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A manual of military surgery, by S.D. Gross, MD,1861 Rare Medical Books

1861

A manual of military surgery - Chapter V: Woundsand other injuries

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MILITARY SURGERY. 45

The excretions should be removed as speed-ily as possible from the apartment, and thevessels in which they are received imme-diately well scalded, the air being at the sametime perfectly purified by ventilation, or ven-tilation and disinfectants.

Finally, the nurse must take care of her-self. She must have rest, or she will soonbreak down. If she is obliged to be up allnight, she should be spared in the day.

CHAPTER V.

WOUNDS AND OTHER INJURIES.

The injuries inflicted in war are, in everyrespect, similar to those received in civillife.The most common and important are frac-tures, dislocations, bruises, sprains, burns,and the different kinds of wounds, as the in-cised, punctured, lacerated, and gunshot.With the nature, diagnosis, and mode oftreatment of these lesions every army sur-geon must, of course, be supposed to befamiliar ; and Ishall therefore limit myself,

5

46 A MANUAL OF

in the remarks which Iam about to offerupon these subjects, to a few practical hintsrespecting their management on the field ofbattle and in the ambulance.

Most of the cases of fractures occurring onthe field of battle are the result of gunshotinjury, and are frequently, if not generally,attended by such an amount of injury to thesoft parts and also to the bone as to demandamputation. The bone is often dreadfullycomminuted, and consequently utterly unfitfor preservation. The more simple fractures,on the contrary, readily admit of the reten-tion of the limb, without risk to life.

In transporting persons affected with frac-tures, whether simple or complicated, theutmost care should be used to render themas comfortable as possible, by placing the in-jured limb in an easy position, and applying,if need be, on account of the distance towhich they have to be carried, or the modeof conveyance, short side splints of binders'board, thin wood, as a shingle, or junks ofstraw, gently confined by a roller. For wantof due precaution the danger to limb andlife may be materially augmented. Perma-

47MILITARYSURGERY.

nent dressings should be applied at the ear-liest moment after the patient reaches thehospital. If the fracture be attended withsplintering of the bone, all loose or detachedpieces should at once be extracted; a pro-ceeding which always wonderfully simplifiesthe case, inasmuch as it prevents, in greatmeasure, the frightful irritation and suppura-tion which are sure to follow their retention.When this point has been properly attendedto, the parts should be neatly brought to-gether by suture, and covered with a com-

press wet with blood. As soon as inflamma-tion arises

—not before

—water-dressings are

employed. A suitable opening, or bracket,should be made in the apparatus to facilitatedrainage and dressing.

Dislocations, accidents by no means com-mon in military operations, are treated ac-

cording to the general rules of practice ; theyshould be speedily reduced, without the aidof chloroform, if the patient is faint or ex-hausted; with chloroform, if he is strong' orreaction has been fully established. Theoperation may generally be successfully per-formed by simple manipulation; if,however,

48 A MANUAL OF

the case is obstinate, pulleys may be neces-sary, or extension and counter-extensionmade by judicious assistants.

Bruises, or contusions, unless attended withpulpification, disorganization, or destructionof the tissues, are best treated, at first, untilthe pain subsides, with tepid water impreg-nated with laudanum and sugar of lead, orsome tepid spirituous lotion, and afterward,especially if the patient be strong and robust,with cold water, or cold astringent fluids.If the injury be deep seated, extensive, andattended with lesion of very important struc-tures, the case will be a serious one, liable tobe followed by the worst consequences, re-quiring, perhaps, amputation.

Sprains are often accompanied with exces-sive pain and even severe constitutional symp-toms. They should be treated with the freeuse of anodynes and with warm water-dress-ings medicated with laudanum, or laudanumand lead. The joint must be elevated andkep*t at rest in an easy position. Leechesmay be applied, if they can be obtained;otherwise, if plethora exist, blood may betaken from the arm. By-and-by sorbefacient

49MILITARY SURGERY.

liniments and friction come in play. Passivemotion should not be instituted too soon.

