HX00018805 R SURGERy DELORME '^X>\^V xr^-^^ in tl|? (Eit^ 0f N?m f nrk Epferftirf ICtbrarg U.'. I WAR SURGERY WAR SURGERY BY EDMOND DELORME M^DECIN INSPECTEUR G^N^RAL DE l'aRMEE ANCIEN PRESIDENT UU COMITE CONSULTATIF DE SANT6 DE l'aRm6e MEMBRE DE l'aCAD^MIE DE M^DECINE MEMBRE ET ANCIEN PRESIDENT DE LA SOCI6t6 DE CHIRURGIE TRANSLATED BY H. DE MERIC SURGEON TO IN-PATIENTS, FRENCH HOSPITAL, LONDON WITH ILLUSTRATIONS PAUL B. HOEBER 67 & 69 EAST 59TH STREET NEW YORK 1915 {Printed in England]^ HI \^> EXTRACTS FROM AUTHOR'S PREFACE ^ ;f: ;{i ^ 5(c Unity of doctrine is absolutely essential. This I set forth in my " Advice to Surgeons." In order to avoid the excess of operative measures which has been seen in recent wars, it was urgent to lay stress on the almost uniform conserva- tism of our present surgery, but a rapid, synthetic outline was not sufficient. It was necessary to complete it by information on the special aspect of the wounds we see, on their complications, and also by adequate details with regard to the best methods for us to follow. Therefore the present work became a necessary supplement. It is intended both for beginners and also for those sur- geons whose everyday practice— often specialized — has not allowed them to follow the advances made in military surgery. I have been obliged to give a scientific form to many descrip- tions, and to lay stress on legitimate reasons for the methods I have advised ; I was also forced to give up the concrete, imperative form, which is excellent in addressing young surgeons just entering the profession, but insufficient to secure conviction from those on whom, in the rear, the whole vi EXTRACTS FROM AUTHOR'S PREFACE weight of the most important treatment of the wounded will fall. I hope 'both these categories will follow my writings in the few moments of leisure left them by their daily work. . . . They will be able to turn to account what the book teaches them, and our brave wounded will be benefited. ***** TRANSLATOR'S NOTE In translating the work of so distinguished a military surgeon as Dr. Delorme, I have endeavoured so far as possible to keep closely to the French text. H. DE MERIC. CONTENTS CHAPTER I. WEAPONS AND PROJECTILES (rIFLES) - - I II. PROJECTILES (guns) - - - - l6 III. WOUNDS OF DIFFERENT TISSUES - - 23 IV. WOUNDS OF ARTERIES - - - " 3^ V. WOUNDS OF THE NERVES - - - 54 VI. FOREIGN BODIES - - - - - 61 VII. BONY LESIONS OF THE DIAPHYSES - 1^ VIII. LESIONS OF THE ARTICULATIONS - - lO;^ IX. GENERAL COMPLICATIONS OF WOUNDS BY FIRE- ARMS - - - - - - 113 X. WOUNDS BY LARGE PROJECTILES AND THEIR FRAGMENTS - - - - " I23 XI. AMPUTATION - - - - -I26 XII. WOUNDS OF THE SKULL AND BRAIN - - 1 28 XIII. WOUNDS OF THE FACE - - - - 145 XIV. WOUNDS OF THE NECK - - - "152 XV. WOUNDS OF THE CHEST - - - " 158 XVI. WOUNDS OF THE ABDOMEN - - - 167 vii viii CONTENTS CHAHTEK PAGE XVII. WOUNDS OF THE LUMBAR REGION AND OF THE KIDNEYS ----- i8l XVIII. WOUNDS IN THE REGION OF THE PELVIS - 184 XIX. WOUNDS OF THE VERTEBRAL COLUMN AND OF THE SPINAL CORD - - - - I90 XX. WOUNDS OF THE UPPER LIMBS - - - I97 XXI. WOUNDS OF THE LOWER LIMBS - - - 21 7 INDEX 243 WAR SURGERY CHAPTER I WEAPONS The weapons used in warfare are either defensive (helmets, cuirass) or offensive (cold steel, firearms). We will not stop to consider defensive ones, as projectiles from modern rifles go through them at whatever distance an action is engaged. Cold Steel. Amongst cold steel weapons we may include the bayonet, the sword-bayonet, the sabre-bayonet, the cavalry sword, the lance. Bayonets have a straight styloid blade with a slender point, two sides (Lebel rifle), and sharp serrated edges. Some are merely a kind of hunting-knife (Germany, Austria, England, Italy). Bayonets are employed as puncturing or stabbing weapons, the direction being specially towards the abdomen or the upper part of the lower limbs. The serious injuries thus inflicted are somewhat analogous to wounds made by pointed instruments, or by those that at the same time are pointed and cutting. During the Balkan War bayonet injuries were very frequently observed. In certain battles they reached a pro- portion of lo per cent, of the wounded. The injured regions 2 WEAPONS were mainly the body, the abdomen, the upper part of the lower limbs. The sabre or sword, having a blade with hollow sides, straight or curved, is used for stabbing and thrusting in the same way as the bayonet, or as a cutting weapon. The wounds it inflicts are generally numerous (two, four, twenty). They are usually found on the head, the right elbow, the upper part of the left arm. The lance is a pointed weapon that has considerable power behind it. The head of the French lance is 15 centi- metres long (5-9 inches) and 2 centimetres (07 inch) in diameter ; its section is quadrangular. The head of the German lance is 30 centimetres long (11 -8 inches) and 15 millimetres (o-6 inch) in diameter ; its section is tri- angular. In the attack the point of the lance is directed against the trunk. Wounds by cold steel, rarely observed during relatively recent wars, now tend to increase in number. During the war of 1870 only 600 cases were recorded among 98,000 wounded. They now occur in the proportion of 5 per cent. Weapons of Offence (Firearms). These comprise rifles, mitrailleuses, guns. The pro- jectiles from these arms are alone of interest to the military surgeon. Projectiles of Firearms carried by the Soldier. They are projected by means of smokeless powder, which has increased their velocity. At the present time they are pointed instead of conical cylinders. Their calibre has been reduced from 11 to 8, and even to 6-5 millimetres (from 0-43 to 0-31, and even 0-25 inch) (D bullet). Their length, on the contrary, has increased : from 2 calibres it has risen to 3, 4, and even 5 (D buUet). Their weight, on the other PROJECTILES OF FIREARMS hand, Las diminished : from 25 grammes (386 grains) to 15 grammes (231 grains), to 12-50 grammes (193 grains) (bullet D), to 10 grammes (154 grains) (bullet S). Some bullets are of a uniform composition of soft or French Bullets. Gekman Bullets. S Bullet and its Section. AusTRL-^N Bullets. Mannlicher Bullet and its Section. Mauser Bullet. Russian Bullet. D Bullet. English Bullet. M Bullet, or Lebel Rifle Bullet. Belgian Bullet. Fig. I. hardened lead, steel, or copper ; others have a protective envelope. The central nucleus of hardened lead is covered by a casing of steel, copper, nickel, or nickel silver, which is either closed or open at the base. We shall only describe the smaller projectiles used by the belligerent Powers. 4 WEAPONS The German S Bullet. — The S bullet of the German Mauser is a pointed cylinder, ogival-shaped projectile of hardened lead, surrounded by an envelope of soft steel plated with nickel. Its cylindrical part hardly exceeds a fourth of its total length; its point, which measures 19 millimetres (075 inch), is very tapering, and ends in a very small flat apex, measuring about i millimetre (0*04 inch). Its calibre is 7 millimetres (0*28 inch), its length 28 millimetres (i-io inches), its weight 10 grammes (154 grains). The S bullet is shorter and lighter than the D bullet. The Austrian Bullet, of the Austrian Mannlicher rifle, is formed of hardened lead compressed in a steel wrapper. It weighs 15-8 grammes (244 grains) ; it is 31-8 millimetres long (i"25 inch), and yg millimetres (o'3i inch) in diameter. It is conico-cylindrical, with a truncated extremity, which is rounded and not tapering. The French Bullet- — The D bullet is of brass, without envelope ; it is biogival, the point being very sharp in front, and the bullet truncated at its base. Its calibre is 8 milli- metres (0*31 inch), its length 39 millimetres (1*53 inches), its weight 12*80 grammes (197 grains). The M bullet consists of a nucleus of hardened lead surrounded by an envelope of brass and steel. Its calibre is 8 millimetres (0*31 inch), its length 30 millimetres (i-i8 inches), its weight 15 grammes (231 grains). The Russian Bullet is ogival in shape, with a blunt extremity. It has an envelope of nickel, surrounding a nucleus of hardened lead. Calibre, 7-6 millimetres (0-3 inch) ; length, 30*5 millimetres (1-2 inches) ; weight, 1370 grammes (211 grains). The English Bullet is ogival, with a blunt apex and a casing of nickel. Calibre, 770 millimetres (0-3 inch) ; length, 31 millimetres (1-2 inches) ; weight, 15*90 grammes (215 grains). The Belgian Bullet. — Ogival, with blunt apex, nucleus BALLISTIC DATA 5 of hardened lead, envelope of nickel. Calibre, 7-6 milli- metres (0-3 inch); length, 30 millimetres (i*i8 inches); weight, 14*10 grammes (213 grains). The Mitrailleuse fires rifle bullets. Use is made of the infantry rifle cartridge. The multiplicity of the injuries inflicted, rather than their nature, distinguishes the mitrailleuse. Ballistic Data (Bullets). The military surgeon must be familiar with a certain number of ballistic data in order to understand, from a scientific and practical point of view, the effects of bullets. We shall content ourselves by recalling, and we hope with- out dryness, the essential data ; but it is quite indispensable for him to thoroughly know what we are now going to set forth. Velocity Transit. — A bullet has two kinds of velocity : a velocity of transit, by which the bullet passes through space ; and a velocity of rotation, which sustains it during its trajectory. The velocity of transit of a bullet is one of the principal factors of its active force {vis viva), or, in other words, of its power and of its eff"ects. The initial velocity of a bullet is expressed by the number of metres over which it would travel during the first second after leaving the muzzle, were it not subjected to gravity. The remaining velocity, which is of far greater importance for us to know, is the velocity the bullet still has at the different distances of its trajectory. The " remaining " velocity decreases with the distance of the bullet from the muzzle of the rifle, owing to the force of gravity and the resistance of the air. The initial velocity of the bullets now in use is consider- able. The German bullet S has the greatest initial velocity, amounting to 860 metres, or 940*5 yards, which is 160 metres 6 WEAPONS (165-0 yards) superior to that of the French bullet D; but he latter, being heavier, retains its velocity better during the remainder of its course ; it is thus still very dangerous at distances at which the S bullet is harmless. The French bullet D possesses an initial velocity of 701 metres (767 yards); the M, or the bullet of the Lebel rifle, 651 metres (712 yards); the Russian, 643 metres (703 yards) ; the Austrian, 626 metres (684 yards) ; the English, 574 metres (628 yards, etc.).* The remaining velocity is inversely proportional to the square of the diameter of the bullet and proportional to its leitgth and its weight. At 400 metres (437*4 yards) bullet S has 650 metres (710*8 yards) remaining velocity; bullet D has 536 metres (580-2 yards). At 600 metres (656'2 yards) bullet S has 470 metres (514-0 yards) remaining velocity ; bullet D has 470 metres (514-0 yards). At 1,000 metres ( 1093*6 yards) bullet S has 301 metres (329-2 yards) remaining velocity ; bullet D has 365 metres (399-2 yards). At 2,000 metres (2187-2 yards) bullet S has 166 metres (i8i*5 yards) remaining velocity; bullet D has 210 metres (229*7 yards). Velocity of Rotation. — To maintain the bullet on its trajectory, the grooves of the rifle impart to it a rotatory movement. The longer the projectile, the greater its move- ment of rotation ; the latter, however, has but little influence upon the effect of the projectile ; it remains constant for the same projectile. Bascule Movements. — The S and D bullets are subject to movements of oscillation and of deflection, to which other projectiles are also subject, but in a slighter degree. Bullets may turn cross-wise or with their base in front ; * The English bullet has a muzzle velocity of 2,000 feet-=666'6 yards. BALLISTIC DATA 7 this rnay occur when they encounter a small obstacle in their course, or when they strike the human body. With bullet M, and also with the old German bullet, at 400 metres a fourth of such deflection has been noticed ; at 600 metres one-third. These overturnings occur more frequently with the bullets S and D, a fact that the military surgeon must bear in mind, as well as the frequency of ricochets. Trajectory. — The course followed by the bullet, its trajectory, was formerly represented by a long curve; the trajectory of modern bullets is straighter, and so increases the vulnerability of the object fired at, and also the extent of the dangerous space. The effect of the tension imparted to the bullet insures a more direct trajectory. Up to 500 metres the trajectory of modern bullets is almost a straight line. Range. — The great speed of the bullets now in use enables them to attain a range of 3 kilometres, or more (3,800 metres — 2-36 miles) in the case of bullet D. Active Power {Vis Viva). — The damaging effects of bullets are dependent on their active power {vis viva). This WV2 is expressed by the formula P = , W being the weight and V the velocity of the projectile. The following table represents in kilogrammetres the initial active power {vis viva) and the remaining velocity of the S bullet, of the Mannlicher, and of the French D bullet : Distances in Metres. 100 200 300 400 500 600 700 800 900 1,000 2,000 Germany Austria ... France . . . 310 344 239 223 230 186 167 183 145 139 147 113 119 121 90 104 lOI 76 92 86 68 81 73 63 73 64 58 67 56 53 61 50 23 31 19 This table shows that the acting or damaging power is practically the same for the three projectiles ; it is tremendous at 100 metres, considerable up to 500 metres. 