CHAPTER XL. (Part 2)

the thigh and leg; wire gauze splints with stcel margins or strips of ordinary card-board applied with some variety of adhesive bandage 138 «© GUNSHOT AND OTHER WOUNDS IN SfLITARY PRACTICE, for the arm and forearm; and plain wooden splints of various lengths for any situation.” (Makins, Surgical Experiences in South Africa.) Senn says, referring to the Spanish-American war, that it is a source of regret that fixation of the fractured limbs by plaster-of-Paris sp was not more generally practised. Owing to the want of reliable Pio, 95. Can wpliat for epper extrensity. (Malina) laster of Paris, w sort to various kinds of splints and single. and double-inclis Ta some ¢ sion will also be required. ‘Transportation ix 5 possible, for the reason that it always agera- vates the difficulties of keeping the wound sterile, ‘There is no advan- to be avoided TREATMENT OF GUNSHOT FRACTURES. 139 * tage which transportation will secure which will offset the advantage of an aseptic wound. « © The third class of cases, those with extensive comminution and great destruction of the soft parts, always raises the question of amputa- tion. The question of viability hinges upon the blood supply, and if it is determined definitely that it is cut off, immediate amputation is indicated. On the other hand, if the blood supply is yet intact, however much the bone may be shattered, it is advised to sterilize the wound, get the fragments in as good position as possible, and dress antiseptically and immobilize as before. In any case of doubt either as to repair or in- fection, this conservatism is proper. Laser Hine of demarcation or a dangerous sepsis may call for am- putation; on the other hand, the suspected tissues may heal without interruption. If infection occurs, osteomyelitis may arise and a fatal issue is likely in such a case. Senn sums up in this manner the modern treatment of recent gun- shot fractures: 1. No probing of the wound. 2. No primary debridement. 3- Early efficient first-aid dressing. 4. Immobilization of fracture, preferably by plaster splints. 5. Immobilization combined with extension, if there is a tendency to undue shortening. 6. First-aid dressing must not be removed, unless this becomes necessary by the appearance of local or general symptoms that indicate the existence of wound infection. Each of the bones of the extremities presents a few special features, which may be hurriedly noted. The humerus is quite frequently wounded. The most characteristic complication is musculo-spiral paralysis, either immediate or remote. As a rule, perforation of the upper end gives little trouble to the joint. ‘The ulna and radius are usually injured separately. The ulna, on account of its superficial location, ,is often the seat of explosive exit wounds. This is also true of the lower end of the radius. . 149 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE. ‘The phalanges suffer much, the tendons are lacerated and acquire adbesions, or the fingers may be completely carried away. With respect to the treatment, the perforating wounds of the humerus are cleansed and occluded. The comminuted wound i wiped clean of débris, an ample dressing applied, and the arm immobilized with light splints, Pasteboard splints are as good ax any, applied wet, molded into shape, and fixed with adhesive strips. ‘The femur is quite often wounded and is a fertile source of mortality, Pho, 95.—Helgen spat for tectaret thigh. (Mositian? ‘There is a tendency to great shattering of the shaft, although, owing to its deep location, the wound of exit is rarely “explosive.” Trans verse fracture is rare. Perforation af the lower extremity is common. ‘These fractures are nearly always accompanied by shock, both con- stitutional and local. As a result of local shock, shortening it often delayed, only to be quite marked when the muscles regain their tone. The prognosis is extremely bad in the case of the upper third, but Letter for the middle and lower third. Punctured wounds and oom- minuted fracture with small skin wounds are treated by aseptic occla- sion and immobilization. TREATMENT OF GUNSHOT WOUNDS OF JOINTS. ut Comminuted fracture with large wound of exit requires a more formal cleansing, first of the skin and then of the wound, with removal of the fragments of bone which will stand no chance of reunion. The wound is not sutured and drainage is usually unnecessary, If trans- portation is necessary, plaster of Paris is the safest dressing. For the field hospital, Makins recommends some adaptation of