There is not space to follow the details of the treatment of this case. The cure was protracted by large and troublesome bed-sores; and attention to these, to the discharges from the wound, and preserving favorable position, occupied much time and care daily, and caused many changes in the appliances for these objects to be from time to time necessary. On November the 4th, union had so far taken place that he was able to raise his body from the knee upward while in bed, without apparent motion at the seat of fracture. On November 15th, in consequence of the great explosion at the right siege-train, he had to be carried to another division of the camp; this was effected without harm. In the middle of January he was able to sit in a chair without inconvenience; and on February 22d he left the Crimea for England, being able to walk with the assistance of crutches. Union was then firm; but a slight serous oozing continued from the wound of exit, and there was much stiffness of the ankle and knee joints from the long-continued constrained position to which he had been subjected. In July, 1856, after his arrival in Ireland, indications of pus collecting manifested themselves at the wound of exit; and Professor Tufnell, on passing a bougie about seven inches in the course of the wound, evacuated a small abscess, and felt a piece of bone trying to make its way to the surface. This was subsequently removed, and, underMr. Tufnell’s able care, the stiffness of the joints gradually disappeared, and he was enabled to return to duty.Dr. Macleod says that, after many inquiries respecting cases of this nature in the hospitals of the other armies engaged in the war, excepting one presented by Baron Larrey to the Société de Chirurgie in 1857, he never could hear of any other but that of a Russian whose greatly shattered and deformed limb he often examined.[13]It had united almost without treatment. Two cases of united fractures of the femur in the upper third have arrived from the late mutiny in India, and in both, Dr. Williamson records, a good and useful limb had resulted, one with shortening of 1-1/2, the other 3-1/2, inches. Still more recently, M. Jules Roux, of the St. Maudrier Hospital, at Toulon, has given a list of no less than twenty-one cases of gunshot injuries of the upper third of the femur, which he had examined on their return from the Italian war of 1859, in all of which consolidation of the fracture had taken place. We have no data by which we can estimate the proportion of these cases of union to those in which other results ensued.The proportion of recoveries in amputations in the upper third of the femur in the Crimean war was under 13 per cent. Amputation at the hip-joint, both in the French and English armies, in all instances proved fatal. The two patients who survived the longest were operated on by the late Director-General after the battle of the Alma: one, a soldier of the 33d Regiment, died at Scutari three weeks after the operation; the second, a Russian, died on the thirtieth day after, from “extensive sloughing and great debility.”[14]One case of excision of the head, neck, and trochanterof the femur in the Crimea recovered, operated upon by Dr. O’Leary; the only known successful case of excision of the hip-joint after a gunshot wound. The operation was performed on the same day that the wound was received. In the Sleswick-Holstein campaigns, amputation at the hip-joint was performed seven times; one patient only survived, a young man, aged seventeen years, operated upon by Dr. Langenbeck. Resection of the upper part of the femur, including the head and two inches below the small trochanter, was performed once, but the patient died from pyemia. At the post-mortem examination, the right shoulder and ankle joints were found to be filled with pus. The operation in this instance was performed three weeks after the injury. No case of amputation, nor of resection, at the hip-joint has returned from the Indian mutiny. M. Legouest, in a recent essay in theMemoirs of the Society of Surgery, at Paris, maintains that amputation at the hip-joint should be reserved for cases of fracture with injury to the great vessels, and that where the vessels have escaped, resection should invariably be performed. He also inculcates, as a general principle, not to perform immediateprimaryamputation at the hip-joint in any case; but, even in the severest forms of injury, to postpone the operation as long as possible.[15]For theconsecutiveresults of gunshotwounds, the operation presents a less unfavorable aspect than for immediate injuries. M. Jules Roux has recently, at Toulon, performed amputation at the hip-joint six times for the consequences of wounds received during the war in Italy, and of these, four have been successful.With regard to gunshot fractures in the middle and lower third of the femur, the experience of the French and English armies in the Crimea has tended to confirm the doctrine of the older military surgeons, that many lives are lost which might be otherwise preserved, by trying to save limbs; and that, of the limbs preserved, many are little better than incumbrances to their possessors. In the late Italian battles, the practice of trying to save lower extremities, after comminuted fractures in these situations of the thigh, appears to have been abandoned. Eight cases of union after compound gunshot fractures of the femur in these situations have, however, returned from the late mutiny in India; and this is a much larger proportion than was that of the recoveries from the Crimea. Dr. Williamson, who records these cases, is inclined to attribute this success in a great measure to the use of dooleys for the conveyance of wounded, and argues that it would be advantageous to introduce them into European warfare. But wounds generally, where proper care is taken, heal more favorably in southern latitudes, east or west, probably owing to the climate admitting of so much more free an access of fresh air by day and night to the patient than can be afforded, without inconvenience, in colder or more variable climates. The dooley is most advantageous and comfortable as used in the East, where it is an ordinary mode of conveyance among all classes, and the bearers—a special race in each Presidency—are trained from childhood to the occupation; but, from experience of the peculiar habits and tenets of these men, both Madrassees and those of Bengal, it seems scarcely probable that they would prove efficient, even if they could exist, or that their wants could be provided for in the numbers necessary to beserviceable, with armies in northern latitudes. French surgeons have remarked how much more favorably,cæteris paribus, wounds heal in Algeria, where they have only the same kinds of conveyance for wounded as in Europe; and the difference is accounted for by the favorable influence in this respect of a warmer climate.In fractures of the leg, where neither the knee nor ankle joints are implicated, the results of conservative attempts have been more favorable. In the Crimea, the recoveries without amputation being resorted to were: in fractures of both bones, nearly 19; tibia only, 36·3; fibula only, 40·9 per cent. When the fracture is comminuted, and implicates the knee or ankle joint, opening the capsule, amputation is necessary. The knee-joint was once excised in the Crimea, but the patient died; as was the case in the only other instance where this operation is known to have been performed for gunshot injury in the Sleswick-Holstein campaign. In the treatment of fractures of the leg, where it has been determined to seek union, the same remarks apply as those made above in respect to fractures in the upper extremity. In wounds of the foot it is especially necessary to remove as early as possible all the comminuted fragments of the bones injured, or tedious abscesses and much pain and constitutional irritation are likely to ensue.AMPUTATION.It is not necessary to refer at much length to the question which was formerly disputed upon—the advantages ofprimaryas compared withsecondaryamputation in gunshot wounds—for military surgeons, whether acting at sea or on land, have practically determined the subject. For a long time the directions of John Hunter, that amputation should not be performed until the first inflammation was over, based on the argument that the “amputation is a violence superaddedto the injury, and therefore heightens the danger,” and that this danger is aggravated in the instance of a man laboring under mental agitation, as on the field of battle, had great weight among English surgeons; but experience has led to a different practice. The greater success of primary amputation appears to be attributable to the facts, that a contused and mangled limb is a constant source of accumulating irritation; that the exciting circumstances connected with battle lead a man to bear with courage at an early stage what subsequent suffering and anxiety may render him less willing to submit to; that a soldier, when first wounded, is most probably in stronger health than he will be after hospital restraint and confinement; that though the amputation is a violence, it is one the patient is likely to submit to with resignation, knowing that it is performed to remove parts which, if unremoved, will destroy life; and lastly, because the operation takes away a source of dread which must weigh down the sufferer so long as it is impending. The present practice has resulted from testing both modes of amputation. Mr. Guthrie showed, from the experience of the Peninsular war, that the loss in secondary amputations had constantly exceeded that from primary amputations in both the upper and lower extremities. More recent observations in both English and French campaigns have confirmed this result. Dr. Scrive records that the experience of the French army in the Crimea showed the success of primary amputation sometimes exceeded by two-thirds that of secondary amputation. He excepts amputations at the hip-joint, and cites, as his reason for this exception, that in nine cases where the hip-joint amputation was performed primarily, death followed the operation a few instants or a few hours afterward; while in three cases which he witnessed, where the amputation was consecutive, one lived five, another twelve, and the third twenty days. In respect to the particular time at which primary amputation is to be performed, the general practice of the present day is, whenthe operation is inevitable, to perform it as soon as it can be done; provided the more intense effects of “shock,” where it has supervened on the injury, have passed off; and this practice generally accords with the feelings of soldiers, who not unfrequently press the surgeon for an early turn in being relieved from the suffering resulting from a shattered limb. In the cases where primary amputation is to be performed, a further reason given by Dr. Scrive