Fig. 43.Fig. 43.
Four Soft-nosed Bullets of small calibre shown in fig. 37. Twenty large-calibre leaden carbine and rifle bullets from cartridges found in Boer arsenals. These were not very extensively used, but specimens of most varieties were at times removed from our wounded men. It will be noted that some are of great weight, and a large proportion either cupped or flattened at the apex to increase area of impact and consequent resistance. The 'express' bullet with a copper core is included in this series. It is worth remarking that all the bullets of this nature in the Pretoria Arsenal were waxed, and that the wax retained its white colour on the lead.
I still, however, incline to the opinion that the bullet in these cases had come into contact with some bone, or was one of the larger varieties of projectile. A few cases of wound of the calf did, however, come under my observation which presented fairly typical 'explosive' characters without evidence of solution of continuity of the bones. I will shortly recount two of them. In the first the exit opening was very large and on the outer aspect of the limb in the upper third. The bullet had apparently passed between the bones. Secondary hæmorrhage from the anterior tibial artery necessitated exploration of the wound and ligature of the vessel (Mr. Carré). When the wound was thus laid open no injury to the bones could be detected, but I do not consider that it could be actually excluded. In the second case a wound traversed the calf transversely, just above the centre; the exit aperture was large and ragged. Deep suppuration occurred, and the wound had to be laid open, when a fracture of the tibia without solution of continuity was discovered. I also saw one or two wounds of the buttock in which very large exit apertures were present with small entry openings; in these again it was impossible to exclude passing contact of the bullet with a part of the pelvic wall. Unfortunately in all these cases it is impossible to obtain the bullet responsible for the injury. In this relation I append a diagrammatic illustration of a peculiar wound shown to me by Mr. Hanwell. In this case a typical small entry wound was situated at the outer margin of the left erector spinæ muscle in the loin. The bullet had taken a subcutaneous course of not more than three-quarters of an inch, while the exit opening was a long shallow wound measuring 4½ in. in length by 1½ in. width. (Fig. 44.)
The wound was stated to have been received at a distance of from fifty to a hundred yards. I think we can scarcely assume that impact with the margin of the erector spinæ could have resulted in 'setting up' of the bullet, while an irregular tongue of skin at the point where the wound crossed the spines of the lumbar vertebræ did suggest possible bony contact. That the latter must have been of the slightest nature is evident, as no signs of concussion of the spinal cord were noted. I should rather be inclined to compare this case to one of gutter wound quoted on p. 56, and to assume thatthe bullet passed so closely beneath the surface as either to entirely sever the skin, or at any rate to allow it to give way on flexion of the back on movement.
Fig. 44.Fig. 44.
Small Circular Entry, large 'explosive' skin wound of back. Track only an inch or less in length (see text)
On the ground of the observations made in the foregoing pages it will be gathered that the opinion I formed was against either the very free use or the great wounding power of so-called expanding bullets of small calibre. I believe that a great number of the injuries which were attributed to the employment of these missiles were produced either by ricochet regulation bullets of small calibre, or by large leaden bullets of the Martini-Henry type.
Symptoms.—I very much doubt whether the general symptoms observed as the result of wounds from bullets ofsmall calibre differ in more than slight degree from those described when larger bullets were regularly employed. Great variation was met with, but I do not think a diminution in serious results in this direction corresponding to the comparatively limited nature of the direct injury to the organs or tissues can be affirmed. It is true that the immediate symptoms in many patients were amazingly slight, but after all, this has always been a feature of gunshot injuries on the field of battle and cannot be assigned a position of distinctive importance.
1.Psychical disturbance and shock.—Some remarkable instances of psychical disturbance were observed, and although perhaps in no way influenced by the calibre of the projectile, they seem worthy of note in this place. Thus a patient wounded over the cervical spine and who suffered later with a slight degree of spinal concussion emitted an involuntary shriek like that of a wounded hare on being struck; another (Martini wound), after receiving a wound of the chest, lost all sense of his surroundings for a considerable period, and occupied himself in attempts to write on a white stone lying near him on the veldt; then suddenly realising his position he was greatly bewildered in trying to account for his own action. A similar instance of preoccupation is probably offered by the dead man in the accompanying photograph (fig. 45), whose arms, forearms, and hands had evidently been in play until the actual moment of death. Again the influence of the psychical state on the actual occurrence of shock was often illustrated by the mental condition of the wounded after a battle; thus after the battles of Belmont and Graspan the patients came into hospital in excellent spirits, and minimised their injuries in the wish of rapidly regaining the front; while after the battle of Magersfontein the men were depressed and miserable, shock was more pronounced, and their sufferings were undoubtedly greater.
On the whole, however, shock was by no means a prominent symptom in the small-bore injuries of soft parts, and was possibly less than when larger bullets were the rule, and again it was often remarkably slight after the infliction of serious visceral injury. Still shock was observed in aconsiderable proportion of the patients, and its occurrence appeared to vary under very much the same conditions as obtain in civil practice. Grades of severity depended on individual idiosyncrasy, on the degree of excitement or preoccupation at the moment of injury, and to a certain degree on the range of fire at which the injury was received.
