[Ill.u.s.tration: FIG. 46.--Two flattened Leaden Cores to ill.u.s.trate means of determination of nature of bullet. Note ring at base. The right-hand bullet is probably a 'man-stopping' revolver bullet; it flattened against bone]

Other information beyond that furnished by the external wounds may be gleaned from the presence of fragments of lead in the wound; these, if unaccompanied by portions of casing, afford some presumptive evidence of the use of an unsheathen bullet, especially if found on the fractured surface of the bones; but it must be borne in mind that in the case of ricochet bullets the leaden core often perforates when entirely freed from its mantle. Pieces of the mantle again may give useful information both from examination of their thickness and composition. Lastly a naked core nearly always retains the marking on its base corresponding to the turning over of the mantle, this not being likely to suffer impact calculated to efface the groove. When this groove existed the employment of any of the soft-nosed bullets used in this campaign might be safely excluded (fig. 46).

_Prognosis._--The question of general mortality amongst the wounded has already been considered (Chapter I. p. 11), and it has been shown, putting aside those dying at once on the field, or during the first twenty-four hours, that the mortality was a low one. Some other points specially dependent on the nature of the injury are, however, worthy of mention in this place. First, it has been shown, with a slight reservation as to when a wound can be considered definitely sound, that if suppuration did not occur, healing was rapid, and that many men with slight wounds were back with their regiments in the course of a very few days. Again, that suppuration when it did occur tended to be local in character; none the less, if it was at all extensive, it often proved very prolonged and difficult of treatment, while residual abscesses after apparent healing were not uncommon. In connection with this subject I may quote from Colonel Stevenson[12] an observation that limbs the subject of marked local shock are especially liable to furnish septic discharges. Parts the subject of local shock when infected show a lesser degree of vitality and power of resistance to the spread of infection than do normal ones, and if infected do badly. I think I convinced myself of this on many occasions, and also of the fact that cases of fracture in which this condition was marked were slow in consolidating. Again I am inclined to think that the bad results which sometimes followed the tying of the limb arteries were also consequent on lowered vitality, and possibly vaso-motor disturbance due to the effects of the exquisite vibratory force to which the nerves had been subjected. On this account I was never anxious to hurry operations in such cases, unless obviously necessary at the moment.

The larger question of general nervous breakdown as the result of injuries from bullets of small calibre is at present hardly capable of an answer, and is so complicated by the co-existence of concurrent mental anxiety, exposure, &c., that a definite answer will always be difficult. I think there is already sufficient evidence, however, to suggest that the remote effects of many of these injuries may be far more serious than we expected at the moment, especially in the direction of sclerotic changes in the nervous system.

_Treatment_.--In view of the remarks on the treatment of special injuries contained in succeeding chapters, I shall confine myself here to the question of the treatment of wounds of the soft parts alone.

This consisted during the campaign in the primary application of the regulation first field dressing by one of the wounded man's comrades, an orderly, or less commonly an officer or a medical man. This dressing is composed of a piece of gauze, a pad of flax charpie between layers of gauze, a gauze bandage 4-1/2 yards long, a piece of mackintosh water-proof, and two safety pins, enclosed in an air-tight cover. Mr.

Cheatle,[13] in insisting on the importance of an immediate antiseptic dressing in the field, recommends the following. A paste contained in a collapsible tube, made up in the following proportions: Mercury and zinc cyanide grs. 400, tragacanth in powder gr. 1, carbolic acid grs. 40, sterilised water grs. 800; sufficient bicyanide gauze and wool for the dressing of two wounds, a bandage, and four safety pins; the whole enclosed in a mackintosh bag. The paste possesses the advantage over any liquid or powder, that it can be applied in any position of the body to severe wounds, and its application in the open air is not interfered with by draughts of wind. Mr. Cheatle used a similar preparation with success during the campaign.