Among the accidents of war are burns, and,occasionally, also scalds. The former may beproduced by ordinary fire or by the explosionof gunpowder, either casual or from the blow-ingup ofredoubts, bridges, houses, or arsenals,and vary from the most trivial to the mostserious lesions, involving a great extent ofsurface or of tissue, and liable to be followedby the worst consequences. Such injuriesalways require prompt attention; for, apartfrom the excessive pain and collapse which sooften accompany them, the longer they re-main uncared for the more likely will theybe to end badly.

Various remedies have been proposed forthese injuries. Ihave myself always foundwhite-lead paint, such as that employed inthe arts, mixed with linseed oil to the consist-ence of very thick cream, and applied so asto form a complete coating, the most soothingand efficient means. The dressing is finishedby enveloping the parts in wadding, confinedby a moderately tight roller, It should notbe removed, unless there is much discharge or

5*

50 A MANUAL OF

swelling, for several days. If vesicles exist,they should previously be opened with aneedle or the point of a bistoury. A lini-ment or ointment of glycerin, lard or simplecerate, and subnitrate of bismuth, as sug-gested by my friend, Professor T. G. Rich-ardson, of New Orleans, is also an excellentremedy, and may be used in the same man-

ner as the white-lead paint. In the mildercases, carded cotton, cold water, water andalcohol, water and laudanum, or solutions oflead and laudanum, generally afford promptrelief. Amputation will be necessary whenthere is extensive destruction of the muscles,bones, or joints. Reaction must be promotedby the cautious use of stimulants ; while painis allayed by morphia or laudanum given withmore than ordinary circumspection, lest itinduce fatal oppression of the brain.

Inburns from the explosion of gunpowder,particles of this substance are often buried inthe skin, where, if it be not removed, theyleave disfiguring marks. The best way to getrid of them is to pick out grain after grainwith the point of a narrow-bladed bistoury orcataract needle.

51MILITARY SURGERY.

The subject of wounds is a most importantone in regard to field practice, as these lesionsare not only of frequent occurrence, but pre-sent themselves in every variety of form andextent. Their gravity is influenced by numer-ous circumstances which our space does notpermit us to specify, but which the intelligentreader can readily appreciate. In many casesdeath is instantaneous, owing to shock, orshock and hemorrhage ; in others it occursgradually with or without reaction, at a periodof several hours, or, itmay be, not under sev-eral days. Sometimes men are destroyed byshock, by, apparently, the most insignificantwound or injury, owing, not to want of cour-age, but to some idiosyncrasy.

The indications presented in all wounds, ofwhatever nature, are

—Ist, to relieve shock;2dly, to arrest hemorrhage ; 3dly, to removeforeign matter ; 4thly, to approximate andretain the parts; and, sthly, to limit theresulting inflammation.

1. Itis not necessary to describe minutelythe symptoms of shock, as the nature of thecase is sufficiently obvious at first sight, fromthe excessive pallor of the countenance, the

52 A MANUAL OP

weakened or absent pulse, the confused stateof the mind, the nausea, or nausea and vomit-ing,and the excessive bodily prostration. Thecase must be treated promptly ;by free ac-

cess of fresh air and the use of the fan, byloosening the dress or the removal of allsourcesof constriction, by dashing cold water intothe face and upon the chest, by recumbencyof the head, and by a draught of cold water,or water and spirits, wine or hartshorn, if thepatient can swallow ;aided, if the case be ur-

gent, by sinapisms to the region of the heart,the inside of the thighs and the spine, andstimulating injections, as brandy, turpentine,mustard, or ammonia, in a few ounces ofwater. No fluid must be put into the mouthso long as the power of deglutition is gone,lest some of it should enter the windpipe, andso occasion suffocation. Whatever the cause ofthe shock may have been, let the medicalattendant not fail to encourage the sufferer bya kind and soothing expression, which is oftenof more value inrecalling animation than thebest cordials.