8 WEAPONS From 500 to 1,000 metres the damaging power decreases rapidly ; it is very small between 1,000 and 2,000 metres. We thus understand why the classical works on army surgery, when dealing with the effects of bullets, are always careful to bring these effects within touch of the question of the distance at which the firing has taken place, and to speak of very short distances from o to 100 metres, short distances up to 500 metres, middle distances from 500 to 800 and 1,000 metres, great distances from 1,000 metres upwards. The greater the active power (vis viva), the more extensive are the injuries inflicted. The power of penetration of a bullet is dependent on its active power (vis viva), on the extent of the surface on which it strikes, on its density of section — i.e., the weight that prolongs backwards each unit of surface that is oppos- ing resistance. This is the reserve of active molecules. A last condition that influences the penetrating force is the state of its surface of peripheral friction. It follows from the above that the pointed S and D bullets have more power of penetration than the cylindro-ogival bullet with a flat apex ; that the D bullet, being longer, has more power of penetration than the shorter S bullet ; that a projectile that has ricochetted and struck sideways is less penetrating than one fired point-blank. The resistance opposed by the tissues to penetration, of projectiles of equal speed, is inversely proportional to the square of the diameters. The bullet exercises on any obstacle it meets a more or less great pressure. The coefficient of pressure depends on the active power [vis viva) and on the calibre of the projectile. The smaller the calibre, the greater the pressure. Ricochets. — Injuries inflicted by ricochetting bullets are very frequent. They are observed in the proportion of 1 in 3 of all cases. A projectile ricochetting from the ground is deflected, and strikes the body obliquely or transversely. It is put MODUS OPERANDI OF BULLETS 9 out of shape, flattened, turned out of its course, broken up, separated from its envelope, and so the number of injuries to which it gives rise is multiplied. To be put out of shape a leaden projectile must have a velocity of 450 metres, a bullet with an envelope a remaining velocity of 750 metres (Journee). The S bullet, formed of hardened lead and covered by its envelope, is more easily put out of shape, flattened, and broken up on striking the ground, than the D bullet, which is made of brass. Injuries inflicted by vicochetting projectiles are more serious than those caused by bullets fired point-blank. Modus Operandi of Bullets. Pointed bullets such as the S and D bullets make a puncture-like opening in the tissues when they reach them from a point-blank discharge. After penetrating, they push the tissues aside, but without greatly bruising them, thus creating very favourable conditions for spontaneous healing. More- over, they do not carry with them to any great extent foreign bodies derived from the clothes of the ivounded man. These are essential points to bear in mind. When the S and D bullets have tipped over — when they have ricochetted in their course — they strike the body with a much enlarged irregular surface, and so exert sixong pressure upon the tissues. Their mechanism then becomes punch-like, with a tearing and bruising action. Moreover, they carry with them foreign bodies derived from the clothes, and may be soiled by contact with the earth. These are points of paramount importance. The greater the remaining velocity of the bullet and the more tearing its efl"ects (bullets that have tipped or lost their shape), the greater the amount of active force it imparts to particles of tissue it separates. The fragments of tissue torn off play the part of secondary projectiles, which, lo . WEAPONS at first propelled in front of the bullet, whose track they prepare by slipping over its sides, transversely enlarge the track of the wound, giving rise to more or less bruising and disturbance. The intensity of the action of the so-called secondary projectiles varies with the velocity of the bullet, its shape, the nature of the tissues with which it has come into contact, and with the easy dissociation of these last, and their mobility. An intense action is chiefly observed with projectiles pos- sessing very great or great velocities — that is to say, at short distances, varying from o to loo up to 500 metres {from o to 109 and to ^^y yards (zone of so-called explosive effects). With pointed projectiles, discharged at point-blank range, it is possible that the above-mentioned effects may no longer be seen. At all events, they occur more rarely than W'ith conico-cylindrical bullets having a flat apex, or with bullets having a calibre of more than 8 millimetres (o'3i inch, Gras bullets). On the other hand, they are produced by the S and D bullets when these projectiles become deviated whilst proceeding at a high velocity. This has been observed over and over again in the present war. Intense divulsive and propulsive action is exercised with greater facility the more the tissues are capable of dissociation, the less they show elasticity (muscles), and the freer the molecules (parenchymatous organs, brain). In- compressibility and their frequent projection explain the awful extension of the havoc that at times is wrought by bullets upon organic receptacles (bladder, intestines, stomach, gall-bladder). Not only may these receptacles present enormously enlarged apertures of exit, but they may also burst, and show large openings at some distance from the track pursued by the bullet. The most elastic tissues of the body (tendons, fasciae, aponeurosis), especially when they are movable (tendons of the wrist, of the instep), can transmit for some distance MODUS OPERANDI OF BULLETS n the' active force {vis viva) imparted by a bullet. Thus they bruise and split up the neighbouring and less resistant tissues (integuments, muscles). Fragments of bone de- tached by a bullet act like fragments of the projectile or like the bullet itself, forming a shower of secondary pro- jectiles, which, from the centre of the injured limb, are propelled outwards through the soft tissues. When the active powev (vis viva) is of average strength (beyond the 500 metres, and up to the 1,000 metres range), the action of the bullet remains localized. The injury is of the nature of a puncture or an abrasion, with a weak projection, and more rarely with hard or soft secondary projectiles. Such is the usual normal type of the lesions. When the active power [vis viva) is weak (beyond the range of 1,000 metres), the lesions are still more circum- scribed ; again, the bullet acts by puncture, and especially separates the fibres of the tissues. The zones of the action of a bullet have been classed as follows : 1. Explosive zones (up to 500 metres). 2. Perforation zones (regular course, from 500 to 2,000 metres). 3. Contusion zones (beyond 2,000 metres). Although the above classification has been criticized, it deserves to be maintained for bullets such as those of the Lebel rifle. Projectiles of a calibre greater than 8 millimetres (0-31 inch), in addition to their divulsive effect, have a vibratory action which may be transmitted over a more or less considerable distance from the bullet's course, this vibratory action showing itself by phenomena of inhibition and of local or general shock. With pointed bullets fired point-blank, these phenomena are no longer observed. It may even happen that the wounded, even when their atten- 12 WEAPONS tion has not been taken off by the excitement of the battle, are unaware of the very serious injuries inflicted on them. The S and D bullets pass through the flame of a candle without causing it to flicker. On the contrary, when de- flected, the S and D bullets frequently produce this shock. The considerable active power {vis viva) possessed by the bullets now in use enables them to pass through several bodies, and a fortiori through more than one limb. The S bullet fired from a distance of 2,000 metres can still go through two men. The damage extends from the first to the last body or limb traversed by the projectile, if they are near to one another. An active power {vis viva) of 8 kilogrammetres is sufficient to disable the combatant. Contour wounds no longer occur with point-blank firing. The So-called Humanitarian Bullets. — The modern S and D bullets cause a considerable immediate mortality, a fact often too little remembered by the surgeon who treats the wounded in the rear. The fortunate influence exercised by their pointed form and their small diameter is counter- balanced by the frequency of their turning over ; this widens the bullet's track from its aperture of entry to its deep resting-place, and gives rise to contamination of the wound by the foreign bodies carried in by the bullet. Therefore S and D projectiles are not humanitarian. According to Journee, fatal injuries are in the ratio of 25 per cent., serious injuries 15 per cent., slight injuries 60 per cent. Generally, the same ratio is observable throughout. If, in a certain measure, owing to their small calibre, to their pointed shape, and, as in the case of the D bullet, to their composition in a single piece, the present bullets give rise to a long series of slight traumatisms, whose very mild- ness, when the wounded are taken to the rear, strikes not only the surgeons, but also the general pubHc, there is no MODUS OPERANDI OF BULLETS 13 reason for bestowing upon them, and on some of those that have been used previously, the so abusively eulogistic Ger- man appellation of humanitarian bullets. The average of wounds, other than very small ones of the soft parts, remains grave ; therefore we may repeat in regard to these bullets what we have said in speaking of the others : it is truly pushing the love for paradox very far to call humani- tarian a bullet that goes through several men when fired from a short distance, and that is capable of causing great slaughter in a zone of more than 3,000 metres. The adoption of bullets that, on meeting the slightest obstacle, turn on their axis, strike obliquely or trans- versely, giving rise to wounds that are often relatively of a large size, the making use of bullets that so easily turn over in the tissues and drive forward " foreign " bodies, certainly does not constitute progress from a humanitarian point of view. The greater the velocity of the bullet, the more serious are the lesions, the graver the fractures of bone. Other things being equal, the extent and severity of the injuries caused by rifle-fire depend on the active power {vis viva) of the bullet. But, far from the distance between the combatants being increased, it has remained unchanged ; even it was noticed during the Balkan War, and has already been observed in the present war, the distance tends to decrease, and firing is carried on in zones in which the bullets acquire an excessive active power {vis viva), and the wounds they inflict are amongst the most dangerous known. In short-distance rifle-firing the mortality is appalling. The kind of madness soldiers feel in a charge {furie frangaise) is heavily paid for, and charging would be most criminal were it useless. To appreciate as a whole the gravity of the injuries inflicted by bullets, we must take into account not only those injuries the surgeon sees in patients brought to the 14 WEAPONS rear, but also the wounds that are treated at the front, the patients being subsequently removed to hospital, and the injuries seen on the battlefield in soldiers that have been killed. When all these data are united, instead of one only being kept in view, the impression with regard to the small bullets now in use, far from being favourable, becomes, on the contrary, unfavourable. If all these injuries be taken as a whole, the pointed bullets now in use do not present any essential differences from the projectiles used in former times. Explosive Bullets or Dum-Dum Bullets. — At the outbreak of every war there are always questions raised with regard to the employment of dum-dum bullets. It is so to-day. We have seen wounded men in the present campaign concerning whom this old error has been brought forward. The terrible injuries that have given rise to this mistake differ so greatly in character from those usually observed that it seems impossible to attribute them to the action of a bullet which causes but very small apertures of entry and of exit. This, however, is not so. In such cases it is a question of explosive shots due to projectiles of very high velocity becoming more or less broken up in their course through the tissues. The fury with which our soldiers have many times fallen on the enemy, and the fact of their being hit by bullets from very short distances, sufficiently account for these wounds that need no further explanation. Systematic use of explosive bullets would show a want of common sense, because we rely on the effects of ricochetted bullets, a ricochet occurring in the proportion of i in 3 of bullets discharged ; besides, an explosive bullet can no longer hit a man if it has touched the ground, however slightly. Fig. 2.— Effects of Explosive Fire (S Bullet). {Augtist 20, 1914.) CHAPTER II PROJECTILES FROM FIREARMS NOT CARRIED BY INFANTRY (GUNS) These projectiles are those of field, motmtain, garrison, siege, naval, and coast guns. Projectiles from garrison, siege, naval, and coast guns, being chiefly directed against armoured objects in defence or attack, are distinguished from the first by their massiveness and by the small tendency they have to divide. We will not stop to consider them. On the other hand, the two first-mentioned guns, mainly destined to be used against troops, will be minutely studied from the point of view of their construction, their ballistic qualities, and, lastly, of their effects. Shells of Field Artillery. As a general rule, shells from field guns are metallic cylinders of cast iron or steel, cylindro-conoidal in shape, with thick walls ; the shell is subdivided into cavities which contain the bursting charge, and usually the projectiles. The shell's anterior extremity, which is well strengthened, and is called the ogive, contains the fuse, which is separable, and is formed by an irregular mass of copper. The shell's posterior extremity, which is also strengthened, and can often be separated, is called the rear-piece. On the outer surface of the shell are the forcing hands, which can be detached ; they are formed of copper rings, i6 SHELLS OF FIELD ARTILLERY 17 of girdles of lead, of side-pieces, of nuts. Some howitzer shells are provided with discs. The shell, when acted upon by the time fuse, explodes in the air ; when acted upon by a percussion fuse it explodes on striking the ground. Some fuses have a double action, and are both time and percussion fuses. Shells are designated according to their calibre : shell of 75, of 77, etc., or according to their mode of bursting : shells having a systematic mode of bursting, shells con- taining grape-shot (mitraille), shrapnel, explosive shells. 1. Shells whose Bursting is Systematic are projectiles with double-lined sides, showing lines of rupture, and breaking up into large fragments ; others of the same kind have in the interior of their thick external envelope a number of piled up cast-iron rings, which break up into large and sharp fragments. These shells are but little employed. 2. Shells containing Mitraille have an outer shell containing metallic discs hollowed out into alveoli, for round bullets from 12 to 15 millimetres (0-47 to 0*59 inch). Segmentation, which takes place at the level of the alveoli, sets free fragments of cast iron irregularly cubic in shape and with sharp angles. Such is the present French mitraille shell. 3. Shrapnel. — The outer shell in this instance is thin ; it rests in front upon a heavy ogive, at the back, upon a thick rear-piece. The interior of the shell is filled with free spherical bullets (10 to 16 millimetres, 0*39 to 0-63) of hardened lead. In some shrapnel the charge of powder is placed behind, by the rear-piece (Austria) ; great force is thus imparted to the bullets. In other cases the charge is placed in front ; it then lessens the speed of the bullets, but facilitates their scattering. Lastly, the charge may be mixed with the bullets ; this facilitates their scattering, and increases their power (French shells). With this shell the ignition of the charge is secured by a PROJECTILES FROM FIREARMS central tube. The French shrapnel of 75 centimetres con- tains 290 bullets of 12 grammes each (185 grains) ; the German shrapnel of 77 centimetres has 300 bullets of 10 grammes (154 grains) each. Fig. -German Shrapnel Bullets. (Natural size.) Fig. 4. — German Shrapnel. The shrapnel of the German field-howitzer contains 500 bullets of 10 grammes each. 4. Explosive Shells. — Their moderately thick steel walls are hollowed out into a large cavity filled with an explosive material (gun-cotton, melinite, cresylite, etc.). The explosive shells are generally fired in the proportion of I to 3 by all artillery. SHELLS OF FIELD ARTILLERY 19 The, variable quantity of explosive material contained in a shell has a very great influence on the effects pro- duced. The German shell containing but 150 grammes (2,315 grains) of melinite is far less destructive than the French grape-shot shell, which contains 800 grammes (176 pounds) of the same material. From the outset of the war considerable difference has been observed between the injuries inflicted by German and French shells. 