On arrival at the Field hospital, or in some cases at the station of the bearer company, the wounds were then commonly dressed as follows: The parts around the wound were cleansed with an antiseptic lotion, either solution of perchloride of mercury 1 in 1,000, or 2-1/2 per cent.

solution of carbolic acid. The wound itself was then cleansed, and a dressing of double cyanide of mercury and zinc applied. This was covered with a pad of wool and secured with a bandage. The gauze was usually wrung out in the lotion before application as a precaution against previous contamination, and the moistening was also useful as helping to ensure the dressing from subsequent displacement. It was early recognised that the drier the dressing the better, and hence anything like a mackintosh layer was carefully avoided. In some instances, antiseptic powders were employed, but they did not find much favour, and because they tended to favour slipping of the dressing, and to prevent the adhesion of the gauze dressing to the wound, they were certainly not desirable when there was any necessity for the patient to travel. In the absence of reliable water the use of antiseptic lotions was obligatory, and such is likely to be the case in most campaigns; in the present one, filtration of the thick muddy water was impossible, without a considerable expenditure of time, which could only be obtained when the hospitals were fairly stationary. I very much preferred carbolic acid lotions.

The wound having been once cleansed, or rather the surroundings of the wound, the drier the surface was kept the better; hence a too heavy or impervious dressing was not satisfactory; in point of fact, I think some of the slighter wounds in which all the dressings slipped off, and in which there was less consequent chance of the dressing being moistened with the sweat of the patient, did as well as any.

I do not think the bicyanide gauze, absorbent wool, and common open-wove bandages, together with a good supply of nail brushes, soap, and carbolic acid for the primary disinfection of the skin and the external wound, are to be greatly bettered at the present day as materials for the first permanent dressing of cases in the field. The wound itself should be carefully shielded during the preliminary cleansing of the skin by a firmly applied antiseptic pad, and then the dressing applied as above described. The one desirable improvement is some mode of ensuring the dressing being kept in good position, and for this some form of adhesive covering for the gauze and wool should be devised. When the atmosphere is such as to allow of rapid drying, thin moistened book-muslin bandages would be preferable to the plain open-wove ones.

The one period of danger is that of transport, and when that is over, the dressing in Stationary or Base hospitals should give no trouble.

As a rule the wounds themselves need no interference, but in some instances either the exit or entrance wounds may be in undesirable positions for purposes of asepsis, when a large opening may seem safer closed and actually sealed. I saw this method tried in a few cases, but without much success. It is one which might be of much use in Base hospitals if the patients were brought directly into them, but in the Field hospitals, in face of the rush with which the first dressings have to be done, I think it is seldom applicable, and consider the interference with the wound as rather likely to increase the danger of infection than to decrease it.

Dressings should not be too frequent; two should suffice for simple wounds with type forms of entry and exit; there is little discharge and usually no bleeding: hence the more the dry scab form of healing can be simulated the better. When a dressing needs changing from fouling of its outer parts, it is preferable to cut round the adherent part of the deep layers and apply some fresh gauze over the central scab rather than to remove it. One point should be kept in mind: the first dressing in the Field hospital seals the fate of the wound as to the chances of primary union, and hence too much care is impossible with it.

Operations in the Field hospitals were proportionately not numerous, and they should be kept down in number, as far as possible. At the same time such operations as are necessary are mostly of capital importance, such as the treatment of fractures of the skull, abdominal section, the ligature of arteries, and amputations. Of these only the first and last cla.s.ses occur with any degree of frequency. In order to be prepared for these a stock of filtered water which has been boiled, and some special sterilised sponges, should be at hand if possible, also some small towels which can be wrung out in antiseptic lotion. If sterilised sponges are not to be had, wool pads wrung out in carbolic lotion must be subst.i.tuted.

Primary amputations bore transport badly. I saw few sent down from the front within a few days of their performance in which the flaps did not slough, or worse consequences ensue. On the other hand, if the first fortnight could be tided over at the front, they did well enough. The head cases on the other hand bore movement fairly well, provided only that asepsis was ensured.