During an actual engagement, the medicalofficers, as well as their servants, should carry

MILITARY SURGERY. 53

in their pockets such articles as the woundedwillbe most likely to need on the fieldof bat-tle, as brandy, aromatic spirits of hartshorn,and morphia, put up in suitable doses.

2. The hemorrhage may be arterial or ve-nous, or both arterial and venous, slight orprofuse, primary or secondary, external orinternal. The scarlet color and saltatory jetwillinform us when it is arterial; the purplehue and steady flow, when it is venous."When the wound is severe, or involving a

large artery or vein, or even middle-sizedvessels, the bleeding may prove fatal in a fewminutes, unless immediate assistance is ren-dered. Hundreds of persons die on the fieldof battle from this cause. They allow theirlife-current to run out, as water pours froma hydrant, without an attempt to stop it bythrusting the finger in the wound, or com-

pressing the main artery of the injured limb.They perish simply from their ignorance,because the regimental surgeon has failed togive the proper instruction. Itis not neces-sary that the common soldier should carry aPetit's tourniquet, but every one may putinto his pocket a stick of wood, six inches

54 A MANUAL OP

long, and a handkerchief or piece of roller,with a thick compress, and be advised how,where, and when they are to be used. Bycasting the handkerchief round the limb, andplacing the compress over its main artery,he can, by means of the stick, produce suchan amount of compression as to put at oncean effectual stop to the hemorrhage. Thissimple contrivance, which has been instru-mental in saving thousands of lives, consti-tutes what is called the field tourniquet. Afife, drum-stick, knife, or ramrod may beused, if no special piece of wood is at hand.

The most reliable means for arresting hem-orrhage permanently is the ligature, ofstrong,delicate, well-waxed silk, well applied, withone end cut off close to the knot. Acupres-sure is hardly a proper expedient upon thebattle-field, or in the ambulance, especiallywhen the number of wounded is considerable.The rule invariably is to tie a wounded arteryboth above and below the seat of injury, lestrecurrent bleeding should arise. Anotherequally obligatory precept is to ligature thevessel, ifpracticable, at the place whence theblood issues, by enlarging, if need be, the

55MILITARY SURGERY.

original wound. The main trunk of the ar-

tery should he secured only when it cannot betaken up at the point just mentioned. Lastly,itis hardly requisite to add that the operationshould be performed, with the aid of the tour-niquet, as early as possible, before the super-vention of inflammation and swelling, whichmust necessarily obscure the parts and in-crease the surgeon's embarrassment, as wellas the patient's pain and risk.

Venous hemorrhage usually stops sponta-neously, or readily yields to compression,even when a large vein is implicated. Theligature should be employed only in the event

of absolute necessity, for fear of inducing un-due inflammation.

Torsion is unworthy of confidence in fieldpractice, and the same is true of styptics, exceptwhen the hemorrhage is capillary, or the bloodoozes from numerous points. The mostapproved articles of this kind are Monsel'ssalt, or the persulphate of iron and the per-chloride of iron; the latter deserving thepreference, on account of the superiority ofits hemostatic properties. Alum and lead areinferior styptics.

56 A MANUAL OP

Temporary compression may be made withthe tourniquet, or a compress and a roller. Itmay be direct, as ¦when the compress is ap-plied to the orifice of the bleeding vessel, orindirect, as when it is applied to the trunk ofthe vessel, at some distance from the wound.

Constitutional treatment inhemorrhage isof paramount importance. It comprisesperfect tranquillity of mind and body, cool-ing drinks, a mild, concentrated, nourish-ing diet, especially when there has been ex-cessive loss of blood, anodynes to allay pain,induce sleep, and allay the heart's inordinateaction, fresh air, and a properly regulatedlight.

Internal hemorrhage is more dangerousthan external, because it is generally inac-cessible. The chief remedies are copiousvenesection, elevated position, opium andacetate of lead, cool air, and cool drinks.

