by a sharp object which divides

the tissues abruptly and with a minimum amount of disruption. They

invariably bleed, sometimes seriously, even to a fatal degree, the

hemorrhage in such cases being due to severance of large vascular

trunks. Like contused wounds they vary as infinitely in extent as

in locality. According to their locality and dimensions important

structures may be severed, _e. g._, the trachea, the large nerve trunks

of the body, the tendons, etc., while visceral and joint cavities may

be more or less widely opened. When death occurs soon after injury it

is generally from hemorrhage. They are attended by the same dangers of

septic infection as are punctures, especially when there is neglect in

the emergency dressing. Should the pleural cavity be opened there may

be collapse of the lung.

_Hemostasis_ is the paramount indication in all incised wounds which

bleed seriously. Hemorrhage is to be controlled temporarily by any

expedient, later by ligation or suture, or both. The remarks above in

relation to possible injury to vessels and nerves are of equal force in

this consideration. Every divided nerve trunk, as well as every severed

tendon, should be reunited by suture. If a joint have been opened it

should be cleansed and drained, even though the incision be closed.

Should there be injury to any of the viscera, the wound may be enlarged

in order that exploration may be made and suitable remedies applied.

This is true of every punctured or incised wound. No hesitation need be

felt about enlarging it so as to permit of investigation. Hemorrhage

having been checked and all required attention having been given, the

closure of an incised wound may be made partial or complete according

to its condition. If fresh and clean it may be almost completely

reunited, using deep and buried sutures in order to bring into contact

its deeper portions, while superficial sutures will suffice for the

skin. Drainage may be by tubes or gauze or by loose suturing of the

surface; but no incised wound whose surfaces have become contaminated

should be completely closed by primary suture until all such surfaces

have been freely cut away and appear healthy and uninfected. An old

infected and gaping incised wound may be cleaned by the application of

brewers’ yeast, and when granulating it may be closed secondarily with

sutures, by which granulating surfaces are brought into close contact.

_Of wounds in general_ it may be said that there are mixed types as

well as illustrative examples. Thus a wound made by a hatchet or axe

may partake of the nature of contusion and of incision. In instances

where personal violence has been applied multiple wounds of varied

character may complicate the case. The statements made above pertain to

their conventional and common characteristics. Treatment which would

be proper in one case may be impossible in another. There is always

room for discretion and good judgment, though there are fundamental

rules which apply to all cases, and include exact hemostasis, surgical

cleanliness, repair of severed nerves and tendons, removal of foreign

bodies and involved tissue, and the enforcement of physiological rest.

REPAIR OF WOUNDS.

The process of repair is _essentially the same_, being modified

only by the needs of the wound and the tissues involved, and by

their environment. Whether soft tissues or bones are being repaired

the differences are apparent rather than real, as bony tissue is

temporarily decalcified, and then, as soon as the process permits, is

once more stiffened by deposition of calcium salts.

The process of repair should be begun immediately after the cessation

of the disturbance which has produced the wound, and as soon as the

bleeding is checked. It may be materially influenced and retarded by

the presence of bacteria or other foreign bodies, but its character

remains unchanged. Healing has been described as occurring by _primary

union_, or by “_the first intention_,” and by _granulation_, or the

“_second intention_.”

Wounds which have been permitted to remain clean, with their edges

brought together so that the surfaces are in contact, are healed

with a minimum of waste of reparative material, the process being

as follows: The small vessels are occluded with thrombi up to the

first collateral branches; the leukocytes begin to penetrate the

film of blood, which, having coagulated, serves as a cement to help

hold the surfaces together. By their proliferation and more complete

organization the gap between the surfaces is bridged with both fibrous

and capillary bloodvessels, and within sixty or seventy hours the clot

has become largely replaced by organized cells. Meantime from the

endothelial cells of the vessels and vascular spaces, as well as from

the fixed cells of the connective tissue, the so-called _fibroblasts_

are formed, which are later converted into connective tissue. Many of

the cells which have wandered to the scene of activity, or have been

there reproduced in unnecessary numbers, disappear again, either into

the circulation or they serve as food for the fibroblasts. Branching

cells attach themselves more intimately, and thus the original clot is

completely converted into _fibrous and connective tissue_, and this

becomes a _scar_, which extends as deeply as did the original injury.

New capillaries are rapidly formed by a budding process, and supply

the pabulum required for nourishment of the new cells. By fusion or

amalgamation of neighboring vascular buds complete new vessels are

formed, extending through the new tissue from one side to the other,

while around them the fibroblasts or connective-tissue elements arrange

themselves. From this it will appear that the coagulum which forms

within a wound is desirable as a scaffolding upon which the process

of repair may be begun. But it is desirable that this coagulum should

be small in amount, in order that these processes may not be too long

delayed; hence the advisability of removing all clots within a wound

when closing it, and preventing the formation or leaving of _dead

spaces_ in the tissues in which blood clots may collect.

_The process of granulation_ is not dissimilar to that described above,

save only in its gross appearances. Granulations consist of vascular

buds surrounded by leukocytes and lightly covered by them, while around

the base of each bud epithelioid and spindle cells arrange themselves,

these fixed cells organizing themselves more and more, as the wound

fills up, with the more superficial layers of granulations. In time

they are converted into a dense fibrous tissue which forms later what

is known as the _scar_. As before, also, the spaces between the young

capillary loops are filled with large nucleated cells derived from

the fixed cells of the tissue, and from the endothelial lining of the

newly formed vessels. Thus fibroblasts are produced in each case, and

are often more or less mingled with giant cells, especially if some

foreign body, such as a silk ligature, be embodied in the tissues. The

particular function of the leukocytes seems to be the removal of red

corpuscles and fibrin from the original clot.

The _granulation tissue_ thus constituted by capillary loops and

proliferating cells constitutes the basis of all wound repair. Later

this tissue assumes more of the fibrous and less of the cellular

character, while the fibroblasts arrange themselves in accordance with

the mechanical requirements of the tissues and the stress or strain

placed upon them. This tissue is at first vascular, but as it condenses

its capillaries become less numerous and smaller, and the final white

fibrous scar is usually almost bloodless.

When there has been loss of skin, or when skin edges are not brought

together, the deeper process of granulation needs an epithelial

covering, which cannot be afforded by mesoblastic or endothelial cells.

The formation of an epithelial or epidermal covering is a process

peculiar to epithelial tissue alone, and takes place mainly from the

cells of the rete Malpighii.