for the operation being done on the same day that the wound is received is, that chloroform acts then so much more benignantly and readily; while, on the following day, or day after, traumatic excitement becomes very energetic, and considerable resistance is offered to its influence by wounded men, and longer time and a much larger dose of the chloroform are required to produce the state of anesthesia. If only a moderate amount of “shock” exist, this does not appear to be a sufficient reason for delaying amputation; for a moderate exhibition of stimulus and a few consolatory words will often remove this, and, even though some faintness, pallor, and depression remain, no ill consequences ensue. The late Director-General, in a letter to the late Mr. Guthrie, written in 1855, mentioned the case of a soldier of the 90th Regiment, whose right arm he removed at the shoulder-joint on the 10th of July, for great destruction of soft parts and extensive injury to the bone: “The patient was so low when placed on the table that brandy and water were given to him, and he was then immediately afterward placed under chloroform. When I had finished, it was observed that his pulse was stronger than before the operation.” This man recovered without a bad symptom, and is now one of the Commissionaires in London. Indeed, in the Crimea, primary amputations were repeatedly performed where shock had not wholly disappeared, and no harm resulted from the practice. The introduction of chloroform, by its negative operation of preventing pain or alarm, and by its positive action as a stimulus, has done much to remove many of theobjections which were urged by John Hunter against early amputations after gunshot wounds. If collapse be intense, more than is accounted for by the wound to the extremity, suspicion will be excited that some internal injury has been also inflicted, and delay will be necessary for further observation of the patient. When active operations are proceeding, and it is necessary to carry the wounded to any distance, the advantages of early removal of shattered limbs are obvious.SECONDARY HEMORRHAGE.Army surgeons meet in practice with secondary more frequently than primary hemorrhage in gunshot wounds. It may arise in several ways. Sometimes it results from the coagulum being forced out of an artery in which hemorrhage had previously been spontaneously averted by the ordinary natural process, this accident being consequent upon muscular exertion or increased impulse of the circulating system from any cause. This occurrence in the bottom of a deep wound will be often found to be a very troublesome complication. Sometimes an artery which did not appear to be injured in the first instance ulcerates or sloughs; or, without direct injury, a vessel may become involved in unhealthy deterioration of the wound, and give way; or, in a granulating wound, general capillary hemorrhage may be excited by stimulus of any kind, such as venereal excitement or excess in drinking; or the coats of the vessel may ulcerate under pressure from a detached fragment of bone or from some foreign body; or the artery may be accidentally penetrated by the end of a sharp spiculum. Secondary hemorrhage has been said to arise from increased arterial action, from the first to the fifth day; from sloughing, the effects of contusion, from the fifth to the tenth; from ulceration, to any more distant date. M. Baudens has remarked that he has observed secondary hemorrhage to be most frequent about the sixth day after the wound—the traumatic fever havingthen reached its highest point of intensity, and the sharp, hurried contractions of the heart having most power in forcing out the coagula. If we could compare all the cases of hemorrhage which occur, secondary would, perhaps, statistically appear less dangerous than primary hemorrhage; for the latter, when happening from large vessels, must be very generally fatal, while, when hemorrhage occurs in them secondarily, the collateral branches have become partially adapted to the interruption of the flow of blood through the regular channel. Moreover, the larger arteries, when once filled with coagula and well contracted, fortunately do not frequently yield to the impulse which serves to produce secondary hemorrhage in vessels of smaller caliber.Secondary hemorrhage is not uncommon after deeply-penetrating gunshot wounds of the face, and sometimes it is difficult to determine the site of the bleeding vessel. It may be so situated that the rule of tying both ends of the bleeding artery in the wound cannot be carried out, and where, if the ordinary styptics fail, resort must be had to the ligature of the common trunk from which the bleeding vessel branches. In the museum at Fort Pitt is a cranium showing the passage of a musket-ball from the inner side of the right orbit to the entrance of the carotid canal in the petrous portion of the temporal bone, where the ball had lodged. Death ensued, ten days after the wound, by hemorrhage from the internal carotid. In another case, a branch of the external carotid artery was wounded by a ball which penetrated at the zygomatic fossa. Secondary hemorrhage ensued, and the usual means failed to arrest it. The external carotid was tied; but blood continued to flow, though less abundantly than before. Compression in the wound, which failed previously, now served to arrest the hemorrhage, and cure followed. Care must be taken, before tying the trunk, that pressure upon it exerts control over the hemorrhage from the wound; for the irregular course of projectiles is not unlikely to lead to mistakes, such as tying the common carotid,which is stated to have been done when the hemorrhage has been from the vertebral artery.The rule of treatment, however, holds good in secondary as in primary hemorrhage—the bleeding vessel must be secured at the wounded part whenever practicable, and it must be tied both above and below the line of division, taking care to ascertain that the spot where each ligature is applied is sound. Hemorrhage from general oozing, from sloughing, and other causes must be treated on the general principles applicable in all such cases.WOUNDS OF NERVES.Temporary paralysis from contusion of a nerve in the passage of a projectile is not unfrequent. Complete loss of power of motion and sensibility in a limb occasionally follows gunshot injuries, and generally indicates complete division of the nerve. Instead of complete paralysis, there may remain only modified deprivation of sensibility, partial loss of muscular force, and diminished power of resisting cold, with or without pain; and these symptoms may either be the result of contusion, with the effects perhaps of inflammatory action or of partial division. When a foreign body is lodged in or among nerves, it may induce tetanic symptoms of a fatal character, or great irritation and intense pain may result; and unless the source of these latter symptoms can be found and removed, if in a large nervous trunk of one of the extremities, they will sometimes lead to the necessity of amputation. The gunshot injuries which cause division of large nerves, however, are usually attended with so much destruction of other parts that the question of amputation has scarcely ever to be considered in reference to lesions of nerves alone. Atrophy of tissues and contractions of muscles are common results of injuries to nerves from gunshot, and often lead to soldiers being disabled for further service. Occasionally, after severe injuries, the functions of sensation andpower of motion gradually return, in some instances with perfect cure, but mostly with impaired power of resisting rapid alternations of temperature, especially cold. A case is mentioned in the Surgical History of the Crimean War where a soldier had the right sciatic nerve severely injured by the passage of a musket-ball. Total loss of sensation in the right foot followed. The wound was healed a month after it was received, and sensation slowly returned in the foot; but the restoration was attended with intensely burning pain, unrelieved by any applications. Gradual recovery took place. Dr. Williamson’s returns show eight cases of gunshot wounds with direct injury to nerves among the men invalided from India, after the late mutiny; all were wounds involving the brachial plexus, and in all there was paralysis, partial or complete, of the upper extremity on the injured side. In one case, the loss of function appears to have been almost confined to the hand; all the fingers were fixed in a straight position, and numb, and any attempt at bending them occasioned intense pain in the course of the median nerve. The hand was cold and affected with nervous tremor, but the motor power and sensibility of the thumb were preserved. The following hitherto unrecorded case illustrates several points: A soldier of the 37th Regiment was wounded at Azinghur, on the 27th of March, 1858, by a musket-ball, through the right side of the neck. It entered just below the horizontal ramus of the jaw, and made its exit behind, over the scapula. About three pints of blood escaped, supposed to be from the external jugular vein. The wound healed favorably, but he lost the use of his right arm, at first completely, and afterward partially, for three months. At the expiration of that period the power of the arm was restored; but he was invalided home on account of severe pain in the back of the neck, “resembling toothache,” which all treatment failed to relieve. This pain spontaneously and gradually ceased; there is still some loss of substance of the trapezius muscles of the right side of the neck, and of the right as comparedwith the other arm, with occasional numbness when the man is in heavy marching order; but in all other respects he is well, and is at his regular duty.TETANUS.One cause of fatal termination in gunshot wounds is tetanus. It is generally believed that the proportion of deaths from this source is greater after actions in tropical climates, and that exposure to the night air in such regions has some especial effect in producing them. The most common cause appears to be, however, the local injury to nerves, already mentioned, producing irritation along their course, and so leading to some morbid condition of the ganglionic portions of the motor tracts of the spinal cord. In the Crimean campaign, the proportion of tetanus was remarkably small as compared with former wars, being, according to the returns, only 0·2 per cent. of the number wounded. Dr. Scrive records that not more than thirty cases of tetanus occurred among the French wounded during the whole Crimean war, and this would show a somewhat less ratio even than in the British army. Dr. Stromeyer records only six cases of tetanus among 2000 wounded in the campaign of 1849 against the Danes. Three of these, in which the disease assumed a chronic form, recovered. There was only in one case injury of bone. Warm baths