'SURGERY. 
736 
separation and turning out of the wound are 
inevitable; you must throw all loose, put a 
large sott poultice round the whole, and for- 
sake without hesitation all hopes of procuring 
adhesion; for should you in this critical 
juncture persist in keeping the parts together 
by sutures, the inflammation would, in the 
form of erysipelas, extend itself over the whole 
limb, attended with a fetid and bloody sup- 
puration, wasting the skin w ith great loss of 
substance. Therefore throw all loose, apply 
your poultice, allow the wound to separate 
right as it is, and to pass slowly into a soft 
and easy state of suppuration ; and then a 
second time try to bring the edges up to 
one another, not by stitches, but by adhesive 
straps, or by a gentle bandage. 
“ When the wound has fallen into a full sup- 
puration, then the suppuration, granulation, 
and all that follows, belong (as indeed ad- 
hesion also does) to nature alone, over 
which we have no other power than that of 
supporting the action of parts, i. e. keeping 
the system in good health ; and when the 
suppuration goes wrong, it is in general by 
taking the form of a profuse, thin, gleety dis- 
charge; and this profuse discharge is to be 
suppressed, and the right suppuration re- 
stored, by bark, wine, rich diet, and good 
air; and this is what is usually meant by 
supporting the suppuration, or moderating 
the profuse discharge.” J. Bell’s Discourses 
on Wounds. 
Of contused, and lacerated, and gun-shot 
wounds. 
From the above observations, it will readily 
be inferred that (unless in cases of systematic 
irritation, or unfavourable circumstances), if 
a wound does not unite and heal, it is because 
its divided edges are not placed and preserv- 
ed in neat and even contact; and this in- 
ference will serve to explain why those 
wounds are of most difficult and intractable 
treatment, which are not simple and fair divi- 
sions of parts with cutting instruments, but 
are what authors term contused and lacerat- 
ed. A contused wound, in systematic lan- 
guage, is that in which, without the skin be- 
ing penetrated, the parts below are crushed 
or broken, rather than divided ; if the outer 
skin is broken at the same time, the wound 
is said to be contused and lacerated; such 
are gun-shot wounds. Suppose an individual 
to receive a ball from a musket or pistol, in 
the arm or thigh ; suppose that the ball has 
entered at one point and passed out at the 
opposite, has taken a more oblique direction, 
or, instead of passing out, has lodged among 
the muscles of the part; in either case we shall 
have not a mere division of substance, in 
which the divided vessels can be secured, and- 
the separated edges brought again into con- 
tact, but there will be a bruise rather than a 
clean cut ; it will of course be impossible to 
dispose the parts so as that the adhesive 
action shall commence, and therefore “ no 
gun-shot, nor indeed any bruised wound, 
heals by adhesion.” 
In this then consists all the peculiarity of 
gun-shot wounds : it is not that the ball (as 
the autients supposed) is possessed of any 
poisonous quality, that such wounds are diffi- 
cult and tedious in healing; but solely because 
the injury indicted is in the shape of a bruise, 
not of a cut ; the vessels and fibres are crush- 
ed, not divided. 
If then gun-shot or bruised wounds cannot 
be made to heal directly, or by adhesion, it 
follows that the treatment they demand js in 
some measure peculiar; we are, therefore, 
now to discuss the question of such pecu- 
liarity, and in so doing we shall for tiie pre- 
sent limit our remarks to those wounds which 
have not penetrated the thoracic, or abdo- 
minal cavities. The symptoms of wounds in 
the breast and belly, we have already enu- 
merated ; on their management, medical and 
surgical, we shall shortly enlarge. 
Treatment of gun-shot wounds. 
In gun-shot wounds which have neither 
penetrated the two great cav ities of the chest 
and abdomen, nor have been made upon the 
head, the principal points of consideration are, 
the direction or place of lodgment of the 
ball, whether one or more bones have been 
splintered or broken, whether any consider- 
able artery has been torn up, whether the 
wound has reached any of the joints, and 
lastly, whether the ball has carried with it 
any foreign matter, such as the patient’s 
clothes. These points are to be determined 
by an acquaintance with the anatomy of the 
parts ; by probing, scarifying, or dilating the 
wound ; and by an attentive examination of 
the symptoms which the injury has occa- 
sioned. 
“ All probing should be done at the time 
of the wound,” while the parts are §till 
deadened by the injury, and before pain and 
inflammation have come on. The finger is 
the best probing-instrument ; “ it is not apt 
to catch upon tendons or nerves ; it does not 
so much as the probe endanger the arteries ; 
and by feeling with the finger, we judge most 
accurately of the condition of the wound. 