Retained bullets are rarely suitable for removal in the rush of the first work of a Field hospital after an engagement. A short delay is of no importance, and ensures their being removed safely if necessary. With regard to the broad question of the advisability of removing them at all, it may be laid down that they should not be interfered with unless some obvious reason exists. Those most commonly calling for removal are as follows: 1. Bullets lying immediately beneath the skin or quite superficially in any region, or those which, although they have produced an exit opening, yet lie within the body. 2. Those which lie at the bottom of an infected track, or cause secondary suppuration. 3. Those causing pressure on important structures, particularly nerves. 4. Those which interfere with the movements of joints when lodged in the bones or soft tissues in close proximity, or those which lie within the articular cavity itself. Bullets sunk in the great body cavities or in positions difficult of access should never be interfered with. Retained bullets sometimes give rise to unexpected surprises; thus in a man with a retained bullet in the pelvis no steps for its removal were taken.

During the man's voyage home on a transport he had an attack of retention of urine. As a catheter would not pa.s.s, he was placed in a warm bath, and shortly after pa.s.sed a Mauser bullet per urethram, and thus saved himself a cystotomy.

One word may be added as to the treatment of shock when severe. Quiet in the supine position, and the administration of a small amount of stimulant, was usually all that was required. Hypodermic injections of strychnine sulph. grs. 1/30 to 1/10 were useful, and in some severe cases, especially where operations were needed, saline infusions with a small amount of stimulant were made into the veins, either at the elbow, or in amputation cases into one of the large veins exposed.

The treatment of haemorrhage is dealt with in Chapter IV.

The after treatment of simple wounds needs little comment, but bearing in mind what has been said as to the definite healing of the internal portion of the tracks, it will be obvious that in parts such as the thigh or calf, care was needed as to not commencing active work at too early a date. On the other hand, a too long period of absolute rest is also to be deprecated. The best results were obtained by careful movement and ma.s.sage, commenced after the first week or ten days, according to the appearance presented by the external wound, followed by a gradual resumption of active movement. It was a striking fact that some of the patients suffering from such wounds took longer to become apparently well than many of those who had suffered visceral injuries.

FOOTNOTES:

[9] _Loc. cit._ p. 31.

[10] _Loc. cit._ p. 100.

[11] _Loc. cit._ pp. 54, 55.

[12] _Wounds in War_, p. 83. Longmans & Co. 1897.

[13] A First Field Dressing, _Brit. Med. Jour._ 1900, vol. ii. p. 668.

CHAPTER IV

INJURIES TO THE BLOOD VESSELS

The small calibre of the modern bullet, and its tendency to take a direct course, naturally favour the occurrence of more or less uncomplicated wounds of the large vascular trunks, and both the nature of these wounds and the results which follow them are in some respects most characteristic.

NATURE OF THE LESIONS

1. _Contusion or laceration without perforation._--(_a_)The vessel may be struck laterally, the injured portion then forming a part of the bounding wall of the wound track, or (_b_) one or more layers of the vessel wall may be destroyed over a limited area. Given primary union, these conditions are only of importance in so far as subsequent contraction of the lumen of the vessel may result from implication in the neighbouring cicatrix. One of the most striking features of the wounds as a whole was seen in the hair-breadth escapes of the large limb vessels with no subsequent ill effects, and such injuries were seen in every situation.

In a certain proportion of wounds in close proximity to large vessels, however, a diminution of the normal calibre of the arteries was observed, either shortly after the injury or later in the advanced stages of cicatrisation. As an example of early obstruction, the following may be related. A Mauser bullet pa.s.sed from the inner side of the thigh across the neck and great trochanter of the femur beneath the femoral vessels, and probably struck and grooved the bone, since the aperture of exit was large and irregular, some 3/4 of an inch in diameter. One week later no pulse was palpable in either anterior or posterior tibial arteries at the ankle, and pulsation which was strong in the common femoral artery was very weak in the superficial femoral.