5. Mixed Universal Shells unite the characteristics of shrapnel and of explosive shells. A universal shell with a double effect has been adopted by Germany for her field-gun 98 and for her howitzer 105. In its posterior part there is a powder-charge to project the bullets ; in the centre are the bullets mixed up with a charge of powder. This central part of the shell is crossed by a tube which secures the ignition of the charge in the posterior portion of the shell. Finally, the ogive in front contains a strong charge of an explosive. The shell may be used as shrapnel with time fuse, causing deflagration of the charge behind, or as an explosive shell with percussion- fuse, with or without delay in the explosion after the contact shock, through detonation of the charge in front. Thus it may be easily understood that mixed shells which project shrapnel and sharp fragments of steel in the same way as an explosive shell may give rise to traumatisms of a special nature (Ferraton). Case-shot are cylinders of sheet-zinc containing round leaden bullets held together by sulphur. When fired at a short range, these cylinders burst at once and scatter the leaden bullets ; these are analogous to shrapnel bullets, although heavier (40 grammes, or 617 grains, France). Great use was made of these projectiles during the attack on Liege. Grenades are explosive bombs thrown by hand ; they are spherical in shape and loaded with explosives. The grenade 20 PROJECTILES FROM FIREARMS is often an improvised bomb containing projectiles of every shape and weight. The effect produced by its fragments varies greatly, terrible in general at a short distance. Its action is quickly exhausted. The explosive action of the gases is exerted over only a small area, in which, however, it produces great havoc. Ballistic Data concerning Shells. Following the method adopted in describing bullets, we shall now only consider the data that are of interest to the military surgeon. It may be said that shells only act through their splinters or their bullets. In the case of the ordinary shell with cast-iron walls, the large fragments are almost exclusively supplied by the rear- piece, the ogive, and the fuse. Fragments of average size weigh from loo to 300 grammes (1,543 to 4,630 grains) ; small splinters are about the size of a walnut. The present steel shells eject from their entire periphery small elongated splinters, not very thick, about i or i^ centimetres (0-39 or 0-59 inch), sometimes they are as large as a pea; their dimension, however, may even be that of a small fragment. Fragments of these shells rapidly lose their velocity. The slightest obstacle — a clod of earth, a helmet, a haver- sack, etc. — may serve as a protection from them. The Serbians use the shovels with which entrenchments are being made ; the Bulgarians use earth ; the French soldier his knapsack, which protects his head and shoulders, whilst leaving his hands perfectly free. The French mitvaille shell discharges 416 bullets of 25 grammes (386 grains), besides 288 disc fragments, weighing on an average 40 giammes (617 grains). The larger fragments of shrapnel are supplied by the ogive and the rear-part. BALLISTIC DATA CONCERNING SHELLS 21 The principal projectiles of shrapnel are round hillets, from 10 to 15 millimetres (o'39 to 0*59 inch) in diameter, of small weight, and low velocity ; they may he compared to the old smooth-bore hillets. They inflict, in general, slight injuries, such as contusions or incomplete perforations, the projectile remaining in the wound, rather than through-and-through perforations, and their " cul-de-sac " wounds are often complicated by the pre- sence of foreign bodies derived from the soldier's clothes, which favour suppuration. Fragments from the much sub-divided wall of an explosive shell are usually broken up into small, thin, striated and sharp lamellae ; nevertheless, some of them spread out and act like a badly sharpened knife. These fragments are very small, and sometimes become localized in the body as if they had been sown like seed. Most frequently the shell explodes in the air (time fuse) at more or less distance above the combatants. The distance separating the shell from the ground is called bursting height. When this height is small, the shower of fragments or bullets is dense, that is to say, closely charged with projectiles, and the velocity of these secondary pro- jectiles is increased ; the shell then is very deadly. It would appear that it is of very little use when the bursting height is great, the shower of projectiles is then more spread out, less dense, more apt to produce wounds, but dangerous effects upon the human body are less conspicuous. The shell with percussion fuse, which is rarely used, must strike the ground before exploding. When it falls perpen- dicularly, it either buries itself in the earth or forms a funnel-like excavation, in which its fragments are retained. If it strikes the ground obhquely, it rebounds, gives off a shower of projectiles, the marks of which are shown on the ground as an elongated ellipse. The splinters and the bullets close to the bursting-point have a greater penetrating 22 PROJECTILES FROM FIREARMS force than those from a greater distance. In general, these last are the ones that cause wounds. The velocity of the fragments and of the bullets at the point of explosion is that of the shell at the time of falling. The velocity is — At i,ooo metres : 422 metres, French shell ; 369 metres, German shell. At 2,000 metres: 346 metres, French shell; 310 metres, German shell. At 3,000 metres : 300 metres, French shell ; 279 metres, German shell. In the case of the time-fuse shell, this velocity is increased by the active power (vis viva), communicated by the charge in the interior. With the percussion-fuse shell, the bullet has to travel over several hundred metres before reaching the body ; and during its course in the air, owing to its shape and size, it undergoes great loss of velocity. Whether the bullets or splinters proceed from a shell with a percussion fuse or from a shell with a time fuse, when they penetrate into the tissues the large rounded shape of the former, the spread out and irregular shape of the latter, considerably limit the power of penetration, as the resistance of the tissues is proportional to the square of the diameters of the projectiles. Consequently J one may say that these bullets or splinters do not possess half the penetrating power of rifle bullets. Explosive shells directed against obstacles, but which reach the defending troops, are commonly and deliberately used at the present time against the enemy. These ex- plosion shells, as well as the ordinary percussion shells, under certain circumstances, may loosen and hurl about stones and debris that play the part of accessory projectiles. Explosive shells are often productive of multiple wounds. Six, seven, ten, and more, have been observed in one wounded m.an. CHAPTER III WOUNDS OF DIFFERENT TISSUES The injuries inflicted by bullets on the soft parts are very frequent. This frequency is a factor of great importance to the army surgeon, who has to take it into consideration in the preparation and distribution of dressings when arranging for transport, and making a computation of invalided men and of those who return to duty. - - The percentage of the injuries of the soft parts is estimated at about 45 or 50. The percentage even rose to 80 during the American War. Fischer stops at 65 per cent. Injuries of the Soft Parts due to Bullets. We will first study the injuries caused by rifle bullets. The division here adopted should be maintained in statistics. Contusions. — These are produced by spent bullets or tangential firing, frequently also caused by bullets from a shell. Contusions may be very slight, or they may end in sloughing. Erosions, Furrows, result from tangential rifle fire — small scratches — at the level of which the skin dries up and becomes covered with a brownish pellicle ; no cica- tricial trace is then present. Sometimes these are cutaneous abrasions more or less extensive, occasionally 5, 6, or 7 centi- metres long and 2 or 3 centimetres wide, owing to the 23 24 WOUNDS OF DIFFERENT TISSUES retraction of the skin, showing regular or contused per- pendicular edges. Their deeper part is formed of cellular or muscular tissue ; they leave cicatrices. Cul-de-sac Wounds are due to the action of bullets of low velocity which have frequently ricochetted. They leave a blind track more or less deep, generally containing the projectile that has caused the wound. When the track is short, the bullet may have been displaced by some move- ment or by the removal of the clothes. The cutaneous aperture of entry is generally of less dimensions than the diameter of the projectile — it is per- fectly round or oblique ; on the contrary, it is large and irregular v/hen caused by a bullet that has been deflected before striking the body. Setons are perforations that go through and through. We will now study their apertures and track. The aperture of entry varies in aspect : sometimes it is rounded, circular (in point-blank fire), with an apparent diameter much smaller than that of the projectile ; there is loss of substance. On other occasions, especially with pointed bullets, it is punctiform, and so narrow that it is difficult to identify it. It has been compared to a flea-bite. More often than not it is soiled by the projectile that in passing has rubbed off against it the impurities gathered during its course ; the epidermis has been destroyed, and the derma bruised around the apertures. At times it is contaminated by shreds of clothing that have penetrated farther than its edges. As to its dimensions, they vary, in general, with the velocity of the bullet. They are a little larger with short distances, a little smaller with middle, and insignificant with long ranges. They are also larger when the integument lies on a resistant plane, and smaller when the skin can be depressed. When the bullet strikes obliquely, the aperture of entry is increased in size, oval or elliptical in shape, with bruised edges. INJURIES OF SOFT PARTS DUE TO BULLETS 25 The. tension of the tissues, the position of the limb, the direction of the cutaneous folds, may modify its shape. The aperture of exit is nearly always irregular, and shows in the form of a cleft, which may be either simple or radiated, and is sometimes circular and punctiform. It appears larger than the aperture of entry, but in reality it is smaller, as it is probable that the skin has been much distended before being perforated. Now and then its edges are everted, and not bruised like those of the aperture of entry. The dimensions are commonly, although not regularly, proportional to the velocity of the bullet — that is to say, inversely proportional to the distance of the firing. Under the loosened integument a little pouch filled with blood sometimes forms Pirogoff's pouch. Track. — In the great majority of cases the track may be represented by a straight line uniting the apertures of entry and of exit, always supposing the limb or the trunk to be in the same position as at the time when hit by the bullet. The lamince or accimitUations of cellular tissue that the bullet meets with are, according to the velocity of the projectile and to their nature, freely perforated (lamince), or only dissociated {accumidations) ; the paniculate masses of adjoin- ing adipose tissue then fill up where there has been a loss of substance, thus forming an aseptic occlusion. Superficial fascicd are wounded, and present circular or oblique apertures, when the velocity of the bullet is great ; but with average or low rates of velocity, only the trans- versal or uniting fibres are dissociated. The longitudinal fibres become forced apart, and, as we have before demon- strated (and the fact carries very great interest), the wound is no longer represented by a loss of substance, but by what re- sembles an incision, a sort of button-hole-like slit with retmited edges. These aponeurotic button -holes sectire the occlusion the track. In muscles the track is always cylindrical, widened in the 2 6 WOUNDS OF DIFFERENT TISSUES living by muscular contraction, filled up with blood, exuda- tion, and inflammatory swelling. The track is larger than the diameter of the projectile. Its size varies with the velocity of the bullet, as is the case with other tissues. In close-range firing the track is much larger than in middle ranges, and still more than in long ranges. Tracks in muscles are narrower when the bullet is pointed than when its apex is flattened ; the fissures they cause are typical when the firing is point-blank. When the track follows the direction of the muscular fibres, it is not an easy matter to find its course on the dead body (Ferraton). By reason of their mobility, their elasticity, their shape, and of their being made up of linear fibres, tendons are, of all tissues, the ones that ofl"er the most successful resistance to the action of the bullets. Being loose in their sheath, they are displaced and eroded ; if they are more or less fixed, they are indented and lineally perforated. Exceptionally they are completely divided, but it is doubtful whether this can occur with pointed bullets. This question must be further studied at autopsies. To sum up, the track modern bullets make in the soft parts, as it was with the old bullets, is irregularly cylindrical. It shows constrictions at the level of the linear aponeurotic slits, and even irregularities at the level of the thick cellular layers, and of the tendons that have only been displaced. It is filled with a magma of broken-down soft tissues and with blood. Infiltrations of blood and histological fissura- tion have been noticed a few millimetres, even a few centi- metres, from the course followed by the bullet. Theoretically, when the velocity of the bullet is very great, the dimensions of the track should increase as it approaches the aperture of exit ; but the layers of aponeurosis generally resist the divulsive and progressive action of the projected particles of tissue by arresting them on their passage. INJURIES OF SOFT PARTS DUE TO BULLETS 27 The track is more especially enlarged in the case of bullets that have tipped up and have remained in the tissues. It is still more enlarged, but in this case from one end to the other, when the bullet has ricochetted on the ground before reaching the injured part, or when it strikes obliquely or sideways. When deflected in the midst of the tissues its track is irregular. Enfilade Wounds. — Certain tracks are greatly extended when the firing is from above downwards or from below upwards, as in cases in which hills, buildings, or houses are attacked. One frequently sees that a bullet under these circumstances has pierced for itself a course from the neck to the buttocks, from the hip-joint to the lower part of the leg, etc. Under normal conditions of firing one finds that the bullet may have travelled a considerable distance through different segments of the same upper limb, fore- arm, axilla, etc. The prone horizontal position that is frequently assumed by the infantry soldier in the intervals during the rapid advances that bring him nearer to the enemy renders his body liable to be wounded over a lengthy extent, and explains why, even under ordinary conditions, enfilade wounds have become very frequent. A great many tracks are multiple, either caused by several projectiles, by fragments of bullets broken up by having ricochetted near the wounded man, or by the same bullet having successively perforated two different parts of the body — arm and thorax, arm and forearm, both right and left thigh, etc. We must bear in mind when the velocity of the bullet is very great, the second track is often larger than the first. When the soft tissues are the only ones involved, no explosive lesions are observed from pointed bullets fired at short range. Nevertheless they may occur, especially in tendinous regions. Wounds of the soft tissues, inflicted by projectiles from 28 WOUNDS OF DIFFERENT TISSUES modern rifles, are not painful ; many of them bleed suffi- ciently to stain the clothing. Wounds from Revolver Shots. — They are analogous to the injuries of rifle bullets. The apertures and tracks are narrow ; no explosive effects are noticed in their case. The projectile often remains in the wound. Injuries inflicted by Bullets from Shells and by Small Shell Splinters. — The round balls from shrapnel, like rifle bullets, cause simple contusions, cul-de-sac wounds and setons, which may be compared with the wounds from rifle bullets ; the description of the former, therefore, may refer also to the latter. Contusions are very frequent, as also cul-de-sac wounds, in which the bullet and foreign bodies derived from the clothes remain in the wound. Cul-de-sac