Fig. 45.Fig. 45.—Note position of head, neck, and forearms in upper figure
The last is the only special factor, and as far as my observation went it was one of considerable importance. When the soft parts only were affected, even high velocity did not produce much effect; but when to a flesh wound a severe bone fracture or injury to any part of the nervous system was added, shock might be severe or profound. The question of shock dependent on visceral injury will be considered in succeeding chapters, but it may be well to state here that the most severe shock appeared to follow injuries to the central nervous system especially to the spinal cord, fracture of the larger bones, and wounds of the abdominal and thoracicviscera, the latter especially when the cardiac neighbourhood was encroached upon: hence the severity depended almost solely on the importance of the part injured and the degree of damage inflicted. I never observed instances of entire absence of shock in visceral injuries, unless the range of fire had been an especially long one.
To these remarks on constitutional shock I should add a few on the 'local shock' exhibited by the actual part of the body struck. The phenomena were of a severity I was quite unacquainted with in civil practice, and apparently were attributable to the local vibration transmitted to the whole structure of a limb or part of the trunk. In many fractures, and in some wounds of the soft parts alone, without the direct implication of any large nerve trunk, the loss of functional capacity of the limb was complete, and this condition persisted for hours or even days.
2.Pain.—As an initial symptom the occurrence of pain varied greatly with the idiosyncrasy of the patient, and according to the circumstances under which the wound was received. Some individuals are remarkably insensitive, and in these the fact of a wound being a gunshot injury in no way altered their habitual insensibility, but in persons of what may be termed the normal type in this particular great differences were observed.
When a wound was received in the full excitement of battle during a rapid advance, pain was often slight, or so trifling in degree that it was almost unnoticed; many patients did not realise that they had been struck until a second wound, possibly implicating a bone or some specially sensitive structure, was superadded. In such instances the pain was often described as 'burning' in character, or even likened to a 'sting from an insect.' Occasionally the pain was referred to a distant part; thus a man struck in the head first felt pain in the great toe, and another struck in the abdomen also felt pain in his foot only. Again in some multiple injuries, pain was only felt in the more sensitive of the regions implicated; thus a patient in whom a bullet (Martini) traversed the arm and chest emerging in the neck to again enter the chin and comminute the mandible, only felt painin the chin and first realised that he had been wounded elsewhere when he undressed. A striking instance of the entire absence of initial pain was afforded by a man shot through the buttock, the bullet then traversing the abdomen: this patient remained unaware that he had been hit until on undressing he found blood in his trousers and exclaimed: 'Why I have got this bloody dysentery!' None the less his internal injuries were sufficiently severe to lead to death during the next thirty-six hours.
Although initial pain might be slight or absent, practically all the patients complained of some of varying severity at the end of an hour after reception of the wound.
In a large proportion of the wounded, however, pain was more or less severe from the first, and this was especially the case when the men had been exposed to fire for some hours behind inadequate 'cover.' The most common descriptions under these circumstances were that they felt as if they had been struck by 'a brick,' 'a ton of lead,' or 'a sledge-hammer.'
3.Hæmorrhage.—This question is fully treated under the heading of injuries to the blood-vessels. It will suffice here to say that hæmorrhage was rarely of a dangerous nature so far as life was concerned, unless the large visceral vessels or those in the walls of serous cavities were concerned, when death was often rapid. From limb wounds, even when the largest trunks were implicated, the general tendency was to spontaneous cessation of the hæmorrhage. Consequently, except these patients were seen on the field, one seldom had to deal with serious bleeding. None the less, the condition of the patients' clothes bore testimony to a free rush immediately after the injury, and pools of blood were occasionally found where patients had lain. In nearly all cases the rush of the bullet determined the initial flow of the blood from the exit wound, and this aperture usually furnished any hæmorrhage of importance.
Diagnosis.—The only diagnostic point which it is necessary to consider in this chapter is the determination of the nature of the bullet which has caused the particular injury under observation, and this is more a matter of interest than importance.
The primary indication lies in the size of the aperture of entry, which naturally varies with the calibre of the bullet employed, and the difference, except in the case of large projectiles, is not always easily determined, unless we can be sure that the impact of the bullet was at right angles. In the latter case it is possible to distinguish even between, for instance, a Lee-Metford and a Mauser wound, if the resistance likely to be offered by the part struck is kept in mind. A ricochet bullet, on the other hand, may upset all our calculations, if size alone be taken as an indication; but here the irregularity of the wound often serves to exclude one of the larger varieties as the cause. The appearances of the exit wound are less useful in determining the nature of the bullet employed, as irregularities of outline are so much more common whatever projectile may have emerged; but examination of this wound often gives us useful information as to the existence of an injury to the bones not involving loss of continuity.
Fig. 46.Fig. 46.