Slight fulness existed in the hollow of Scarpa's triangle, but not sufficient to make any serious difference in the contour of the two limbs. No thrill or abnormal murmur was discoverable. There was no oedema of the limb, which was also normal in temperature. The patient was kept at rest in the supine position for three weeks, during which time the tibial pulses gradually returned. Three weeks later he was invalided home, the pulses, however, still remaining considerably smaller than normal.

In the advanced stages of cicatrisation narrowing of the lumen of the trunk vessels was far from uncommon, especially in cases of wounds of the arm crossing the course of the brachial artery; in many of these the radial pulse was diminished almost to imperceptibility. How far this condition may prove permanent there has been little opportunity of judging; nor as to the possible ultimate weakening of the vessel wall and the development of a secondary aneurism has time allowed the acquisition of experience. In the light of the observation of so many cases in which large vessels were wounded without the occurrence of severe haemorrhage, either primary or secondary, it is impossible to be certain whether some of the cases of arterial obstruction were not secondary to perforating lesions of the vessels.

Pressure on, or minor lesion of the vessel was sometimes evidenced by the development of a murmur, as in the following case. A Mauser bullet entered immediately within and below the left coracoid process, and emerged at the back of the arm at its inner margin, 2-1/2 inches above the junction of the right posterior axillary fold. During the first week dysphagia and some pain and soreness in the episternal notch, with pain and difficulty of respiration, were noticed. Eight weeks later no trouble with the pharynx or oesophagus remained, but a short sharp systolic murmur was audible over the first part of the left axillary artery, which could be extinguished by pressure on the subclavian; the radial pulse was normal.[14]

When primary union failed or was prevented by infection and suppuration, lesions, although incomplete, of the vessel coat naturally frequently gave rise to secondary haemorrhage.

2. _Perforation of the vessels._--(_a_) This may be oblique or transverse to the long axis of a trunk; when the vessel is impinged upon laterally, an oval or circular notch, as the case may be, is produced; or (_b_) the bullet may strike more or less in the centre of the vessel, perforating both in front and behind, while lateral continuity is maintained; (_c_) beyond these degrees a vessel may, of course, be completely divided. Cases of notching of the vessel will be referred to under the heading of traumatic aneurism; those of perforation under that of aneurismal varix and varicose aneurism, the perforations in these cases affecting a parallel artery and vein.

RESULTS OF INJURY TO THE VESSELS

1. _Haemorrhage._--The fact that haemorrhage was not a prominent feature in the wounds received during this campaign can scarcely be regarded as an experience confined to injuries caused by bullets of small calibre.

The same observation was often made in the case of larger bullets in old days, and the absence of severe haemorrhage has previously been regarded as a special characteristic of gunshot wounds. None the less, as high a proportion as 50 per cent. of deaths occurring on the field in earlier days has been ascribed to this cause.

Unfortunately no new facts can be furnished on this point, although a few cases of rapid death from primary haemorrhage will be found recounted under the heading of visceral injuries. Beyond these the general evidence offered by observations on men brought in from the field with vascular injuries, was opposed to the frequent occurrence of death from haemorrhage, at any rate of an external nature. This subject will be dealt with under the cla.s.sical three headings of primary, recurrent, and secondary haemorrhage.

_Primary haemorrhage._--A marked distinction needs to be drawn between external and internal haemorrhage. External haemorrhage from the great vessels of the limbs, or even of the neck, proved responsible for a remarkably small proportion of the deaths on the battlefield. This statement may be made with confidence, since it is not only my own experience, but coincides with what I was able to glean from many medical officers with the Field bearer companies. It is, moreover, supported by the facts that cases in which primary ligature had been resorted to were extremely rare at the Base hospitals, while, on the other hand, traumatic aneurisms and aneurismal varices of any one of the great trunks of the neck and limbs were comparatively common. Again, primary amputation for small-calibre bullet wounds, except when complicated by severe injury to the bones, was so rare as to render more than doubtful the frequent occurrence of severe primary haemorrhage on the field. Only one case of rapid death due to bleeding from a limb artery was recounted to me. In this a wound of the first part of the axillary artery proved fatal in the twenty minutes occupied by the removal of the patient to the dressing station. The amount of haemorrhage in many instances was no doubt checked by the application of pressure at the time of the first field dressing; but it can scarcely be argued that such dressings as were applied were of sufficient firmness to control bleeding from such trunks as the brachial, femoral, or carotid arteries.