Epithelial elements of the skin will afford a large amount of covering,

and yet even their activity sometimes is insufficient and has to be

atoned for by _skin grafting_. Should the granulating surface be small,

and so situated that the fluid upon its surface may dry by evaporation,

there will result a crust or scab, which, while it conceals from

observation what is going on beneath, serves as an admirable

protection, beneath which proliferation of epithelium takes place. A

spontaneous detachment of the scab may take place when this process

is complete, and with the loosening of the crust it is apparent that

repair has become complete. This is known as _healing under a scab or

under a crust_.

Two clean and healthy granulating surfaces may be so placed in contact

with each other as to blend together by exactly the same process as

that by which granulations are first formed. This is called _secondary

adhesion_, or by the older writers the “_third intention_.” Advantage

is taken of this possibility in the application of what are called

_secondary sutures_, which may be placed some days before they are

utilized, with the intent to bring together surfaces so soon as they

shall present granulations.

One of the most interesting of all healing processes is that by which

_severed tissues_, when promptly replaced, often reëstablish vascular

communication and grow again in a satisfactory manner. Thus a severed

ear, nose, or finger-tip may be replaced, and, if carefully held _in

situ_, the parts being kept at rest, will prevent disfigurement and the

loss of important tissues. In these cases the severed tissue remains

passive several days until it has become vascularized. Meantime its

nutrition seems to be maintained through the medium of the living

tissues to which it has been affixed, probably by absorption of their

blood plasma.

Two human tissues are essentially non-vascular, the _cornea_ and

_cartilage_. The former appears to be nourished by cellular interspaces

which may admit leukocytes from the surrounding tissues, and through

these proliferation and vascularization occur; while a scar in the

cornea remains permanent, and the new tissue by which repair is brought

about never becomes transparent like the cells composing the cornea

proper. In cartilage scar tissue is produced, as in other tissues, by

a similar process, in spite of the extent of the cartilaginous layer

and its non-vascularity. In general the more specialized a tissue the

less completely does it heal, and the specialized tissues, like the

retina, etc., seem to be incapable of reproducing themselves. Low down

in the animal scale some parts can be more or less reproduced. In the

ascending forms there is less tendency in this direction; in man there

is little reproduction of an original tissue, scar tissue taking the

place of most of that which has been lost. An apparent exception to

this is seen in the osseous system, where a large amount of bone may

often be reproduced. Epithelium, also, whether on the external or

internal surfaces of the body, can regenerate itself in large degree

and amount. From every small island or mass of epithelial cells which

can be retained new cells may thus be reproduced; hence accrues the

advantage of leaving such epithelial collections whenever possible,

and wherever they may be beneficial. If upon a burnt area it happens

that epithelium has not been completely destroyed, new skin may be

confidently looked for from each clump of epidermal cells. It should

be remembered, however, that with the epidermization of a surface

under these circumstances merely an epithelial covering is secured.

The distinctively dermal appendages, such as hair, sweat glands, and

sebaceous glands, are not reproduced. If the highest ideal results are

to be secured in any case the parts must be put in the most favorable

condition, which means early surgical attention to every wound.

INJURIES TO VESSELS.

Bloodvessels are subject to contusion, to laceration, and to incision.

They may be contused by superficial blows, compressed against

underlying bone, torn in the replacement of old dislocations, or

punctured or incised by accidental or homicidal injuries. A vessel

which is not abruptly divided but is seriously injured will usually

sustain a separation of its internal and middle coats, which curl

up within the external coat, occlude the channel, and lead to

_thrombosis_. A vessel thus occluded may tend to gangrene of the parts

supplied by it or to a temporary ischemia, with numbness and pallor

if an artery, or to passive edema if a vein. In cases of such injury

it is always hoped that the blood supply will be provided through

the collateral circulation. If a vessel be torn or cut across there

may result a hematoma which may lead to immediate prostration, from

hemorrhage, and to gangrene by stopping the blood supply. Such blood

tumor rarely pulsates, but may cause extreme pain. The character and

the size of the swelling will depend upon the tissues which surround

the injured vessel. Cessation of the pulse on the distal side of an

injury nearly always implies temporary occlusion. _Traumatic aneurysm_

may be produced by lateral injury to an arterial trunk, by which its

continuity as such is yet not completely disrupted.

If a large outpour of blood has occurred it will be safer to incise

and turn out the clot and secure the injured vessel. In milder cases

the surgeon should do all that he can by rest and by position to

favor restoration of blood circulation. After the subsidence of acute

symptoms massage and gentle motion will serve to promote absorption of

the escaped blood. Cases will occasionally occur in which the principal

arterial trunk of a limb should be tied, hoping thereby to save the

member. Amputation may be the last resort when gangrene is impending.

_Injury to the veins_ is of a less serious nature in so far as

immediate consequences are concerned; nevertheless a punctured wound

or a large vein is always a serious matter. The pressure of the blood

may produce gangrene, or cause so large a hematoma that it should be

incised.

Fine silk sutures may be applied to wounded vessels, arteries or veins,

when they have been partially severed.

The healing process in all these cases is essentially the same. It

may mean the formation of a clot in or around a vessel, followed by

absorption of its principal portion and organization of what remains.

A vessel itself which has once been occluded by thrombus will usually

remain closed, a cord of fibrous tissue taking its place. Only in rare

instances is continuity of the blood channel preserved or regained. In

such cases the collateral circulation affords the life-saving feature.

The granulations which intrude themselves into the clot gradually

substitute tissue for coagulum, the conversion beginning promptly, but

often occupying weeks for its completion.

_Lymph vessels_ may be lacerated in almost any injuries and more or

less lymph escape with the blood. When the skin is torn from the

underlying parts lymph collects in the cavity thus made, while its wall

may undergo more or less organization, and formation of a _lymph cyst_

results. Should one of these connect with a good-sized lymph duct,

as, for instance, in the neck the thoracic duct, then lymph cysts of

considerable size might form. Should these rupture or be opened lymph

fistulæ might result.

INJURIES OF NERVES.

By small hemorrhages into a nerve sheath nerve function may be either

temporarily or permanently disturbed. A compression too long-continued

may lead to degeneration within the nerve fibers. Providing this do

not occur there may be complete restoration of function, or there may

result chronic neuritis, with pain and irritation. A later consequence

of all nerve injuries is more or less serious disturbance of sensation,

while still later parts supplied by the affected nerves may undergo

more or less atrophy as well as spastic contraction, by which loss of

function and deformity are produced.