and opium were the remedies in the successful cases.Sir G. Ballingall made the calculation that one in seventy-nine is the average number of tetanic cases among wounded, and states that the proportion of recoveries is so small as scarcely to be taken into account. Three cases occurred to the writer, in the Crimea, after gunshot wounds; all proved fatal. In one there was a severe fracture of the ischium and injury of testicle by grape-shot. In a second, a rifle-ball entered just above the left knee, and lodged. Eight days after the injury an abscess was opened near the tuberosityof the ischium, and the ball was removed from that spot. The same day tetanus set in, and he died three days afterward. The ball had injured the sciatic nerve, which was found to be reddened superficially; while the neurilema, also, under an ordinary magnifying-glass, showed indications of inflammation. A piece of cloth was found lying midway in the long, sinus-like wound made by the ball. In a third, the bullet passed through the axillary region. The patient progressed favorably for some days, when tetanic symptoms appeared, and under these he sank. At the post-mortem examination, some detached pieces of woolen cloth were found lying entangled among the axillary plexus of nerves. Twenty-one cases altogether supervening on gunshot injuries are shown in a table in the Crimean records. Of these, ascertained injuries to nerves by projectiles, or division of nerves by amputation, occurred in eleven cases; three followed compound fractures, and seven flesh wounds. The average period at which the tetanic symptoms appeared was eight days and a half after the receipt of the injury; their duration prior to death, three days and a half. One case only recovered—a soldier of the 93d Regiment, wounded in the right buttock by a shell explosion. A fragment nearly a pound in weight was removed soon after the injury. Seventeen days after trismus set in, when a further examination of the wound led to the discovery of an angular fragment of shell which had been previously overlooked. It was deeply lodged, and resting on the sciatic nerve. On removing this, which weighed eighteen ounces, the sheath of the nerve was seen to be lacerated to nearly one inch in extent. Calomel and opium were now given; salivation appeared three days afterward, the trismus subsided, and the man gradually convalesced.Beyond the extraction of any foreign bodies which may have lodged, as in this last case, it is not known that there are any indications for special treatment of tetanus as occurring after gunshot injuries. The employment of woorali hasagain been brought into notice by its successful administration by M. Vella, of Turin, in the case of a French sergeant wounded in the metatarsus of the right foot, on the 4th of June, 1859, at the battle of Magenta, by a musket-ball which lodged. The projectile was extracted three days after his admission into hospital at Turin, on the 10th of June, and tetanus set in three days afterward. But the woorali failed in two other cases; and it has yet to be determined, should it be found to possess any peculiar power over tetanic spasm, to what class of cases its properties are applicable.Hospital gangrene, a common disease of wounded soldiers when circumstances of war lead to overcrowding in ill-ventilated buildings, and to deficiency in the proper number of attendants for securing personal cleanliness and purity of atmosphere, with inferior diet; andPyemia, a frequent cause of fatal termination after gunshot fractures, injuries of joints, and other suppurating wounds, especially under the influence of circumstances like those above named, are treated separately under their respective heads.ANESTHESIA IN GUNSHOT WOUNDS.The complete applicability of chloroform on the field to injuries caused by gunshot, as to all others in civil practice, is established among Continental surgeons, and among a majority of British army surgeons. The first opportunity of testing chloroform largely as an anesthetic agent in British military surgery occurred in the Crimean war, and a long report on the subject will be found in the published Surgical History of the Campaign. The general tenor of this report is to limit considerably the use of chloroform—in minor operations, on the ground of occasional bad results, even when the drug is of good quality and properly administered; or, in cases where the shock is very severe, on the ground that such do not rally, owing to the depressing effect of the drug, after the anesthesia has gone off; or in secondary operations,from the systems of the patients having been much reduced by purulent discharges. But from the report it appears that only one patient died from the effects of chloroform; and in this instance, Professor Maclagan, of Edinburgh, to whom a portion was forwarded for examination, reported the drug to be “acrid and nauseous when inhaled,” and “totally unfit for use.” On the other hand, Dr. Scrive, chief of the French Medical Department in the East, has written, in his Relation Médico-Chirurgicale de la Campagne d’Orient, p. 465: “De tous les moyens thérapeutiques employés par l’art chirurgicale, aucun n’a été aussi efficace et n’a réussi avec un succès aussi complet que le chloroforme; jamais, dans aucune circonstance, son maniement sur des milliers de blessés n’a causé le moindre accident sérieux;” and, more recently, Surgeon-Major M. Armand has written: “During the Italian war, chloroform was as extensively used and was as harmless as in the Crimea. I never heard of an accident from its use.”At the commencement of the Crimean war, the Inspector-General at the head of the British Medical Department circulated a memorandum “cautioning medical officers against the use of chloroform in the severe shock of serious gunshot wounds, as he thinks few will survive where it is used;” but as far as chloroform was available, it was used by many medical officers from the commencement of the campaign, and its employment became more general as the campaign advanced. It was constantly used in the division to which the writer belonged throughout the war; and no harm was ever met with from its use, while certain advantages appeared especially to fit it for military surgical practice. So far from adding to the shock of such cases as an army surgeon would select for operation, the use of chloroform seemed to support the patient during the ordeal; and the writer has several times seen soldiers, within a brief period after amputation for extensive gunshot wounds, and restoration to consciousness, calmly subside into natural and refreshing sleep.One reason for not using chloroform in the Inspector-General’s caution was, that the smart of the knife is a powerful stimulant; but “pain,” it has been remarked by a great surgeon, “when amounting to a certain degree of intensity and duration, is itself destructive;” and there can be little doubt that the acute pain of surgical operations, superadded to the pain which has been endured in consequence of severe gunshot fractures, has often, where chloroform has not been used, intensified the shock, and led to fatal results. In civil surgery, statistical evidence has demonstrated that the mortality after surgical operations has lessened since the use of chloroform; and it is believed the same result would be shown, if opportunity existed, in army practice. In the report of a case in the Crimea, instancing, perhaps, the greatest complication of injuries from gunshot of any which recovered, Dr. Macleod remarks casually in his Notes, p. 265: “This amputation was of course done under chloroform, otherwise it is questionable whether the operation could have been performed at all, the patient was so much depressed.” Mr. Guthrie, in the Addenda to his Commentaries, remarked, from the reports and cases which had reached him, that chloroform had been administered in all the divisions of the army save the second, and had been generally approved; and that the evidence was sufficient to authorize surgeons to administer it even in such wounds as those requiring amputation at the hip-joint. The late Director-General amputated in three instances at the hip-joint, after the battle of the Alma, under chloroform—two on the 21st and one on the 22d September—and all these lived to be carried on board ship on the latter-named day, and two, as before stated, lived several weeks. The absence of increased shock from pain during the amputation very probably enabled these patients to withstand the fatigue of removal to the coast and embarkation on board ship. With regard to the objection of occasional bad results, a recent estimate has shown that the probable proportion of all the deaths which have occurred from chloroformto the operations performed under its influence, exclusive of its use in midwifery, dental surgery, and private practice, has been one in 16,000; and as these accidents may equally occur during “minor operations,” in army practice as in civil life, it should be used or not at the option of the patient.In respect to the danger of anesthetics in the secondary operations connected with gunshot wounds, Dr. Scrive’s experience has led him to remark: “When consecutive amputation is rendered necessary by the gradually increasing debility of a wounded man from purulent discharges, chloroformization takes place with the most perfect calm on the part of the patient;” and he classes its use under “chloroformization de nécessité.” The general rules followed in civil surgery must be equally applicable in these cases.It must frequently happen in military practice that several operations have to be performed in rapid succession on the same person, from necessity of a speedy removal of the wounded; and, moreover, from the number of cases which are suddenly thrown on the care of the army surgeons after a general engagement, it must frequently occur that the diagnosis of a case is more or less doubtful. In such instances, the use of chloroform, by diminishing pain and preventing shock, and thus giving the opportunity of more accurate examination of parts, becomes particularly valuable in army practice. After the battles of Alma and Inkerman, when orders were given to remove the wounded as speedily as possible, the first-named consideration frequently occurred. The case of Sir T. Trowbridge is quoted by Mr. Guthrie. This officer had both feet completely destroyed by round shot at Inkerman, and it was necessary to amputate, on one side at the ankle-joint, on the other in the leg: the use of chloroform enabled the two operations to be performed within a few minutes of each other with perfect success. The amputations were done by the late Director-General of the Army Medical Department. In illustration of the secondcasualty, the following, which happened to the writer at Alma, may be named. A man of the Grenadier company of the 19th Regiment had a leg smashed by round shot. It was a question whether