the Hodgen splint as the best, most practical, and efficient (Fig. 96). Uncontrollable hemorrhage, great injury to the soft parts, or grave infection calls for amputation; but this is very rare, as the result of these wounds, ‘The tibia and fibula present condi- tions of special importance. The soft paris are often severely injured, the vessels are implicated and, in the case of the ends of these bones, the joints are involved. Suppuration is common, followed by secondary hemorrhage and purulent arthritis (Fig. 97). Conservative treatment is the best tule—asepsis, careful dressing, im- res toentin of Soon nd of form of splint will do, but the plaster of Paris is probably the most The foot is important in respect to these injuries, for not only are several bones involved, but also several joints, Infection, unfortu- nately, is not uncommon, ‘The first dressing must insure immobilization in a good position. TREATMENT OF GUNSHOT WOUNDS OF THE JOINTS, ‘Makins says: “We had merely to do our first dressings with care, fix the joint for a short time, and be careful 1o commence passive motion as S00n as the wound was properly healed, to obtain, in the great majority of cases, perfect results." —— 442 GUNSHOT AND OTHER WOUNDS IN SNLITARY PRACTICE. Infection is the chief danger, If suppuration occurs, an immediate arthrotomy is indicated, except in cast there is much comminution and disorganization, when amputation will be the safer measure, ‘The skoulder-joint may be involved directly or by fissure from the shaft. Perforating wounds furnish an excellent prognosis. Aseptic occlusion and immobilization usually effect a cure in three or four weeks, In the severer cases, cleanse thoroughly, ligate bleeding vessels, restore: the parts as nearly as possible, pack lightly with gauze, cover amply, and infection will usually be avoided. The elbow may be injured along with the humerus and ulna; the prognosis is worse when the humerus is involved. The olecranon may be perforated without injury to the joint. Anchylosis is frequent, but evea if suppuration oceurs, a good joint may be obtained. The joint is immobilized in the position of flexion. The hip-joint seems not to be very frequently wounded, but the purog- nosis is bad, both on account of infection and complications, such as wounds of the bladder, rectum, great nerves, etc. Anchylosis and shortening in an abnormal position must be expected, Greatly lacerated wounds call for amputation; the moderately severe, for conservative treatment. The Ance-joint is very frequently wounded, and the damage is always serious; any or all of the component structures thay be injured. Per- foration of the joint without injury to the articular surfaces is a possi- bility, Hemorrhage into the joint is a constant feature. ‘This bemar- throsis disappears in about a month in the favorable cases, Under conservative and expectant treatment, the results are st prisingly good. On the battle Seld, the wound is covered with a first aid dressing, and some sort of splint applied. At the dressing station or Geld hospital, the dressings may be removed and further cleansing applied if necessary, and the limb immobilized in extension. As spon as the flesh wound has healed, passive motion ix to he begun. Tf sap puration occurs, arthrotomy must be done withoat delay. The anble is usually involved along with several banes and jolts, either directly or by fissuring. ‘The degree of comminution is variable, On account of the foot coverings, these wounds are nearly always badly infeeted and phlegmons are frequent. TREATMENT OF GUNSHOT WOUNDS OF THE SKULL. 143 For these reasons secondary amputations are frequent, but the treat ment must be conservative. Immobilize the foot at a right angle and be on guard for suppuration, TREATMENT OF GUNSIOT WOUNDS OF TILE SKULL AND DRAIN, Perforating wounds of the skull will always be a certain source of mortality. The fatalities increase as the range shortens and as the base is approached (especially the base in the middle and posterior fossa), due to destruction of the automatic centers or to their depression following concussion, hemorrhage, or intra-cranial edema. ‘The most recoveries follow injury to the frontal lobes and the occipital lobes, although blindness may result from the latter class of injuries. Primary union of the scalp wound is an element in favorable prog- nosis, since by this means infection is often shut out. First aid on the battle ficld will look to the hemorrhage and the use of the first-aid dressing, which should aim to