I he finger both directs our operations, and 
instructs us what is to lie done. Perhaps we 
feel the ball, and then we cut directly upon 
it; perhaps we feel the wound making a 
crooked or spiral turn, and we follow it with 
our incisions ; perhaps we are sensible that 
it touches a great artery, and in working with 
our bistoury we are careful of that artery ; 
we know also where the ball has touched a 
joint, or broken any bone ; accidents which 
not only increase the danger, but which may 
even incline us in certain circumstances to 
cut off the limb. In short, all that we re- 
solve, is from the information that we have 
through the finger, and it directs all our 
operations.” 
What are these operations ? Either to 
scarify or dilate the wound, as circumstances 
shall demand, to make, a coufiter-opening 
when necessary, and to extract balls, clothes, 
or splinters of bone. The purposes of sca- 
rifying are, “ to open the vessels that they 
may bleed, to enlarge the wound that when 
it inflames it may have room to swell,” and 
to enable the surgeon when requisite to take 
up the bleeding arteries, and to extract the 
ball, the splinters of - bone, or any other 
foreign and irritating material. 
Every gun-shot wound which is deep and 
penetrating, with a narrow opening, and with 
a tense fascia (even if no foreign body is to 
be extracted), requires immediate scarifica- 
tion; the incision, it must be carefully re- 
membered, is “ to pass through the fascia as 
well as the skin ; the wound must have vent, 
as the older surgeons were wont to express 
themselves, in other words u it must have 
room to swell” during that inflammation 
which inevitably precedes its cure. The j 
stricture, as in strangulated hernia, must be \ 
taken off. Bo far then all is plain and simple. 
But the practice is loo often in the cure of 
gun-shot wounds more complicated. Counter- 
openings are sometimes to be made ; splin- 
ters or foreign matters are to be searched 
for and taken out, and great vessels to be se- 
cured. When the ball has passed entirely 
through, the opening which it has formed by 
its exit is called the counter opening; when 
it has passed a considerable way, but not 
entirely through, it becomes the business of 
the surgeon to make this counter-opening in 
orderTo extract the ball. This practice is 
advised by the generality of surgeons, “ when 
the ball has only passed two-thirds through 
the limb.” Such direction is for the most 
part to be followed, and the operation should 
be performed as speedily as possible. 
But there is also another kind of counter- 
opening (let this rule be especially attended 
to), which the surgeon is at times obliged to 
practise. The opening which he must after- 
wards make in the middle of a long wound, 
wh$n the track of the wound swells, or when 
the abscess forms, and the matter, the sloughs, 
and the foul ichor, seem to be confirmed. For 
example: a man is wounded by a ball, which 
breaks one or two of the fingers, pierces the 
hand, runs up the fore arm, rakes along the 
bones, and goes out far from its entrance, as 
at the elbow or shoulder-joint. Here we can 
hardly prevent a long suppuration, and too • 
often an exfoliation or spoiling of the bones: 
and three openings are required ; one where 1 
the ball entered, another at the counter- 
opening or that by which the ball passed 
'out, and if the swelling, pain, irritation, or 
perhaps nervous symptoms, come on, then 
there will be required also another opening 
in the middle of the wound. Such an open- 
ing will ease the swelling, and prevent a 
suffocation of the wound. It will prevent 
gangrene, bring on a good suppuration, and 
allow a free vent for the matter ; it will also 
prevent sinuses, and so save the arm ; and it 
will save us from the severe or rather cruel 
practice of the older surgeons, who were ac- 
customed, in such cases, to run a large seton 
through the tube of the longest wound, i 
These last (setons) are only proper when the j 
wound has become entirely callous, and poyrs 
out a thin gleety discharge ; or when, from the ; 
adherence of some piece of cloth which pre- . 
vents its healing, healthy action cannot other- 
wise lie excited. 
So far then with respect to the scarifica- 
tions which are required in gun-shot wounds; 
we now proceed to treat of the extraction of 
balls, cloth, or splinters of bones. 
Here dilatations rather than scarifications are j 
needful: for there is this difference between 
scarifying and dilating ; that scarifying is that :, 
superficial incision of the mouth of the , 
wound by which we relieve the tension of the 
fascia or the stricture of the skin; but dilat- 
ing is that deeper incision which we make ' 
by pushing our finger deep, and to the bot- ' 
tom of the wound, following it with the . 
bistoury, to make a free way for getting at * 
the bleeding artery, or extracting 'the frac- 
tured bone. When we wish then to extract 
the ball, we are to employ free incisions, * 