Two flattened Leaden Cores to illustrate means of determination of nature of bullet. Note ring at base. The right-hand bullet is probably a 'man-stopping' revolver bullet; it flattened against bone
Other information beyond that furnished by the external wounds may be gleaned from the presence of fragments of lead in the wound; these, if unaccompanied by portions of casing, afford some presumptive evidence of the use of an unsheathen bullet, especially if found on the fractured surface of thebones; but it must be borne in mind that in the case of ricochet bullets the leaden core often perforates when entirely freed from its mantle. Pieces of the mantle again may give useful information both from examination of their thickness and composition. Lastly a naked core nearly always retains the marking on its base corresponding to the turning over of the mantle, this not being likely to suffer impact calculated to efface the groove. When this groove existed the employment of any of the soft-nosed bullets used in this campaign might be safely excluded (fig. 46).
Prognosis.—The question of general mortality amongst the wounded has already been considered (Chapter I. p. 11), and it has been shown, putting aside those dying at once on the field, or during the first twenty-four hours, that the mortality was a low one. Some other points specially dependent on the nature of the injury are, however, worthy of mention in this place. First, it has been shown, with a slight reservation as to when a wound can be considered definitely sound, that if suppuration did not occur, healing was rapid, and that many men with slight wounds were back with their regiments in the course of a very few days. Again, that suppuration when it did occur tended to be local in character; none the less, if it was at all extensive, it often proved very prolonged and difficult of treatment, while residual abscesses after apparent healing were not uncommon. In connection with this subject I may quote from Colonel Stevenson[12]an observation that limbs the subject of marked local shock are especially liable to furnish septic discharges. Parts the subject of local shock when infected show a lesser degree of vitality and power of resistance to the spread of infection than do normal ones, and if infected do badly. I think I convinced myself of this on many occasions, and also of the fact that cases of fracture in which this condition was marked were slow in consolidating. Again I am inclined to think that the bad results which sometimes followed the tying of the limb arteries were also consequent on lowered vitality, and possibly vaso-motor disturbance due to the effects of the exquisite vibratory force to which the nerves had been subjected. Onthis account I was never anxious to hurry operations in such cases, unless obviously necessary at the moment.
The larger question of general nervous breakdown as the result of injuries from bullets of small calibre is at present hardly capable of an answer, and is so complicated by the co-existence of concurrent mental anxiety, exposure, &c., that a definite answer will always be difficult. I think there is already sufficient evidence, however, to suggest that the remote effects of many of these injuries may be far more serious than we expected at the moment, especially in the direction of sclerotic changes in the nervous system.
Treatment.—In view of the remarks on the treatment of special injuries contained in succeeding chapters, I shall confine myself here to the question of the treatment of wounds of the soft parts alone.
This consisted during the campaign in the primary application of the regulation first field dressing by one of the wounded man's comrades, an orderly, or less commonly an officer or a medical man. This dressing is composed of a piece of gauze, a pad of flax charpie between layers of gauze, a gauze bandage 4½ yards long, a piece of mackintosh water-proof, and two safety pins, enclosed in an air-tight cover. Mr. Cheatle,[13]in insisting on the importance of an immediate antiseptic dressing in the field, recommends the following. A paste contained in a collapsible tube, made up in the following proportions: Mercury and zinc cyanide grs. 400, tragacanth in powder gr. 1, carbolic acid grs. 40, sterilised water grs. 800; sufficient bicyanide gauze and wool for the dressing of two wounds, a bandage, and four safety pins; the whole enclosed in a mackintosh bag. The paste possesses the advantage over any liquid or powder, that it can be applied in any position of the body to severe wounds, and its application in the open air is not interfered with by draughts of wind. Mr. Cheatle used a similar preparation with success during the campaign.
On arrival at the Field hospital, or in some cases at the station of the bearer company, the wounds were then commonly dressed as follows: The parts around the woundwere cleansed with an antiseptic lotion, either solution of perchloride of mercury 1 in 1,000, or 2½ per cent. solution of carbolic acid. The wound itself was then cleansed, and a dressing of double cyanide of mercury and zinc applied. This was covered with a pad of wool and secured with a bandage. The gauze was usually wrung out in the lotion before application as a precaution against previous contamination, and the moistening was also useful as helping to ensure the dressing from subsequent displacement. It was early recognised that the drier the dressing the better, and hence anything like a mackintosh layer was carefully avoided. In some instances, antiseptic powders were employed, but they did not find much favour, and because they tended to favour slipping of the dressing, and to prevent the adhesion of the gauze dressing to the wound, they were certainly not desirable when there was any necessity for the patient to travel. In the absence of reliable water the use of antiseptic lotions was obligatory, and such is likely to be the case in most campaigns; in the present one, filtration of the thick muddy water was impossible, without a considerable expenditure of time, which could only be obtained when the hospitals were fairly stationary. I very much preferred carbolic acid lotions.
The wound having been once cleansed, or rather the surroundings of the wound, the drier the surface was kept the better; hence a too heavy or impervious dressing was not satisfactory; in point of fact, I think some of the slighter wounds in which all the dressings slipped off, and in which there was less consequent chance of the dressing being moistened with the sweat of the patient, did as well as any.