Exhaustion from hemorrhage should betreated according to the principles whichguide the practitioner in cases of severeshock. Opium should be given freely as soonas reaction begins to quiet the tremulousmovements of the heart and tranquilize the

MILITARY SURGERY. 57

mind. When the bleeding is internal, thereaction should be brought about gradually,not hurriedly, lest we thus become instrumentalinpromoting or re-exciting the hemorrhage.

Secondary hemorrhage comes on at avariable period, from a few hours to a num-ber of days; it may depend upon imperfectligation of the arteries, ulceration, softeningor gangrene of the coats of these vessels, or

upon undue constriction of the tissues by tightbandages. In some cases it is venous, andmay then be owing to inadequate support of theparts. Whatever the cause may be, it shouldbe promptly searched out, and removed.

3. The third indication is to remove allforeign matter. This should be done at onceand effectually; with sponge and water,pressed upon the parts, with finger, or fingerand forceps. Not a particle of matter, not ahair, or the smallest clot of blood must beleft behind, otherwise it willbe sure to pro-voke and keep up irritation.

4. As soon as the bleeding has been checkedand the extraneous matter cleared away, theedges of the wound are gently and evenly

G

58 A MANUAL OF

approximated and permanently retained bysuture and adhesive plaster, aided, if neces-sary, by the bandage. The best suture,because the least irritating, is that madeof silver wire; but if this material is notat hand, strong, thin, well-waxed silk isused. The adhesive strips are applied insuch a manner as to admit of free drainage.The bandage is required chiefly in injuriesextending deeply among the muscles; whenthis is the case, its use should be aided bycompresses arranged so as to force togetherthe deep parts of the wound.

5. When the wound is dressed, the nextduty of the surgeon is to moderate the re-sulting inflammation. For this purpose theordinary antiphlogistic means are employed.In general, very little medicine will be re-quired, except a full anodyne, as half a grainof morphia, immediately after the patienthas sufficiently recovered from the effects -ofhis shock, and perhaps a mild aperient theensuing morning, especially if there be con-stipation with a tendency to excessive reac-tion. The drinks must be cooling, and thediet light and nutritious, or otherwise, accord-

MILITARY SURGERY. 59

ing to the amount of depression and loss ofblood. In the latter event, a rich diet andmilk-punch may be required from the begin-ning. A diaphoretic draught willbe neededifthe skin is hot and arid, aided by frequentsponging of the surface with cool or tepidwater. General bleeding willrarely, ifever,be required; certainly not if the injury is atall severe, or if there has already been anyconsiderable waste of blood and nervousfluid.

Much trouble is, at times, experienced bothin civil and military practice, especially invery hot weather, in preventing the access offlies to our dressing. The larvae which theydeposit are rapidly developed into immensemaggots, which, creeping over the woundsand sores of the patient, and gnawing theparts, cause the most horrible distress. Thesoldiers in Syria, under Larrey, were greatlyannoyed by these insects, and our wounded inMexico also suffered not a little from them.The best prevention is bran, or light saw-dust,with which the injured parts should be care-

fully covered. The use of cotton must beavoided, inasmuch as it soon becomes hot and

60 A MANUAL OP

wet; two circumstances highly favorable toincubation.

The best local applications are the water-dressings, either tepid, cool, or cold, accord-ing to the temperament of the patient, thetolerance of the parts, and the season of theyear. Union by the first intention is, in allthe more simple cases, the thing aimed atand steadily kept in view, and hence the lessthe parts are encumbered, moved or fretted,the more likely shall we be to attain theobject.

The medical attendant should have a con-stant eye to the condition of the bladder afterall severe injuries, of whatever character, asretention of urine is an extremely commonoccurrence, and should always be promptlyremedied. Attention to this point is themore necessary, because the poor patient, inhis comatose or insensible condition, is fre-quently unable to make known his wants.

Such, in a few words, are the general prin-ciples of treatment to be followed in allwounds; but there are some wounds whichare characterized by peculiarities, and thesepeculiarities are of such practical importance

MILITARY SURGERY. 61

as to require separate consideration. Of thisnature are punctured, lacerated, and gunshotwounds.