There is a form of nerve injury which is due to the temporary pressure

of the elastic tourniquet, frequently applied around limbs previous

to operations, or to pressure which is made by crutch handles upon

the axillary plexus, and called _crutch paralysis_. _Limbs carelessly

allowed to hang over the edge of the operating table_ during prolonged

operations also have suffered in the same way. Such lesions are of the

character of a contusion, but are often followed by paresis, paralysis,

and by various sensory disturbances.

Injury to a nerve trunk having been recognized by a study of the

local features of a given case requires special treatment in case

laceration or more localized division can be assumed. The nerve known

to be lacerated and torn across should have its ends freshened and

be reunited by fine catgut sutures; also a nerve trunk known to be

punctured or divided. Such injury is not necessarily inflicted from

without, as it may be produced by a fragment of bone; in this case

the operation should be directed toward the bone as well as toward the

nerve trunk itself. A divided nerve trunk, if neatly sutured, heals by

the organization of blood clot, as in other instances, actual nerve

communication being made across the intervening clot by a process

of regeneration or reduplication of the true nerve elements, the

peripheral neurilemma playing an important part. Autogenetic power

decreases with the age of the individual. By careful nerve suturing

disability may be prevented.

Even months after injury much can be accomplished by nerve suture

properly performed. Symptoms similar to those of division may occur

when a nerve trunk is surrounded and compressed by bone callus after

fracture, as when the ulnar nerve is thus caught. If too long a time

have intervened it may be necessary to exsect the injured portion

and then bring the ends into apposition by sutures. Other methods of

atoning for these nerve injuries by nerve grafting, etc., will be

described in the chapter on Surgery of the Peripheral Nerves.

Neuritis may be overcome by counterirritation, preferably with the

_actual cautery_, _i. e._, the “flying cautery,” by massage, and by

galvanization. The pain in many of these cases can be mitigated, if not

completely relieved, by the x-rays, or by the high-frequency current.

In some cases nerve elongation may be brought to bear and a tender and

irritable nerve be thus brought under subjection.

INJURIES TO MUSCLES AND TENDONS.

Lacerations or divisions of muscles are usually repaired at first by

fibrous tissue, the result of organization of a clot. Later a true

muscle regeneration takes place and muscle scar finally disappears.

Atrophy of a muscle is not a sign of injury directly to itself, but

often results from injury to the nerve which supplies it; for example,

the circumflex nerve may be injured in shoulder dislocations, while the

deltoid muscle, which is supplied by it, speedily undergoes atrophy.

Muscle fibers may be torn by violent exertion. Such an accident may be

followed by pain and loss of function. An interval can often be felt,

even from the outside, between the torn muscle ends. The injury will

produce considerable hemorrhage. The amount of function regained in a

muscle will depend to some degree on the extent of its injury. If it

have been injured by an incised wound it will depend upon the way in

which it is brought together after an open incision. The origin and

insertion of such a muscle should be approximated by proper position,

and so maintained by the dressings, in order that perfect rest may be

more easily maintained. When a portion of the fascia or aponeurosis is

torn the muscle fiber may protrude and form a _hernia of muscle_.

_Tendons_ often suffer from _contusion_, in consequence of which

they may become adherent within their tendon sheaths; this leads to

stiffness of the part and more or less loss of function. Sometimes they

calcify, as does the adductor magnus tendon in the formation of the

so-called _rider’s bone_. The tendon most frequently injured is that of

the quadriceps, near the knee.

If it can be decided that a tendon has been divided or torn across its

prompt reunion by suture should be always practised. Also a divided

muscle, if exposed, should be drawn together with sutures, chromic

or hardened, so as to make them more reliable. Tears of aponeuroses

and fasciæ should also be sutured. Tendon suturing is nearly always

successful, especially if it can be done in a cleanly manner; while

tendon grafting is a measure which may be reserved to overcome the

consequences of injuries to muscles and tendons not disposed to repair.

INJURIES TO BONES.

Aside from simple and compound fractures, which are essentially bone

wounds, there may be seen hemorrhages beneath the periosteum or in the

immediate vicinity of bones, which are usually small in amount, yet may

cause considerable disturbance. The _traumatic hematoma of the scalp_

which often follows delivery is an illustration of an injury of this

class, the periosteum itself being sometimes separated. Collections of

blood under these circumstances which fail to disappear by absorption

may be incised and the contained clot turned out.

[Illustration: PLATE XII

FIG. 1

Young Granulation Tissue Following Bur., _a_, _aa_, thin-walled

capillaries. Large nuclei, fibroblasts horseshoe nuclei, leukocytes. ×

250.

FIG. 2

Young Scar. Numerous capillaries perpendicular to surface. Spindle

elements, fibroblasts considerably smaller than in Fig. 1. × 250.

FIG. 3

Mature Scar. Dense fibrous connective tissue with a few fibroblasts. At

_a_, a small bloodvessel. × 250.

Granulation Tissue organizing into Cicatricial Tissue. (Karg and

Schmorl.)

Illustrating statements made on several of the foregoing pages.]

CONTUSIONS OF THE VISCERA.

Contusions of the viscera may be followed by many and disastrous

consequences. They compromise such lesions as rupture of the liver,

kidney, spleen, laceration of the bowel, bladder, or gall-bladder,

and may occur by blows which do not break the surface; or any of the

viscera may be lacerated, punctured, or gashed by gunshot, punctured,

or incised wounds. These will be more completely considered in Chapter

XLV.

CHAPTER XXII.

GUNSHOT WOUNDS.

Gunshot wounds are usually considered with the special subject of

military surgery. Military surgery as such, however, consists in the

application of general surgical principles. Nevertheless a gunshot

wound is essentially the same whether it be received upon the

battle-field or in civil life, and the injury inflicted by a piece of

flying shell is in no sense different from that which may be received

in a blasting accident.

A gunshot wound is always contused and lacerated, and often punctured.

According to its size and shape, its location, the nature and velocity

of the missile, the distance at which the weapon was discharged will

depend its severity and prognosis.

Shot vary in size from those which weigh but a fraction of a grain

to buckshot which weigh nearly one-third of an ounce. Revolver and

pistol bullets vary in diameter from 0.22″ to 0.45″, and in weight

from twenty-five grains to ten times that amount, and nearly always

of conical form. They are usually made of compressed lead, sometimes

hardened by the addition of tin or antimony.