I do not think the bicyanide gauze, absorbent wool, and common open-wove bandages, together with a good supply of nail brushes, soap, and carbolic acid for the primary disinfection of the skin and the external wound, are to be greatly bettered at the present day as materials for the first permanent dressing of cases in the field. The wound itself should be carefully shielded during the preliminary cleansing of the skin by a firmly applied antiseptic pad, and then the dressing applied as above described. The one desirable improvement is some mode of ensuring the dressing being kept in goodposition, and for this some form of adhesive covering for the gauze and wool should be devised. When the atmosphere is such as to allow of rapid drying, thin moistened book-muslin bandages would be preferable to the plain open-wove ones. The one period of danger is that of transport, and when that is over, the dressing in Stationary or Base hospitals should give no trouble.
As a rule the wounds themselves need no interference, but in some instances either the exit or entrance wounds may be in undesirable positions for purposes of asepsis, when a large opening may seem safer closed and actually sealed. I saw this method tried in a few cases, but without much success. It is one which might be of much use in Base hospitals if the patients were brought directly into them, but in the Field hospitals, in face of the rush with which the first dressings have to be done, I think it is seldom applicable, and consider the interference with the wound as rather likely to increase the danger of infection than to decrease it.
Dressings should not be too frequent; two should suffice for simple wounds with type forms of entry and exit; there is little discharge and usually no bleeding: hence the more the dry scab form of healing can be simulated the better. When a dressing needs changing from fouling of its outer parts, it is preferable to cut round the adherent part of the deep layers and apply some fresh gauze over the central scab rather than to remove it. One point should be kept in mind: the first dressing in the Field hospital seals the fate of the wound as to the chances of primary union, and hence too much care is impossible with it.
Operations in the Field hospitals were proportionately not numerous, and they should be kept down in number, as far as possible. At the same time such operations as are necessary are mostly of capital importance, such as the treatment of fractures of the skull, abdominal section, the ligature of arteries, and amputations. Of these only the first and last classes occur with any degree of frequency. In order to be prepared for these a stock of filtered water which has been boiled, and some special sterilised sponges, should be at hand if possible, also some small towels which can bewrung out in antiseptic lotion. If sterilised sponges are not to be had, wool pads wrung out in carbolic lotion must be substituted.
Primary amputations bore transport badly. I saw few sent down from the front within a few days of their performance in which the flaps did not slough, or worse consequences ensue. On the other hand, if the first fortnight could be tided over at the front, they did well enough. The head cases on the other hand bore movement fairly well, provided only that asepsis was ensured.
Retained bullets are rarely suitable for removal in the rush of the first work of a Field hospital after an engagement. A short delay is of no importance, and ensures their being removed safely if necessary. With regard to the broad question of the advisability of removing them at all, it may be laid down that they should not be interfered with unless some obvious reason exists. Those most commonly calling for removal are as follows: 1. Bullets lying immediately beneath the skin or quite superficially in any region, or those which, although they have produced an exit opening, yet lie within the body. 2. Those which lie at the bottom of an infected track, or cause secondary suppuration. 3. Those causing pressure on important structures, particularly nerves. 4. Those which interfere with the movements of joints when lodged in the bones or soft tissues in close proximity, or those which lie within the articular cavity itself. Bullets sunk in the great body cavities or in positions difficult of access should never be interfered with. Retained bullets sometimes give rise to unexpected surprises; thus in a man with a retained bullet in the pelvis no steps for its removal were taken. During the man's voyage home on a transport he had an attack of retention of urine. As a catheter would not pass, he was placed in a warm bath, and shortly after passed a Mauser bullet per urethram, and thus saved himself a cystotomy.
One word may be added as to the treatment of shock when severe. Quiet in the supine position, and the administration of a small amount of stimulant, was usually all that was required. Hypodermic injections of strychnine sulph. grs. 1/30 to 1/10 were useful, and in some severe cases, especially whereoperations were needed, saline infusions with a small amount of stimulant were made into the veins, either at the elbow, or in amputation cases into one of the large veins exposed.
The treatment of hæmorrhage is dealt with in Chapter IV.
The after treatment of simple wounds needs little comment, but bearing in mind what has been said as to the definite healing of the internal portion of the tracks, it will be obvious that in parts such as the thigh or calf, care was needed as to not commencing active work at too early a date. On the other hand, a too long period of absolute rest is also to be deprecated. The best results were obtained by careful movement and massage, commenced after the first week or ten days, according to the appearance presented by the external wound, followed by a gradual resumption of active movement. It was a striking fact that some of the patients suffering from such wounds took longer to become apparently well than many of those who had suffered visceral injuries.
FOOTNOTES:[9]Loc. cit.p. 31.[10]Loc. cit.p. 100.[11]Loc. cit.pp. 54, 55.[12]Wounds in War, p. 83. Longmans & Co. 1897.[13]A First Field Dressing,Brit. Med. Jour.1900, vol. ii. p. 668.
[9]Loc. cit.p. 31.
[9]Loc. cit.p. 31.
[10]Loc. cit.p. 100.
[10]Loc. cit.p. 100.
[11]Loc. cit.pp. 54, 55.
