CHAPTER VI CONSTITUTIONAL TREATMENT OF WOUNDED SOLDIERS IN Exhaustion among men wounded in the field. — Having considered the local treatment in the field and field hospitals of patients suffering from gunshot wounds, it is necessary to glance at the general or constitutional treatment which should accompany it. It is hardly too much to say that next to arresting conditions which threaten the immediate extinction of life, such as loss of blood from wounded vessels and extreme shock, there is nothing more important for the welfare, and sometimes for the safety of men who are badly wounded than the early administration, occasionally of a moderate stimulant, and always of proper nutrient support. This support is as necessary, in the early condition in which wounded men are usually found, as a preventive against mischief, as its subsequent administration is for maintaining a healthy process of repair in their wounds. It is true that remarkable instances of recovery occasionally occur under circumstances of extreme neglect, of exposure, and enforced abstinence, extending over several days and nights. It may be admitted that rather than crowd wounded men in confined rooms, it is better to subject them to all sorts of inclemency of weather in the open air; but it is certain that a considerable number of wounded men will sink under such circumstances, unable to resist the prostration due to the want of means of counteracting the depressed state of system, physical and moral, into which they are thrown by their injuries and the exposure combined. In many, no rallying, or only very partial reaction from the condition of collapse, takes place; the heart's action flags more and more, and eventually stops altogether. It is notorious that soldiers, although appearing to present a high standard of physical strength in campaigning, are often only stimulated to this appearance by the excitement of the circumstances in which they are placed. As soon as this excitement ceases, and the condition of tension is succeeded by one of enervation, as usually happens when a soldier is placed hors de combat; when the man is suddenly removed from a condition of extreme bodily activity in the discharge of his duties, and of mental diversion owing to the constantly recurring changes of scene which accompany them, and, instead, is reduced by injury to a state of enforced quietude in an ambulance, and is probably oppressed by pain and anxiety; then the previous fatigue, the broken rest, irregularity of meals, and the disturbance of his ordinary habits of life, which he has been undergoing during the campaign, soon manifest their effects by a state of constitutional exhaustion in the patient. This exhaustion happens even under favourable hygienic circumstances in campaigning. Even among the troops of the Federal armies during the war of the rebellion in the United States, notwithstanding all the liberal supplies and scientific skill devoted to the preservation of their health, the fatigues and circumstances of the prolonged war induced a prevailing condition of exhaustion, which in many instances influenced unfavourably the results of treatment both of sickness and injury. It is, of course, much more marked when the circumstances in which the soldier has been placed have been unfavourable to bodily vigour and health. When a campaign has been carried on in a marshy or otherwise unhealthy country; when troops have been camped in tents, overcrowded or too closely pitched together; when they have been exposed to any deleterious epidemic influence, or subjected to wet and much vicissitude of weather; if they have been shut up in a besieged town or fortress; and especially if they have been badly nourished-a deteriorated state of body approaching to a scorbutic taint is engendered before the ordinary signs of this disorder are manifested, and the depression that follows disablement from injury becomes proportionably all the more profound. In all campaigns in which the rations have been coarse and deficient in nutritious qualities, without sufficient variation and ill-cooked, a weak and impoverished condition of constitution, closely allied to that of scurvy, and frequently scurvy itself, have been from this cause alone gradually engendered among the troops. Hence, when wounds have occurred, many of them, which might have taken on a healthy action under other circumstances, have only progressed from bad to worse, until in a large proportion of instances a fatal termination has closed the scene. Gangrene, pyæmia, bowel diseases, fevers, and other grave complications find a ready soil and ready means of development among wounded men when a scorbutic condition of constitution has been induced by the long-continued use of food inadequate in nutritive value to meet the physical wear and tear to which the troops have been subjected during a campaign, especially when this defective nutrition has been joined with some of the other unhygienic conditions which have been previously mentioned. The influence of the unwholesome diet, combined with the unsanitary conditions to which the British troops were subjected in Bulgaria,30 contributed in a great measure to the untoward results that attended many of the wounds received in the first great battle-that on the Almaafter the landing in the Crimea; while it favoured the scorbutic taint, which gradually became fully developed under the privations of the first winter in the Crimea itself, and was the chief source of the unhealthy action taken by the wounds (fortunately com paratively few in number) received during that period of the war. In all prolonged sieges, down to the siege of Paris in 1870, especially at the later periods of them, the difficulty of treating wounds with success among the besieged has been greatly enhanced by the deteriorating effects of the scarcity, privations, and unhygienic conditions to which the patients have been previously subjected. Depression of bodily energy, from whatever cause it may arise, unless it can be removed by judicious care and treatment, must always form a grave feature in the condition of a wounded man. Of course, if his depressed state should have been complicated with any considerable loss of blood at the time of the injury; or if excessive cold and damp are present to assist in enfeebling the general circulation, as was the case during the winter of 1854-55 in the Crimea, the hazardous character of this exhaustion becomes aggravated in a greatly increased degree. Necessity for early nutrient support. From all that has been previously said, it follows that in all severe gunshot wounds inflicted during a campaign, but especially whenever there has been previous constitutional deterioration, the administration, as early as practicable, of warm nourishment in a suitable form is a point of much importance. The first object is to prevent the wounded man sinking so low as to make it a matter of uncertainty whether he will be able to mount from his state of exhaustion again; the second is to increase the vigour of his constitution, and prepare it for future trials. The restorative powers must be rallied, and also maintained, that