The old military weapons, such as the Springfield rifle, have been

entirely abandoned, and for them have been substituted rifles of

smaller bore, projecting bullets of from 0.25″ to 0.31″, varying

in weight from one-fourth to one-half ounce and attaining a muzzle

velocity of nearly 2500 feet per second. They have, therefore, a

much increased range and may kill at two miles. Their trajectory is

flatter and the character of the wound caused by these modern weapons

is different from those inflicted, for instance, during the Civil

War. The bullets now in use in the armies and navies of the world are

nearly all encased in a thin covering of steel, copper, etc., which

is known as the _jacket_ or _mantle_. They are from 3.5″ to 4″ in

length, possessing a much greater range than a shell bullet, while the

rifling of the weapon is so made as to give them a more rapid rotation.

In active service, moreover, these are usually fired with smokeless

powder. The so-called “dangerous zone,” _i. e._, that where mounted men

or infantry can be injured, is much wider than formerly.

In India the practice has been introduced of leaving the point of

the bullet uncovered by the mantle, so that when it strikes it would

“mushroom”--especially in the bone. These “Dumdum bullets,” as they

are called, from the place of manufacture, inflict much more serious

injuries than do the relatively smooth perforations made by the others,

and have been considered so cruel that they are excluded from use in

civilized warfare.

During the Russo-Japanese war, in which nearly all previous records

were broken, the deaths from gunshot wounds constituted but a small

proportion of the entire loss in camp and warfare, a larger number of

soldiers dying from disease and exposure. Statistics also show that out

of every 100 cases of gunshot wounds 12 per cent. have been produced by

bullets, the remaining portion being caused by shell, etc. De Nancrède

has epitomized some interesting figures which may be here quoted:

In the United States army during the Spanish war 4750 casualties

were accurately studied; of these wounds of the lower extremities

constituted nearly 33 per cent., those of the upper extremities nearly

30 per cent., those of the trunk a little over 22 per cent., and those

of the head and neck a little over 15 per cent. During the South

African campaign the mortality among the wounded was 5.7 per cent.,

essentially the same as that during our Cuban and Filipino campaigns,

and in marked contrast to the 14 per cent. mortality of the Civil War.

Considering that with our Mauser weapons the trajectory is practically

flat up to 500 yards, and they may kill up to a distance of two miles,

it will be seen that this difference in figures is important. The

British discovered in their campaign against the Afghans, who were

using antiquated weapons, that their own Lee-Metford bullets would

pass through their enemies without disabling them, while the British

soldiers who were once struck by the large, soft-lead bullets of their

antagonists were far more seriously injured or absolutely disabled.

As one explanation of the injury inflicted by modern projectiles there

has been advanced the theory that a bullet with a high-muzzle velocity,

striking an object while it still retains most of its original speed,

compresses and forces ahead of it into the wounded tissues a small

column of air, which, exercising an expansive force, produces more or

less explosive effect, that may be seen along the bullet track or at

the point of exit. These explosive effects are proportionate to the

size of the bullet, its bluntness, and its velocity. This theory was

more tenable in the days of large and blunt projectiles than today,

for in time past experiments have shown that when a bullet is dropped

into water from a height there is forced into the water along with it a

certain amount of air, estimated by Longmore at twenty times the actual

volume of the bullet itself. It may be doubted, however, whether the

rifle projectiles of today can produce sufficient air pressure to cause

the destructive effects thus attributed to it.

[Illustration: FIG. 47

_a_, completely shattered after perforating a horse’s thigh-bone at

220 yards; steel mantle stripped; _b_, ball with mantle torn off and

rolled up, core deformed, after shattering human tibia at 60 yards;

_c_, wholly disorganized ball, which destroyed middle metatarsal bone

of horse at 660 yards, steel-mantled; _d_, ball which shattered a human

femur at about 750 yards, steel-mantled; _e_, remains of steel mantle

and part of core lodged in human femur, wound inflicted at about 1100

yards; _f_, _g_, fragments of mantle found near the orifice of the

wound of exit at about 1100 yards’ range, steel-mantled; _h_, piece

of steel mantle split off by striking a dried horse’s metatarsal at

over 1300 yards; _i_, steel-mantled ball which perforated the internal

femoral condyle and lodged beneath the skin at nearly 2200 yards.

(Recent foreign report.) (De Nancrède.)]

Another method of accounting for shattering effects noted in many

of these wounds is hydrodynamic pressure, depending upon the

incompressibility of fluid and of tissue containing it, and the

narrowing of the space occupied by fluid as a result of the transfer

of pressure in all directions. Other things being equal, the most

marked effects would be manifest in organs containing the most fluid,

the effect increasing with the amount of fluid, the speed of the

bullet, its size, and any alteration of shape which it has undergone

in transit. It has been shown that the hydrodynamic pressure of

steel-jacketed modern bullets varies from six to eight atmospheres.

This theory accounts for the peculiar destructive effects seen in the

brain, the heart, the stomach, and intestines when struck at short

range.

Another method of accounting for the results of a bullet wound takes

account of the peculiar effect due to the rapid rotation of the bullet,

the movement given it by the rifling of the barrel from which it is

fired. It appears that a bullet travelling at the rate of 620 meters

per second will average about four rotations per meter. Even in passing

through a human body this would scarcely give it but two rotations in

transit, while in passing through any given bone the force would be too

slight to be appreciable.

While the theories mentioned above, the _hydraulic_ and _hydrodynamic_,

are attractive, yet they are unsatisfactory; we can do little more than

sum up the damage done by a rifle ball as due to arrest and divergence

of its energy, penetration depending upon its remaining velocity, its

preservation of its original shape, and the resistance offered by the

part injured. If the latter be great, and its shape be but slightly

changed, there are pronounced explosive effects. Moreover, one end of

the bullet is a little heavier than the other, and this will tend to

produce a certain amount of tilting, by which a key-hole wound may be

also produced. Fig. 47, from De Nancrède, shows the many alterations

in shape which may be produced under various circumstances. Again,

hard-metal jackets or mantles may be stripped off bullets before the

latter reach the body, or in passing through it, as has been shown.