Punctured wounds are inflicted by variouskinds of weapons, as the lance, sabre, sword,orbayonet. In civil practice they are mostgenerally met with as the result of injuriesinflicted by nails, needles, splinters, and frag-ments of bone. They often extend into thevisceral cavities, joints, vessels, and nerves;and are liable to be followed by excessivepain, erysipelas, and tetanus ;seldom heal byadhesive action; and often cause death byshock or hemorrhage. When the vulneratingbody is broken off and buried, itmay be diffi-cult to find and extract it,especially whensmall and deep seated. When this is thecase, the wound must be freely dilated, an eyebeing had to the situation of the more im-portant vessels and nerves. Inother respects,the general principles of treatment are similarto those of incised wounds. Opium shouldbe administered largely ; and, if much ten-sion supervene, or matter form, free incisionswillbe necessary.

In lacerated wounds the edges should beG*

62 A MANUAL OP

tacked together very gently, and large in-terspaces left for drainage. A small por-tion will probably unite by the first inten-tion; the remainder, by the granulating pro-cess. Such wounds nearly always suppuratemore or less profusely, and some of the tornand bruised tissues not unfrequently perish.The same bad consequences are apt to followthem as inpunctured wounds. Warm waterconstitutes the best dressing, either alone orwith the addition of a little spirits of cam-phor. Opium should be used freely internally,and the diet must be supporting.

Gunshot wounds, in their general character,partake of the nature of lacerated and con-tused wounds. They are, of course, the mostcommon and dangerous lesions met with inmilitary practice ; often killinginstantly, or,at all events, so mutilating the patient as todestroy him within a few hours or days aftertheir receipt. The most formidable woundsof the kind are made by the conical rifle andmusket balls and by cannon balls, the latteroften carrying away the greater portion of alimb, or mashing and pulpifying the musclesand viscera in the most frightful and destruc-

63MILITARYSURGERY.

tive manner; while the former commit terribleravages among the bones, breaking them. intonumerous fragments, each of which may, inits turn, tear up the soft tissues, in a wayperhaps not less mischievous than the ballitself. The old round ball is a much lessfatal weapon than the conical, which seldombecomes flattened, and which has been knownto pass through the bodies of two men andlodge in that of a third some distance off.

When a ball lodges itmakes generally onlyone orifice;but it should be remembered thatit may make two, three, and even four, andat last bury itself more or less deeply. Suchcases are, however, uncommon. Should themissile escape, there willnecessarily be twoopenings ;or, if itmeet a sharp bone and bethereby divided or cut in pieces, as sometimeshappens, there may be even three. The orificeofentrance and the orifice ofexit differ in theirappearances. The first is small, round, andoften a little discolored from the explosion ofthe powder ; the other, on the contrary, iscomparatively large, slit-like, everted, andfree from color. These differences, however,are frequently very trifling,particularly ifthe

64 A MANUAL OF

ball be projected with great velocity and itdo not encounter any bone. The openingof entrance made by the round ball is oftena little depressed or inverted, but such an ap-pearance is extremely uncommon in woundsmade by the conical ball.

Itis often a matter of great importance todetermine, when two openings exist in a limb,whether they have been made by one ball,which has passed out, or by two balls, whichare retained. The question is of grave im-portance, both in a practical and in a medico-legal point of view;but its solution is, unfor-tunately, not always possible. Sometimesthe openings of entrance and exit are materi-ally modified by the introduction but non-escape of a foreign body, as a piece of breast-plate, belt, or buckle, along with the ball,which alone passes out, or by the flatteningof a ball against a bone, or its division by abone into several fragments, each of whichmay afterward produce a separate orifice.Generally speaking, the missile, at the placeof entrance, carries away a piece of skin,and rends the skin where it escapes, the for-mer being often found in the wound.

65MILITARYSURGERY.