wounds are usually pretty superficial ; their apertures and track, like those of the setons, are larger and more gaping than is the case with rifle bullets. They resemble the bullet wounds of old times. The wide gaping of these wounds and the presence of foreign bodies^ chiefly derived from the clothes, tend to facilitate their infection. Evolution and Progress of Wounds of the Soft Tissues. — Most wounds of the soft tissues by rifle bullets heal by first intention, without a trace cf suppuration, or else with a slight and passing secretion from the contused cutaneous aperture of entry. These wounds are quickly covered by a small protecting darkish scab, due to the drying up of the blood-clot, under which cicatrization takes place. Our modern methods of dressing powerfully contri- bute to this healing ; but as ii was observed to take place even before the adoption of modern methods of treatment, and as at present it is frequently noticed in patients in whose case treatment by a surgeon has been impossible, or who have even been badly dressed, we are forced to admit that other reasons must be brought forward to explain so favourable a result. At one time it might be considered INJURIES OF SOFT PARTS DUE TO BULLETS 29 due to, surgeons having abandoned septic and frequent explorations of the wound ; but to-day it is atrributed to the ever-increasing narrowness of the wounds^ in consequence of the small diameter and of the shape of the bullet, to the extremely slight gaping of the wound, to the much less frequent presence of foreign bodies, and, above all, to a fact upon which we have dwelt again and again — the occlusion of the track at the level of the aponeurotic septa. Long discussions have taken place on the primary and direct contamination of the wound by the bullet and the dirt with which the projectile may be coated, by the shreds and pieces of clothing which it may carry with it ; also on indirect contamination by contact with the wearing apparel, with the patient's fingers, or with the fingers of those of his comrades who may have administered first aid. To-day the problem is solved. To sum up, the germs carried along by a bullet are not pathogenic, and the bullet itself does not infect ; the contamination brought by the clothing is anni- hilated by the defence set up by the tissues. Besides, a wound infected by a bullet, especially by a pointed bullet, having an average velocity, fired point-blank, carrying with it no large foreign bodies derived from clothing, is in the very best condition for spontaneous healing. Dressing but affords a fresh guarantee to a natural tendency towards cicatrization. Aseptic evolution is frequent, especially in cases of narrow wounds ; but large wounds, such as those resulting from a bullet that has been deflected by touching the ground, wounds soiled or contaminated by large pieces of clothing, wounds that have remained a long time in contact with clothing, or that have been badly dressed and badly looked after, are all subject to suppvtration, and therefore must be carefully watched. The evolution of such wounds will then be either relatively aseptic or decidedly septic. In the first case there will be slight suppuration of the 30 WOUNDS OF DIFFERENT TISSUES cutaneous apertures and of the track. Slight, but not pain- ful, swelling of the soft tissues will be noticed at first ; next, a slightly indurated cord-like feeling will be found along the track, after which the natural condition will be re-established ; the muscles will recover their suppleness, healing will take place without consecutive disturbance. Such is an ordinary course of wounds resulting from infected bullets, but these wounds must have been watched and treated by capable surgeons, having a good armamentarium, in good sanitary quarters, and provided the wounded men present normal organic resistance. In the second case — and the condition is customary in wounds due to shrapnel bullets, to shell splinters, to bullets deflected by contact with the ground, or in wounds badly dressed, and whose apertures are plugged by some foreign body — suppuration takes place. It is more or less abundant, sometimes foetid ; it is accompanied by tension and redness of the limb ; the pus extends and burrows. Certain cases develop a diffuse phlegmon. Wounds inflicted by shrapnel or by small shell splinters, generally show rapid formation of pus, with more or less intense local reaction, which usually quickly yields to anti- sepsis at the seat of the mischief, to free incision, and to removal of foreign bodies, either metallic, or composed of pieces of clothing. To recapitulate : From a general and practical point of view, the wound by a rifle bullet may be considered as aseptic. Many of these wounds become infected and threaten suppuration. The greater number heal naturally. Healing takes place in a few days or weeks. Wounds by shrapnel or by small shell splinters usually sup- purate. Very large and extensive wounds that are lacerated, bruised, and frequently very dirty, and result from large fragments of shell, the lesion containing or not containing the INJURIES OF SOFT PARTS DUE TO BULLETS 31 body that has caused the mischief, are hopelessly doomed TO SUPPURATION. Healing is obtained after eHmination of the scabs and when the wound has granulated. Local and general phenomena of reaction, sometimes very intense, subside rapidly if the wound is dressed with a solution of hydrogen peroxide. When the wound has been cleaned, its size may be reduced by means of careful bandaging, or by means of U-shaped mediate sutures. Treatment. — The first treatment of bullet wounds in the soft tissues consists in carrying out the indications that Ferraton has so well recapitulated : 1. Do not touch the apevtuves. 2. Do not explore the wound. 3. Carry out the dry toilet of the skin by means of an aseptic swab which may be wrung out in alcohol or in tincture of iodine. 4. Apply the ordinary dressings. Occlusion of the apertures, suturing, incisions to relieve con- striction in the wound, must all be avoided. For first aid to bullet wounds the dressings contained in the packet each soldier carries will suffice. As a rule the first dressing should be applied at the part of the field where the man has been wounded, or at the first aid station. Individual Dressing-Packet carried by the French Soldier. — These packets are of various patterns. The old pattern has two wrappers of ordinary canvas, then a water- proof covering, partly tacked together, partly stuck together, which protects the contents from external impurities and from humidity. Each packet contains (i) a square piece of gauze; (2) a square piece of purified tow surrounded by gauze ; (3) a cotton bandage ; {4) two safety-pins. The gauze and the tow are antiseptic ; they are impreg nated with bichloride of mercury. Events have not allowed us to completely replace the old 32 WOUNDS OF DIFFERENT TISSUES packets by the new model, which differs from the former one — 1. In the solidarity of the different pieces. 2. It guarantees the dressing of two wounds at a distance from one another. 3. It is aseptic. The contents of the new model are wrapped in Japanese paper, which is strong, waterproof, and at the same time very light. The packet is opened by pulling on a small linen tape which projects from one of its corners. It contains two dressings ; each consists of a pad of hydro- phyllous cotton-wool enveloped in gauze. One of these dressings is fixed, being sewn to the linen bandage destined to bind up the w^ounded limb ; the other is movable, and slides along the bandage by means of two tapes. The materials forming this second dressing have been sterilized in the autoclave, and render unnecessary the use of an antiseptic. The solidarity of the various parts forming the dressing facilitates its application and diminishes its risks of being contaminated. In order to better insure it against contamina- tion, two distinct signs (a red cross and a black cross, surrounded by a circle) mark the places where the dressing should be taken up, one sign for the right hand and one for the left. To displace the movable dressing without soiling it, a little red tag will be found sewn on one of its corners by which it should be held. It is impossible for us to lay too much stress on the fact that the individual dressing is " a reserve supply of material for ready use carried by the wounded." As a general rule the dressing should not be applied by the wounded man himself, nor by his comrades, nor by a N.C.O. ; it should be applied by a medical man, or by a trained member of the Army Medical Service. This is undisputable ; it is INJURIES OF SOFT PARTS DUE TO BULLETS 33 better not to dress a wound at all than to dress it badly, and it is as well to look upon with suspicion, and as necessitating a fresh application, any dressing that has not been carried out by a competent person (H. Billet). The necessity of a preliminary disinfection of the skin renders a new dressing imperative. Dressings must be directly applied to the skin, the clothes having been unstitched or cut open into strips so as to expose the wound and its surrounding parts ; this should be the exclusive duty of a surgical attendant. Another atten- dant should open the packets containing the dressings. The man who dresses the wound should first carefully dis- infect his hands ; washing the hands with soap is less practical than immersing them during three minutes in alcohol at 90°, or, if necessary, in methylated spirit, con- taining per litre 5 c.c. of i in 10 tincture of iodine (the whole solution being i in 2,000). When we wish to disinfect the circumference of the wound with iodine- — an excellent plan, and one which is held in high esteem in the surgical practice of all armies — the above application should be made dry, without previous cleansing with soap, water, alcohol, or ether, etc. One single coating with iodine will suffice. More than one layer would be useless, or might even be injurious. Friction of any kind should be avoided. For the cheeks, the eyelids, or the genital organs, diluted tincture of iodine should be used ; for all other regions of the body the pure tincture should be employed. Acci- dents, brought about occasionally by tincture of iodine, such as erythema, vesication, excoriation, or ulceration, are chiefly due to the applications having been made over too extensive a surface or too plentifully, to frictions having been carried out, or to antiseptic reaction, but also to the use of tincture of iodine that age has rendered stale. The medical staff is now provided with unalterable tinc- 3 34 WOUNDS OF DIFFERENT TISSUES ture of iodine (Courtot), of easy transport, thanks to its having been compressed (Pellerin). The compressed tincture is instantly dissolved in alcohol at 95°, each block being made up so as to give a solution of i in 20, which is not caustic. Robert and Carriere have enclosed sublimated iodine in glass ampullae. When required, the ampulla is broken, its contents poured into an accompanying tube containing alcohol at 95° in sufficient quantity to obtain tincture of iodine. Tincture of iodine is at present the best and safest disinfectant to make use of in the practice of war surgery^ both in the fighting line and in the rear. Bichloride of mercury and carbolic acid, with which the individual packets of the old pattern were impregnated, like most of the individual dressings in use in different armies, render the patient liable, when tincture of iodine is used — an antiseptic to which preference is given nowadays for first aid treatment of a wound — to symptoms of irritation, which are but rarely observed with a simple aseptic dressing. In the Manchurian campaign these symptoms of irrita- tion were so pronounced that the Russians and the Japanese who made use of bichloride of mercury dressings were obliged to give up tincture of iodine for the disinfection of wounds. We have been able to verify on wounded men in the present war the cutaneous irritation pointed out by the Russian surgeons. The difficulty might be overcome and these untoward incidents avoided by first of all applying under the dressing a little square of folded gauze ; this should be done at the collecting and first aid stations. The first dressing of the wound will generally be held in place by the bandage contained in the packet. An extra bandage will make the dressing more secure. In the ambulances in the rear, where the dressing has lost INJURIES OF SOFT PARTS DUE TO BULLETS 35 the fixity it had at the front, the use of adhesive rubber spara- drap, of the leucoplastic or vulvoplastic type, has been ad- vised. Personally, we have not been satisfied with the results we have seen of this method. There are counter indications to repeated dressing of wounds of the soft parts produced by bullets ; these lesions are very slight, and already present conditions most favour- able for spontaneous healing. We have already seen that wounds by ricochetted bullets are subject to symptoms of suppuration coming on very rapidly. After incisions have been made dressings will be applied of the usual topical remedies. Hydrogen peroxide here is particularly worthy of recommendation for the first consecutive dressing. Strong carbolic acid solu- tions, touching the wound with a i in 10 solution of chloride of zinc, iodine by instillation, or by simple applica- tion, instillations of ether, etc., are all of great use. We must not forget that these wounds are often complicated by foreign bodies derived from the clothes, or by the presence of the bullet itself ; in such cases the only topic to be employed is hydrogen peroxide. The wounds we are now considering are among those in which there is always a danger of tetanus and of emphy- sematous gangrene ; hydrogen peroxide is known to be a toxic for anaerobic microbes, which are the provocative agents of these complications. The same principles should be followed acd the same methods applied in dressing extensive wounds of the soft tissues resulting from shrapnel or shell fragments. We will not dwell upon this subject at present, as we shall have to consider it again in dealing with complications. CHAPTER IV LESIONS OF THE VESSELS Wounds of Arteries. Judging from the medical history of warfare, wounds of the large vessels are rare ; but, on the other hand, post- mortem examination has shown that they are very frequent (Delorme, Chauvel, Fessler). Their extremely serious nature is the explanation of the rarity of cases which have been observed and subsequently published. There are new and precise data to be contributed with regard to their total as well as their relative ratio. With the Gras and Lebel bullets, in the great majority of cases, when the projectile encountered arteries in its course, it either broke through them or bruised them. Their elasticity, their mobility, the fluid nature of their contents, hardly ever allowed them to escape from the action of the bullet. It was the same with the G bullet during the Balkan War. The lesions seen in arteries are — Contusions, lateral wounds, perforations, and section. Contusions. — They are reported less exceptionally than wounds, because overwhelming haemorrhage is not here a fatal consequence. Three degrees of contusions may be noted : In the first degree the artery is ecchymosed on its surface, and in its interior it exhibits slight fine transverse lacera- 36 WOUNDS OF ARTERIES 37 tionSj which look as if they had been produced by the point of a pin. These solutions of continuity correspond to the horizontal interstices in the muscular and elastic fasciculi of the middle coat of the artery. The contusion is there- fore represented by a series of internal wounds. If the middle coat is deeply and transversely fissured at points corresponding to where the bullet has passed — if it shows what is really an internal wound which is localized and irregular — then we have the second degree. In the third degree there are deep lesions exhibiting the same characteristics ; however, they are no longer localized, but extend over the whole lumen of the vessel. The out- side of the artery is more ecchymosed, and the vessel is narrowed at the wounded part. Knowledge of these facts is very important. If, strictly speaking, in the first degree the formation of an obliterating clot is not fatal (Matthew), the same thing is certain to occur in the two last, and the friction to which the arterial wall has been exposed renders it liable to gangrene. Yet in the last degree the complete rolling up of the inner coats makes the clot much firmer than in the second degree. These contusions therefore can, especially in aseptic wounds, be of no consequence (first degree) ; they may cause obliteration of the artery, local ischgemia, and dis- appearance of the pulse of the vessel ; they may be followed by the formation of a scab, especially in septic wounds ; or they may be followed by consecutive terrible haemor- rhages ; and, lastly, they may give rise to the formation of an aneurysm. There are no characteristic features in the troubles of sensation and of motility caused by arterial contusion ; there is strong probability of gangrene occurring at a distance ; the only sign of real value is derived from — I. The close relationship the course of the bullet assumes with the artery. 