The spontaneous cessation of haemorrhage is rather to be ascribed to the special method of production and the consequent nature of the wound. The lesions were the result of immense force strictly localised in its application, which might well induce very complete and rapid contraction of the vessel wall; while the track in the soft parts was not only narrow, but also lined by a thin layer of tissue possibly so devitalised superficially as to specially favour rapid coagulation of the blood.

Beyond this the tracks were often sinuous when the position of the limb at the time of reception of the injury was replaced by one of rest. The influence of mere narrowness of the track is ill.u.s.trated by cla.s.sical experience in the development of aneurismal varices after stabs by knives or bayonets; and in the injuries under consideration the frequent development of large interst.i.tial haemorrhages into the tissues of the limbs indicated that blood does not readily travel along the wound track. It was noteworthy that when haemorrhage did occur it was most free from, or often limited to, the wound of exit. This is due to the direction of the active current set up by the rush of the bullet through the tissues. The mechanical factor is, no doubt, the most important.

Control of primary haemorrhage from a wounded vessel by the impaction of a foreign body was of much less frequent occurrence than appears to have been the case with the older bullets. I saw a case in which, on removal of a fragment of sh.e.l.l (Mr. S. W. F. Richardson), very free haemorrhage occurred from a wound of one of the circ.u.mflex arteries of the thigh, but not a single one in which a similar result followed the extraction of a bullet of small calibre. The comparative infrequency of retention of modern bullets is probably one of the main elements in this relation.

A very curious instance of provisional plugging of a wound in the upper part of the brachial artery by an inserted loop of the musculo-spiral nerve was related to me by Mr. Clinton Dent. This instance must, I think, be regarded as an accident definitely dependent on the size and outline of the bullet and on the nature of the force transmitted by it to neighbouring structures.

While, however, deaths from external primary haemorrhage were rare, a considerable number resulted from primary internal haemorrhage. In some of these, injury to the largest trunks in the thorax or abdomen led to an immediately fatal issue; in others wounds of the large visceral arteries, as of the lungs, liver, or mesentery, were scarcely less rapid in their results. In such cases the potential s.p.a.ce offered by the peritoneal or pleural cavities favours the ready escape of blood from the wounded vessel, while the tendency of the blood effused into serous cavities to rapid coagulation is notably slight. Beyond this the comparative deficiency in direct support afforded by surrounding structures to vessels running in the large body cavities is also an important element in their behaviour when wounded.

These remarks receive support from the observation that few, if any, patients survived an injury to the external iliac vessels within the abdomen, while the remarkable instances of escape from fatal haemorrhage from large vessels recorded below (cases 1-19) indicate that the mere size of a wounded vessel is not to be regarded as the sole factor in prognosis.

_Recurrent haemorrhage_ was occasionally met with both in the case of the limb and trunk vessels. In the limbs it often necessitated ligature of the artery. I saw several cases in the lower extremity where recurrent haemorrhage on the second or third day was treated by ligature of the femoral or popliteal artery, and it also occurred during the course of development of one of the carotid aneurisms recounted below. On two occasions I saw rapid death follow recurrent abdominal haemorrhage; in one I was standing in a tent when a man who had been wounded the day before suddenly exclaimed: 'Why, I am going to die after all.' The appearance of the man was ghastly, and on examining the abdomen it was found greatly distended, and with dulness in the flanks; the patient expired a few minutes later. Another example of recurrent abdominal haemorrhage is related in case 169, p. 432.

_Secondary haemorrhage._--In simple wounds of the soft parts by _small-calibre bullets_ this was decidedly rare. In wounds complicated by fractures of the bones, especially when they exhibited the so-called 'explosive' character, secondary haemorrhage was not uncommon, and this not necessarily in conjunction with infection and suppuration.