the fracture of bone extended into the knee-joint. Two superior staff-surgeons were near; a hasty consultation was held, and it was decided that the probabilities were in favor of the joint being intact. Amputation was performed, and the tibia sawn off close to the tubercle. It was then rendered evident that there was fissured fracture into the joint. As soon as the man had recovered from the state of anesthesia, the necessity of amputation above the knee was explained to him, and he readily assented. This was shortly afterward done, and the man recovered without any unusual symptoms, and was invalided to England. It is not likely, without chloroform, in a doubtful case of this kind, that the chance of saving the knee would have been conceded.In the British army in the Crimea chloroform was generally applied by simply pouring a little on lint. The chief objection against this in the open air is probably the waste which is likely to be occasioned. Dr. Scrive says it always appeared to him most advantageous to use a special apparatus, as well to measure exactly the doses, as to guarantee a proper amount of mixture of air; and that although he never saw a fatal result, he had several times seen excess of chloroformization from the use of lint rolled up in the shape of a funnel. The instructions which he gave were, never to pass the stage of strict insensibility to pain, never to wait for complete muscular relaxation; and to this direction being carried out he attributes the fact that no death occurred from chloroform in the French army in the Crimea. In an article on anesthetics, in theMedico-Chirurgical Review, October, 1859, Dr. Hayward, of Boston, has strongly advocated the use of sulphuric ether above all other anesthetics. The quantity required to produce anesthesia—from four to eight ounces—would render the use of this agent almost impracticable in extensive army operations in the field.AFTER-USEFULNESS OF WOUNDED SOLDIERS.The results of wounds unfit soldiers for military service in many ways, according to the nature of the wound and the region in which it is inflicted; and the pensions consequent on their discharge entail heavy expenses of long duration on the country. It was hoped that the improvements in conservative surgery would have diminished the number of disabled soldiers as compared with former wars; but the corresponding improvements in the power and means of destruction, with other circumstances, have defeated this hope, and the returns do not show such to be the result. Even the cases where resections of the joints have been performed, and fractures united, which previously would have been treated by amputation, have rarely presented such cures as to render the men available for military service, though the preserved limb may still be of use in the work of civil life. Formerly, all men who thus became unfitted to perform any of the duties to which a soldier is liable were removed from the army; but, by an order from the Horse Guards of 1858, wounded soldiers, though rendered unfit for active service in the field, were directed to be retained for modified duty in such employments as they are capable of executing. The results of the increased practice of conservative surgery may, therefore, prove valuable to the public service, now that the opportunity of secondary employment is laid open. The reports from the hospitals in Italy show that during the recent campaign in that country the practice of conservative surgery after gunshot fractures has been very limited, and in the lower extremity has been almost wholly abandoned, early amputation being practiced instead.It is believed, that should England become again involved in war, a greater amount of systematic scientific observation will be brought to bear upon the subject of gunshot woundsthan circumstances have ever previously admitted. Hitherto, the majority of the younger medical officers of the army have found themselves, on the occasion of war, suddenly in possession of a large number of wounded officers and soldiers to treat, with only those general principles of surgery to guide them which they had originally obtained in their studies in civil hospitals and schools; but this knowledge, essential and absolutely necessary above all other as it is, has been long admitted in the first-class powers of the Continent, whose military experience is necessarily greatest, to be incomplete for this purpose. Now that an Army Medical School has been established in England, and that in it the large number of sick and wounded who annually return from all parts of the world—serving to illustrate, among other subjects, the consequences of wounds and of the surgical operations performed for them in all their varieties—will be turned to account, as well as the great collection of preparations in the museum of the Army Medical Department, it is only reasonable to hope that the opportunities of study in these specialties which will be afforded to every medical officer at his entrance into the army will cause each individual, not only to be ready to apply at any moment all the improvements derived from experience and observation, up to the most advanced period, in this branch of the profession of surgery, but will also best prepare the members of the department for extending still further the sphere of usefulness which has been cultivated by their predecessors.THE END.MEDICAL BOOKSPUBLISHED BYJ. B. LIPPINCOTT & CO.Power’s Anatomy of the Arteries.Anatomy of the Arteries of the Human Body. ByJohn Hatch Power, Fellow of the Royal College of Surgeons. Profusely illustrated. Authorized and adopted by the Surgeon-General for Field and Hospital Use. 12mo. $2.00.Guthrie’s Surgery of War.Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands, from the battle of Roliça, in 1808, to that of Waterloo, in 1815, with additions relating to those in the Crimea in 1854-55; showing the improvements made during and since that period in the great art and science of Surgery on all the subjects to which they relate. ByG. J. Guthrie, F.R.S. One vol. 12mo. $2.25.Macleod’s Surgery of the Crimean War.Notes on the Surgery of the War in the Crimea; with Remarks on the Treatment of Gunshot Wounds. ByGeorge H. B. Macleod, M.D., F.R.C.S., Surgeon to the General Hospital in Camp before Sebastopol, Lecturer on Military Surgery in Anderson’s University, Glasgow, &c. &c. One vol. 12mo. $1.50.Beck’s Medical Jurisprudence.Elements of Medical Jurisprudence. ByTheodric Romeyn Beck, M.D., LL.D., andJohn B. Beck, M.D.Eleventh edition. With Notes by an association of the friends of Drs. Beck. The whole revised byC. R. Gilman, M.D., Professor of Medical Jurisprudence in the College of Physicians and Surgeons of New York. Two vols. 8vo. Nearly 1900 pages. Sheep. $10.00.Smith’s Surgery.The Principles and Practice of Surgery, embracing Operative Surgery. Arranged for the use of Students, byHenry H. Smith, M.D., Professor of the Principles and Practice of Surgery in the University of Pennsylvania. Illustrated with numerous steel and wood engravings. Two vols. 8vo. [In press.]Wood’s Practice of Medicine.A Treatise on the Theory and Practice of Medicine. ByGeo. B. Wood,M.D., Professor of Theory and Practice of Medicine in the University of Pennsylvania, &c. &c. Fifth edition, enlarged. Two vols. 8vo. $7.00.Wood’s Therapeutics and Pharmacology.A Treatise on Therapeutics and Pharmacology or Materia Medica. ByGeo. B. Wood, M.D. Second edition. Two vols. 8vo, sheep. $7.00.Wood & Bache’s Dispensatory.Dispensatory of the United States. By Drs.WoodandBache. Eleventh edition, much enlarged and carefully revised. $6.00.Hospital Steward’s Manual.The Hospital Steward’s Manual. For the Instruction of Hospital Stewards, Ward-Masters, and Attendants in their several duties. Authorized and adopted by the Surgeon-General for use in Hospitals of the United States Army. ByJoseph Janvier Woodward, M.D., Assistant Surgeon U.S.A. 12mo. $1.25.Leidy’s Anatomy.Human Anatomy. An Elementary Text-Book for Students. ByJoseph Leidy, M.D., Professor of Anatomy in the University of Pennsylvania. One vol. 8vo. Elegantly illustrated from original designs. Sheep. $5.00.Longmore on Gunshot Wounds.Longmore’s Gunshot Wounds. A Treatise on Gunshot Wounds. ByT. Longmore, Deputy Instructor of Hospitals, Professor of Military Surgery at Fort Pitt, Chatham. In two parts. Part I., Gunshot Wounds in General. Part II., Gunshot Wounds in Special Regions of the Body. One vol. 12mo. 75 cts.Malgaigne’s Fractures.A Treatise on Fractures. By Prof.Malgaigne, of Paris. Translated from the French byJohn H. Packard, M.D. 8vo, with numerous illustrations. $4.00.Gerhard on the Chest.The Diagnosis, Pathology, and Treatment of the Diseases of the Chest. ByW. W. Gerhard, M.D., Fellow of the College of Physicians of Philadelphia, Member of the American Philosophical Society, and one of the Physicians to the Pennsylvania Hospital, &c. Fourth edition, revised and enlarged. One vol. 8vo. Cloth, $3.00; sheep, $3.25.J. B. LIPPINCOTT & CO., Publishers,PHILADELPHIA.FOOTNOTES:[1]Notes on the Surgery of the Crimean War, p. 104, J. B. Lippincott & Co.’s edition.[2]See Guy’s Hospital Reports, 3d series, vol. v., 1859—case of Gunshot Wound in the Loins, by S. O. Habershon, M.D.[3]The portion of cranium referred to, with the piece of ball weighing half an ounce, which lodged in the cerebrum, are in the museum at Fort Pitt.[4]In the Medical and Surgical History of the War against Russia in the Years 1854-55-56, published by authority, vol. ii. p. 265, the physical effects of concussion in producing “shock” are strongly dwelt upon. It is remarked: “The shock of the accidents frequently witnessed by the military surgeon differs, often in a very material degree, and possibly in kind also, from that witnessed in civil life. When a cannon-shot strikes a limb and carries it away, the immense velocity and momentum of the impinging force can scarcely be supposed to have no physical effect upon the neighboring or even distant parts independent of, and in addition to, the ‘shock,’ in the ordinary acceptation of the term, which would result from the removal of the same part by the knife of the surgeon, or the crushing of it by a heavy stone or the wheel of a railway wagon. * * In the great majority of cases, the whole frame is likewise violently shaken and contused, and, probably, independent of these physical effects, a further vital influence is exerted, which exists in a very minor degree, if at all, in the last-named injuries, and may possibly depend upon the ganglionic nervous system.”