Bruns has shown that with the ordinary small arms the size of the

wounds of entrance and exit diminishes with the decrease in velocity

or increase of the distance, although allowance should be made for

the manner and angle at which the bullet strikes the surface, the

wound being circular or oval according to these conditions. The wound

of exit will depend upon the direction of the axis of the bullet at

the instant it leaves it; thus it may be oval or irregular. When the

bullet in transit shatters or comminutes a bone the wound of exit may

be made much larger and more ragged than otherwise. In a general way

Bruns makes the statement that, other things being equal, the damage

inflicted by the escape of a projectile from the body varies according

to distance from the weapon. Thus up to fifty meters a considerable

amount of destruction of muscle, etc., may be produced. The area is

small and the track of the bullet is smooth and little larger than

the caliber of the projectile. Between 100 and 300 meters there is

little destruction of muscle, and the wound of exit is smooth and may

contain some bone debris. Thus Bruns would make it appear that the

distinguishable characteristics of near and distant shots appear in the

variations to be noted between the wounds of entrance and exit.

After a careful study of the alterations in the shape of the bullets

themselves, Coler and Schjerning reported at the Twelfth International

Medical Congress that only in 4.5 per cent. of all hits does deforming

of the bullet occur; if hits in the bones only are considered, the

percentage would be much greater. In wounds of the other parts alone

there is rarely any deforming effect upon the projectile. They also

show that careful distinction must be made between the deformity of

the bullet caused by the body and that resulting from impact upon some

object before reaching the body. Thus if a bullet have first struck a

branch of a tree, or some object upon the ground, it may have become so

altered in shape as to correspond almost to a Dumdum bullet. The harm

done by such a ricochet shot depends upon its unexpended energy and its

altered shape, but will always be greater than if it had struck in the

direction of its long axis.

The question of the heat imparted to a projectile in its course and the

possibility of its being sterilized by such heating are questions which

have been carefully investigated. The heat of a bullet produced by

penetration into a hard material will depend upon the striking distance

and the density of the material. In the human tissues the heat attained

by a bullet, even when penetrating a bone at short range, is rarely

100°C., while at long range it will scarcely amount to half of that.

There is no accurate measure of the heat that may be engendered in its

passage through the atmosphere, but the question is one of interest,

in that it brings up the possible sterilization of the bullet and its

capacity for destroying such septic material as it may carry in with

it. A series of experiments made in Baltimore and elsewhere permit the

following conclusions to be drawn:

1. The majority of cartridges in their original packages are free from

septic germs, this freedom being due to the precautions observed during

their manufacture.

2. As a result of this cleanliness the majority of gunshot wounds are

not septic.

3. Such resistant germs as those of anthrax, when applied to the small

bullet of a hand weapon, are rarely completely destroyed by the act of

firing, and it is possible to infect an experimental animal with such a

projectile.

4. The ordinary germs of suppuration are not always destroyed, and may

also cause infection.

These conclusions may be epitomized in these two statements: that

bullets from small hand weapons are not necessarily sterilized by the

act of firing, and that they also may infect.

The principal features to be noted in a case of gunshot wound are the

following:

1. Hemorrhage.

2. Shock.

3. Pain.

4. Powder burn.

5. Localizing symptoms.

6. Multiplicity of wounds.

7. Entrance of foreign material.

8. Explosive effects.

9. Perforation of large vessels and the viscera.

1. =Hemorrhage.=--Hemorrhage may be internal or external. When internal

it is rarely so accessible as to permit of the saving of life, yet

the effort should be made to ascertain the source of the hemorrhage,

as only in this way can life be saved. For example: A patient may

bleed to death from injury to an intercostal artery, an epigastric,

etc., while in either case a very simple expedient would tend to

save life. External hemorrhage is generally due to injury of main

vessels, and may end fatally unless first help be instantly rendered.

Since the introduction into the army of a trained hospital corps,

and a widespread diffusion of a knowledge of “first-aid dressings,”

this is much less likely to occur than in the days previous to the

use of the emergency packet. Recent military experiences have been

that hemorrhages from limb vessels are much more likely to subside

spontaneously than those of the viscera.

2. =Shock.=--Shock is present in a large proportion of gunshot

injuries, especially those of the viscera and the region of the spine.

Experienced army surgeons speak of the peculiar facial expression in

those cases of shock which demand immediate attention.

3. =Pain.=--The symptom of pain is exceedingly variable. It is

rarely complained of at the time of infliction, especially when the

individual is laboring under stress of excitement. The pain of a

wound will be increased by every movement of the body. When momentary

pain is followed by local anesthesia, and especially if the latter be

permanent, it will indicate the division of a nerve trunk, which will

justify an operation for exposure of the site of the injury and nerve

suture.

4. =Powder Burn.=--Powder burn is met with only as one of the

complications of a short range and injury of an exposed part. Its

degree is modified by the distance of the injured part from the muzzle,

by the character of the powder, and the dimensions of the barrel.

Fish has shown that in a pistol wound at short range the burning or

scorching effects, which he calls the “_brand_,” are always found on

the hammer side of the weapon which inflicted the wound, _i. e._, if

the hammer were held up the brand would be above the entrance wound.

The bullet wound in such a case shows the direction of the aim, but the

recoil will so far change the direction of the barrel as to divert the

stream of gases of combustion, so that they follow the new direction

of the barrel, which is always toward the side of the hammer. This is

a point in medical jurisprudence which has been testified to in the

courts. The use of smokeless powder minimizes any effect of this kind.

It has been claimed that a homicide has been recognized in the dark

by the flash of the old-fashioned gunpowder used in the weapon, but

the use of smokeless powder would obviate this possibility. The most

distinctive part of a powder burn is the appearance of the tattooing

caused by the lodgement under the skin of grains of unconsumed

powder. Such grains, when accidentally or purposely contaminated with

germs, are not purified by the act of firing. This is less true of

certain brands of smokeless powder. Nevertheless the opinion prevails

that gunpowder may serve for conveyance of infection. The so-called

_smokeless powders_ are of secret composition, although it is known

that in a general way they are composed of gun-cotton, dynamite (_i.

e._, nitroglycerin), or picric acid. Melinite is composed of picric

acid and collodium--_i. e._, gun-cotton. There are many of the modern

explosives which depend for their final effect upon the combination of

two or more substances. In the smokeless powers there is usually enough

nitroglycerin to have a very noticeable effect should they be touched

to the tongue, while even the fumes might be disagreeable or disabling.