38 LESIONS OF THE VESSELS 2. The disappearance of the arterial pulse when there has not been any considerable primary haemorrhage, and no aneurysm has been noticed. These signs are valuable, because they can be looked for at once. A wounded man who is suspected of suffering from a contusion of a large artery should not be moved. He must be closely watched. His fate depends partly on asepsis, partly on a septic condition of the wound, bringing about the falling off of the scab. It is prudent, if one has any doubt concerning the asepsis of the wound, to search for the vessel without waiting for the occurrence of haemorrhage ; and if it is found to be much ecchymosed, and especially if it is narrowed, to ligature it both above and below the contused part. Would incision into the artery, turning out the clot and suture of the vessel, be of any use ? (This operation has been proposed.) After ablation of the clot, however, another one would recur in the same place through contact with the internal irregularities of the arterial wall, and, furthermore, suture of the contused wall certainly would not hold. Lateral Wounds. — These consist of loss of substance of a curved shape, which may involve a quarter, a third of the transverse diameter of the vessel. The indentation is clean, sometimes it has fissures on its margins. All the arterial tunics are divided on the same level, and the middle coat is not retracted. Very superficial and slight scratches, but with no opening into the artery, have been described. When the wound has involved nearly the whole of the diameter of the artery, owing to movements of the injured limb, the vessel may burst ; this may be regarded as a fortunate circumstance. Complete Perforation. — Through and through perfora- tions, as well as lateral perforations, are often described in post-mortem examinations. They are circular or nearly WOUNDS OF ARTERIES 39 oval, exceptionally linear with the Gras bullets and the Lebel bullet, which last is analogous to the Austrian Mannlicher and the German Mauser bullets. With pointed projectiles will linear wounds become less excep- tional ? This is a matter to investigate. The edges are clean, scarcely fimbriated ; both above and below the lesion the internal tunics are not retracted. The dimensions of the apertures are small or the con- trary according to the greater or less velocity of the projectile. They are still smaller, with a pointed bullet of small diameter. As a general rule, both the walls of the artery are perforated. Those gaping wounds, the spontaneous plugging of which was impossible, gave rise in former times to awful external haemorrhage ; the blood poured freely from wounds with large external orifices. Now that these last contract, external bleeding is less fatal and less abundant; primary false anettrysms are more often seen, and they constitute a fortunate termination. Complete Division. — This is more especially noticed in small arteries. In the larger vessels it seems to be caused by the action of bullets having a very high velocity. Deflected bullets and those from shrapnel very often produce it. A priori, these wounds would seem to be very grave ; in reality they are not so, for the transverse tearing, the shreds and strips of the middle coat, the fraying out of the external coat at the two ends where the division has occurred, promote the formation of clots in the same way as the total narrowing of the walls is consecutive to retrac- tion of the two segments of the vessel."^ * During the Balkan War it was observed that at short distances, clear loss of substance of the artery, with haemorrhage, took place ; at average distances there occurred lateral wounds, more frequently per- forations, more rarely simple contusions, complete sections, the vessel being often contused and reduced to pulp, tearing of the artery when the bullet came from a cross direction ; at long distances there were princi- pally contusions. — Ferraton. 40 LESIONS OF THE VESSELS Wounds of arteries the results of the bursting of shells present the characteristics of lesions caused by tearing, by direct contusion, by lateral perforation or section (sharp- pointed or linear fragments). Small shell splinters might produce linear perforation. Shrapnel bullets generally give rise to contusions of arteries, and less frequently to perforation and section. When a limb is torn off by large projectiles or their big fragments, the vessel, besides being divided, is drawn out for some distance. Thus can be explained the absence of bleeding, in spite of the gaping of the large arteries. Arterial wounds caused by splinters thrown out by the bursting of a shell are beyond all description. The close relations of the large arteries to the large veins are the cause of both vessels being often wounded at the same time. Symptomatology — Prognosis. — Everyone knows the fundamental signs of wounds of arteries : hcBmoyvhage nearly always in jets ; the bright colour of the blood. This bleeding may be stopped by proximal pressure ; cessation of the pulse on the distal side of the vessel. The concomitance of arterial and venous wounds rather mars the clearness of this description. Haemorrhage with narrow wounds often becomes haematoma, but this last brings with it a new sign — its pulsation. External haemorrhage^ in contradistinction to what one would suppose, is not always of great importance when large vessels are affected. Amongst twelve cases of lesions of large vessels Hildebrandt and Kuttner only found abundant haemorrhage six times^ whilst there were five insignificant haemorrhages and one average bleeding. These are ambulance reports which really only deal with a part of the reality. Wounded men with grave haemorrhage succumb before arriving at the ambulance station if their external wounds are extensive. WOUNDS OF ARTERIES 41 A fact, the result of the experience acquired in recent wars, is that, by reason of the narro.wness of the track made by the present bullets, and of the antisepsis or asepsis of the wounds, the prognosis of the lesions of the large vessels has been improved, a little, a very little, without, however, having become much less unfavourable. It is specially the prognosis of wounds of average-sized vessels that has been modified. Treatment. — i. On the field of battle^ at the receiving and first aid stations, indirect digital compression, followed at once by indirect mechanical compression^ are the first methods to employ. Indirect digital compression still retains its superiority for wounds of the carotid and of the subclavian. Morel's garrot and Mayor s cravat bandage ''' (cravat with a knot which is applied to the course of the artery) are the best means of applying indirect mechanical compression. They only show to disadvantage when their use is pro- longed, which is quite contrary to their purpose. They should be employed almost as makeshifts, their application being only temporary. Forced extension or flexion of the limbs is helpful and useful. In certain large wounds the surgeon may utilize aseptic plugging. This, however, is disadvantageous if left in too long, and if the wounded man is lost sight of (Russo- Japanese and Balkan Wars). If the wounded man arrives at the ambulance station fixed up in some apparatus, or in one that it is possible to fix, he should remain in it. Whatever the future treatment decided upon, the patient must not be transported. Transport renders the clots liable to displacement, and removes the wounded man from direct supervision. Soldiers wounded in the chest during the Transvaal War * This is probably a modification of Mayor's handkerchief dressing for fractured clavicle. — Note by Translator. 42 LESIONS OF THE VESSELS were attacked with internal haemorrhage and ha^mothorax in the proportion of 90 per cent, when they were trans- ported from one locality to another, and in the proportion of 30 per cent, when they were kept at one place (Makins). Whatever the treatment made use of, it should he employed when possible before the patient has recovered from his condition of syncope, or at any rate whilst he is recovering. The first indications of the so-called definite treatment should he settled at the ambulance. They are transcribed from, and explained in, the following lines taken from my communi- cation to the Academy, February 24, 19 14: *' For a long time the practice of war surgery in cases of wounds of the large arteries has been reduced to the two following formulae : " I. The opening into a large artery necessitates, as immediate treatment, compression in the interval before the application of a direct double ligature, that is to say, one that is carried both over and under the lesion. This ligature was looked upon as an operation of urgency. "If the haemorrhage has ceased when the surgeon sees the wounded man, he can either wait, keeping the patient under close observation, or apply a direct ligature if he fears a recurrence of the haemorrhage. ** This was the rule ; its carrying out had to take the risks which might be set up by the surroundings of the case. In fact, immediate or rapid ligatures of the large vessels could be counted by units in the histories of cam- paigns, and in spite of the large number of well-known and much-talked-of extemporary compressors, first aid hardly ever arrived in time. Deaths through haemorrhage, on or close to the field of battle, reached the enormous propor- tions that are well known ; the blood so easily escaped through the relatively large wounds made by bullets and through still larger orifices left by shells. " The suppuration that invaded these wounds, whilst WOUNDS OF ARTERIES 43 giving ri^e to the displacement or the softening of the clot, and, in contusions of arteries, to the separation of the scab, and, finally, to various other infections, consecutively in- creased the number of deaths through haemorrhage. Cases of aneurysm were very rare. I had a great deal of trouble to find, for my Treatise on War Stirgery, the number of cases of aneurysm that satisfied me. Otis, during the American Civil War, amongst several hundred thousand cases, only observed seventy-four ; and Pirogoff, that veteran of Russian campaigns, tells us that he never saw an arterio- venous aneurysm the result of a projectile. " First aid has been better understood of late years, but of more importance still are certain characteristics of the wounds brought about by modern bullets, and also, we are bound to say, the more rapid and more simple healing of the external lesions, all these have caused, in this terrible prognosis of wounds of the large vessels, a mitigation that began to be noticed by surgeons during the Transvaal War, and which continued to make an impression on medical men during the Manchurian and Balkan campaigns. The nature of the arterial and venous traumatisms was the same : contusions, indentations or lateral perforations, central perforations with a piece, as it were, punched oitt, that have been described by Lidell and me ; but where the greatest change occurred was in the narrowness of the course the bullet made in the thickness of the soft parts — this facilitated spontaneous hsemostasis. *' Speaking generally, the number of cases of profuse external haemorrhage has diminished, whilst that of arterial haematomata, of aneurysms both arterial and arterio-venous, has increased sufficiently to make it imperative for surgeons to take notice of the change and to discuss the methods of active treatment applicable to these last conditions. Surgeons were even, to a certain extent, deluded as to their degree of frequency, this being shown by Loison's formula : 44 LESIONS OF THE VESSELS in past wars hcEmorrhage was frequent and aneurysms were rare ; in present wars it has been exactly the reverse. The aneurysms, however, remained rare. Bornhaupt, amongst 3,600 wounds seen in the ambulances at the rear, only found 8 cases ; this is a great many compared with the zero of former times, but perhaps it is not enough to warrant us having an excessive confidence in the benefit conferred by the forma- tion of these aneurysms, and, relying on their possible appearance, to give out as a definite rule that — "7;? wounds of large vessels we must no longer put on a ligatiire whilst the patient is on or near the field of battle, but we must rest content with compression and with securing immobility of the limb. The wounded man, transported at once to the rear^ and placed in a fixed ambulance which he reaches after an interval it is impossible to specify, can, if necessary, be treated there for his aneurysm. " This maxim was suggested to us during the Manchurian War by a surgeon who saw the wounded in the rear — that is to say, that he only saw a part of the scene ; but Manteuffel, whose experience, on the contrary, was acquired on the field of battle and at the halting-places of the troops, had been struck by the grave nature of the haemorrhages that occurred under fire, and had seen on the line of march cases of gangrene brought on and hastened by haemostatic com- pression continued for too long a time, and finally hsemor- rhagic relapses due to the displacement of clots during the transport. Manteuffel remained an adherent of the practice of rapid ligature and of keeping the patient immobilized on the spot. ' One must not have seen,' he says, ' these blood- less corpses abandoned in large numbers at every station by the convoys of wounded in order to realize the gravity of wounds of vessels, in spite of their apparently benignant nature.' " Such are the sights the surgeon sees, such is the very best opinion. It is the one commonly adopted in everyday WOUNDS OF ARTERIES 45 practice. It is one I have always supported, however difficult 'its application during a campaign, and it is the one to which we must have recourse. I reduce it to the follow- ing formula : In wounds of the large vessels, ligatiive after compression should remain an operation of iirgency for cases in which the haemorrhage continues ; if it stops, the patient should be immobilized on the spot and closely watched. Supervision would certainly be better carried out in the first hne than in halting-places on the road or on the railway. When the surgeon considers the proper time has arrived, he will send the wounded man on to the nearest hospital. We must not, however, carry to an exaggerated degree the number of the operations or the length of the super- vision, both of which must be greatly limited by the in- variably grave nature of wounds of the large arteries even when caused by small modern bullets ; this was proved by the remarks of Brentano during the Manchurian campaign. On the other hand, we must not forget that lesions of arteries by projectiles of war are nearly always gaping wounds, with no retraction of the arterial coats ; for these