[11]Loc. cit.pp. 54, 55.
[12]Wounds in War, p. 83. Longmans & Co. 1897.
[12]Wounds in War, p. 83. Longmans & Co. 1897.
[13]A First Field Dressing,Brit. Med. Jour.1900, vol. ii. p. 668.
[13]A First Field Dressing,Brit. Med. Jour.1900, vol. ii. p. 668.
The small calibre of the modern bullet, and its tendency to take a direct course, naturally favour the occurrence of more or less uncomplicated wounds of the large vascular trunks, and both the nature of these wounds and the results which follow them are in some respects most characteristic.
1.Contusion or laceration without perforation.—(a)The vessel may be struck laterally, the injured portion then forming a part of the bounding wall of the wound track, or (b) one or more layers of the vessel wall may be destroyed over a limited area. Given primary union, these conditions are only of importance in so far as subsequent contraction of the lumen of the vessel may result from implication in the neighbouring cicatrix. One of the most striking features of the wounds as a whole was seen in the hair-breadth escapes of the large limb vessels with no subsequent ill effects, and such injuries were seen in every situation.
In a certain proportion of wounds in close proximity to large vessels, however, a diminution of the normal calibre of the arteries was observed, either shortly after the injury or later in the advanced stages of cicatrisation. As an example of early obstruction, the following may be related. A Mauser bullet passed from the inner side of the thigh across the neck and great trochanter of the femur beneath the femoral vessels, and probably struck and grooved the bone, since the aperture of exit was large and irregular, some 3/4 of an inch in diameter. One week later no pulse was palpable in either anterior or posterior tibial arteries at the ankle, andpulsation which was strong in the common femoral artery was very weak in the superficial femoral. Slight fulness existed in the hollow of Scarpa's triangle, but not sufficient to make any serious difference in the contour of the two limbs. No thrill or abnormal murmur was discoverable. There was no œdema of the limb, which was also normal in temperature. The patient was kept at rest in the supine position for three weeks, during which time the tibial pulses gradually returned. Three weeks later he was invalided home, the pulses, however, still remaining considerably smaller than normal.
In the advanced stages of cicatrisation narrowing of the lumen of the trunk vessels was far from uncommon, especially in cases of wounds of the arm crossing the course of the brachial artery; in many of these the radial pulse was diminished almost to imperceptibility. How far this condition may prove permanent there has been little opportunity of judging; nor as to the possible ultimate weakening of the vessel wall and the development of a secondary aneurism has time allowed the acquisition of experience. In the light of the observation of so many cases in which large vessels were wounded without the occurrence of severe hæmorrhage, either primary or secondary, it is impossible to be certain whether some of the cases of arterial obstruction were not secondary to perforating lesions of the vessels.
Pressure on, or minor lesion of the vessel was sometimes evidenced by the development of a murmur, as in the following case. A Mauser bullet entered immediately within and below the left coracoid process, and emerged at the back of the arm at its inner margin, 2½ inches above the junction of the right posterior axillary fold. During the first week dysphagia and some pain and soreness in the episternal notch, with pain and difficulty of respiration, were noticed. Eight weeks later no trouble with the pharynx or œsophagus remained, but a short sharp systolic murmur was audible over the first part of the left axillary artery, which could be extinguished by pressure on the subclavian; the radial pulse was normal.[14]
When primary union failed or was prevented by infectionand suppuration, lesions, although incomplete, of the vessel coat naturally frequently gave rise to secondary hæmorrhage.
2.Perforation of the vessels.—(a) This may be oblique or transverse to the long axis of a trunk; when the vessel is impinged upon laterally, an oval or circular notch, as the case may be, is produced; or (b) the bullet may strike more or less in the centre of the vessel, perforating both in front and behind, while lateral continuity is maintained; (c) beyond these degrees a vessel may, of course, be completely divided. Cases of notching of the vessel will be referred to under the heading of traumatic aneurism; those of perforation under that of aneurismal varix and varicose aneurism, the perforations in these cases affecting a parallel artery and vein.
1.Hæmorrhage.—The fact that hæmorrhage was not a prominent feature in the wounds received during this campaign can scarcely be regarded as an experience confined to injuries caused by bullets of small calibre. The same observation was often made in the case of larger bullets in old days, and the absence of severe hæmorrhage has previously been regarded as a special characteristic of gunshot wounds. None the less, as high a proportion as 50 per cent. of deaths occurring on the field in earlier days has been ascribed to this cause.
Unfortunately no new facts can be furnished on this point, although a few cases of rapid death from primary hæmorrhage will be found recounted under the heading of visceral injuries. Beyond these the general evidence offered by observations on men brought in from the field with vascular injuries, was opposed to the frequent occurrence of death from hæmorrhage, at any rate of an external nature. This subject will be dealt with under the classical three headings of primary, recurrent, and secondary hæmorrhage.