5. =Localizing Symptoms Due to the Presence of the Bullet.=--The

greater the distance and the smaller the velocity the more likely is

a bullet to lodge within some portion of the body instead of passing

through it. In the Cuban campaign the proportion of cases of lodgement

was less than 10 per cent. of the entire number of bullet wounds. A

bullet which rests within the body either will or will not produce

disturbances which may be more or less lasting. In a large proportion

of cases the latter will prevail. The number of pensioned soldiers who

are carrying unremoved bullets in some portions of their body is by

no means small. A rifle bullet may remain in certain portions of the

cranium without producing much disturbance. _Bullets which cause no

trouble are best left undisturbed. Those which produce serious symptoms

should be removed._ To Esmarch is attributed the dictum that the harm

produced by a bullet is usually done during its passage, and after it

has found lodgement it ceases to be a source of trouble. While not

invariably true, this is so generally the case that acceptance of this

statement has revolutionized the previously prevailing view, _i. e._,

that a bullet should be always removed if it be possible to locate

and extract it. In some instances it may be located by a study of the

symptoms; as, for instance, in certain areas of the brain, or when

lying in close proximity to joint surfaces it interferes with their

function; although a bullet embedded in bone often does not seriously

interfere with the use of the affected part. The bullet which divides a

nerve trunk rarely lodges in such position as to be considered when the

repair of the nerve injury is undertaken; such wounds will generally be

found to be perforating.

[Illustration: FIG. 48

Multiple shot wounds of arms and back. The ulcer over the spine was

produced by pressure, not by the ball (case in Cincinnati Hospital,

1884). (Conner, Dennis’ System of Surgery.)]

6. =Multiple Wounds.=--The same bullet may sometimes inflict _multiple

wounds_, and, with modern projectiles, these are now more common, as

many as six wounds having been made by one missile in its passage, _e.

g._, wounds of the arm and body. Thus multiplicity of wounds may not

indicate that the patient has really been shot more than once. In cases

of perforation, for each wound of entrance there should be found one

of exit, and at the first examination of the patient the discovery and

consideration of each of these injuries should be part of the routine.

If on examination but one wound be discovered, then the inference is

natural and unavoidable that the bullet is still within the patient’s

body (Fig. 48).

7. =Entrance of Foreign Material.=--The entrance of fragments of

cloth or other extraneous matter is now less frequent, for bullets of

tremendous velocity rarely carry in any perceptible material, their

diameter being small and their surfaces polished. A ricochet bullet may

carry tetanus or other spores from the earth, and lockjaw may be the

result. In other words, gunshot wounds now are less likely to become

infected wounds than they were years ago.

8. =Explosive Effects.=--The shattering and explosive effects of the

impact of bullets upon certain of the viscera are sometimes disastrous,

and yet not easily seen from the outside. This is especially true in

the brain, heart, liver, spleen, kidneys, and bones. Almost complete

pulpification of the semisolid viscera may occur as the result of

perforation by a small missile, and the general condition of the

patient should be relied upon to indicate this fact.

9. =Perforation of the Large Cavities of the Body= usually implies

perforation of at least a portion of their contained viscera. Thus if a

man be shot through the chest it may be assumed that perforation of the

lung has occurred, while in a case of bullet wound of the abdomen it

will rarely be found that the viscera, especially the intestines, have

escaped perforation. Still, remarkable cases are occasionally recorded.

Thus I have seen a man who had been shot through the abdomen from

front to back, the bullet entering just above the pubis and escaping

near the lumbar spine, who never seemed to have suffered seriously

from his injury, although the bullet was a large soft one from the old

Springfield musket.

=Diagnosis.=--More or less characteristic appearances pertain to most

wounds of entrance and of exit, which render them reasonably distinct

and recognizable, even though no history be obtained. Nevertheless much

depends upon distance, velocity, and any deformation of the bullet

due to its impact upon some other substance previous to its entering

the body. An elongated wound may suggest that the direction of the

bullet was at an angle with the surface struck. Such wounds are known

as “key-hole” wounds. A bullet already deformed may inflict a wound

that will baffle speculation. The wound of exit is usually a little

larger than that of entrance. When much larger a bone lesion should be

expected. Trifling punctures, perhaps made by particles of the bullet,

may be found around the principal wound or in the bone which it has

shattered.

Diagnosis may include a recognition not merely of the general character

of the injury, but whether it was inflicted by one or more bullets;

whether these bullets have escaped; and if not, in what part they are

probably lodged. In the preantiseptic days much of this information

was gathered by the use of the probe, and the porcelain-tipped probe

devised by Nélaton was relied on for much more than it could possibly

safely tell. In those days probing was indiscriminately practised, and

accomplished more harm than good. Now the probe is rarely used, at

least at first, and when used, it is connected with some electrical

device by which results are attained with a minimum of handling. For

this purpose the telephone probe of Girdner was formerly a popular and

ingenious device, which has been more recently supplanted by a simpler

mechanism by which, when the end of the probe comes in contact with

metal, a little bell, or buzzer, is rung. No probe or other instrument

should be introduced into a gunshot wound, for diagnostic or other

purposes, without observing aseptic precautions.

The most valuable expedient for the detection and location of bullets,

as of other foreign bodies, is the Röntgen ray. With a suitable

apparatus of this kind the surgeon can not only decide as to the

location of the missile, but whether it is best to attempt an operation

for its removal.

=Prognosis.=--In gunshot wounds not speedily fatal the prognosis

depends upon the part injured, the size and shape of the missile, its

velocity, the distance from the weapon, the amount of blood lost before

attention was given, the character of the attention first received, and

the absence of such complications as exposure, rough handling, etc. The

dictum that the _fate of a wounded man is in the hands of the surgeon

who first attends him_ made its author, Esmarch, famous. The patient

having escaped the dangers of hemorrhage and shock is to be carefully

guarded from sepsis, and if thus guarded can be protected against most

of the other visible dangers save those due to perforations of large

cavities. If, therefore, a gunshot wound can be promptly provided with

a primary aseptic or antiseptic dressing, and in other respects be let

alone, the outlook for the patient will be encouraging. The prognosis

often depends upon how completely the patient is let alone after the

application of occlusive dressing.

