16. The state of constitution, the difficulties and distresses of military warfare, exposure to the inclemency of the weather, the season of the year, or the imprudence of individuals, will sometimes bring on a train of serious symptoms, in wounds apparently of the same nature as others in which no such evils occur. After the first two or three days, the symptoms gradually increase, the swelling is much augmented, the redness extends, and the pain is more severe and constant. The wound becomes dry, stiff, with glistening edges, the general sensibility is increased, the system sympathizes, the skin becomes hot and dry, the tongue loaded, the head aches, the patient is restless and uneasy, the pulse full and quick; there is fever of the inflammatory kind. The swelling of the part increases from deposition in the areolar tissue to a considerable extent above and below the wound, and the inflammation, instead of being entirely superficial or confined to the immediate track of the ball, spreads widely. The wound itself the sufferer can hardly bear to be touched; it discharges but little, and the sloughs separate slowly. Pus soon begins to be secreted more copiously, not only in the track of the wound, but in the surrounding parts; sinuses may form in the course of the muscles, or under the fascia, and considerable surgical treatment be necessary, while the cure is protracted from three to four, and even to six months; and is often attended for a longer period with lameness, from contraction of the muscles or adhesions of the areolar tissue. The parts, from having been so long in a state of inflammation, are much weaker, and if the injury have been in the lower extremity, the leg and foot swell on any exertion, which cannot be performed without pain and inconvenience for a considerable time. The treatment should be active; the patient, if robust, ought to be bled if no endemic disease prevail, vomited, purged, kept in the recumbent position, and cold applied so long as it shall be found agreeable to his feelings; when that ceases to be the case, warm fomentations ought to be resorted to, but they are to be abandoned the instant the inflammation is subdued and suppuration well established. The feelings of the patient will determine the period, and it is better to begin a day too soon than one too late. If the inflammation be superficial, leeches will not be of the same utility as when it is deep seated; but then they must be applied in much greater numbers than are usually recommended. The roller and graduated compresses, or pressure made by slips of adhesive plaster under them, are the best means of cure in the subsequent stages, with change of air, and friction to the whole extremity, which alone, when early and well applied, will often save months of tedious treatment. If the limb become contracted and the cellular membrane thickened, it is principally by friction (shampooing) that it can be restored to its natural motion.
17. If the ball should have penetrated without making an exit, or have carried in with it any extraneous substances, the surgeon must, if possible, ascertain its exact situation, and remove it and any foreign bodies which may be lodged; indeed, if there be time, every wound should be examined so strictly as to enable the surgeon to satisfy himself that nothing has lodged. This is less necessary where there are two corresponding openings evidently belonging to one shot; but it is imperiously demanded of the surgeon, where there is one opening only, even if that be so much lacerated as to lead to the suspicion of its being a rent from a piece of shell; for it is by no means uncommon for such missiles, or a grape-shot, to lodge wholly unknown to the patient, and to be discovered by the surgeon at a subsequent period, when much time has been lost and misery endured. A soldier during the siege of Badajoz had the misfortune to be near a shell at the moment of its bursting, and was so much mangled as to render it necessary to remove one leg, an arm, and a testicle, (a part of the penis and scrotum being lost.) In one of the flesh wounds in the back part of the thigh and buttock a large piece of shell was lodged, and kept op considerable irritation until it was removed. The man recovered.
18. In examining a wound, a finger should be gently introduced, if possible, in the course of the ball, to its utmost extent; in parts connected with life, or liable to be seriously injured, it is the only sound usually admissible. While this examination is taking place, the hand of the surgeon should be carefully pressed upon the part opposite where the ball may be expected to lie, by which means it may perhaps be brought within reach of the finger, and for want of which precaution, it may be missed by a very trifling distance. While the finger is in the wound the limb may be thrown as nearly as possible into that action which was about to be performed on the receipt of the injury, when the contraction of the muscles and the relative change of the parts will more readily allow the course of the ball to be followed. If this should fail, attention should be paid to the various actions of the limb, the attendant symptoms arising from parts affected, and what may be called the general anatomy of the whole circle of injury. A muscle, in the act of contraction, may oppose an obstacle to the passage of an instrument in the direction the ball has taken, especially if it should have passed between tendons or surfaces loosely connected by cellular membrane; as by the side of, or between the great blood-vessels, which by their elasticity may make way for the ball, and yet impede the progress of a sound. When the ball is ascertained to have passed beyond the reach of the finger, a blunt silver sound or elastic bougie may be used, and the opposite side of the limb should be carefully examined, and pressure made on the wounded side, when it will probably be found more or less deeply seated. If the ball should not be discoverable by these means, the surgeon should consider every symptom, and every part of anatomy connected with the wound, before he decides on leaving the ball to the operations of nature.
19. It is unnecessary to dilate a wound without a precise object in view, which might render an additional opening requisite. This dilatation or opening, when made, should always be carried through the fascia of the limb. A wound ought not to be dilated because such operation may at a more distant period become necessary. The necessity should first be seen, when the operation follows of course.