reasons they are lesions that present very unfavourable conditions for haemostasis and spontaneous cicatrization. Suture of the arteries has been recommended of late in bullet wounds. The large size of the vessels, their characteristics derived from loss of substance, from bruised edges, from infection, which is always to be feared, the knowledge also that suture can only be successful in absolutely aseptic wounds, all tend to militate generally against such a procedure. At most, in theory, this method, with its uncertain results in wounds by ordinary bullets, seems admissible in those linear lesions (pointed bullets, small shell spHnters) which are brought to light during attempts at ligature. Suture would certainly be more worthy of trial in wounds 46 LESIONS OF THE VESSELS of the large veins, but bleeding from these last is very much less to be feared than that from the arteries. Carrel's direct suture with silk, either in form of a U or continuous, is to be preferred. Haemostatics are only of use in arresting general oozing (solutions of alum, concentrated alcohol^ antipyrine, adrenalin, hydrogen peroxide, horse serum, etc.). Arterial haemorrhage gives rise to acute anaemia with which we must deal. We shall speak of this later on. Wounds of Veins. The walls of veins are less fragile than those of arteries, and are more extensible laterally. Experiments have demonstrated that veins escape more often than arteries from the action of projectiles that graze them. When the accompanying artery is apparently contused or shows a lateral wound, the vein appears to be intact. The traumatisms produced by bullets are conttisions, lateral woimds, complete perforations^ or section. Contusions. — Contused veins do not exhibit the lesions that are so characteristic in arteries. Whilst the external coat presents evident signs of friction, we do not see, in the dead body, any fraying or dividing of the internal coat. Circulation of blood is not interrupted in the vessel. Lateral Wounds. — These are indentations similar to those seen in arteries. Total Perforation. — The same remarks apply as in the case of arteries ; but already with the old bullets we find the perforations were reduced in size, often linear in shape, with insignificant contusion of the edges, and they were seen in vessels of smaller calibre. Sections. — Caused by unequal tearing or crushing of the coats of the vessel at one point. Sometimes they are clean sections. WOUNDS OF VEINS 47 The wounds produced by fragments of large projectiles are very similar to the arterial lesions, but ruptures at a distance are not seen. We lay no particular stress on the well-known sign of venous haemorrhage : dribbling of black blood, which can be stopped by distal compression. Contusion may be suspected when there is neither haemor- rhage nor sanguineous suffusion, and when the track of the bullet corresponds to that of the venous trunk. In nearly all cases the vein remains permeable ; its primary thrombosis is rare. Introduction of air into veins is a very exceptional complication, and only takes place in certain regions. Arterio-venous aneurysms, formerly very rarely seen, are less exceptional at the present time. Compression generally suffices to arrest haemorrhage of the large veins. Ligature would only be employed in cases of very severe venous bleeding with extensive external wounds, or occurring in a lesion in which we are seeking for the accompanying artery, which also has been wounded. Complications of Wounds of the Large Vessels. In the first rank must be placed acute ancemia^ going as far as apparent death. Acute Anaemia. — To the ordinary signs that form part of the symptomatology of haemorrhage the following may be added : Tinnitus aurium, dizziness, shivering, nausea, vomiting, involuntary emission of urine, dilatation of the pupils, great acceleration, and at the same time smallness of the pulse, great fall in the temperature, discoloration, and flabbiness of the integuments, cold sweats, vertigo, syncope, or great tendency to it. The syncope is often providential. These are the primary signs; later on they may be sup- plemented by more or less persistent general weakness, diarrhoea. 48 LESIONS OF THE VESSELS The anaemia is all the more acute when the loss of blood has been rapid ; its influence on the brain and on the medulla oblongata is immediate. Successive losses of blood delay the healing of the wounds, increase the tendency to suppuration, and open a way to infection (Kirmisson). HcBmorrhage having been arrested, we should deal with the syncope by making the patient lie down, with the head low, by frictions, flagellation, artificial respiration, inhalations of ether, etc., elevation of the limbs. If necessary, we can make use of suhcutaneous injections of sulphuric ether (the con- tents of one, two, or three Pravaz syringes), of injections of camphorated oil, of caffeine, of injections of normal salt solution (sea-salt 7 per 1,000). Subcutaneous injections of normal saline are employed in the least serious complications, and intravenous injections in the most serious. These in- jections take the place of transfusion, which, moreover, it would be almost impossible to make use of in war surgery, even were it more efficacious and absolutely free from danger. Apparent Death. — Although syncope going as far as apparent death can be produced by pain, violent moral impressions, cold, extreme fatigue, or hunger, it is most often caused by severe haemorrhage. When syncope is prolonged — and this frequently happens — it might give rise on the field of battle to mistakes, did we not make a point at the time of interment of seeking for the positive signs of death. When there is the slightest doubt, the wounded man should be left on the spot where he has been found. The following examples should always be borne in mind by the military surgeon : L , corporal in a line regiment, received a bullet in the face, and was left for dead on the Medole plain. It was only on the follow- ing day when burying the dead was being carried out that signs of life were discovered. L is now living on his pension (Chenu). WOUNDS OF THE LARGE VESSELS 49 I experienced, says Nusbaum, an awful shock after the Battle of Orleans,' October 10 and 11, 1870, when, during a gloomy, cold and dark night, I found there were a very large number of cases of lethargy. Many times we returned with four or five stretcher-bearers to wounded men who had been left for dead, although the beating of their heart could still be felt. After we had brought them in, made them warm, given them food, we succeeded in bringing them back to life. Loss of blood, exhaustion, hunger, cold, fright, seemed to me to have been the causes of the lethargy. It is dreadful to think that these poor brave young men could have remained lying in a moribund condi- tion in the ditches at the sides of the road whilst the ambulance men went to and fro without noticing them. There is not the slightest doubt but that lethargy can change into absolute death when several hours elapse before the wounded are attended to or afforded warmth (Nusbaum). Traumatic Aneurysms— Arterial Aneurysms. — Trau- matic aneurysms of the arteries are seen under different aspects. Sometimes we see a diffuse, tense hsematoma with a souffle ; sometimes a more or less extensive hsema- toma which a sudden haemorrhage, when compression is taken off, has increased ; at other times it is a more or less extensive infiltration having no souffle, the peripheric pulse being weakened, but still perceptible (Laurent). It can be easily understood that these last aneurysms are not recog- nized at the beginning of a campaign; this has been pointed out by Professor Laurent of Brussels. Sometimes the haematoma is tense, very painful, and infected. It might be taken for a vast phlegmonous exudation, which one might be tempted to incise. It is well known that such errors have been committed by the greatest surgeons. After several weeks or months of waiting, during which time the cellular tissue of the limb which has been com- pressed by the blood has had time to become organized, to thicken, to form a genuine sac, we have to deal more often with a localized, well circumscribed, small, hard tumour which has a souffle ; this constitutes the arterial or arterio- venous aneurysm ripe for operation. In all cases the treatment — that is to say, the operation — should 4 50 LESIONS OF THE VESSELS be in the hands of a skilled surgeon, for it is difficult and requires nerve. This operation in primary diffuse arterial haematoma con- sists, after preliminary compression at some distance of the principal artery, in the free laying open of the sac, search after the wounded vessel, ligature heloiv and above the lateral per- foration, or the through-and-through perforation, and cross- section of all that remains of the divided vessel. When the operation, instead of being performed at once, has been delayed for a week or two, the changes that have taken place in the sac, in its contents, or in the neighbouring parts, render the search after the artery more difficult, but the method of closing it is the same. In a completely circumscribed aneurysm recourse must be had to one of the following plans, which at the present time are both classical : (i) Dissecting out the aneurysm like a tumour and removing it, after having ligatured the artery both above and below ; (2) opening the sac, and search for the artery in its lowest part. The vessel is then tied with a double ligature, and the sac excised either partially or completely. Extirpation, which nowadays is the operation of choice, gives favourable results in these cases. After the Man- churian War, Bornhaupt mentioned fourteen cases of trau- matic aneurysm treated by this method about four weeks after the wound had been received ; a cure was obtained in all the fourteen. Saigo, after the same campaign, reported fourteen cases of cure among fifteen extirpations of arterial aneurysms. The results obtained by Professor Laurent of Brussels are quite as conclusive. Arterio- Venous Aneurysms. — Surgeons have been struck by the relative frequency of arterio-venous aneu- rysms in recent wars. Whilst during the 1870-71 war only I case in 2,000 wounded was noticed, Hildebrandt has seen 4 cases in 100 wounds of the vessels. In the WOUNDS OF THE LARGE VESSELS 51 Morocco campaign many wounded were treated in our base hospitals for these aneurysms (Rouvillois). During the present war we should make a point of computing the number of these cases, and of elucidating some points in their history that are still obscure. Arterio-venous aneurysms occur after complete arterio- venous perforation, after an indentation of both the artery and the vein by a projectile that had insinuated itself between them, or, finally, after a double arterio-venous contusion, or after a contusion of a vessel in close proximity to a traumatic indentation in another. These aneurysms present themselves under two principal clinical aspects : Sometimes we see a haematoma which has occurred at once that is diffuse, progressive, becoming rapidly of an enormous size, threatening the whole limb with rup- ture and gangrene, very painful, easily recognizable by its intense souffle, whose thrill is carried for a considerable distance. Sometimes we see a progressive circumscribed tumefaction of moderate size, which seems to indicate expectant measures as much as the first points to imme- diate ligature or amputation. Occasionally we see a tumour that appears at a late moment without any notable haemor- rhage ; in reality it is an aneurysmal varix. These different characteristics partly depend on the kind of lesion. Two indentations tend to give rise to aneurysmal varix ; arterio-venous contusion to the late tumour ; exten- sive perforation and indentations to rapid tumefaction. The sac of an organized aneurysm is either on the side of the vessel or completely surrounding it. As a general rule these aneurysms should be treated at the rear by a skilled surgeon, as is done with arterial aneu- rysms whose condition is not threatening ; but when they develop very rapidly, they necessitate immediate ligature or a more simple operation — namely, amputation. It really seems that on this point there ought to be no further discussion. 52 LESIONS OF THE VESSELS Vital interests are here concerned, and as, at the beginning, any medical man may be left in charge of the case, he must not hesitate to amputate. Under other conditions we may employ conservative methods. Ligature at a distance has been condemned ; it is insufficient. Extirpation entails injurious damage to a limb, the vitality of which is already much impaired. We must have recourse to incision of the sac followed by ligature in the sac of the artery and the vein above and below the lesion. Suture can only be successful in cases of fissure or very small indentation of the artery or of the vein. If necessary it may be combined with ligature of the second vessel. Late and Secondary Haemorrhage.— Laf^ hemorrhage generally comes on at the end of twenty-four or forty-eight hours after either spontaneous or surgically produced haemo- stasis. Cessation of syncope, untimely movements on the part of the wounded man, or those caused during the application of the dressings, or during the carrying out of exploration whilst searching for splinters of bone, movements caused by transport, all tend to displace the obturating clots. Late haemorrhage is much more rarely seen after wounds of veins than after wounds of arteries. Secondary Hcsmorrhage. — It is specially connected with a septic condition of the wound. It was very frequent in former times, but has become rare in modern days ; but it still is seen (septicaemia, scurvy, etc.). The fall of the scab that had formed on a contused artery, ulceration of a vessel by a splinter, by a metallic foreign body, more often disaggregation of a clot through suppuration, premature falling of a septic or even of an aseptic ligature, may all be causes of secondary haemor- rhage. We speak of haemorrhage occurring from the eighth to WOUNDS OF THE LARGE VESSELS 53 the fifteenth day as precocious, and of haemorrhage appear- ing from the thirtieth to the fortieth day as late. Very often, and especially when it is connected with the falling of scabs, the haemorrhage is indicated by premonitory symptoms which the surgeon must not fail to notice : rigors, vague pains, slight oozing of blood, renewed and increasing in quantity in proportion as the scab becomes more separated, and staining the dressings a roseate hue (Roux). Direct or indirect compression are the first methods to employ until it is possible without further delay to ligature the two divided ends of the vessel. Such is the treatment for choice. Putting a ligature on at a distance would be a deplorable mistake. Hot water, solutions of alum, of adrenalin, of gelatine (5 to 10 grammes of gelatine absolutely sterilized in a litre of normal saline), of antipyrin, of antidiphtheritic serum, are all useful ; they should be employed alone or with direct compression and in conjunction with ergotine in hypodermic injections (fluid extract of the codex — the French Pharmacopoeia — 0*50 in one dose, and 2-50 grammes in the twenty-four hours), white gelatine in hypodermic in- jections (^^^th), chloride of calcium (4 grammes every day for four or five days), horse serum as a topic or in hypo- dermic injections, quinine in large doses. CHAPTER V WOUNDS OF THE NERVES By reason of their form, their mobility, their elasticity, they escape to a certain extent the action of bullets, espe- cially when these last are pointed and have only a small degree of velocity. The lesions are contusion, partial abrasion, perforation, total abrasion. 1. Contusions. — We find ^ze/o degrees of contusion: In the first the contusion is trifling. The nerve does not appear to have suffered externally ; in its interior a few fibres have been destroyed. In the second degree the external form of the nerve has changed, it is contracted at the place where the bullet struck, above and below it shows a spindle-shaped dilatation caused by the forcing back of the myelin. The neurilemma is separated. 