include both the wound of entrance and exit, If the visible hemorrhage is dangerous, do not pack the wound, for that will only cause compression. A few strips of sterile gauze, loosely placed in the wound, will favor both hemostasis and antisepsis. At the dressing station or, better still, at the ficld h symptoms are not too urgent, a craniectomy must be done, ‘All surgeons experienced in recent wars agree on the necessity of exploring every such wound as soon as possib! Shave and cleanse the scalp and then cleanse the wound. Raise a flap with the base toward the blood supply and with the entrance bullet hole in the center. Enlarge the wound in the ekull sufficiently {0 introduce a finger and determine the presence ot absence of frag: ments within the cavity. Enlarge the wound as necessary, the brain of débris. All splinters must be remo ‘The brain pulp and clots arc to be wiped out with sterile gauze and the wound closed with only such dminage as the original wound of entry will afford. (See Urgent Craniectomy.) The subsequent treatment requires the patient to be kept as quiet a5 possible, his dict limited and bowels kept open ital if the we 4 CUMSHOT AND OTHER WOUNDS 18 MILITARY PRACTICE: If sepsis occurs, there must be no hesitation in reopening the wound. “Such cases of sepsis needed secondary exploration, and the won- derful success of this operation was perhaps one of the most striking experiences of the surgery in general." (Makins, Surgical Experiences in South Africa.) TREATMENT OF GUNSHOT WOUNDS OF ‘TIE FACE. ‘The chief dangers in gunshot wounds of the face are hemorrhage and interference with respiration. These wounds are also much Predispesed to infection. The eye, the fifth and seventh nerves are most likely to be involved. If hemorrhage cannot be controlled by ordinary means, the facial, the temporal, or even the external carotid arteries may need to be ligated. Careful cleansing and packing with iodoform gauze secure excellent results, TREATMENT OF WOUNDS OF THE NECK. ‘These wounds are always dangerous, and yet in no region does the unexpected more frequently happen in the passage of a bullet. ‘The fact of hair-breadth escape of important structures is explainable only by the small size of the army bullet and the mobility of the structures. ‘The commonest form is the transverse or oblique track. Such wounds a8 are not immediately fatal are likely to permit recovery. If sepsis oceurs, it usually has its origin in the air passages or esophagus. Injuries to the trachea commonly give rite to hemoptysis, or emphysema. Many patients with injury of the esophagus will die of sepsis, with perhaps a gangrenous condition of the esophagus. Such wounds of the large vessels as do not produce immediate death give rise to many instances of arterio-venous aneurysm, The spinal nerves or the pocumogastric may be injured. If the recurrent laryngeal is divided, hoarseness, aphonia, laryngeal cough and occasional vomiting will be the result. Stevenson reports cases” with injury to the cervical sympathetic, in which the most prominent — symptoms were suppression of sweating, myosis, and pseudo-ptosis: TREATMENT OF GUNSHOT WOUNDS OF THE ABDOMEN. 145 on the injured side. As a rule, no special treatment aside from anti- sepsis is required. Tracheotomy may be called for; and if the spine is fractured, immobilization will be necessary. TREATMENT OF WOUNDS OF THE SPINE. ‘These wounds are so extremely fatal that nothing more need be said of the treatment than that it should be conservative and the patient should be moved as little as possible. If the patient survives with pressure symptoms then later on a laminectomy is to be considered. TREATMENT OF WOUNDS OF THE THORAX. The non-perforating wounds need only an antiseptic dressing. Broken ribs will require adhesive strapping. The perforating wounds presenting no special indications of hemor- rhage from the chest wall are to be treated by aseptic occlusion, The internal mammary or the intercostal arteries may need to be controlled. If the hemorrhage is visceral, opium and compression of the chest wall by firm bandaging seem to be the last resort in time of war. Under no circumstances is the wound to be probed or examined with the finger. ‘Transportation is always to be feared. In every way the patient is to be kept as quiet as possible. He must be made to realize the seriousness of his injury. Puracentesis should not be performed in the case of hemothorax until the bleeding has ceased. Thorac- otomy is to be performed if suppuration occurs. (See Injuries of Thorax.) TREATMENT OF GUNSHOT WOUNDS OF THE ABDOMEN, Non-perforating wounds require only aseptic occlusion. Perfora- ting wounds are always to be regarded seriously, yet uncomplicated wounds of the solid viscera heal without difficulty. Of the hollow viscera, the ascending and descending colon and cecum give the best prognosis following perforation. ‘The stomach is not quite so favorable and the transverse colon and small intestine give the worst prognosis. 