—More or less characteristic appearances pertain to most wounds of entrance and of exit, which render them reasonably distinct and recognizable, even though no history be obtained. Nevertheless much depends upon distance, velocity, and any deformation of the bullet due to its impact upon some other substance previous to its entering the body. An elongated wound may suggest that the direction of the bullet was at an angle with the surface struck. Such wounds are known as “key-hole” wounds. A bullet already deformed may inflict a wound that will baffle speculation. The wound of exit is usually a little larger than that of entrance. When much larger a bone lesion should be expected. Trifling punctures, perhaps made by particles of the bullet, may be found around the principal wound or in the bone which it has shattered.
Diagnosis may include a recognition not merely of the general character of the injury, but whether it was inflicted by one or more bullets; whether these bullets have escaped; and if not, in what part they are probably lodged. In the preantiseptic days much of this information was gathered by the use of the probe, and the porcelain-tipped probe devised by Nélaton was relied on for much more than it could possibly safely tell. In those days probing was indiscriminately practised, and accomplished more harm than good. Now the probe is rarely used, at least at first, and when used, it is connected with some electrical device by which results are attained with a minimum of handling. For this purpose the telephone probe of Girdner was formerly a popular and ingenious device, which has been more recently supplanted by a simpler mechanism by which, when the end of the probe comes in contact with metal, a little bell, or buzzer, is rung. No probe or other instrument should be introduced into a gunshot wound, for diagnostic or other purposes, without observing aseptic precautions.
The most valuable expedient for the detection and location of bullets, as of other foreign bodies, is the Röntgen ray. With a suitable apparatus of this kind the surgeon can not only decide as to the location of the missile, but whether it is best to attempt an operation for its removal.
Prognosis.
—In gunshot wounds not speedily fatal the prognosis depends upon the part injured, the size and shape of the missile, its velocity, the distance from the weapon, the amount of blood lost before attention was given, the character of the attention first received, and the absence of such complications as exposure, rough handling, etc. The dictum that the fate of a wounded man is in the hands of the surgeon who first attends him made its author, Esmarch, famous. The patient having escaped the dangers of hemorrhage and shock is to be carefully guarded from sepsis, and if thus guarded can be protected against most of the other visible dangers save those due to perforations of large cavities. If, therefore, a gunshot wound can be promptly provided with a primary aseptic or antiseptic dressing, and in other respects be let alone, the outlook for the patient will be encouraging. The prognosis often depends upon how completely the patient is let alone after the application of occlusive dressing.
Treatment.
—Hemorrhage is the first consideration, and should be the first care of the surgeon. Digital pressure may be resorted to, which may suffice until a temporary expedient has been supplied. Next in importance is disinfection of the area surrounding the wound and the application of a sterilized absorbent dressing, with pressure to prevent loss of blood. The use of the probe, or any attempt to at once ascertain the location of the bullet, is not advisable. The question is not, “Where is the bullet?” but, “How much harm has it already done?” And the first attention should be addressed to atoning for any harm that may have been done. Even though the intestines have been perforated, or the heart wounded, there is no need in doing anything more than meeting the immediate emergency. If shock be extreme it may be atoned for in some measure by lowering the head and bandaging the extremities; while in extreme cases hypodermoclysis or venous infusion of saline solution, often with the addition of a little adrenalin, will be of service.
Again, physiological rest of the part injured, i. e., immobilization, as well as absolute rest of the patient’s body and mind, must not be neglected.
Primary laparotomy has been done upon the battle-field, and is of itself a testimony to the intrepidity and zeal of those who have done it; yet, as a practice, it is to be condemned. All operations upon gunshot wounds should be done in a well-equipped hospital.
Fig. 49