[5]M. Scrive gives the following as the weight of the linen dressings consumed by the wounded of the French army in the campaign in the Crimea:—English weight.tons.cwt.qr.lb.Linen cloth101,779kilogrammes=1002123Rolled bandages46,446”=4513214Charpie47,776”=461934And estimates the following as the proportion consumed by each of the wounded:—English weightavoirdupois.lb.oz.dr.gr.Linen cloth2kil.482grammes=57010Rolled bandages0”891”=115713Charpie1”181”=29110——————————————Total4”554”=100223In an Army Medical Department Circular, dated 27th May, 1855, it was announced that the Secretary of State for War had decided the following “Field Dressing” should form part of every British soldier’s kit on active service, so as to be available at all times and in all places as a first dressing for wounds:—Bandage of fine calico, 4 yds. long, 3 in. wide.Fine lint, 3 in. wide, 12 in. long.Folded flat and fastened by 4 pins.[6]Perchlorure de fer, 30 drops, two or three times daily as a tonic, and diluted with six parts of water as an injection.[7]Dict. des Sciences Méd., Paris, 1813, p. 217.[8]See Edin. Med. and Surg. Journal, vol. xiv.—Case of gunshot wound of the heart, by J. Fuge, Esq.[9]For 1855, vol. i. p. 606, and vol. ii. p. 437.[10]Bulletin de l’Académie Impériale de Médecine, 24th April, 1860. See also Des Amputations consécutives à l’Ostéomyélite dans les Fractures des Membres par armes à feu, par M. H. Baron Larrey, Paris, 1860.[11]Dupuytren made a division of the splinters of bone broken by gunshot into three classes, viz.: primary sequestra, those directly and completely separated by the force of the projectile; secondary sequestra, those retaining partial connections by periosteal, muscular, or other attachments, but afterward thrown off during the suppurative process; and tertiary sequestra, or necrosed portions, produced by the effects of the contusion and prolonged inflammatory action in parts adjoining the seat of fracture. In accordance with this arrangement, the removal by the surgeon of the primary and secondary splinters has been regarded as simply anticipating nature in her work; but Dr. Esmarch states, as one result of the experience of the surgeons of the Sleswick-Holstein army, that, in the majority of comminuted fractures, the removal of splinters retaining any connection with periosteum is unnecessary and often injurious, as is also the practice of sawing off the broken ends of the bone projecting from the comminuted part. By proper treatment and under favorable circumstances, he asserts, such splinters become impacted in callus, and in time unite with the other fragments of the bone, and in this manner a cure is completed without operative interference. It is a matter, however, of frequent observation that splinters which have thus become impacted in callus lead to mischief in various ways, or are subsequently discharged as if they were so many foreign bodies, while the removal of the jagged ends of the broken bone seems to be a valuable means of preventing irritation, and thus of favoring union between them; and English surgeons, therefore, generally pursue the practice above recommended.[12]The officer referred to must have greatly improved in condition since Dr. Macleod wrote, as he has been of late on active service in India.[13]Notes on the Surgery of the Crimean War, p. 264.[14]In the surgical history of this war, this statement, which was quoted by the late Mr. Guthrie, in the Addenda to his Commentaries, is said to be a mistake, on account of the absence (not to be wondered at, amid the confusion of that period) of official records on the subject. Special reports on these cases were obtained at the time from Scutari, and were shown to the writer by the late Director-General shortly before his decease.[15]A committee was appointed by the Surgical Society of Paris to examine and report upon this essay of Dr. Legouest on Coxo-femoral Disarticulation for Gunshot Wounds. Baron Larrey drew up the report, which will be found in the 5th vol. of the Mémoires de la Société de Chirurgie, 1860. It confirms the principle laid down by Dr. Legouest, excepting only those cases of fracture where the mutilation of the limb from a heavy projectile has been so great as to partly separate it from the pelvis, and those in which there has been simultaneous lesion of the crural vessels and femur near the pelvis, with extensive laceration of the surrounding tissues.
There is not space to follow the details of the treatment of this case. The cure was protracted by large and troublesome bed-sores; and attention to these, to the discharges from the wound, and preserving favorable position, occupied much time and care daily, and caused many changes in the appliances for these objects to be from time to time necessary. On November the 4th, union had so far taken place that he was able to raise his body from the knee upward while in bed, without apparent motion at the seat of fracture. On November 15th, in consequence of the great explosion at the right siege-train, he had to be carried to another division of the camp; this was effected without harm. In the middle of January he was able to sit in a chair without inconvenience; and on February 22d he left the Crimea for England, being able to walk with the assistance of crutches. Union was then firm; but a slight serous oozing continued from the wound of exit, and there was much stiffness of the ankle and knee joints from the long-continued constrained position to which he had been subjected. In July, 1856, after his arrival in Ireland, indications of pus collecting manifested themselves at the wound of exit; and Professor Tufnell, on passing a bougie about seven inches in the course of the wound, evacuated a small abscess, and felt a piece of bone trying to make its way to the surface. This was subsequently removed, and, underMr. Tufnell’s able care, the stiffness of the joints gradually disappeared, and he was enabled to return to duty.
Dr. Macleod says that, after many inquiries respecting cases of this nature in the hospitals of the other armies engaged in the war, excepting one presented by Baron Larrey to the Société de Chirurgie in 1857, he never could hear of any other but that of a Russian whose greatly shattered and deformed limb he often examined.[13]It had united almost without treatment. Two cases of united fractures of the femur in the upper third have arrived from the late mutiny in India, and in both, Dr. Williamson records, a good and useful limb had resulted, one with shortening of 1-1/2, the other 3-1/2, inches. Still more recently, M. Jules Roux, of the St. Maudrier Hospital, at Toulon, has given a list of no less than twenty-one cases of gunshot injuries of the upper third of the femur, which he had examined on their return from the Italian war of 1859, in all of which consolidation of the fracture had taken place. We have no data by which we can estimate the proportion of these cases of union to those in which other results ensued.
The proportion of recoveries in amputations in the upper third of the femur in the Crimean war was under 13 per cent. Amputation at the hip-joint, both in the French and English armies, in all instances proved fatal. The two patients who survived the longest were operated on by the late Director-General after the battle of the Alma: one, a soldier of the 33d Regiment, died at Scutari three weeks after the operation; the second, a Russian, died on the thirtieth day after, from “extensive sloughing and great debility.”[14]One case of excision of the head, neck, and trochanterof the femur in the Crimea recovered, operated upon by Dr. O’Leary; the only known successful case of excision of the hip-joint after a gunshot wound. The operation was performed on the same day that the wound was received. In the Sleswick-Holstein campaigns, amputation at the hip-joint was performed seven times; one patient only survived, a young man, aged seventeen years, operated upon by Dr. Langenbeck. Resection of the upper part of the femur, including the head and two inches below the small trochanter, was performed once, but the patient died from pyemia. At the post-mortem examination, the right shoulder and ankle joints were found to be filled with pus. The operation in this instance was performed three weeks after the injury. No case of amputation, nor of resection, at the hip-joint has returned from the Indian mutiny. M. Legouest, in a recent essay in theMemoirs of the Society of Surgery, at Paris, maintains that amputation at the hip-joint should be reserved for cases of fracture with injury to the great vessels, and that where the vessels have escaped, resection should invariably be performed. He also inculcates, as a general principle, not to perform immediateprimaryamputation at the hip-joint in any case; but, even in the severest forms of injury, to postpone the operation as long as possible.[15]For theconsecutiveresults of gunshotwounds, the operation presents a less unfavorable aspect than for immediate injuries. M. Jules Roux has recently, at Toulon, performed amputation at the hip-joint six times for the consequences of wounds received during the war in Italy, and of these, four have been successful.
With regard to gunshot fractures in the middle and lower third of the femur, the experience of the French and English armies in the Crimea has tended to confirm the doctrine of the older military surgeons, that many lives are lost which might be otherwise preserved, by trying to save limbs; and that, of the limbs preserved, many are little better than incumbrances to their possessors. In the late Italian battles, the practice of trying to save lower extremities, after comminuted fractures in these situations of the thigh, appears to have been abandoned. Eight cases of union after compound gunshot fractures of the femur in these situations have, however, returned from the late mutiny in India; and this is a much larger proportion than was that of the recoveries from the Crimea. Dr. Williamson, who records these cases, is inclined to attribute this success in a great measure to the use of dooleys for the conveyance of wounded, and argues that it would be advantageous to introduce them into European warfare. But wounds generally, where proper care is taken, heal more favorably in southern latitudes, east or west, probably owing to the climate admitting of so much more free an access of fresh air by day and night to the patient than can be afforded, without inconvenience, in colder or more variable climates. The dooley is most advantageous and comfortable as used in the East, where it is an ordinary mode of conveyance among all classes, and the bearers—a special race in each Presidency—are trained from childhood to the occupation; but, from experience of the peculiar habits and tenets of these men, both Madrassees and those of Bengal, it seems scarcely probable that they would prove efficient, even if they could exist, or that their wants could be provided for in the numbers necessary to beserviceable, with armies in northern latitudes. French surgeons have remarked how much more favorably,cæteris paribus, wounds heal in Algeria, where they have only the same kinds of conveyance for wounded as in Europe; and the difference is accounted for by the favorable influence in this respect of a warmer climate.
