Cunshoill'onnds.—En modern warfare the majority of i ifle-bullet wounds are found to heal by first intention owing to the great velocity of the projectile through the air causing sterilisation of the small missile, and producing an aseptic wound which tends spontaneously to close and seal its track from the air. There is still some difTerence of opinion regarding the routine procedure of extracting the bullet when it remains in the tissues, but owing to the efficacy of the X rays in localising the exact situation of the projectile, the danger of introducing septic organisms in the operation of probing must he avoided, and the tendency is growing to treat all rifle-bullet wounds on conservative principles.
A rifle bullet passing through a limb usually causes little all that is necessary is to apply a pad of dry antiseptic gauze to each opening, and thoroughly sterilise the skin, enveloping the entire limb in dry dressing, no attempt being made to inject the track of the pro jectile with any antiseptic liquid.
Even when the projectile remains in the tissues, the best procedure is to carry out a purely expectant line of treatment, and this was formerly the practice also in thoracic and abdominal cases. Recently the rule has been, in chest cases, first to close the chest cavity as early as possible, even if it have to be opened up again, cleansed, and the edges excised. " Sucking wounds " of the chest must be closed at the earliest possible moment if life is to be saved. In abdominal cases, after the preliminary hypodermic of morphia restoratives in the form of heat, saline, &c., are given, and the abdomen is opened as early as possible, the first step in the operatiort being the sterilisation of the skin wound and excision of its edges.
In pistol or revolver bullet injuries the closer ranges and lower pro jectile velocity do not tend to produce aseptic wounds. When the abdomen is penetrated or the skull fractured in this class of injury im mediate resort to a surgical operation is often imperative. Where the bullet can be located and easily reached by enlarging the skin opening, it will usually be advisable to cut down upon it and effect its removal, afterwards sterilising the tissues through which it has passed, and pro viding for free drainage.
The massive injuries caused by shell explosions afforded the most difficult surgical problems of the Great War from the point of view of sterilisation. This was due mainly to two causes—viz., (i) the extensive damage caused to the tissues in the vicinity of the wound. and (2) the
virulent nature of the micro-organismal flora present in the ground and on the soldier's clothes. In the early days of the war the aseptic method of dealing with wounds received an extensive and careful trial, the rarity of wound infections in civil surgical practice leading surgeons to adopt similar methods at the front. It was soon found, however, that neither the aseptic method nor the antisepsis in common use at home was effective in the production of healthy healing in the grave wounds characteristic of the trench warfare waged throughout the greater part of the fighting in France.
The first great advance in the treatment of wounds was due to Gray of Aberdeen, who suggested that all damaged and infected tissues around the wound should be carefully but completely excised, great care being taken that no infection should be conveyed from one part of the wound to another by the surgeon's gloves, his instruments, or the swabs. if a complete excision was possible (owing to involvement of important structures, such as nerves, &c., it was not always possible), then a primary suture was performed, and in a fair proportion of cases healing by first intention followed.
When complete excision of infected structures was not possible, then sonic form of disinfection had to be resorted to. A great variety of methods have been advocated, and the results obtained vary greatly, sometimes appearing to depend as much on the thoroughness with which the method is carried out as on the actual method adopted.
c. Wright's method consisted in complete excision as far as possible of all infected tissues, in opening up and exploring all pockets,in removing all foreign bodies, and in the introduction into each pocket of a small tube connected with a reservoir above the bed. In the reservoir was contained a solution of common salt of 5 per cent. strength, and con taining in addition !, per cent. of sodium citrate. Drainage of the exuded fluids and excess of salt solution was provided for by a tube at the most dependent part of the wound. The saline solution was allowed to escape slowly through the tubes into the recesses of the wound, and so a stream was constantly passing over the infected tissues, carrying away the micro organisms as they were exuded. At a later stage, when the wound had become clean, the hypertonic was replaced by an isotonic solution. The latter encourages the phagocytes and promotes healing.