A. Pre-Inflammatory Period

As soon as the patient arrives at the hospital (ambulance, Fr.), he is warmed and cleaned up. If needed, treatment for shock is carried out. Then surgical treatment of the wounds is immediately proceeded with.

1. Clinical and Radiological Examination. - (a) Notes of the wounds having been taken, their relations to the various organs of the damaged region are examined. The opening of the wound should be neatly trimmed according to its requirements. The fascia is split or torn by the projectile. Muscles present as a hernia or retract to leave a gaping hole. Lastly, blood issues from the wound, either alone or mingled with the fat coming from a fracture, cerebro-spinal fluid, brain matter, urine or faeces. Inspection of the orifice often yields valuable indications of underlying injuries. The surrounding skin may be red and tense. Sometimes a furrow ending at the orifice gives the direction of the projectile. At another part of the limb a cutaneous bruise may be seen without solution of continuity of the skin. Frequently the projectile is found at this spot. The whole region in which the wound is situate is more or less swollen. Occasionally it is puffy around the opening.

In certain cases the whole segment of the damaged limb is swollen and hard. Very rarely is pulsation felt or a murmur heard. This swelling is due nearly always to haemorrhagic infiltration of the inter-muscular cellular tissue, particularly of the posterior aspect of the calf or thigh. It is a lesion which it is important to bear in mind. In fact, serious infections often occur in these layers of connective tissue, whose blood-infiltration may be widely extended and form an ideal culture-ground. Just as often, instead of swelling we find a localised depression between the two orifices. This depression corresponds to a sub-cutaneous section of the muscles by a projectile which has traversed the limb seton-fashion. It is well to have this information before operating, because it determines the nature of the surgical interference. Because, if muscles are severed, we may unite the two openings of the seton by an incision at right angles to the long axis of the limb; whereas, if the muscles are sound, the two orifices should be opened up by incisions parallel to the long axis of the limb.

Pain may prove a useful guide. Often a tender spot points out the site of the projectile. The bony skeleton must be examined, not only to recognise a complete fracture, almost always easy to identify, but also to ensure that the splinters of an incomplete fracture should not escape notice.

The circulation and innervation of the distal portion of the limb are equally subjected to careful investigation.

(b) It is indispensable that the casualty clearing station (ambulance, Fr.) should possess a radiological installation to allow of exact localisation of projectiles. We shall not here go into details as to the most useful method of procedure. Simple radioscopy enables us, if we move certain muscles with the finger, or obtain voluntary contraction, to fix the site of projectiles. It is a quick and practical way of localising multiple projectiles.

To summarise, both a general examination and a minute local examination should be made, as much to decide the actual possibility of surgical interference, as to fix its duration and extent. Equipped with this information, we may proceed as quickly as possible to the mechanical cleansing of the wounds.

2. Anaesthesia. - General anaesthesia should always be employed. Ether should be used; chloroform as rarely as possible. In certain cases spinal anaesthesia is employed.

3. Opening-up and cleaning a Wonnd of the Soft Parts. - The skin is sterilised with tincture of iodine. As the cutaneous apertures of entrance and exit of projectiles are too small to allow of an examination of the course taken by the foreign body, they must be enlarged. The extent of opening-up depends upon the depth of the track of the missile. The eye must be able to survey the whole extent of the wound, especially when fracture exists. The incisions, therefore, are as long as may be needful, and parallel with the long axis of the limb or the fibres of the underlying muscles. As a matter of fact, the track of the bullet nearly always goes through the muscles we are intending to clean, and which must be cut as little as possible. The muscular track, therefore, is laid open by an incision as wide as the skin-opening. We do not insist upon the necessity for respecting vessels and nerves. In the case of a blind track, if it does not suffice to lay open the orifice, a counter-opening should be made, which will permit examination of the whole extent of the wound.

In wounds of the "seton" type, the two orifices are laid open separately, parallel with the long axis of the limb, so that the entire track is plainly visible. If this seton-type of wound is superficial, it is sometimes advisable to lay it open from one orifice to the other. Should muscles be severed by the projectile it is preferable to open up the wound completely, in order to clean it the more thoroughly.

There is no call for hesitation in making very free incisions, because they can be brought together again after a few days. Extensive opening-up of soft parts nearly always yields earlier closing.

(a) The bruised portions of the track are carefully excised. To Depage and the surgeons of his school is due the merit of having shown how useful it is to resect almost the whole of the walls of the wound. The skin which surrounds the opening, the sub-cutaneous cellular tissue, the superficial fascia, and above all, the muscles in the first third of the track, are almost always riddled with threads of wool or cotton from the clothing. These shreds are embedded in the tissues. No amount of sluicing or swabbing is capable of getting rid of them. They can only be removed by removing the tissues themselves. This line of conduct is all the more justified by the fact that muscular or cellular tissue thus impregnated with tiny foreign bodies is certainly destined to necrosis and elimination.