8. The best probe is the surgeon’s finger, and for its use the patient generally requires an anesthetic and free incision.
When muscle is torn and needs suturing, or when tendons or nerves are divided and need the same resource; when bones are shattered and fragments need to be removed; when the skull has been fractured and portions of bone driven into or upon the brain; when the intestines have been perforated; when even the heart has been wounded and the pericardium is filling with blood so that the heart’s action is becoming impeded; in any or all of these emergencies the patient needs surgical relief. But this should be of a kind that, save in an emergency, should be postponed until suitable preparation can be afforded.
Fig. 50
Fig. 51
Wound inflicted at 1300 yards by steel-mantled ball (from a recent foreign report). (De Nancrède.)
Shattering of humerus at long range with modern projectile; fusible metal cast showing extent and character of laceration of soft parts (from a recent foreign report).
In regard to regional indications in the treatment of gunshot wounds it will only be possible here to give some brief general hints, the reader being referred to the chapters on [Regional Surgery] for more specific instructions. Nearly all gunshot wounds of bones are compound fractures, and are comminuted as well. The best treatment is primary aseptic occlusion and immobilization, without effort in the direction of exploration. In an open wound the vessels should be secured, loose pieces of bone removed, and jagged bone ends trimmed; while in some instances a wire suture or other mechanical expedient may be resorted to with advantage. Provision should also be made for drainage.
In the regions of the large joints the same general principles are applicable. Under the old regime a gunshot wound of the knee would condemn a person to amputation in the middle of the thigh. Now, if such a limb be promptly provided with suitable antiseptic dressing, and placed at rest, the patient may save not only the limb, but the use of the joint. Extensive comminution may call for excision. Amputation is seldom necessary, except when important bloodvessels have been divided.
Fig. 52