=Treatment.=--_Hemorrhage_ is the first consideration, and should be

the first care of the surgeon. Digital pressure may be resorted to,

which may suffice until a temporary expedient has been supplied. Next

in importance is disinfection of the area surrounding the wound and

the application of a sterilized absorbent dressing, with pressure to

prevent loss of blood. The use of the probe, or any attempt to at once

ascertain the location of the bullet, is not advisable. The question

is not, “Where is the bullet?” but, “_How much harm has it already

done?_” And the first attention should be addressed to atoning for any

harm that may have been done. Even though the intestines have been

perforated, or the heart wounded, there is no need in doing anything

more than meeting the immediate emergency. If shock be extreme it may

be atoned for in some measure by lowering the head and bandaging the

extremities; while in extreme cases hypodermoclysis or venous infusion

of saline solution, often with the addition of a little adrenalin, will

be of service.

Again, physiological rest of the part injured, _i. e._,

_immobilization_, as well as absolute rest of the patient’s body and

mind, must not be neglected.

Primary laparotomy has been done upon the battle-field, and is of

itself a testimony to the intrepidity and zeal of those who have done

it; yet, as a practice, it is to be condemned. All operations upon

gunshot wounds should be done in a well-equipped hospital.

[Illustration: FIG. 49

Gunshot wound of forearm. Bullet _in situ_ in bone.]

The probing of bullet wounds is so unwise that it may be well to state

the reasons for its general condemnation:

1. As it used to be practised, neither probe nor skin nor the

operator’s hands were sterilized.

2. Even when carefully done it is often absolutely disappointing, the

probe failing to reveal the presence of the bullet.

3. By the time the probe is introduced the wound will be usually more

or less filled with blood clot. To stir this with a probe is to invite

a secondary hemorrhage or annoying oozing.

4. Even when properly used the probe may carry in infectious material

from the surface.

5. Most wounds made by modern bullets, even pistol bullets, are of such

a character that it is difficult to follow their track without using

force.

6. I have known a wound on the anterior surface of the body to be

probed for a bullet that had escaped, as shown by an examination of the

other side of the body, which the attendants had failed to search.

7. If there be good reason for exploration of a wound let it be

postponed until the surgeon is prepared to follow a bullet and extract

it. _When it does not call for extraction, it does not call for

probing._

8. The best probe is the surgeon’s finger, and for its use the patient

generally requires an anesthetic and free incision.

When muscle is torn and needs suturing, or when tendons or nerves

are divided and need the same resource; when bones are shattered and

fragments need to be removed; when the skull has been fractured and

portions of bone driven into or upon the brain; when the intestines

have been perforated; when even the heart has been wounded and the

pericardium is filling with blood so that the heart’s action is

becoming impeded; in any or all of these emergencies the patient

needs surgical relief. But this should be of a kind that, save in

an emergency, should be postponed until suitable preparation can be

afforded.

[Illustration: FIG. 50

Wound inflicted at 1300 yards by steel-mantled ball (from a recent

foreign report). (De Nancrède.)]

[Illustration: FIG. 51

Shattering of humerus at long range with modern projectile; fusible

metal cast showing extent and character of laceration of soft parts

(from a recent foreign report).]

In regard to _regional indications_ in the treatment of gunshot wounds

it will only be possible here to give some brief general hints, the

reader being referred to the chapters on Regional Surgery for more

specific instructions. Nearly all gunshot wounds of bones are compound

fractures, and are comminuted as well. The best treatment is primary

aseptic occlusion and immobilization, without effort in the direction

of exploration. In an open wound the vessels should be secured, loose

pieces of bone removed, and jagged bone ends trimmed; while in some

instances a wire suture or other mechanical expedient may be resorted

to with advantage. Provision should also be made for drainage.

In the regions of the _large joints_ the same general principles are

applicable. Under the old _regime_ a gunshot wound of the knee would

condemn a person to amputation in the middle of the thigh. Now, if such

a limb be promptly provided with suitable antiseptic dressing, and

placed at rest, the patient may save not only the limb, but the use of

the joint. Extensive comminution may call for excision. Amputation is

seldom necessary, except when important bloodvessels have been divided.

[Illustration: FIG. 52

Perforating bullet wound of head, wound of exit showing brain

protrusion. Sloughing pressure-sore of scalp. Complete paralysis of

motion and loss of speech. Battle of Mukden. (Major Charles Lynch.)]

[Illustration: FIG. 53

Perforating bullet wound of head, with prolapse of brain at wound of

entrance. Operation done in Russian Red Cross Hospital at Mukden. Left

hemiplegia; mind clear. (Major Charles Lynch.)]

[Illustration: PLATE XIII

Radiograph of Head viewed from the Left Side, showing Mauser Bullet

Lodged in Brain. (Surgeon-General’s Report on Use of Röntgen Ray,

1900.)]

[Illustration: FIG. 54

Perforating gunshot wound of head; two wounds converted into one by

removal of comminuted bone. From Russian Red Cross Hospital, Mukden.

(Major Charles Lynch.)]

[Illustration: FIG. 55

Result of accidental explosion of hand grenade, in a Chinese coolie

with Fourth Division of Japanese Army, near Mukden. (Major Lynch.)]

[Illustration: FIG. 56

Shrapnel wound of leg necessitating amputation. Japanese soldier at

battle of Mukden. (Major Lynch.)]

_About the head_ may be seen all varieties of gunshot wounds and their

complications. The bullets from small weapons may not penetrate, but

those from larger ones usually penetrate and sometimes perforate.

Infection is not an uncommon sequel to all of these injuries, even

if involving the skin alone; the skull, especially the diploë;

the membranes, or the brain itself. (See Chapter XXXVI.) Septic

complications are more likely to occur in proportion to disregard of

antiseptic precautions in the first treatment. Usually the most serious

head injuries are those connected with penetrating bullets. Sometimes

the skull undergoes extensive shattering, and occasionally the base

is fractured. Instantaneous death, such as occurs when a soldier is

beheaded by a cannon ball, sometimes causes a peculiar cataleptic

rigidity, which is a species of immediate postmortem rigidity, by which

a body may be maintained in the position it occupied when struck.

Obviously, lesions at the base are still more serious than those of

the vertex, and wounds of the cerebrum are nearly always fatal. I have

seen a number of men who had been shot entirely through the head--by

Mauser or smaller bullets--who, nevertheless, recovered more or less

completely. In one soldier, I recall, the bullet traversed an orbit in

such a way as to divide the optic nerve. He was blinded, but recovered

most of his other functions; he remained well for some years, and

then developed symptoms of insanity. Epilepsy and other psychical

disturbances are all more or less frequent after head injuries. Plate

XIII illustrates how a bullet may be, apparently, harmlessly embedded

in the interior of the cranium. Sometimes years after such injuries

active symptoms make their first appearance. There can be no question

as to the value of the information usually afforded in such cases by

the aid of the _x_-rays.