Primary hæmorrhage.—A marked distinction needs to be drawn between external and internal hæmorrhage. External hæmorrhage from the great vessels of the limbs, or even of the neck, proved responsible for a remarkably small proportion of the deaths on the battlefield. This statementmay be made with confidence, since it is not only my own experience, but coincides with what I was able to glean from many medical officers with the Field bearer companies. It is, moreover, supported by the facts that cases in which primary ligature had been resorted to were extremely rare at the Base hospitals, while, on the other hand, traumatic aneurisms and aneurismal varices of any one of the great trunks of the neck and limbs were comparatively common. Again, primary amputation for small-calibre bullet wounds, except when complicated by severe injury to the bones, was so rare as to render more than doubtful the frequent occurrence of severe primary hæmorrhage on the field. Only one case of rapid death due to bleeding from a limb artery was recounted to me. In this a wound of the first part of the axillary artery proved fatal in the twenty minutes occupied by the removal of the patient to the dressing station. The amount of hæmorrhage in many instances was no doubt checked by the application of pressure at the time of the first field dressing; but it can scarcely be argued that such dressings as were applied were of sufficient firmness to control bleeding from such trunks as the brachial, femoral, or carotid arteries.
The spontaneous cessation of hæmorrhage is rather to be ascribed to the special method of production and the consequent nature of the wound. The lesions were the result of immense force strictly localised in its application, which might well induce very complete and rapid contraction of the vessel wall; while the track in the soft parts was not only narrow, but also lined by a thin layer of tissue possibly so devitalised superficially as to specially favour rapid coagulation of the blood. Beyond this the tracks were often sinuous when the position of the limb at the time of reception of the injury was replaced by one of rest. The influence of mere narrowness of the track is illustrated by classical experience in the development of aneurismal varices after stabs by knives or bayonets; and in the injuries under consideration the frequent development of large interstitial hæmorrhages into the tissues of the limbs indicated that blood does not readily travel along the wound track. It was noteworthy that when hæmorrhage did occur it was most free from, or often limitedto, the wound of exit. This is due to the direction of the active current set up by the rush of the bullet through the tissues. The mechanical factor is, no doubt, the most important.
Control of primary hæmorrhage from a wounded vessel by the impaction of a foreign body was of much less frequent occurrence than appears to have been the case with the older bullets. I saw a case in which, on removal of a fragment of shell (Mr. S. W. F. Richardson), very free hæmorrhage occurred from a wound of one of the circumflex arteries of the thigh, but not a single one in which a similar result followed the extraction of a bullet of small calibre. The comparative infrequency of retention of modern bullets is probably one of the main elements in this relation. A very curious instance of provisional plugging of a wound in the upper part of the brachial artery by an inserted loop of the musculo-spiral nerve was related to me by Mr. Clinton Dent. This instance must, I think, be regarded as an accident definitely dependent on the size and outline of the bullet and on the nature of the force transmitted by it to neighbouring structures.
While, however, deaths from external primary hæmorrhage were rare, a considerable number resulted from primary internal hæmorrhage. In some of these, injury to the largest trunks in the thorax or abdomen led to an immediately fatal issue; in others wounds of the large visceral arteries, as of the lungs, liver, or mesentery, were scarcely less rapid in their results. In such cases the potential space offered by the peritoneal or pleural cavities favours the ready escape of blood from the wounded vessel, while the tendency of the blood effused into serous cavities to rapid coagulation is notably slight. Beyond this the comparative deficiency in direct support afforded by surrounding structures to vessels running in the large body cavities is also an important element in their behaviour when wounded.
These remarks receive support from the observation that few, if any, patients survived an injury to the external iliac vessels within the abdomen, while the remarkable instances of escape from fatal hæmorrhage from large vessels recorded below (cases 1-19) indicate that the mere size of a wounded vessel is not to be regarded as the sole factor in prognosis.
Recurrent hæmorrhagewas occasionally met with both in the case of the limb and trunk vessels. In the limbs it often necessitated ligature of the artery. I saw several cases in the lower extremity where recurrent hæmorrhage on the second or third day was treated by ligature of the femoral or popliteal artery, and it also occurred during the course of development of one of the carotid aneurisms recounted below. On two occasions I saw rapid death follow recurrent abdominal hæmorrhage; in one I was standing in a tent when a man who had been wounded the day before suddenly exclaimed: 'Why, I am going to die after all.' The appearance of the man was ghastly, and on examining the abdomen it was found greatly distended, and with dulness in the flanks; the patient expired a few minutes later. Another example of recurrent abdominal hæmorrhage is related in case 169, p. 432.
Secondary hæmorrhage.—In simple wounds of the soft parts bysmall-calibre bulletsthis was decidedly rare. In wounds complicated by fractures of the bones, especially when they exhibited the so-called 'explosive' character, secondary hæmorrhage was not uncommon, and this not necessarily in conjunction with infection and suppuration.
In the chapter on fracture some remarks will be found on the prolongation of healing often observed in the exit portion of the wound track, which is explained by the well-known fact that, given an aseptic condition of the wound, sloughs of tissue separate very slowly. Secondary hæmorrhage in these cases is due to lesions of the vessel short of perforation, but severe enough to so lower the vitality that local gangrene of the wall occurs. In such instances hæmorrhage most usually occurred on the tenth to the fourteenth day, but occasionally still later. In one instance of ligature of the anterior tibial artery for such hæmorrhage three-quarters of the whole lumen of the vessel had been devitalised. The resemblance of some cases of secondary hæmorrhage of this class to those occasionally observed after amputation, and due to accidental non-perforative injury of the artery at the time of operation above the point of ligature, was very striking.
