Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

7. It is not always possible, from their appearance, to decide which opening is the entrance, which the exit of an ordinary sized round ball; or when two holes are distant from each other, to ascertain whether they have been caused by one, or by two distinct balls. When a ball is not impinging with much impetus, it may become a penetrating, without being much of a contused wound, which will close in and heal with little suppuration. If the ball do not press upon, or interfere with some important part, the slight degree of irritation which follows may give rise to the formation of a sac, which adheres to it and possibly keeps it quiet for years, if not for life.

8. The wound made by the entrance of an ordinary musket-ball is usually circular, depressed, of a livid color, and capable of admitting the little finger, the exit being more ragged, and not depressed. It is sometimes little more than a small slit or rent, although at others, as in the face or in the back of the hand, it may be much torn, giving to an otherwise simple wound a more frightful appearance, such as is not usually seen in the thigh, or other equally firm fleshy part.

9. Wounds from flattened or irregular-shaped musket-balls, pieces of shells, or other sharp-edged destructive instruments, are often very much lacerated, and their entrance is less marked. The part thus torn can generally be preserved, and the wound healed with comparatively little loss of substance.

10. When it is desirable to ascertain the exact course of a ball, and, if possible, the internal part injured by it, the sufferer should be placed in the position he was in when he received the injury, with especial reference to the probable situation of the enemy, when that will often become very intelligible which was before indistinct. My attention was directed, after the battle of Toulouse, to a soldier, whose foot was gangrenous without an apparent cause, he having received merely a flesh wound in the thigh, not in the exact course of the main artery, which, nevertheless, I said was injured. On placing the man in the same position with regard to us, that he supposed himself to have been in toward the enemy when wounded, the possibility of such an injury was seen; and dissection after death proved the correctness of the opinion.

11. When one opening only can be seen, it is presumed the ball has lodged; but this does not follow, although the finger of the surgeon may pass into the wound for some distance. At the battle of Vimiera, I pulled a piece of shirt, with a ball at the bottom of it, out of the thigh of an officer of the 40th Regiment, into which it had gone for at least three inches. After the battle of Toulouse, a ball, which penetrated the surface of the chest, and passed under the pectoral muscle for two inches, was ejected by the elasticity of the rib against which it struck. Scarcely any inconvenience followed, and the officer rapidly recovered. After the battle of Waterloo, I was requested to decide whether a young officer should be allowed to die in a few days, or to have a chance for his life by losing his leg above the knee. The joint was open, the suppuration profuse. A large or grape-shot was supposed to be lodged in the head of the tibia. The limb was amputated, and he is now alive, forty years afterward, but no shot was found in his limb. It had dropped out after doing the injury.

12. The treatment of simple gunshot or flesh wounds should be, under ordinary circumstances, as simple as themselves. Nothing should be applied but a piece of linen or lint, wetted with cold water; this may be retained by a strip of sticking-plaster, or any other thing applicable for the purpose of keeping the injured part covered. A compress of linen, or other similar substance, moistened with cold or iced water when procurable, will be useful; and a few inches of a linen bandage may be sewed on, to prevent the compress from changing its position during sleep. When the wound becomes tender, a little oil, lard, or simple ointment may be placed over it. A roller, as a surgical application, is useless, if not injurious. At the first and second battles in Portugal, every wound had a roller applied over it; it soon became stiff, bloody, and dirty. They did no good, were for the most part cut off with scissors, and thus rendered useless. When really wanted, at a later period, they were not forthcoming. An advancing army cannot, and ought not to carry casks full of rollers into the field; and the apothecary-general had better have instead, two casks or boxes full of good wax candles; for, although every regimental surgeon ought to have four in his panniers, kept as carefully for emergencies as his capital instruments, they will require from time to time to be replaced. No roller should be more than two inches and a quarter wide, and made of good, strong, coarse linen, very much, in fact, the reverse of the rollers which have until lately been supplied to the army.

13. Cold or iced water may be used as long as cold is grateful to the sufferer. When it ceases to be so, it should be exchanged for warm, applied in any convenient way which modern improvements have suggested, whether by piline, gutta-percha, oiled silk, etc. An evaporating poultice may be used in private life, but no poultices should be permitted in a military hospital, until the principal surgeon is satisfied they are necessary. They are generally cloaks for negligence, and sure precursors of amputation in all serious injuries of bones and joints. They are properly used to alleviate pain, stiffness, swelling, the uneasiness arising from cold, and to encourage the commencing or impeded action of the vessels toward the formation of matter. As soon as the effect intended has been obtained, the poultice should be abandoned, and recourse again had to water, hot or cold, with compress and bandage. I was in the habit of calling a poultice when misapplied a cover-slut.

14. Many simple flesh wounds are cured in four weeks; the greater part in six. Fresh air and cold water are essential. Purgatives may be occasionally given, and abstinence is an excellent remedy. Emetics, bleeding, and something approaching to starvation as to solids, are of great importance if the sufferers should be irregular in their habits, or the inflammatory symptoms run high. In weakly persons, a generous diet with tonic remedies will be necessary.

15. In wounds of muscular parts inflammation usually occurs from twelve to twenty-four hours after the injury, and the vicinity of the wound becomes more sensible to the touch, with a little swelling and increase of discoloration. A reddish serous fluid is discharged, and the limb becomes stiff and nearly incapable of motion, from its causing an increase of pain. These symptoms are gradually augmented on or about the third day; the inflammation surrounding the wound is more marked; the discharge is altered, being thicker; the action of the absorbents on the edges of the wound may be observed; and, on the fourth or fifth, the line of separation between the dead and living parts will be very evident. The wound will now discharge purulent matter mixed with other fluids, which gradually diminish as the naturally healthy actions take place. The inside of the wound, as the process of separation proceeds, changes from a blackish-red color to a brownish yellow, moistened by a little good pus. On the fifth and sixth days, the outer edge of the separating slough is distinctly marked, and begins to be displaced; the surrounding inflammation extends to some distance, the parts are more painful and sensible to the touch; the discharge is more purulent, but not great in quantity. On the eighth or ninth day, the slough is, in most cases, separated from the edges of the track of the ball, and hanging in the mouth of the wound, although it cannot yet be disengaged; the discharge increases, and the wound becomes less painful to the patient, although frequently more sensible when touched.

If there be two openings, the exit of the ball, or the counter-opening, is in general much the cleaner, being often in a fair granulating state before the entrance of the ball is free from slough. If the inflammation have been smart, the limb is at this time a little swollen and discolored for some distance around; fibrin and serum are thrown out into the cellular membrane, or areolar tissue, as it is now termed; the redness diminishes; the sloughs are discharged, together with any little extraneous substances which may be in the wound; and there is frequently a slight bleeding, if the irritable granulations are roughly treated. The limb on the twelfth, and even fifteenth day, retains the appearance of yellowness and discoloration which ensues from a bruise, and which continues a few days longer. The sloughs do not, sometimes, separate until this period, and, in persons slow to action, not even until a later one. The wound now contracts; the middle portion of the track first closes, and is no longer pervious; the lower opening soon heals, while the upper, or that usually made by the entrance of the ball, continues to discharge for some time, and toward the end of six weeks, or sometimes two months, finally heals with a depression and cicatrix, marking distinctly the nature of the injury that has been received.