they may have a fair chance of being able to resist the depressing influences of hospital confinement, and at the same time have the requisite energy for repairing the injury which has been inflicted. To accomplish the first purpose, it is often better to postpone the primary examination and dressings at the ambulance or hospital until some suitable refreshment has been taken, than to postpone the nourishment till the dressing has been done. This will especially be the case if much time has elapsed between the receipt of the wound and the removal into hospital; if the patient is cold from having been lying a long time on the ground where he has fallen, from exposure at night, or if there be so many wounded that a good deal of delay must occur before all can be surgically attended to. The free use of good nourishment before and after their injuries was one of the advantages which the British wounded enjoyed in the Crimea after the first winter had passed, and was probably one important source of the different results of the treatment in the English and French hospitals during the latter period of the campaign; and almost all the surgeons who were engaged in practice during the great civil war in the United States refer to the liberal and varied dietary given to the wounded in the field and general hospitals as having been one of the chief causes of the general success which attended their treatment. Constitutional conditions of wounded patients.-Many gunshot wounds, owing to improved methods of treatment, become healed without any constitutional disturbance or interruption. Others, from various causes, do not progress so favourably, but pass through periods of suppuration, or sloughing, and granulation, as of old, before they become cicatrised. In such cases successive changes in constitutional condition may usually be noticed. The first is generally a condition of depression more or less prolonged, according to the specific nature of the wound, its concomitant circumstances, and the patient's degree of strength; the second, one of simple reaction of varying amount; the third, a condition of constitutional irritability, more or less marked, which continues during the suppurative and reparative stages of the injury. Constitutional treatment during the first stage.--The necessity for restoratives in the shape of moderate doses of stimulants, warm refreshing beverages, and proper nutriments in the first condition has been sufficiently remarked upon. All that can usually be done to meet this need on the field of battle itself, even though the ground may be clear of the enemy, is to give a little spirit and water to an exhausted patient. This will enable him to bear the transportation to the first dressing-station better. On arrival at it, some of the medical comforts provided in the bearer-company's waggons or field panniers ought to be administered as speedily as circumstances allow. These consist of such articles as cocoa-milk, tea, arrowroot, and the concentrated extract of meat for forming beef-tea. It is advised that finely broken-up biscuit or some farinaceous article should be added to the beef-tea to increase its nutritive quality. If the field hospitals be established in houses or other buildings where the opportunity is afforded for making such arrangements, or if the patients can be carried at once from the field into hospitals. of a more permanent character, as may happen in besieged places, then, whenever necessary, in addition to warm stimulants or warm broth, warmth and reaction should be encouraged by getting the patients speedily into bed, applying heat to the extremities, and adopting any other means available for accomplishing the purpose. An excess of alcoholic stimulation must be particularly guarded against in the first stage of depression, as indeed it should be throughout the whole course of treatment. The exhibition of an undue quantity of alcoholic beverage ceases to be a simple restorative; it creates an over-excitement which must lead to a proportionate depression of energy afterwards. The amount of stimulus that is confined to simply restoring the disturbed balance of power for the time will be serviceable; all stimulus beyond what will contribute to this result will be hurtful. There is little probability of nutrient restoratives being given in excess at the first period of treatment; if they are exhibited beyond the powers of the patient to assimilate them, either he will refuse them when offered, or, if he swallow them, the stomach will reject them. With alcoholic drinks the case is different; the habits of many soldiers, and the nature of such stimulants, cause an excessive quantity to be very readily taken. There is an unfortunate custom in some armies of issuing a spirit ration to the men shortly before going into action. It is a most pernicious practice under the usual circumstances of warfare; for although it may stimulate soldiers during a limited time, if the engagement be prolonged, it will not fail in the end to make them more exhausted than they would have been if they had not taken it. To soldiers who fall badly wounded it is especially hurtful: it intensifies thirst, leads to increased depression, and often prepares the way for serious complications when their wounds are of a grave character. The treatment of men who have been drinking a considerable quantity of spirituous liquor immediately before the receipt of their wounds requires great caution, and is always a matter of special difficulty. Constitutional treatment during the second stage.—During the stage of reaction the power of assimilating food, as well as the desire for it, will in a great measure be wanting; so that still only nutrients in a very diluted and easily assimilable form are admissible. Two things usually attract attention in this stagethe local reaction at the seat of injury, and the systemic reaction. These are in part independent of each other, in part dependent on each other. If the wound be one not involving organs of first importance, and the patient be in a sound condition, the reaction, both local and general, under favourable hospital circumstances, will be so moderate as to cause no anxiety to a surgeon. If a similar wound occur in a patient debilitated by long-continued fatigue or exposure to unhygienic conditions, the reaction may be very different in degree and in its nature. Other causes the extent of the injury, its nature and complications, a plethoric condition of the patient, previous panic and nervous excitement-may induce excessive reaction, and the question of the proper treatment to be pursued becomes one requiring careful consideration. In former days bleeding was freely resorted to under such circumstances. Venesection was supposed to be absolutely necessary to restrain the vascular excitement within moderate limits. Depletion in various other forms was also resorted to. Nauseants, purgatives, restriction in diet and drinks, were called into requisition to aid the antiphlogistic treatment. Few modern surgeons believe that such a drain on the circulation, or such depressing medicines and regimen, are beneficial, much less |