In other cases secondary hæmorrhage was the result of perforation of the vessel by a sharp spicule of bone, but inthe large majority sepsis and suppuration were the cause. Naturally therefore the accident was commoner in the more severe kinds of wound, and in those caused bylargebullets or fragments of shell. The symptoms in nearly all cases were the classical ones of repeated small hæmorrhages followed by a sudden copious gush.
The forms of secondary hæmorrhage, however, which afforded most interest were the interstitial and the internal, mainly on account of the scope they allowed for diagnosis.
Characteristic examples of internal secondary hæmorrhage are furnished by cases of chest injury accompanied by hæmothorax and fully dealt with under that heading (Chapter X.). Cases of interstitial secondary hæmorrhage are also described under the heading of traumatic aneurism and abdominal injuries (No. 194, p. 445). It therefore suffices here merely to remark on the diagnostic difficulties the condition gave rise to. These mainly depended upon the elevation of general bodily temperature by which the hæmorrhage was often accompanied. Further evidence of the condition was furnished by the development of local swellings, or physical signs indicative of the collection of fluid in a serous cavity. These signs developed rapidly, and the rise of temperature was sudden and decided enough to suggest commencing suppuration. In several cases incisions were made under the supposition that this had already occurred.
The fever accompanying blood effusions was generally a somewhat special feature in the wounds of the campaign. At first bearing in mind that in every case a track, even if closed, led from the surface to the effused blood, one was disposed to suspect an infection of the clot of a somewhat innocuous nature. The absence of subsequent suppuration, however, was definitely opposed to this view, and suggested that the fever resulted from absorption of some element of the blood, possibly the fibrin ferment, or some form of albumose. A pronounced illustration was in fact afforded of the evanescent rise of temperature usually the accompaniment of simple fractures in the case of the limbs, and of the more marked rise not uncommon in cases of traumatic blood effusion into the peritoneal cavity, or when the pleuræ or jointswere the seats of the mischief. In the case of interstitial hæmorrhages I only remember to have seen fever of such marked continued type in the subjects of hæmophilia with recent effusions, although one is of course acquainted with it in a less pronounced form as a result of hæmorrhage into operation wounds.
In primary interstitial hæmorrhages a similar continued rise of temperature was also common, and I cannot perhaps better illustrate its character than by the brief relation of two instances.
In a patient wounded at Kamelfontein the bullet entered four inches below the acromion, pierced the deltoid, splintered the humerus, and crossed the axilla. A large blood extravasation developed in the axilla, accompanied by cutaneous ecchymosis extending halfway down the arm. There was no perceptible pulsation in either the brachial or radial artery, but the limb was warm. There was partial paralysis of the parts supplied by the ulnar and musculo-spiral nerves and complete loss of power and sensation in the area of distribution of the median nerve. Six months later the radial pulse was still absent in this patient, but there was no sign of the development of an aneurism.
Temperature Chart 1.Temperature Chart 1.
Axillary Hæmatoma. Shows range of temperature during process of absorption and consolidation without suppuration
The accompanying temperature chart is characteristic.The blood effusion gradually gained in consistency and underwent steady diminution in size. No suppuration occurred.
The median paralysis was found to be accompanied by the inclusion of the nerve in a sort of foramen of callus, when the patient was explored at a later date by Mr. Ballance.
In a patient wounded at Paardeberg, a Mauser bullet entered by the left buttock, pierced the venter ilii, traversed the pelvis, and emerging at the brim of the latter, crossed the back, fractured the spine of the fourth lumbar vertebra, and escaped below the twelfth right rib. The track suppurated where it crossed the back, but the man did well until the twentieth day, when a swelling developed in the left iliac fossa and the general temperature rose to 102°. An abscess was at once suspected and the swelling incised by Major Lougheed, R.A.M.C. A large subperitoneal hæmatoma only was discovered, and evacuated. The temperature at once fell and the after progress was uneventful, the wound healing by primary union.
Primary.—No deviation from the ordinary rules of surgery should be necessary in the majority of cases, but in a certain number the conditions are so unusual that the special considerations must be taken into account. The natural tendency to spontaneous cessation of primary hæmorrhage in small-calibre wounds is the first of these. Experience has shown that often mere dressing, or at any rate slight pressure, suffices to efficiently stanch immediate bleeding. Although, however, immediate control is to be obtained by such means, the cases of traumatic aneurism of every variety related in the next section show that the ultimate result is in many such cases by no means satisfactory.
Under these circumstances it may be said that the classical rule of ligation at the point of injury should never be disregarded. Against this, however, certain objections may be at once raised; thus in many cases both artery and vein need ligature, a consideration of much importance in the case of such vessels as the carotid and femoral arteries. Again inmany of the injuries to the popliteal artery the wound directly communicated with the knee joint, a complication which, while it may be disregarded in civil practice, must take a much more important place in the circumstances under which many operations in military surgery are performed.