10 446 GUNSHOT AND OTHER WOUNDS IN MILITARY FRACTION. Undoubtedly, recovery may follow perforation of even the small intestine by the army bullet. “The innocuousness of the abdominal wounds inflicted by the Japanese bullet is often wonderful * * * * Of perforating wounds of the abdominal cavity, twenty-five cases came under treat- ment; no operation was possible or attempted. Within twelve days, seven died, a mortality of 28 per cent. Some of these cases had travelled forty miles in rough carts, others came on horseback; only a few were brought on stretchers; eight arrived with peritonitis, “That ‘aly seven died under such condition is, indeed, most remarkable."* (Colonel Valary Havard, Ass't Surg.-Gen'l, U.S, A. in the Journal Ass'n Military Surgeons.) In warfare practice, nearly all authorities reluctantly admit the in- efficiency of operative treatment for this class of gunshot injuries, and the better, though unsatisfactory results, of conservative treatment. SHELL AND SHRAPNELL WOUNDS, These wounds are for the most part lacerated wounds, although some of the smaller fragments of shell (Fig. 98) of the round balls of the shrapnell (Fig. 99) may produce perforating wounds ~ these of bullets. § Naturally, a Large proportion of such wounds will be fatal, laying open the great cavities, lacerating the viscera, or mangling the limbs. ‘They are, in effect, infected wounds and are to be treated on the general surgical principles applicable to infected lacerated wounds, ‘The leaden ballets of shrapnel! are often retained and are to be femoved except when sunk in the chest, abdomen, or pelvis, BOLO WOUNDS. According to Foxworthy (Ft. Wayne Medical Journal, June, 190), every insurgent in the Philippines was armed with a bolo. This bobo yas of iron with a wood of bone handle and varied in shape and size from a sword to a dagger and from a corn knife toa meat ax, It was generally a cruder weapon than the Cuban machete, but every effective BOLO WOUNDS, 47 ip close encounters. As it could be concealed beneath the loose jacket, It was more serviceable than a sword or saber, which was always visible. ‘The Kries is a weapon similer to the bolo, but with a wavy edge like a Christy bread-Knife.. It is often two edged. ‘The wounds produced by the boloand kries were often of great length and usually infected. “Another class of wounds was caused by spears and tomahawks, used by the Igorrotes and Negrites. ‘The tomahawk, having a con- Fu, yS—Praginents of Viewers Maxim vne-pound abell. (Mobins.) eaveedge, was not so apt to glance off the skull as an Indian tomahawk. A blow split the skull wide open. “The spears were often of bamboo, sharpencd to a fine point, and their penctrating power was almost equal to that of an iron-tipped spear. The iron-tipped spear had from onc to four barbs which made ain exceedingly ugly penetrating wound and usually had to be cut out, ‘These wounds were always infected and tetanus frequently developed.”” 148 GUNSHOT AND OTHKR WOUNDS IN MILITARY PRACTICE. FIRST AID ON THE BATTLE FIELD, Colonel Nicholas Senn, in his address before the Lisbon International Medical Congress, 1905, has accurately defined the principles of first aid on the battle field, and his conclusions are herewith summarized: (1) The fate of the wounded depends largely upon the time and Fs, 4. — Normal deformed, and fracvered leaden sbrapoel ballets (Aéabins) thoroughness with which first aid is rendered, ‘Dhis first aid for many Teasons cannot he rendered by the surgeon, but must be given by_ comrades or by the wounded man to himself, First ald administered in this manner will be effective, owing to the aseptic character of the chief wounds of battle, if previous instructions have beea given, It is absolutely essential that the soldier should receive this elementary im- struction when be is taught the art of war, and it should mot be post- ae = | TIRST AID ON THE BATTER YIELD. 149 poned as has bees done only too often in the past until war clouds make their appearance. (2) The first-aid dressing should combine simplicity with safety against