SURGERY. 
716 
quantity and quality of the discharge; by the situation of 
the injury ; by the climate and season of the year ; by the 
effects which the renewal of the dressings seems to produce ; 
and by the feelings, and sometimes the wishes, of the 
patient.” 
There are some wounds of very moveable parts that no 
plaisters or bandages will keep in apposition. These are to 
be united by sewing their edges together. There is a furious 
opposition amongst the English surgeons to the use of these 
sutures, because they cause constitutional irritation. This is 
true, but the matter has been much exaggerated. 
If a great artery has been divided by a wound, our first ob¬ 
ject is to stop the bleeding. This is effected by sticking a tena¬ 
culum through the bleeding vessel, and tying that with a liga¬ 
ture. An operation, in ordinary states, easy enough, with a 
little practice; its only difficulty is to tie the artery, and no¬ 
thing else; no nerve, vein, or flesh. There has been much 
disputation amongst surgeons, as to whether a small ligature 
tied very tightly round a vessel so as to cut through its internal 
or softer coats, or a broad ligature less strictly drawn, are most 
conducive to the safe obliteration of large arteries. Expe-- 
rience seems to decide in favour of the former. 
Arteries not of the largest size may have their bleeding 
stopped by pressure, that is, by means of compresses formed 
of lint, laid over the vessel and bound tightly down. Pres¬ 
sure is also often used as a temporary method of suspending 
haemorrhage, until a ligature can be applied, as when we am¬ 
putate or perform any other operation in which larger arteries 
are involved: in this case the pressure is made by means of the 
tourniquet, a well known instrument, constructed so as to 
apply its pressure exactly over the vessel required to be 
stopped. 
Wounds are dangerous, however, from other causes be¬ 
sides haemorrhage; as for instance, when they involve 
nerves, or any of the viscera; but their varieties, in this 
respect, will be best considered when we come to speak 
of particular regions of the body. Stabs are more dan¬ 
gerous than cuts, because they bruise the parts so as to 
destroy their vitality; the process of adhesion is, therefore, 
not sufficient, and consequently suppuration is always re¬ 
quired. The same may be said of lacerated wounds, which 
are indeed perfectly similar lo stabs, except that they are often 
more extensive. Punctured and lacerated wounds are, however, 
dangerous, independently of their tending to suppuration. 
They excite a peculiar and dangerous irritation of the nerves: 
no wounds are so liable as these to destroy life by the nervous 
depression they cause; none are so frequently attended with 
tetanus. The only local method of treating these wounds is 
by fomentations and poultices, which sooth the pain, and are 
said to promote suppuration. 
In the constitutional treatment of these wounds when 
extensive, as well as of all great accidents, we observe three 
stages. In the first, when the violent impression made on 
the nerves has paralyzed or enervated their powers, it is 
proper to stimulate the patient gently by slight doses of 
brandy, ammonia, and the like. When re-action takes 
place, we are called upon topically and generally to reduce 
inflammation and to regulate and sometimes lower the vehe¬ 
ment actions of the nervous system. Thirdly, when the 
inflammatory action subsides, and suppuration or mortification 
commences, we are called upon to support the strength by re¬ 
gulating diligently the diet and secretions, and by the occa¬ 
sional exhibition of tonics. 
Besides these simple varieties, wounds are rendered much 
worse if any foreign bodies remain within them. Hence, 
partly, though not so much as to their laceration, are we to 
attribute the dangerous nature of gun-shot wounds. 
Foreign bodies should be extracted from wounds when¬ 
ever this can be effected without doing more mischief than 
their remaining is likely to create. Hence it is often requi¬ 
site to leave bullets in the body. Gun-shot wounds illustrate 
the general effects of contusions and lacerations in the 
most remarkable degree, since they are the severest of these 
accidents. They vary, however, very much in. character. 
Mr. Hennen observes, that “ If a musket or pistol ball has 
struck a fleshy part, without injuring any material blood¬ 
vessel, we see a hole about the size of (or smaller) than the 
bullet itself, with a discoloured lip, forced inwards; and if 
the ball has passed through the parts, an everted edge, and 
a more ragged or larger orifice at the point of its exit. The 
haemorrhage is generally very slight, and the pain often in¬ 
considerable, insomuch that in many instances the wounded 
are not even conscious of having received any injury. If, 
however, the ball has louched a large vessel or nerve, tire 
haemorrhage will be profuse, or the pain of the wound severe, 
and the power of the part lost. Some men will have a limb 
carried off, or shattered to pieces by a cannon ball, without 
exhibiting the slightest symptoms of mental or corporeal 
agitation ; while a deadly paleness, instant vomiting, profuse 
perspiration, and universal tremor, will seize another on the 
receipt of a slight flesh wound.” 
Balls which are somewhat spent, and which strike the 
body in an oblique direction, are most curiously bent from 
their original direction. Some very extraordinary instances 
of the reflection of balls, from one part of the body to 
another, are recorded by Mr. Hennen. The ball (he ob¬ 
serves) is in many instances found very close to its point of 
entrance, having nearly completed the circuit of the body. 
In one case, which occurred to a friend of his in the Medi¬ 
terranean, the ball which struck about the pomum Adami 
was found lying in the very orifice of its entrance, having 
gone completely round the neck. This winding course of 
balls is represented as particularly frequent when they strike 
the ribs or abdominal muscles; for, says Mr. Hennen, they 
are turned from the direct line by a very slight resistance 
indeed, although they will sometimes run along a continued 
surface like that of a bone, a muscle, or a fascia, to a very 
extraordinary distance. If there is nothing to check its 
course, and its momentum be very great, it is surprizing 
what a variety of parts may be injured by a musket ball. 
Mr. Hennen affirms, that he has seen cases where it has tra¬ 
versed almost the whole extent of the body and extremities. 
In one instance, which occurred in a soldier with his arm 
extended, in the act of climbing up a scaling ladder, a ball, 
which entered about the centre of the humerus, passed along 
it over the posterior part of the thorax, coursed along the 
abdominal muscles, passed deeply through the glutaei, and 
presented itself on the fore-part of the middle of the opposite 
thigh. In another case, a ball which had struck the breast, 
lodged in the scrotum. 
To determine when limbs are so injured by gun-shot 
wounds or other contusions, that they cannot recover, is 
one of the most difficult and important points in surgery. 
No certain rules on the subject can be laid down, and much, 
therefore, must be left to individual judgment. We may 
state, however, as a general rule, that when the bones are 
fractured into many splinters, and when large arteries or 
nerves are torn through, amputation should be decided on ; 
while on the other hand, most extensive contusions and la¬ 
cerations of the soft parts may be trusted to general surgical 
treatment. With respect to the time an amputation should 
be performed, it seems pretty generally decided by the best 
army surgeons, that this should be as soon after the accident 
as possible, and before inflammation is set up. An exception, 
however, is to be made in favour of those cases where the 
nervous depression is very great, for in such the combined 
influence of the accident and the operation is too much for 
the nervous system to bear, and the patient sinks suddenly. 
It is therefore only when the spirits are not entirely sunk, 
and when the pulse indicates some power in the system, 
that we should proceed to these immediate amputations. A 
soldier betraying extreme debility lying nearly in a state of 
syncope, with hardly any pulse or warmth, should be relieved 
by slight cordials, and when he becomes reanimated and 
begins to feel some stiffness and aching in the limb, this is 
the most favourable time for the amputation to be per¬ 
formed. 
Burns and scalds vary in their appearances. When slight 
they cause merely a little redness of the skin, attended with 
great heat. When more severe^ they produce blisters; a 
violent 