In fractures of the leg, where neither the knee nor ankle joints are implicated, the results of conservative attempts have been more favorable. In the Crimea, the recoveries without amputation being resorted to were: in fractures of both bones, nearly 19; tibia only, 36·3; fibula only, 40·9 per cent. When the fracture is comminuted, and implicates the knee or ankle joint, opening the capsule, amputation is necessary. The knee-joint was once excised in the Crimea, but the patient died; as was the case in the only other instance where this operation is known to have been performed for gunshot injury in the Sleswick-Holstein campaign. In the treatment of fractures of the leg, where it has been determined to seek union, the same remarks apply as those made above in respect to fractures in the upper extremity. In wounds of the foot it is especially necessary to remove as early as possible all the comminuted fragments of the bones injured, or tedious abscesses and much pain and constitutional irritation are likely to ensue.
AMPUTATION.
It is not necessary to refer at much length to the question which was formerly disputed upon—the advantages ofprimaryas compared withsecondaryamputation in gunshot wounds—for military surgeons, whether acting at sea or on land, have practically determined the subject. For a long time the directions of John Hunter, that amputation should not be performed until the first inflammation was over, based on the argument that the “amputation is a violence superaddedto the injury, and therefore heightens the danger,” and that this danger is aggravated in the instance of a man laboring under mental agitation, as on the field of battle, had great weight among English surgeons; but experience has led to a different practice. The greater success of primary amputation appears to be attributable to the facts, that a contused and mangled limb is a constant source of accumulating irritation; that the exciting circumstances connected with battle lead a man to bear with courage at an early stage what subsequent suffering and anxiety may render him less willing to submit to; that a soldier, when first wounded, is most probably in stronger health than he will be after hospital restraint and confinement; that though the amputation is a violence, it is one the patient is likely to submit to with resignation, knowing that it is performed to remove parts which, if unremoved, will destroy life; and lastly, because the operation takes away a source of dread which must weigh down the sufferer so long as it is impending. The present practice has resulted from testing both modes of amputation. Mr. Guthrie showed, from the experience of the Peninsular war, that the loss in secondary amputations had constantly exceeded that from primary amputations in both the upper and lower extremities. More recent observations in both English and French campaigns have confirmed this result. Dr. Scrive records that the experience of the French army in the Crimea showed the success of primary amputation sometimes exceeded by two-thirds that of secondary amputation. He excepts amputations at the hip-joint, and cites, as his reason for this exception, that in nine cases where the hip-joint amputation was performed primarily, death followed the operation a few instants or a few hours afterward; while in three cases which he witnessed, where the amputation was consecutive, one lived five, another twelve, and the third twenty days. In respect to the particular time at which primary amputation is to be performed, the general practice of the present day is, whenthe operation is inevitable, to perform it as soon as it can be done; provided the more intense effects of “shock,” where it has supervened on the injury, have passed off; and this practice generally accords with the feelings of soldiers, who not unfrequently press the surgeon for an early turn in being relieved from the suffering resulting from a shattered limb. In the cases where primary amputation is to be performed, a further reason given by Dr. Scrive for the operation being done on the same day that the wound is received is, that chloroform acts then so much more benignantly and readily; while, on the following day, or day after, traumatic excitement becomes very energetic, and considerable resistance is offered to its influence by wounded men, and longer time and a much larger dose of the chloroform are required to produce the state of anesthesia. If only a moderate amount of “shock” exist, this does not appear to be a sufficient reason for delaying amputation; for a moderate exhibition of stimulus and a few consolatory words will often remove this, and, even though some faintness, pallor, and depression remain, no ill consequences ensue. The late Director-General, in a letter to the late Mr. Guthrie, written in 1855, mentioned the case of a soldier of the 90th Regiment, whose right arm he removed at the shoulder-joint on the 10th of July, for great destruction of soft parts and extensive injury to the bone: “The patient was so low when placed on the table that brandy and water were given to him, and he was then immediately afterward placed under chloroform. When I had finished, it was observed that his pulse was stronger than before the operation.” This man recovered without a bad symptom, and is now one of the Commissionaires in London. Indeed, in the Crimea, primary amputations were repeatedly performed where shock had not wholly disappeared, and no harm resulted from the practice. The introduction of chloroform, by its negative operation of preventing pain or alarm, and by its positive action as a stimulus, has done much to remove many of theobjections which were urged by John Hunter against early amputations after gunshot wounds. If collapse be intense, more than is accounted for by the wound to the extremity, suspicion will be excited that some internal injury has been also inflicted, and delay will be necessary for further observation of the patient. When active operations are proceeding, and it is necessary to carry the wounded to any distance, the advantages of early removal of shattered limbs are obvious.
SECONDARY HEMORRHAGE.
Army surgeons meet in practice with secondary more frequently than primary hemorrhage in gunshot wounds. It may arise in several ways. Sometimes it results from the coagulum being forced out of an artery in which hemorrhage had previously been spontaneously averted by the ordinary natural process, this accident being consequent upon muscular exertion or increased impulse of the circulating system from any cause. This occurrence in the bottom of a deep wound will be often found to be a very troublesome complication. Sometimes an artery which did not appear to be injured in the first instance ulcerates or sloughs; or, without direct injury, a vessel may become involved in unhealthy deterioration of the wound, and give way; or, in a granulating wound, general capillary hemorrhage may be excited by stimulus of any kind, such as venereal excitement or excess in drinking; or the coats of the vessel may ulcerate under pressure from a detached fragment of bone or from some foreign body; or the artery may be accidentally penetrated by the end of a sharp spiculum. Secondary hemorrhage has been said to arise from increased arterial action, from the first to the fifth day; from sloughing, the effects of contusion, from the fifth to the tenth; from ulceration, to any more distant date. M. Baudens has remarked that he has observed secondary hemorrhage to be most frequent about the sixth day after the wound—the traumatic fever havingthen reached its highest point of intensity, and the sharp, hurried contractions of the heart having most power in forcing out the coagula. If we could compare all the cases of hemorrhage which occur, secondary would, perhaps, statistically appear less dangerous than primary hemorrhage; for the latter, when happening from large vessels, must be very generally fatal, while, when hemorrhage occurs in them secondarily, the collateral branches have become partially adapted to the interruption of the flow of blood through the regular channel. Moreover, the larger arteries, when once filled with coagula and well contracted, fortunately do not frequently yield to the impulse which serves to produce secondary hemorrhage in vessels of smaller caliber.
Secondary hemorrhage is not uncommon after deeply-penetrating gunshot wounds of the face, and sometimes it is difficult to determine the site of the bleeding vessel. It may be so situated that the rule of tying both ends of the bleeding artery in the wound cannot be carried out, and where, if the ordinary styptics fail, resort must be had to the ligature of the common trunk from which the bleeding vessel branches. In the museum at Fort Pitt is a cranium showing the passage of a musket-ball from the inner side of the right orbit to the entrance of the carotid canal in the petrous portion of the temporal bone, where the ball had lodged. Death ensued, ten days after the wound, by hemorrhage from the internal carotid. In another case, a branch of the external carotid artery was wounded by a ball which penetrated at the zygomatic fossa. Secondary hemorrhage ensued, and the usual means failed to arrest it. The external carotid was tied; but blood continued to flow, though less abundantly than before. Compression in the wound, which failed previously, now served to arrest the hemorrhage, and cure followed. Care must be taken, before tying the trunk, that pressure upon it exerts control over the hemorrhage from the wound; for the irregular course of projectiles is not unlikely to lead to mistakes, such as tying the common carotid,which is stated to have been done when the hemorrhage has been from the vertebral artery.
The rule of treatment, however, holds good in secondary as in primary hemorrhage—the bleeding vessel must be secured at the wounded part whenever practicable, and it must be tied both above and below the line of division, taking care to ascertain that the spot where each ligature is applied is sound. Hemorrhage from general oozing, from sloughing, and other causes must be treated on the general principles applicable in all such cases.
WOUNDS OF NERVES.