Bullets sometimes glance, bruising the skin,but not penetrating it; at other times theyeffect an entrance, but, instead of passing onin a straight line, are deflected, coursing, per-haps, partially round the head, chest, or ab-domen, or round a limb. Such results aremost commonly caused by a partially spentbullet coming in contact with bones, aponeu-roses, and tendons; and the round is more

frequently served in this way than the conical.Gunshot wounds bleed profusely only when

a tolerably large artery has been injured,and in this event they may speedily provefatal. During the Crimean war, however,many cases occurred in which there was noimmediate hemorrhage, imperiling life, not-withstanding the limbs, lower as well as upper,were left hanging merely by the integuments.Under such circumstances, intermediary hem-orrhage, as itis termed, is apt to show itself assoon as reaction takes place; generally withina few hours after the accident.

The pain is of a dull, burning, smarting,or aching character, and the patient is pale,weak, tremulous, nauseated, and despondent,often in a degree far beyond what might be

66 A MANUAL OF

expected from the apparent violence of theinjury, and that, too, perhaps, when the indi-vidual is of the most undaunted courage andself-possession in the heat of battle. Atothertimes a man may have a limb torn off, or beinjured in some vital organ, and yet hardlyexperience any shock whatever; nay, perhapsbe scarcely conscious that he is seriously hurt.The pain and prostration are always greater,other things being equal, when a bone hasbeen crushed or a large joint laid open, thanwhen there is a mere flesh wound.

The gravity of gunshot wounds of the jointshas been recognized by allpractitioners, bothmilitary and civil,from time immemorial. Theprincipal circumstances of the prognosis arethe size and complexity of the articulation,the extent of the injury, and the state of thesystem. A gunshot wound of a ginglymoidjointis,ingeneral, amore dangerous affair thana similar one of a ball-and-socket joint. Thestructures around the articulation often sufferseverely, thus adding greatly to the risk oflimb and life. Of 65 cases of gunshot woundsof different joints, related by Alcock, 33 re-covered; but of these 21 lost the limb. Of

MILITARY SURGERY. 67

the 32 that died no operation was performedupon 18.

Gunshot wounds of the smaller joints,even those of the ankle, often do verywell,although they always require long andcareful treatment. Lesions of this kind, in-volving the shoulder, are frequently amenableto ordinary means. If the ball lodges in thehead of the humerus, it must be extractedwithout delay, its retention being sure toexcite violent inflammation in the soft parts,and caries or necrosis in the bone, ultimatelynecessitating amputation, ifnot causing death.

Gunshot wounds of the knee-joint are amongthe most dangerous of accidents, and no

attempt should be made to save the limb whenthe injury is at all extensive, especially if itinvolves fracture of the head of the tibia orcondyles of the femur. Even extensive lacer-ation of the ligament of the patella should, Ithink, as a general rule, be regarded as a suf-ficient cause ofamputation. In1854, Macleodsaw upwards of forty cases of gunshot woundsof the knee in the French hospitals in theCrimea, and all, except one, in which an at-tempt was made to save the limb, proved

68 A MANUAL OF

fatal. Of nine cases which occurred in Indianot one was saved. Guthrie never saw a

patient recover from a gunshot wound of theknee-joint; and Esmarch, who served in theSchleswig-Holstein wars, expressly declaresthat all lesions of this kind demand immediateamputation of the thigh.

When, in bad cases of these articular inju-ries, an attempt is, made to save the limb, thepatient often perishes within the first three orfour days, from the conjoined effects of shock,hemorrhage, and traumatic fever. If he sur-vives for any length of time, large abscessesare apt to form in and around the joint, thematter burrowing extensively among the mus-cles, and causing detachment of the perios-teum with caries and necrosis of the bones.

Muscles, badly injured by bullets, generallysuppurate, and are very apt to become perma-nently useless. Special pains should thereforebe taken to counteract this tendency duringthe cure. Large shot and other foreign bodiessometimes lodge among these structures, wheretheir presence may remain for a long timeunsuspected.

Cannon balls often do immense mischief

MILITARY SURGERY. 69

by striking the surface of the body obliquely,pulpifying the soft structures, crushing thebones, lacerating the large vessels and nerves,and tearing open the joints, without, perhaps,materially injuring the skin.

