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 protective 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 irregularly 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 changes of shape, which may be spoken of as-
(1) Lateral changes;
(2) antero-posterior changes;
(3) division into fragments.
The first consist of very regular, continuous abrasions, whichonly occupy a very small portion of the diameter of the bullet.
The second show thepoint turned back, 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 more 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-
(1) At their Point ;
(2) laterally ;
(3) partial separation of the .protecting envelope, with antero-posterior change of shape of the 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.
1. 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.
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 resistant body with very considerable vital force is subjected to a pressure which spreads out its anterior part; the envelope bursts 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 of the Bullet's Nucleus from the Envelope.-Dehiscence of the envelope facilitates 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 these extreme cases the nucleus is represented by a fragment 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 radiography.
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, consisting 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 a riot in St. Petersburg, 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 fragments. On the contrary, with less velocity it passes through the diaphyses without notable change of shape, or even without any change of shape whatever.
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, sometimes 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 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 conglomerate 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 frequently 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 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.
An interesting fact is the projection of these filaments into the thickness of the tissues all around 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 important 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:
1. Examination of the clothes, often impossible, besides being useless, at the front (line), is absolutely necessary when the wounded man has been removed to the rear.
1. 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.
2. At the front we should be careful not to sacrifice clothing through which a bullet has penetrated by cutting it where it has been perforated. At 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. (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.)
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 noticeable than those of the latter; they may even be present as isolated foreign bodies'.
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 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 radioscopy. 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 tolerance 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 wound 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 shin 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 radiography, give rise in many cases to difficulties that protract the operation.
4. A shell fragment that is large, irregular, and sharp, and also a shrapnel bullet, must ALWAYS be removed shortly after the traumatism ; this should be done in a permanent shelter either at the front or in the rear.
5. Ablation of these last foreign metallic bodies is specially 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 7 - Bony Lesions of the Diaphysis