Temporary paralysis from contusion of a nerve in the passage of a projectile is not unfrequent. Complete loss of power of motion and sensibility in a limb occasionally follows gunshot injuries, and generally indicates complete division of the nerve. Instead of complete paralysis, there may remain only modified deprivation of sensibility, partial loss of muscular force, and diminished power of resisting cold, with or without pain; and these symptoms may either be the result of contusion, with the effects perhaps of inflammatory action or of partial division. When a foreign body is lodged in or among nerves, it may induce tetanic symptoms of a fatal character, or great irritation and intense pain may result; and unless the source of these latter symptoms can be found and removed, if in a large nervous trunk of one of the extremities, they will sometimes lead to the necessity of amputation. The gunshot injuries which cause division of large nerves, however, are usually attended with so much destruction of other parts that the question of amputation has scarcely ever to be considered in reference to lesions of nerves alone. Atrophy of tissues and contractions of muscles are common results of injuries to nerves from gunshot, and often lead to soldiers being disabled for further service. Occasionally, after severe injuries, the functions of sensation andpower of motion gradually return, in some instances with perfect cure, but mostly with impaired power of resisting rapid alternations of temperature, especially cold. A case is mentioned in the Surgical History of the Crimean War where a soldier had the right sciatic nerve severely injured by the passage of a musket-ball. Total loss of sensation in the right foot followed. The wound was healed a month after it was received, and sensation slowly returned in the foot; but the restoration was attended with intensely burning pain, unrelieved by any applications. Gradual recovery took place. Dr. Williamson’s returns show eight cases of gunshot wounds with direct injury to nerves among the men invalided from India, after the late mutiny; all were wounds involving the brachial plexus, and in all there was paralysis, partial or complete, of the upper extremity on the injured side. In one case, the loss of function appears to have been almost confined to the hand; all the fingers were fixed in a straight position, and numb, and any attempt at bending them occasioned intense pain in the course of the median nerve. The hand was cold and affected with nervous tremor, but the motor power and sensibility of the thumb were preserved. The following hitherto unrecorded case illustrates several points: A soldier of the 37th Regiment was wounded at Azinghur, on the 27th of March, 1858, by a musket-ball, through the right side of the neck. It entered just below the horizontal ramus of the jaw, and made its exit behind, over the scapula. About three pints of blood escaped, supposed to be from the external jugular vein. The wound healed favorably, but he lost the use of his right arm, at first completely, and afterward partially, for three months. At the expiration of that period the power of the arm was restored; but he was invalided home on account of severe pain in the back of the neck, “resembling toothache,” which all treatment failed to relieve. This pain spontaneously and gradually ceased; there is still some loss of substance of the trapezius muscles of the right side of the neck, and of the right as comparedwith the other arm, with occasional numbness when the man is in heavy marching order; but in all other respects he is well, and is at his regular duty.
TETANUS.
One cause of fatal termination in gunshot wounds is tetanus. It is generally believed that the proportion of deaths from this source is greater after actions in tropical climates, and that exposure to the night air in such regions has some especial effect in producing them. The most common cause appears to be, however, the local injury to nerves, already mentioned, producing irritation along their course, and so leading to some morbid condition of the ganglionic portions of the motor tracts of the spinal cord. In the Crimean campaign, the proportion of tetanus was remarkably small as compared with former wars, being, according to the returns, only 0·2 per cent. of the number wounded. Dr. Scrive records that not more than thirty cases of tetanus occurred among the French wounded during the whole Crimean war, and this would show a somewhat less ratio even than in the British army. Dr. Stromeyer records only six cases of tetanus among 2000 wounded in the campaign of 1849 against the Danes. Three of these, in which the disease assumed a chronic form, recovered. There was only in one case injury of bone. Warm baths and opium were the remedies in the successful cases.
Sir G. Ballingall made the calculation that one in seventy-nine is the average number of tetanic cases among wounded, and states that the proportion of recoveries is so small as scarcely to be taken into account. Three cases occurred to the writer, in the Crimea, after gunshot wounds; all proved fatal. In one there was a severe fracture of the ischium and injury of testicle by grape-shot. In a second, a rifle-ball entered just above the left knee, and lodged. Eight days after the injury an abscess was opened near the tuberosityof the ischium, and the ball was removed from that spot. The same day tetanus set in, and he died three days afterward. The ball had injured the sciatic nerve, which was found to be reddened superficially; while the neurilema, also, under an ordinary magnifying-glass, showed indications of inflammation. A piece of cloth was found lying midway in the long, sinus-like wound made by the ball. In a third, the bullet passed through the axillary region. The patient progressed favorably for some days, when tetanic symptoms appeared, and under these he sank. At the post-mortem examination, some detached pieces of woolen cloth were found lying entangled among the axillary plexus of nerves. Twenty-one cases altogether supervening on gunshot injuries are shown in a table in the Crimean records. Of these, ascertained injuries to nerves by projectiles, or division of nerves by amputation, occurred in eleven cases; three followed compound fractures, and seven flesh wounds. The average period at which the tetanic symptoms appeared was eight days and a half after the receipt of the injury; their duration prior to death, three days and a half. One case only recovered—a soldier of the 93d Regiment, wounded in the right buttock by a shell explosion. A fragment nearly a pound in weight was removed soon after the injury. Seventeen days after trismus set in, when a further examination of the wound led to the discovery of an angular fragment of shell which had been previously overlooked. It was deeply lodged, and resting on the sciatic nerve. On removing this, which weighed eighteen ounces, the sheath of the nerve was seen to be lacerated to nearly one inch in extent. Calomel and opium were now given; salivation appeared three days afterward, the trismus subsided, and the man gradually convalesced.
Beyond the extraction of any foreign bodies which may have lodged, as in this last case, it is not known that there are any indications for special treatment of tetanus as occurring after gunshot injuries. The employment of woorali hasagain been brought into notice by its successful administration by M. Vella, of Turin, in the case of a French sergeant wounded in the metatarsus of the right foot, on the 4th of June, 1859, at the battle of Magenta, by a musket-ball which lodged. The projectile was extracted three days after his admission into hospital at Turin, on the 10th of June, and tetanus set in three days afterward. But the woorali failed in two other cases; and it has yet to be determined, should it be found to possess any peculiar power over tetanic spasm, to what class of cases its properties are applicable.
Hospital gangrene, a common disease of wounded soldiers when circumstances of war lead to overcrowding in ill-ventilated buildings, and to deficiency in the proper number of attendants for securing personal cleanliness and purity of atmosphere, with inferior diet; andPyemia, a frequent cause of fatal termination after gunshot fractures, injuries of joints, and other suppurating wounds, especially under the influence of circumstances like those above named, are treated separately under their respective heads.
ANESTHESIA IN GUNSHOT WOUNDS.
The complete applicability of chloroform on the field to injuries caused by gunshot, as to all others in civil practice, is established among Continental surgeons, and among a majority of British army surgeons. The first opportunity of testing chloroform largely as an anesthetic agent in British military surgery occurred in the Crimean war, and a long report on the subject will be found in the published Surgical History of the Campaign. The general tenor of this report is to limit considerably the use of chloroform—in minor operations, on the ground of occasional bad results, even when the drug is of good quality and properly administered; or, in cases where the shock is very severe, on the ground that such do not rally, owing to the depressing effect of the drug, after the anesthesia has gone off; or in secondary operations,from the systems of the patients having been much reduced by purulent discharges. But from the report it appears that only one patient died from the effects of chloroform; and in this instance, Professor Maclagan, of Edinburgh, to whom a portion was forwarded for examination, reported the drug to be “acrid and nauseous when inhaled,” and “totally unfit for use.” On the other hand, Dr. Scrive, chief of the French Medical Department in the East, has written, in his Relation Médico-Chirurgicale de la Campagne d’Orient, p. 465: “De tous les moyens thérapeutiques employés par l’art chirurgicale, aucun n’a été aussi efficace et n’a réussi avec un succès aussi complet que le chloroforme; jamais, dans aucune circonstance, son maniement sur des milliers de blessés n’a causé le moindre accident sérieux;” and, more recently, Surgeon-Major M. Armand has written: “During the Italian war, chloroform was as extensively used and was as harmless as in the Crimea. I never heard of an accident from its use.”
At the commencement of the Crimean war, the Inspector-General at the head of the British Medical Department circulated a memorandum “cautioning medical officers against the use of chloroform in the severe shock of serious gunshot wounds, as he thinks few will survive where it is used;” but as far as chloroform was available, it was used by many medical officers from the commencement of the campaign, and its employment became more general as the campaign advanced. It was constantly used in the division to which the writer belonged throughout the war; and no harm was ever met with from its use, while certain advantages appeared especially to fit it for military surgical practice. So far from adding to the shock of such cases as an army surgeon would select for operation, the use of chloroform seemed to support the patient during the ordeal; and the writer has several times seen soldiers, within a brief period after amputation for extensive gunshot wounds, and restoration to consciousness, calmly subside into natural and refreshing sleep.One reason for not using chloroform in the Inspector-General’s caution was, that the smart of the knife is a powerful stimulant; but “pain,” it has been remarked by a great surgeon, “when amounting to a certain degree of intensity and duration, is itself destructive;” and there can be little doubt that the acute pain of surgical operations, superadded to the pain which has been endured in consequence of severe gunshot fractures, has often, where chloroform has not been used, intensified the shock, and led to fatal results. In civil surgery, statistical evidence has demonstrated that the mortality after surgical operations has lessened since the use of chloroform; and it is believed the same result would be shown, if opportunity existed, in army practice. In the report of a case in the Crimea, instancing, perhaps, the greatest complication of injuries from gunshot of any which recovered, Dr. Macleod remarks casually in his Notes, p. 265: “This amputation was of course done under chloroform, otherwise it is questionable whether the operation could have been performed at all, the patient was so much depressed.” Mr. Guthrie, in the Addenda to his Commentaries, remarked, from the reports and cases which had reached him, that chloroform had been administered in all the divisions of the army save the second, and had been generally approved; and that the evidence was sufficient to authorize surgeons to administer it even in such wounds as those requiring amputation at the hip-joint. The late Director-General amputated in three instances at the hip-joint, after the battle of the Alma, under chloroform—two on the 21st and one on the 22d September—and all these lived to be carried on board ship on the latter-named day, and two, as before stated, lived several weeks. The absence of increased shock from pain during the amputation very probably enabled these patients to withstand the fatigue of removal to the coast and embarkation on board ship. With regard to the objection of occasional bad results, a recent estimate has shown that the probable proportion of all the deaths which have occurred from chloroformto the operations performed under its influence, exclusive of its use in midwifery, dental surgery, and private practice, has been one in 16,000; and as these accidents may equally occur during “minor operations,” in army practice as in civil life, it should be used or not at the option of the patient.