On the whole, it seems clear that the military surgeon must be guided by circumstances, since it may be far better to risk the chances of recurrent hæmorrhage, or the development of an aneurism or varix, all of which are amenable to successful treatment later, than those of gangrene of a limb or softening of the brain. As a general rule, therefore, on the field or in a Field hospital, primary ligature of the great vessels is best reserved for those cases only in which hæmorrhage persists, while in those in which spontaneous cessation has occurred, or in which bleeding is readily controlled by pressure, rest and an expectant attitude are to be preferred.
A word must be added as to the objections to distant proximal ligature for primary or recurrent hæmorrhage. In some situations this may be unavoidable, and it is sometimes successful, but none the less it is opposed to all rules of good surgery and a most uncertain procedure. It leaves the patient exposed to all the risks attendant on the employment of simple pressure. In one case which I saw, the third part of the subclavian artery had been ligatured for axillary bleeding; secondary hæmorrhage, as might have been expected, occurred, and that as late as five weeks after the operation. In another case ligature of the femoral artery for popliteal hæmorrhage was followed by the development of a traumatic aneurism in the ham.
Secondary.—In secondary hæmorrhage the treatment to be adopted depends upon the nature of the case. When the wound is aseptic, and bleeding the result of the separation of sloughs, local ligature is the proper treatment, and this was often successfully adopted, especially in the case of such arteries as the tibials. In septic cases, on the other hand, it is usually far better if possible to amputate, unless the general state of the patient and the local conditions are especially favourable.
When neither amputation nor direct local ligature ispracticable, proximal ligature may be of use. Sometimes this may be obligatory in consequence of the difficulties attendant on direct local treatment. I saw a few cases successfully treated in this manner: in one the common carotid was tied (Mr. Jameson) for hæmorrhage from an arterial hæmatoma in connection with the internal maxillary artery. Although ligature of the external carotid would perhaps have been preferable, the result was excellent. When even this expedient is impracticable, local pressure is the only resort.
Lastly, as to the treatment of secondary interstitial blood effusions, I believe the best initial treatment is the expectant. If interference is needed, it is much more likely to be satisfactory the more chronic the condition has become, since the source of the bleeding may be impossible to discover. I never saw a patient's life endangered by the amount of such hæmorrhage, but if this should seem to be likely, local treatment is of course unavoidable. In several cases quoted below, incision and evacuation were followed by excellent results; in any such operation too much care to ensure asepsis is impossible.
The experience of the campaign fully bears out that of the past as to the steady increase of the number of aneurisms from gunshot wounds in direct ratio to diminution in the size of the projectiles employed. Every variety of traumatic aneurism was met with, and most frequently of all, perhaps, aneurismal varices and varicose aneurisms. While so experienced a military surgeon as Pirogoff could say, in 1864, that he had never seen a case of aneurismal varix, every young surgeon lately in South Africa has met with a series. Again, although the condition is a well-known one, it has been rather in connection with civil life; for the great majority of recorded cases were the result of stabs or punctured wounds such as are liable to be received in street brawls, or as a result of accidents with the tools of mechanics. Thus of ninety cases collected by K. Bardeleben in 1871, only 12 or 13.33 per cent. were the result of gunshot wound.
False traumatic aneurism or arterial hæmatoma.—This condition was met with comparatively frequently, and bears a very close relation to that already described under the heading of interstitial hæmorrhages. The latter might almost have been included here, since the difference between the two conditions depended merely on the size of the vessels implicated. The exact correspondence in the period of development of some of the arterial hæmatomata, and of the occurrence of the aseptic form of secondary hæmorrhage, also explains the pathology of the two conditions as identical; except that in the former the effused blood is retained in the tissues, while in the latter it escapes externally. The history of these cases was uniform and characteristic. A wound of the soft parts, or sometimes a fracture, was accompanied by a certain degree of primary interstitial hæmorrhage, which might or might not have been associated with external bleeding. A hæmatoma resulted in connection with the wounded vessel, the general tendency in the effusion being to coagulation at the margins and subsequent contraction. Meanwhile the opening in the artery became more or less securely closed by the development of thrombus, and possibly by retraction of the inner and middle coats of the vessel. With the return of full circulatory force as shock passed off, or with the resumption of activity and consequent freer movement of the limb, the temporary thrombus became washed away. The newly formed wall of soft clot bounding the effusion proved insufficient to withstand the full force of the blood pressure, and extension of the cavity resulted. In the more rapidly developing hæmatomata, temporary pressure by the effused blood on the bleeding vessels was also, no doubt, a common explanation of temporary cessation of increase in size.
A diffuse soft fluctuating swelling, sometimes accompanied by pulsation, but oftener without, developed, and not uncommonly diffusion was accompanied by some discoloration of the surface and elevation of the general temperature. Such arterial hæmatomata commonly developed from ten days to three weeks after the original wound. A few examples will suffice.