CHAPTER 3

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 cicatricial trace is then present. Sometimes these are cutaneous abrasions more or less extensive, occasionally 5, 6, or 7 centimetres long and 2 or 3 centimetres wide, owing to the retraction of the skin, showing regular or contused perpendicular 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 movement 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 perfectly round or oblique; on the contrary, it is large and irregular when 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. 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 show in the form of a cleft, which may be either simple of radiated, and is sometimes circular and punctiform. It appears larger than the aperture of entry, but in reality is smaller, as it is probable that the skin has been much distended before being perforated. Now and then its edge are everted, and not bruised like those of the aperture of entry. The dimensions are commonly, although no regularly, proportional to the velocity of the bullet-that 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 lamina or accumulations of cellular tissue that the bullet meets with are, according to the velocity of the projectile and to their nature, freely perforated (lamina), or only dissociated (accumulations); the paniculate masses of adjoining adipose tissue then fill up where there has been a loss of substance, thus forming an aseptic occlusion.

Superficial fasciae are wounded, and present circular on oblique apertures, when the velocity of the bullet is great but with average or low rates of velocity, only the transversal or uniting fibres are dissociated. The longitudina 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 resembles an incision, a sort of button-hole-like slit with reunited, edges. These aponeurotic button-holes secure the occlusion of the track.

In muscles the track is always cylindrical, widened in the living by muscular contraction, filled up with blood, exudation, 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 offer 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 fissuration have been noticed a few millimetres, even a few centimetres, 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.

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, forearm, 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, ne explosive lesions are observed from pointed bullets fired a short range. Nevertheless they may occur, especially in tendinous regions.

Wounds of the soft tissues, inflicted by projectiles from modern rifles, are not painful; many of them bleed sufficiently 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 of 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 contribute to this healing; but as it 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 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 annihilated 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 suppuration, 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 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 hydrophyllous cotton-wool enveloped in gauze. One of these dressings is fixed, being sewn to the linen bandage destined to bind up the wounded 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 contamination, 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 NCO;.it should be applied by a medical man, or by a trained member of the Army Medical Service. This is undisputable; it is btter not to dress a wound at all than to dress it badly, and it is as well to look upon with suspicion, and 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 new dressing imperative.

Dressings must be directly applied to the skin, the clothes having been unstitched or cut open into strips so expose the wound and its surrounding parts; this should the exclusive duty of a surgical attendant. Another attendant should open the packets containing the dressings.

The man who dresses the wound should first carefully disinfect his hands; washing the hands with soap is less practical than immersing them during three minutes in alcohol at 90⁰, or, if necessary, in methylated spirit, containing per litre 5c.c. of 1 in 10 tincture of iodine (the whole solution being 1 in 2,000).

When we wish to disinfect the circumference 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 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.

Accidents, brought about occasionally by tincture of iodine such as erythema, vesication, excoriation, or ulcer 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 tincture 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 1 in 20 which is not caustic.

Robert and Carrière have enclosed sublimated iodine in glass ampullae. When required, the ampulla is broken, its contents poured into an accompanying tube containing alcohol at 950 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 usedan 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 irritation 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 the fixity it had at the front, the use of adhesive rubber sparadrap, of the leucoplastic or vulvoplastic type, has been advised. 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 favourable 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 solutions, touching the wound with a 1 in 10 solution of chloride of zinc, iodine by instillation, or by simple application, 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 emphysematous 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 and 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 4 - Wounds of Arteries