2. Partial Abrasions. — These are more or less regular indentations with forcing back of the myelin. 3. Perforations. — The bullet has pierced the centre of the nerve in a linear manner, leaving the lateral portions apparently intact (Freyer). The lesions are not seen exclusively in the largest nerves. Nerves of a smaller calibre — the median, the musculo-spiral, the ulnar, with a diameter less than that of the projectile — are also perforated. We do not know the degree of frequency of this curious variety of traumatism ; it was not produced by the old bullets, and its frequency still has to be determined. 54 SIGNS OF WOUNDS OF NERVES 55 4. Abrasions : Total Division. — In these cases the nerve shows a solution of continuity. Its extremities are reduced to pulp and the myelin is forced back (bullets, shell splinters). Signs of Wounds of Nerves. — Disturbance of feeling, of movement (paralysis, cramps, contractions) ; disUivhances taking place at a distance through reflex action, these may show themselves immediately or a little while after the traumatism ; they are all too well known for them to delay us. It will be sufficient for us to point out that immediate pain, either localized or at a distance, is rare (less than half the cases), and that immediate trouble at a distance must be referred to the hysterical group of disorders. Consecutive disturbances are those of feeling, of motility, of nutrition, or they may depend on a processus of irritation. If the aseptic evolution of wounds of nerves by firearms takes place without important phenomena of irritation, in cases of infection, of acute neuritis, both the localized and the radiating pain is acute, tenacious, intermittent, or con- tinuous, and sometimes accompanied by fever, spasm, and contraction. The neuritis, when it becomes chronic, may assume the ascending form, and extend even to the medullary roots ; this, however, is less frequent than it used to be. In some cases the pains bring on a regular sensorial tetanus (Weir Mitchell). Hypersesthesia is extreme, and is awakened by the slightest contact, and in a far greater degree at the slightest fear of contact. Causalgia, glossiness of the skin, and acute disturbances of nutrition due to neuritis, are well known ; but let us remind medical men that in extreme cases, even well-marked cerebral disturbance has been remarked. Although far more rare nowadays, thanks to the aseptic evolution of many of the wounds, neurotic phenomena are none the less complications that are to be feared ; there- 56 WOUNDS OF THE NERVES fore we should strive to prevent them or to Hmit them by devoting particular and special care to wounds occurring in the regions of the large nerves. General diagnosis of wounds of the nerves by projectiles is in most cases easy ; but, when it is a question of deter- mining the nature of the lesion, the solution of the problem becomes difficult, often impossible. A great deal of quite unjustifiable interference is thus explained. Treatment. — The treatment, which not long ago was reduced to the symptomatic indications, has been enriched at the end of recent wars by improvements adapted from the technique of everyday surgery. In order to appreciate their full value we will revert to what we recently said on the subject before the Academy of Medicine (February 24, 1914).- This technique, we wish first to point out, concerns specially the work of the surgeons at the rear. At the front any intervention seems to be contra-indicated, were it only on account of the extreme difficulties of the diagnosis, of the complexity of a deceptive and excessive symptomatology, which takes time to be elucidated ; therefore at the front we must content ourselves with dressing the wound and avoiding all irritation. It is all the more indicated to make use of this technique at the rear, inasmuch as surgery of the nerves is not so urgent with regard to the time of intervention as surgery of the arteries ; and inasmuch as in the hospitals at the rear the surgeon can undertake these operations without being hurried, at the hour he chooses, and under the best sur- rounding conditions. One of the conditions for successful operation in these cases is very strict asepsis. We should certainly hesitate to put sutures into wounds * Report on a work by Professor Laurent of Brussels, Aneurysms and Wounds of Nerves in War Surgery, O. C. TREATMENT 57 threatened with infection. It is far preferable to wait for their cicatrization before intervening. On the other hand, the large nerves are nearly always wounded at the same time as the arteries, of which they are the satellites ; and the surgeon naturally has his attention drawn to their injuries only at a consecutive period when he operates on the accompanying aneurysm, the treatment of which would plainly occupy a more important place than that of the nerve lesion. " The lesions presented by nerves injured by projectiles are, we remarked, at the same time less favourable for successful operation and more favourable for spontaneous cicatrization than are wounds we see in everyday practice. In these last the nervous trunks have nearly always been divided by an instrument or by something sharp ; they have not experienced loss of substance, but, if healing has taken place with formation of a neuroma, its excision is not an addition to the loss of substance resulting from the primary traumatism. This consideration, which up to now has not been insisted upon, should not be lost sight of by those who wish to form an appreciation of the indications, the degree of usefulness, and the results of operative interference. " Let us discuss their expediency, first in cases of slight contusions. Although these show originally sensori-motor disturbances which might put us on the wrong scent with regard to their real prognosis, the continuity of the nerve is not interrupted in this instance. "In extensive contusions the nerve is deeply injured ; the forced-back myeline often gives rise to the immediate formation of a small neuroma above the point of injury. Here, again, however, the continuity of the nerve is not interrupted. Why, then, should we operate ? Again, if we intervene a little time after the traumatism, to what extent could we carry the loss of substance necessi- 58 WOUNDS OF THE NERVES tated by the refreshing of the ends of the nerve before suturing ? " Amongst abrasions, some are slight, and only involve to very small extent the circumference of the nervous trunk. Could we but recognize them clinically, no one would dream of meddling with them. There are some, however, that are complete or nearly complete, and the forcing back of the myeline is added to the loss of substance. At the period when one might think of an operation, one must look forward to having to treat a pretty extensive loss of substance joined to a nervous deterioration, which itself is rather large, and has undefined limits. Sutures might be difficult to obtain, and their success problematical. These lesions, which are but little circumscribed, are especially dangerous when the nerve has been injured by a projectile having a very great velocity — that is to say, one that has been fired from a short distance. " In perforations, any immediate intervention would be inexplicable. Freyer, face to face with three wounded men showing such lesions, abstained from all surgical inter- ference. Really, one does not see what other course he could have followed. " It may be gathered from these statements that it seems very difficult to recommend nowadays any active treatment for wounds of nerves by projectiles within a short period from the occurrence of the traumatism, excepting in those cases where the nerve is pierced by a splinter, this having been dis- covered in the course of surgical intervention for some other cause. " Putting aside such cases as these last, we consider it better to allow Nature either to undertake repair, or to show evidence of its incapacity to do so. " On the other hand, in presence of this incapacity, every- thing must be tried to help Nature. Surgical therapeutics, the results of which have not as yet been entirely satis- TREATMENT 59 factory, offer many methods for us to utilize, such as dis- placement, suUifing at a distance according to Assaky's plan, implantations J and splitting and grafting. " A nerve compressed by a fibrous band or by a callus in the process of formation should be liberated and transposed ; partial excisions of neuromata should be done, followed by direct suturing ; total excisions of neuromata, also followed by direct suturing ; a splinter that has pierced a nerve should be removed ; when there is loss of substance, we should have recourse to end-to-end anastomosis." In order to make a protecting canal for these important elements of repair, we can, following the example of Professor Laurent of Brussels, form a sheath for the nerve in a strip of fascia. This surgeon has chiefly taken his strips from the extensive aponeurosis of the fascia lata. From it he detaches, in the form of a graft, a square piece of from 3 to 4 centimetres, that he sutures by means of silk or catgut all round the united ends of the nerve. This way of forming a sheath is only an imitation of the method of Van Lair — the so-called tuhulization. This sur- geon made each divided extremity of the nerve penetrate a tube of decalcified bone. Foratimi(i904) proposed making use of arterial or venous fragments taken from a freshly killed calf; and these pieces were treated by immersion in formol and kept in alcohol.'-' Two Japanese surgeons, Drs. Hashimoto and Takuoka, during the Manchurian War, made use of the method of Foratimi, and had nothing but praise for it.f * Foratimi, Arch. /. Kl. Chir., 1904. t Tiie following is the method of preparation to which these surgeons had recourse : Arteries and veins of different sizes are excised with anti- septic precautions from a recently killed calf ; they are placed on a glass stick ; after hardening in 5 or 10 per cent, formol for forty-eight hours, they are washed in running water for thirty hours, they are then boiled for twenty minutes, and kept in alcohol at 95°. Reabsorption will take place in from two to four months. The same surgeons have 6o WOUNDS OF THE NERVES In the case of one of his men who had a bayonet wound, and on whom he had incised a neuroma of the median nerve, Dr. Laurent formed a sheath for the nerve from a fresh, quite unprepared piece of the jugular vein of a sheep. A sheath made of a graft was not successful. The simple proposal made by M. Cuneo seems to have been forgotten : it consisted in making use, for an isolating tubular piece, of a portion of a large superficial vein taken from the patient himself. Perhaps this is the method of the future.* We may call it an auto-graft. The method presents all the most favourable conditions for its revival, it is always ready to hand, and its asepsis is perfect. On the whole, the questions dealing with the primary and consecutive treatment of wounds of the nerves have not yet had sufficient light thrown on them. The various forms of treatment are numerous, but their results have not been fully studied. These points are worthy of being taken up and completed during the present campaign. In dealing with neuritis the surgeon will fall back on sedatives, on neurotomy, and on neurotripsy. We cannot in such cases speak too highly of powerful, extreme, and instantaneous compression made by the thumb on a level with the wound when the nerves are superficial. To this species of neurotripsy we owe some remarkable successes in old cases that had not been ameliorated by division or amputation of the nerves, and this in wounded soldiers who could not possibly be suspected of hysteria.f also another way of operating, which consists in displacing to a new position in the thickness of the adjoining muscles nerves that have been sutured. They have obtained excellent results. ♦ Cuneo, Treatise by Le Dentu and Delbet, article "Nerves." t Delorme, " On the Disappearance of Neuritic Symptoms by Localized and Forcible Compression," Desportes Prize. Journal de Medecine et de Chirurgic Pratiques, June 25, 1896. CHAPTER VI FOREIGN BODIES Foreign bodies which frequently cause complications in gunshot wounds are of different nature : (i) The projectile in its entirety ; (2) objects torn off by the projectile from wearing apparel, from articles of equipment, accoutrement, or armament (buttons, fragments of clothing, nails, and fragments of leather from boots) ; (3) articles carried in the pockets (spectacles, coins, etc.) ; (4) fragments separated by the projectile in its flight or on exploding (earth, stone, or wood) ; (5) fragments from the equipment, or even from the dead bodies near by. Of all these various foreign bodies, the projectile itself and pieces of clothing are those which are most frequently found in the wound. We find them generally in cul-de-sac wounds, but setons may also be complicated by them. The projectile is either whole or in fragments, in its regular form, or having lost its shape (contact with some part of the bones or with the ground). Its changes of shape and divisions must be well understood. They differ according to whether the bullet is of- soft lead, has a pro- tective covering, or is in a single piece of metal. Bullets of Soft Lead. — Bullets of soft lead, which are still represented by shrapnel or case-shot, spread out irregu- larly on touching the ground; they enter the tissues, but not very deeply, making a large opening, often more broad than long. In contact with the bones they undergo typical 61 62 FOREIGN BODIES changes of shape, which may be spoken of as — (i) Lateral changes; (2) antero -posterior changes ; {^) division into fragments. The first consist of very regular, continuous abrasions, which only occupy a very small portion of the diameter of the bullet. The second show the point turned hack, the bullet more or less flattened out, the flattening being sometimes regularly distributed from the centre, sometimes deviated to one side. In the third case the bullet is completely compressed, flattened, and spread out like a large daisy, the rear-piece forming the centre of the flower. It is in this extreme division into fragments that the projectile is broken up into very small pieces. Bullet with a Protective Covering. — In experimental firing at dead bodies, we have studied with Professor Chavasse, and we have carefully described the changes in shape of bullets with a protective envelope, of the Lebel M bullet, to which the German Mauser bullet and also the present Austrian Mannlicher are analogous.''' Although the protected bullet, when compared with the projectiles of soft lead, is less frequently changed in shape and less frequently arrested in the tissues, we have noticed — and the facts may still be of importance — (a) That this division into fragments was seen all the move readily, and that it was all the more complete the higher the velocity of the bullet and the greater the resistance of the bone struck. (b) That bullets, even when fired from middle distances, were arrested in the tissues — a point at that time much contested. {c) That protected bullets caused divisions into fragments of a special nature, this being due to their structure. The changes of shape of these protected projectiles are— (i) At their point; (2) laterally ; (3) partial separation of the protecting envelope, with antero-posteriov change of shape of the * E. Delorme, Treatise on War Surgery, vol. ii., p. 96 and following. BULLET WITH PROTECTIVE COVERING 63 projectile ; (4) segmentation, the leaden nucleus being completely severed from its envelope. In most cases these changes of shape are isolated ; they can be combined in one and the same bullet, I. Changes of Shape of the Point consist of a cup-like depression of the flattened apex, or of its surrounding parts. At a more advanced degree all the conical part of the projectile has undergone a lateral spreading out in a more or less concave form, with rounded edges ; generally there are fissures in the envelope. Changes in Shape of Bullets that have struck Bones. Changes of shape through contact. Fig. 5. — Bullets of Soft Lead. Changes of shape through perfora- tions. 