The same necessity exists here as elsewhere for primary antiseptic

occlusion, including careful shaving and cleansing of the scalp.

Inasmuch as nearly every gunshot wound of the skull calls for

subsequent operation--just as does almost every compound fracture--the

parts should be prepared for it early, and everything else should

be left until the time when the surgeon is ready to make a complete

operation and meet all the indications. In such a case hemorrhage may

be temporarily checked by tampon. The surgeon should not omit to take

advantage of all the information which a study of cerebral localization

may afford him, since localizing symptoms may reveal not only the

course of a bullet, but something regarding its location.

_Penetrating wounds of the face_ are less serious than those of the

cranium proper. Occasionally a bullet striking a tooth will displace it

and drive it in some other portion of the face, _e. g._, the tongue.

Bullets and loose pieces of bone should be removed in wounds of the

face. Hemorrhage can usually be controlled by tampons. Interdental

splints may often be used to advantage, and in every case where the

mouth has been injured antiseptic mouth-washes should be frequently

used; in the case of the nose, an antiseptic spray should be employed.

The _neck_ is often penetrated, but if the spine and the important

vessels and nerve trunks escape, little apparent damage may be done. If

infection occur and suppuration take place resulting abscesses should

be opened promptly, as they might migrate into the thorax or axilla.

Even in the neck bullets which are producing no disturbance need not be

disturbed; but if positive irritation or paralysis be caused by them

they should be removed. Wounds of the larynx or trachea, by involving

the parts in subsequent stricture, may call for tracheotomy.

_Gunshot wounds of the spinal column_ below the neck are often

complicated by perforations of the thorax or of the abdomen. So far as

the spine is concerned the principal question is regarding the injury

to the cord itself. In rare instances cerebrospinal fluid escapes

from the wound; hemorrhage, or even the possibility of air entering

the canal, is a more common possibility. I have seen perforation of

the spinal canal, in connection with penetration of the thorax and

lung, so that, after the operation of laminectomy, air escaped through

the bullet wound in the spine with each inspiration and expiration.

Infection in spinal injuries is always to be feared and caution should

be observed regarding the maintenance of asepsis. The indications for

laminectomy scarcely differ from those in other injuries to the cord.

(See chapter on the Spine.)

_Wounds of the thorax_ are more likely to be penetrating than formerly,

owing to the conical shape and greater velocity of even small-arm

bullets. Emphysema does not necessarily imply perforation of the lung,

as air may enter through the external wound with each respiratory

effort. When an imaginary line connecting the wounds of entrance and

exit would naturally pass through the lung, it may be assumed that this

viscus has been perforated. Signs indicating such lung injuries are

peculiar pain, disorder of the respiration, more or less cough, usually

with raising of blood; when the pleural cavity is more or less filled

with blood there will be signs of pressure on the lung from presence

of fluid. In other words a bullet wound of the lung will usually lead

to a more or less complete picture of traumatic hydropneumothorax.

Sometimes external hemorrhage is severe, even though it come from an

intercostal or internal mammary vessel; usually the blood from these

vessels escapes within the thorax. I have known an intercostal artery

to be divided by a small pistol bullet which scarcely penetrated the

thorax of a man, who died in consequence, when the insertion of a small

tampon would have checked the hemorrhage and saved his life. Lung

tissue rarely bleeds seriously. When hemorrhage is from the lung it

comes from a divided vessel of some size. A collection of blood in the

chest is subject to the danger of infection, and empyema is a frequent

but somewhat delayed consequence of gunshot wounds of the chest; while

abscesses in the lung or mediastinum occasionally result.

To the _primary occlusion_, which should be the _first attention given

to every bullet wound of the thorax_, there may be added complete

immobilization of the chest. Fluid already present, unless it be

clotted blood, may be withdrawn by aspiration. Traumatic, not to say

septic pneumonia, is a serious complication. Should any operation

be called for, like removal of fragments of rib or the checking of

hemorrhage, it is best to make a free opening and a liberal removal of

all particles or fragments, with ample provision for drainage. Hernia

of any of the viscera through such wounds occasionally occurs.

[Illustration: FIG. 57[12]

Result of frostbite without gunshot. After battle of Mukden. (Major

Lynch.)]

[12] Figs. 57, 58 and 59, as well as the others preceding credited to

Major Lynch, are due to the courtesy of Major Charles Lynch, now of

the United States Army General Staff, who was attached to the Russian

Army as our Military Attaché, and who took them himself.

[Illustration: FIG. 58

Result of frostbite after two days and nights of exposure. After battle

of Mukden. (Major Lynch.)]

The subject of _injuries to the heart_ will be dealt with in the

chapter devoted to the surgery of that organ. Not every perforation of

the heart substance is fatal, and there are enough successful cases on

record of radical intervention by resection of the thoracic wall, and

of exposure of the pericardium, even of the heart itself, to justify

this method of attack in any case which will permit of it. Not the

least of the dangers pertaining to heart injuries is the impediment

to heart action caused by a collection of blood in the pericardial

sac. Should anything further be called for it would be warrantable at

any time to explore this sac and withdraw fluid through the aspirating

needle, through a trocar, or even by incision and drainage.

In the _abdomen_ all conceivable forms of injury may be met with, from

contusions produced possibly by a spent cannon ball, to lacerations

from fragments of a bursting shell and multiple perforations produced

by one or more bullets. A first requisite in all such injuries is

immediate antiseptic occlusion. This will not prevent such prompt and

further study of the case as may indicate suitable treatment. When

shock is extreme, indicating the possible result of contusions or

laceration, or when perforation of the stomach, intestines, or bladder

is probable, laparotomy should be performed at once. According to De

Nancrède the order of probable frequency of these injuries of the

abdomen is small intestine, large intestine, liver, stomach, kidney,

spleen, and pancreas. Multiple lesions are also common. The immediate

dangers are those from shock and hemorrhage, to be supplemented later

by imminent danger of septic peritonitis.

[Illustration: FIG. 59

Scene in operating room in Second Field Hospital of Fifth Division of

Japanese Army, at Mukden Railway Station. (Major Lynch.)]