A very terrible form of contusion is ofteninflicted upon the upper extremity of artil-lerymen by the premature explosion of thegun while in the act of loading; causing ex-cessive commotion of the entire limb, lacera-tion of the soft parts, and most extensiveinfiltration of blood, accompanied, in manycases, by comminuted fracture, and penetra-tion of the wrist and elbow joints. The con-stitutional shock is frequently great. If anattempt be made to save the parts, diffusivesuppuration, and more or less gangrene, willbesure to follow, bringing life into imminentjeopardy. An attempt in such a case tosave the limb would be worse than useless, if,indeed, not criminal ; amputation must bepromptly performed, and that at a consid-erable distance above the apparent seat ofthe injury, otherwise mortification might seizeupon the stump.

In the treatment of this class of injuries,7

the first thing to be done, after arresting thehemorrhage and relieving shock, is to extractthe ball and any other foreign substance thatmay have entered along with it,the next beingto guard against inflammation and other badconsequences.

In order to ascertain where the ball is, thelimb should be placed as nearly as possible inthe position it was supposed tohave been at themoment of the accident. A long, stout, flex-ible, blunt-pointed probe, like that sketchedin the annexed cut, or a straight silver cathe-ter, is then passed along the track and gentlymoved about until it strikes the ball. Inmany cases the best probe is the surgeon'sfinger. Valuable information may often beobtained by the process of pinching, or digitalcompression, the ends of the fingers beingfirmly and regularly pressed against thewounded structures, bones as well as mus-cles, tendons, and aponeuroses. Occasionally,again, as when a ball is lodged in an extrem-ity, its presence is easily detected by thepatient, who may make such an examinationas he lies inbed.

The situation of the foreign body having

71MILITARYSURGERY.

been ascertained, the bullet- forceps, seen in theaccompany engraving, takethe place of the probe, theblades, which should be longand slender, being closed un-til they come in contact ¦withthe ball, when they are ex-panded so as to grasp it, carebeing taken not to include anyof the soft tissues. If therebe any loose or detached splin-ters of bone, wadding, or otherforeign material, itshould nowalso be removed ;itbeing con-stantly borne in mind that,while a ball may occasionallybecome encysted, and is atall times, if smooth, a com-

paratively harmless tenant,such substances always keepup irritation, and should,therefore, if possible, be gotrid of without delay.

Although preference is commonly given tothe bullet-forceps, properly so called, as anextractor, the polypus and dressing-forceps,

72 A MANUAL OP

represented in the annexed figures, generallyanswer quite as well, espe-cially the former, the latterbeing adapted only to caseswhere the foreign body issituated a short distancebelow the surface, or wherethe wound is of unusualdimensions, admitting of thefree play of the instrument.

During the extraction,the parts should be pro-perly supported, and if thewound is not large enoughfor the expansion of the in-strument, itmust be suitablyenlarged. When the ball islodged a short distance fromthe skin, it may often bereadily reached by a coun-ter-opening.

When a bullet is embed-ded in a bone, as in the headof the tibia, or in the con-

dyles of the femur, and the parts are not somuch injured as to demand amputation, ex-

MILITARY SURGERY. 73

traction may be effected with the aid of thetrephine and elevator. Sometimes a bullet-worm, as it is termed, an instrument similarto that used in drawing a ball from a gun,willbe very convenient for its removal.

The operation being completed, the partsare placed in an easy, elevated position, and'enveloped in tepid, cool or cold water-dress-ings, as may be most agreeable to them andto the system. The best plan, almost always, isto leave the opening or openings, made by theball, free, to favor drainage and prevent painand tension. Ifthe track be very narrow, itmay heal by the first intention, but in generalitwill suppurate, and portions of tissue mayeven mortify. Erysipelas, pyemia, and se-condary hemorrhage are some of the badconsequences after gunshot injuries, the latterusually coming on between the fifthand ninthday, the period of the separation of thesloughs.

T*