Suppose a man be brought for assistance with a wound through the thigh, in the immediate vicinity of the femoral artery, which he says bled considerably at the moment of injury, but the hemorrhage had ceased. Is the surgeon warranted in cutting down upon the artery, and putting ligatures upon it on suspicion? Every man in his senses ought to answer, No. The surgeon should take the precaution of applying a tourniquet loosely on the limb, and of placing the man in a situation where he can receive constant attention in case of need; but he is not authorized to proceed to any operation, unless another bleeding should demonstrate the injury and the necessity for suppressing it. By the same reasoning, incisions are not to be made into the thigh on the speculation that they may be hereafter required. If the confusion which has enveloped this subject be removed, and bleeding arteries, broken bones, and the lodgment of extraneous substances be admitted to be the only legitimate causes for dilating wounds in the first instance, the arguments in favor of primary dilatation in other cases must fall to the ground.
When the inflammation, pain, and fever run high, the tension of the part being great, an incision should be made by introducing the knife into the wound, and cutting for the space of two or three inches, according to circumstances, in the course of the muscles, carefully avoiding any other parts of importance. The same should be done at the inferior or opposite opening, if mischief be seriously impending, not so much on the principle of loosening the fascia as on that of taking away blood from the part immediately affected, and of making a free opening for the evacuation of the fluids about to be effused.
It is no less an advantageous practice in the subsequent stages of gunshot wounds, where sinuses form and are tardy in healing. A free incision is also very often serviceable when parts are unhealthy, although there may not be any considerable sinus. Upon the necessity of it where bones are splintered, there is no occasion in this place to insist.
20. In making incisions for the removal of balls in the vicinity of large vessels, particularly in the neck, the hand should always be unsupported, in order to prevent an accident from any sudden movement of the patient. This caution is the more necessary on the field of battle, where many things may give rise to sudden alarm. At the affair of Saca Parte, near Alfaiates, in Portugal, I stationed myself behind a small watch-tower, and the wounded were first brought to this spot for assistance. A howitzer had also been placed upon it, being rising ground, and at the moment I was extracting a ball situated immediately over the carotid artery, the gun was fired, to the inexpressible alarm of surgeon, patient, and orderly, who bolted in all directions. From my hand being unsupported, no mischief ensued, and the operation was completed as soon as all had recovered their usual serenity. When a ball is discovered on the opposite side of a limb, through which it has nearly penetrated, but has not had sufficient power to overcome the resistance and elasticity of the skin, it should be removed by incision. An opening is thus obtained for the evacuation of any matter which may be formed in the long track of such a wound, and any other extraneous bodies are more readily extracted. When a ball has penetrated half through the thick part of the thigh, in such a direction that it cannot readily be removed by the opening at which it entered; or, from the vicinity of the great vessels, it may be considered unadvisable to cut for it in that direction; or if the ball cannot be distinctly felt by the finger through the soft parts, it ought not to be sought for at the moment, for an incision of considerable extent will be required to enable the surgeon to extract it. Much pain will be caused, and higher inflammation may follow than would ensue if the wound were left to the efforts of nature alone, by which, in time, the ball would in all probability be brought much nearer to the surface, and might be more safely extracted. It frequently happens, that after a few days or weeks, a ball will be distinctly felt in a spot where the surgeon had before searched for it in vain. A wound will frequently close without further trouble, the ball remaining without inconvenience in its new situation; and the patient not being annoyed by it, does not feel disposed to submit to pain or inconvenience for its removal. A very strong reason for the extraction of balls during the first period of treatment, if it can be safely accomplished, is, that they do not always remain harmless, but frequently give rise to distressing or harassing pains in or about the part, which often oblige the sufferer to submit to their extraction at a later period, when their removal is infinitely more difficult; and may be more distressing than at the moment of injury.
Nothing appears more simple than to cut out a ball which can be felt at the distance of an inch, or even half an inch below the skin, but the young surgeon often finds it more difficult than he expected, because he makes his incision too small; and cannot at all times oppose sufficient resistance to prevent the ball from retreating before the effort he makes for its expulsion with the forceps or other instrument. The ball also requires to be cleared from the surrounding cellular substance, to a greater extent than might at first be imagined; for all that seems to be required is, that a simple incision be made down to the surface of it, when it will slip out, which is not usually the case. When a ball has been lodged for years, a membranous kind of sac is formed around it, which shuts it in as it were from all communication with the surrounding parts. If it should become necessary to extract a ball which has been lodged in this manner, the membranous sac will often be found to adhere so strongly to the ball that it cannot be got out without great difficulty, and sometimes not without cutting out a portion of the adhering sac.
It often occurs that a ball lodges and cannot be found, especially where it has struck against a bone, and slanted off in a different direction. If the ball should lodge in the cellular tissue between two muscles, it often descends by its gravity to a considerable distance, and excites a low degree of irritation, which slowly brings it to the surface, or terminates in abscess. Colonel Ross, of the Rifle Brigade, was wounded at the battle of Waterloo by a musket-ball, which entered at the upper part of the arm and injured the bone. More than one surgeon had pointed out the way by which it had passed under the scapula and lodged itself in some of the muscles of the back. About a year afterward I extracted it close to the elbow, the ball lying at the bottom of an abscess, which was only brought near the surface by time, by the use of flannel, and by desisting from all emollient applications.[1]