2. Lateral Depressions are slight as a rule, and may be observed on any point of the cylindrical surface of the bullet. 3. The bullet coming straight into contact with a re- sistant body with very considerable vital force is subjected to a pressure which spreads out its anterior part ; the envelope hursts on a level with the flattened-out extremity. Sometimes the change of shape consists of a lateral bending over, either spiral or direct, with or without rupture of envelope. 4. Splitting into Fragments with Separation oj the Bullefs 64 FOREIGN BODIES Nucleus from the Envelope. — Dehiscence of the envelope facili- tates its separation from the nucleus. This separation is either complete or incomplete. When it is complete, each fragment follows a more or less extended but different track. In some cases splitting into fragments and separation are regular ; in others, the envelope is subdivided into small scales, distorted with cutting edges. The nucleus crumbles into dust or into small fragments. The whole mass has been projected in a shower and has exploded. Even in ■S"^ \ t£sJ Changes of shape through contact. Changes of shape through perforations. Separation of the nucleus from the envelope. Fig, 6. — Bullets with Envelope. these extreme cases the nucleus is represented by a frag- ment larger than the others. It would be folly to search for such fragments, the whole limb would have to be cut into, and even then they would not be found. These divergent seed-like fragments are well shown by radio- graphy. These changes of shape and large segments occur through contact with the diaphyses, but they are also seen when the bullet has touched hard ground before reaching the body. The bullet now becomes a foreign body, con- sisting of one or many irregular fragments of the envelope or of the nucleus. During the Cuban War awful traumatisms were caused by very much broken up and ricochetted bullets. During BULLET D 65 a riot in St; Petefsburg, when the order was given, with a humanitarian purpose in view, to aim at the ground when firing, wounds of an exceptionally serious character were caused by the bullets which had ricochetted from the paved road. We saw the same thing happen at Fourmies. This dividing into fragments is brought about by the active force of the bullet that has an envelope. With a very high velocity, the struggle between power and resistance is at the same time so instantaneous and so intense, that in most cases the bullet is subdivided into very small frag- ments. On the contrary, with less velocity it passes through the diaphyses without notable change of shape, or even without any change of shape whatever. Bullet D. — The changes of shape the D bullet, which, as we know, is formed of a single piece of brass, undergoes when in contact with the soil in ricochetting, in striking against metallic parts of the soldier's equipment, or against hard parts of the human body (bones), are far less frequent and not nearly so pronounced as those of other bullets. Bullets changed in shape through contact with stony ground retain but little penetrating power, and after having pierced the tissues by a large aperture, they remain at a short distance from the skin. Average changes of shape consist generally of a turning up of the point, which becomes more or less curved, some- times bent at right angles. The changes of shape of the base show flattening or incurvation, those of the body inflection. Slight changes of shape are of the same nature, but not so pronounced. Prominent and considerable changes of shape are rarely observed when bones are struck by the bullet. After striking against very resistant obstacles, such as certain kinds of stone, gun-shields, or iron plating, bullets may be flattened out into the form of a daisy and become subdivided ; this, however, is rare. Finally, the D bullet 5 66 FOREIGN BODIES has its shape altered rather on striking against external obstacles than against the bones ; when it encounters the latter the alteration in shape is but slight. Bullets from Shrapnel. — These bullets of hardened lead, formed of two parts joined together, are frequently broken into two symmetrical halves. They undergo similar changes of shape to those seen in soft-lead bullets (lateral, antero- posterior alterations of shape, deformation, segmentation). It must not be forgotten that the flat facets they show are due to their collisions against neighbouring bullets at the moment of the shell's explosion. Fragments of Clothing are typified either by conglomer- ate large pieces of material or of many very small bits. The conglomeration is made up of superposed, united pieces in layers of the soldier's tunic, flannel band, shirt, trousers and drawers, the number of pieces being much increased when the clothing happens to be in folds. The diametrical dimensions of the conglomeration are a little less than the bullet's surface of impaction. The projectile produces abrasion, especially when its active power is sufficiently great to enable it to act mechanically as a punch. This conglomeration of pieces of clothing, which is fre- quently observed with soft-lead bullets, and with bullets having a defensive envelope and a flattened apex, is not found in wounds made by conical bullets fired point-blank. On the contrary, they are met with in wounds due to deflected bullets, and usually in wounds from shrapnel and from shell splinters. In our experiments on dead bodies with the Gras and Lebel bullets, we were somewhat surprised to find that in most cases the greater part of the track of the bullet was lined with thin filaments of wool emanating from the trousers and the overcoat, easily recognized by their colour.* The presence in the wound of these very infinitesimal pieces * E. Delorme, Treatise on War Surgery, vol. i., p. 553. FRAGMENTS OF CLOTHING 67 has been confirmed by all those who have carried out similar experiments. Reverdin says that, as a result of his experiments, a wound made through a cloth uniform by bullets having a protecting envelope is, nearly without exception, complicated by the presence of very small debris, especially just under the skin at the aperture of entry. As we have often pointed out, the bullet, when it comes in contact with unyielding fasciae, the fibres of which in most cases it simply thrusts aside, gets rid of the fragments it has carried along. The latter are not only found near the aperture of entry in the subjacent enveloping fasciae, but also in other parts of the track, even in Pirogoff 's pouch — that is to say, between the separated skin and the last layer of aponeurosis traversed by the bullet before reaching the aperture of exit (Reverdin). An interesting fact is the pro}ection of these filaments into the thickness of the tissues all arotind the track at distances we are far from suspecting, sometimes attaining several centimetres. The question dealing with the lodgment of fragments of clothing in wounds is too intimately connected with the evolution of the traumatism for us to neglect its present study ; at this point we can say that it is specially im- portant to recognize the presence of these conglomerations of detached clothing. Now, if diagnosis of metallic foreign bodies is easy, thanks to the methods of exploration now in use, that of particles of clothing seems impossible, as there is nothing to indicate their presence in the midst of the tissues. Such, indeed, would be the case were there not an unfailing means of ascertaining their presence, and that is by direct examination of the clothes themselves. With reference to this question we will formulate the following data : I. Examination of the clothes ^ often impossible, besides being useless, at the front, is absolutely necessary when the wounded man has been removed to the rear. 68 FOREIGN BODIES 2. At the front we should be careful not to sacrifice clothing through which a hdlet has penetrated by cutting it where it has been perforated. A t the rear one should be careful not to deprive the wounded man of his garments^ nor to wash them, as this would alter their aspect. A soiled and torn uniform must not be looked upon as rags, but rather as a trophy ; more- over, it is a valuable component part of a most useful diagnosis, which may have to be renewed by the different surgeons who, in succession, may have the wounded under their charge. 3. When, after the edges of the apertures have been carefully drawn together, we find, in spite of the primary ;and delusive gaping, that there is no notable loss of substance, we may affirm that the wound is free from a conglomeration of pieces of clothing."^ 4. Not only one, but every piece of the wounded man's clothing should be examined, as well as the linings, for linen, being less elastic than cloth, its fragments are frequently more notice- able than those of the latter ; they may even be present as isolated foreign bodies. Diagnosis. — A single wound, hard and painful swelling, localized pain at some distance from the aperture of entry, even in the case of setons, are indicative of the presence of metallic foreign bodies. The numerous methods of exploration and diagnosis that authors formerly dwelt on with such complacency, from the metallic probe to the electric exploring apparatus, have now only an historical value. All these methods are now superseded by radiography, and not only does radiography allow us to attest the * Although in theory it is not important to examine the aperture of exit through which the pieces of clothing might have emerged, as they have already been expelled by the bullet, nevertheless we advise an examination of both apertures, because it is not always possible to diagnose one from the other. TREATMENT 69 presence of foreign bodies, yet it is perhaps going too far to say that it shows us precisely the place where they are located. Wounds in which foreign bodies are thought to be lodged should be examined in the rear by radiography, not by radi- oscopy. If the ambulance is not provided with apparatus, the wounded men should be taken to the nearest hospital to undergo an examination, after which they must be sent back to the point from which they started. Each patient is entitled to one examination. It gives the origin of the mischief. Treatment. — The question as to the expediency of extracting metallic foreign bodies is one that has been greatly discussed. Those lodged in the soft tissues are generally very well tolerated. It is well known nowadays that in this toler- ance their own characteristics, their nature, their form, their size, are not of nearly so much importance as asepsis of the wound. In a septic or suppurating umind a metallic foreign body is not tolerated. Therefore at present, by common consent, it is admitted that — 1. A metallic foreign body, which is tolerated, causing neither uneasiness nor pain, should be left alone. 2. A foreign body that gives rise to pain, is badly tolerated, that causes uneasiness by coming into contact with vessels or nerves, or that is situated in a focus of suppuration, must be removed. 3. A bullet that is almost level with the skin may be removed to gratify the patient, provided that the incision does not open a cavity, and provided also the ablation be done in a permanent shelter where all the usual precautions can be taken. Another reason which militates in favour of this last condition is that certain foreign bodies, which seem to be superficial and easy of extraction in the light of radi- ography, give rise in many cases to difficulties that protract the operation. 70 FOREIGN BODIES 4. A shell fragment that is large, irregtdar, and sharp, and also a shrapnel bullet, must ki^^kys he removed shortly after the traumatism ; this should he done in a permanent shelter either at the front or in the rear. 5. Ablation of these last foreign metallic bodies is speci- ally necessary, because they close the cul-de-sac in which are lodged infecting foreign bodies derived from the clothes, and because ablation of the metallic body is the best way of setting free fragments of wearing apparel. 6. Removal of these last metallic bodies should be carried out very shortly after the traumatism, either immediately or a few days after. Special instruments are not necessary for the extraction of metallic foreign bodies. At the bottom of the exploratory incision, which must be methodically carried out, great care being taken not to injure important organs, a pair of dressing or forcipressure forceps, guided by the surgeon's left forefinger, will suffice for their gentle extraction. CHAPTER VII BONY LESIONS OF THE DIAPHYSES There is no traumatism that brings into such strong relief the striking differences separating war surgery from ordinary surgery as the bony lesions of the diaphyses. A surgeon who considers he can base their treatment on his general ideas would be liable, unfortunately for the wounded, to remain very inferior to the ideal of the duty he has undertaken. The adoption of the new projectiles has brought with it no important modification in the data derived from experi- ments on the dead body, on the one hand, and from experi- ence acquired in recent wars on the other. According to world-wide statistics, lesions of the bones are seen during a campaign in a proportion of one-fifth of all wounds. Cold-steel weapons lead to sections of the diaphyses ; pro- jectiles to contusions, cracks, and fissures^ to fractures by contact, perforation of one side of the bone, perforation right throtcgh, and to grooves. This classification should be adopted by all surgeons, in the first place because it is based on strictly exact and con- stant provisions, in the second place because it originates from our chief practical data. Lesions caused by Projectiles. Contusions. — These are either the result of direct shock or of tangential contact of the projectiles. They are very 71 72 BONY LESIONS OF THE DIAPHYSES frequently produced by bullets, but are often unperceived on account of their giving rise to no immediate signs. At the seat of the contusion the periosteum is involved and destroyed, and the marrow may or may not show either circumscribed or extensive pouring oat of blood. Cracks and Fissures. — Isolated cracks and fissures of the diaphyses are also frequent, but, like bony contusions, they nearly always are unperceived. Wounded men who 5./. oj. .^t-h- -gx ■V. Fig. 7. s./., Symmetrical fissure (direct contact) ; 0/., opposite fissure (tangential contact) ; d.c, direct contact ; t.c, tangential contact. present long fissures of the bones of the lower limbs can walk when left to themselves. A cvach is a cleft whose sides are very near together, and can hardly be seen ; a fissure is a visible cleft whose sides are widely separated. The most remarkable are the longitudinal cracks and fissures, often very extensive ; they are either single or multiple, but some are oblique, some curved. Isolated cracks and Jissuves are outlines of those that fix the limits of fractures by contact, of which they show the direction and position (Delorme). Symmetrical fissure and opposite fissure are the most striking LESIONS CAUSED BY PROJECTILES 73 and the most constant lesions of the diaphyses. The former furrows the side of the bone that has not been hit, and this happens in the plane passing through the point of contact of the projectile. It is the result of direct contact of the bullet (s/.) Opposite fissure is also seen on the side of the bone that has not been hit, but this fissure is found on a perpendicular plane to the track of the projectile. It is the result of a tangential contact {of.). These fissures are seen on all the long bones. Absolute diagnosis up to now has been very difficult, for neither in Direct. Indirect. 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