In respect to the danger of anesthetics in the secondary operations connected with gunshot wounds, Dr. Scrive’s experience has led him to remark: “When consecutive amputation is rendered necessary by the gradually increasing debility of a wounded man from purulent discharges, chloroformization takes place with the most perfect calm on the part of the patient;” and he classes its use under “chloroformization de nécessité.” The general rules followed in civil surgery must be equally applicable in these cases.
It must frequently happen in military practice that several operations have to be performed in rapid succession on the same person, from necessity of a speedy removal of the wounded; and, moreover, from the number of cases which are suddenly thrown on the care of the army surgeons after a general engagement, it must frequently occur that the diagnosis of a case is more or less doubtful. In such instances, the use of chloroform, by diminishing pain and preventing shock, and thus giving the opportunity of more accurate examination of parts, becomes particularly valuable in army practice. After the battles of Alma and Inkerman, when orders were given to remove the wounded as speedily as possible, the first-named consideration frequently occurred. The case of Sir T. Trowbridge is quoted by Mr. Guthrie. This officer had both feet completely destroyed by round shot at Inkerman, and it was necessary to amputate, on one side at the ankle-joint, on the other in the leg: the use of chloroform enabled the two operations to be performed within a few minutes of each other with perfect success. The amputations were done by the late Director-General of the Army Medical Department. In illustration of the secondcasualty, the following, which happened to the writer at Alma, may be named. A man of the Grenadier company of the 19th Regiment had a leg smashed by round shot. It was a question whether the fracture of bone extended into the knee-joint. Two superior staff-surgeons were near; a hasty consultation was held, and it was decided that the probabilities were in favor of the joint being intact. Amputation was performed, and the tibia sawn off close to the tubercle. It was then rendered evident that there was fissured fracture into the joint. As soon as the man had recovered from the state of anesthesia, the necessity of amputation above the knee was explained to him, and he readily assented. This was shortly afterward done, and the man recovered without any unusual symptoms, and was invalided to England. It is not likely, without chloroform, in a doubtful case of this kind, that the chance of saving the knee would have been conceded.
In the British army in the Crimea chloroform was generally applied by simply pouring a little on lint. The chief objection against this in the open air is probably the waste which is likely to be occasioned. Dr. Scrive says it always appeared to him most advantageous to use a special apparatus, as well to measure exactly the doses, as to guarantee a proper amount of mixture of air; and that although he never saw a fatal result, he had several times seen excess of chloroformization from the use of lint rolled up in the shape of a funnel. The instructions which he gave were, never to pass the stage of strict insensibility to pain, never to wait for complete muscular relaxation; and to this direction being carried out he attributes the fact that no death occurred from chloroform in the French army in the Crimea. In an article on anesthetics, in theMedico-Chirurgical Review, October, 1859, Dr. Hayward, of Boston, has strongly advocated the use of sulphuric ether above all other anesthetics. The quantity required to produce anesthesia—from four to eight ounces—would render the use of this agent almost impracticable in extensive army operations in the field.
AFTER-USEFULNESS OF WOUNDED SOLDIERS.
The results of wounds unfit soldiers for military service in many ways, according to the nature of the wound and the region in which it is inflicted; and the pensions consequent on their discharge entail heavy expenses of long duration on the country. It was hoped that the improvements in conservative surgery would have diminished the number of disabled soldiers as compared with former wars; but the corresponding improvements in the power and means of destruction, with other circumstances, have defeated this hope, and the returns do not show such to be the result. Even the cases where resections of the joints have been performed, and fractures united, which previously would have been treated by amputation, have rarely presented such cures as to render the men available for military service, though the preserved limb may still be of use in the work of civil life. Formerly, all men who thus became unfitted to perform any of the duties to which a soldier is liable were removed from the army; but, by an order from the Horse Guards of 1858, wounded soldiers, though rendered unfit for active service in the field, were directed to be retained for modified duty in such employments as they are capable of executing. The results of the increased practice of conservative surgery may, therefore, prove valuable to the public service, now that the opportunity of secondary employment is laid open. The reports from the hospitals in Italy show that during the recent campaign in that country the practice of conservative surgery after gunshot fractures has been very limited, and in the lower extremity has been almost wholly abandoned, early amputation being practiced instead.
It is believed, that should England become again involved in war, a greater amount of systematic scientific observation will be brought to bear upon the subject of gunshot woundsthan circumstances have ever previously admitted. Hitherto, the majority of the younger medical officers of the army have found themselves, on the occasion of war, suddenly in possession of a large number of wounded officers and soldiers to treat, with only those general principles of surgery to guide them which they had originally obtained in their studies in civil hospitals and schools; but this knowledge, essential and absolutely necessary above all other as it is, has been long admitted in the first-class powers of the Continent, whose military experience is necessarily greatest, to be incomplete for this purpose. Now that an Army Medical School has been established in England, and that in it the large number of sick and wounded who annually return from all parts of the world—serving to illustrate, among other subjects, the consequences of wounds and of the surgical operations performed for them in all their varieties—will be turned to account, as well as the great collection of preparations in the museum of the Army Medical Department, it is only reasonable to hope that the opportunities of study in these specialties which will be afforded to every medical officer at his entrance into the army will cause each individual, not only to be ready to apply at any moment all the improvements derived from experience and observation, up to the most advanced period, in this branch of the profession of surgery, but will also best prepare the members of the department for extending still further the sphere of usefulness which has been cultivated by their predecessors.
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[1]Notes on the Surgery of the Crimean War, p. 104, J. B. Lippincott & Co.’s edition.[2]See Guy’s Hospital Reports, 3d series, vol. v., 1859—case of Gunshot Wound in the Loins, by S. O. Habershon, M.D.[3]The portion of cranium referred to, with the piece of ball weighing half an ounce, which lodged in the cerebrum, are in the museum at Fort Pitt.[4]In the Medical and Surgical History of the War against Russia in the Years 1854-55-56, published by authority, vol. ii. p. 265, the physical effects of concussion in producing “shock” are strongly dwelt upon. It is remarked: “The shock of the accidents frequently witnessed by the military surgeon differs, often in a very material degree, and possibly in kind also, from that witnessed in civil life. When a cannon-shot strikes a limb and carries it away, the immense velocity and momentum of the impinging force can scarcely be supposed to have no physical effect upon the neighboring or even distant parts independent of, and in addition to, the ‘shock,’ in the ordinary acceptation of the term, which would result from the removal of the same part by the knife of the surgeon, or the crushing of it by a heavy stone or the wheel of a railway wagon. * * In the great majority of cases, the whole frame is likewise violently shaken and contused, and, probably, independent of these physical effects, a further vital influence is exerted, which exists in a very minor degree, if at all, in the last-named injuries, and may possibly depend upon the ganglionic nervous system.”[5]M. Scrive gives the following as the weight of the linen dressings consumed by the wounded of the French army in the campaign in the Crimea:—English weight.tons.cwt.qr.lb.Linen cloth101,779kilogrammes=1002123Rolled bandages46,446”=4513214Charpie47,776”=461934And estimates the following as the proportion consumed by each of the wounded:—English weightavoirdupois.lb.oz.dr.gr.Linen cloth2kil.482grammes=57010Rolled bandages0”891”=115713Charpie1”181”=29110——————————————Total4”554”=100223In an Army Medical Department Circular, dated 27th May, 1855, it was announced that the Secretary of State for War had decided the following “Field Dressing” should form part of every British soldier’s kit on active service, so as to be available at all times and in all places as a first dressing for wounds:—Bandage of fine calico, 4 yds. long, 3 in. wide.Fine lint, 3 in. wide, 12 in. long.Folded flat and fastened by 4 pins.[6]Perchlorure de fer, 30 drops, two or three times daily as a tonic, and diluted with six parts of water as an injection.[7]Dict. des Sciences Méd., Paris, 1813, p. 217.[8]See Edin. Med. and Surg. Journal, vol. xiv.—Case of gunshot wound of the heart, by J. Fuge, Esq.[9]For 1855, vol. i. p. 606, and vol. ii. p. 437.[10]Bulletin de l’Académie Impériale de Médecine, 24th April, 1860. See also Des Amputations consécutives à l’Ostéomyélite dans les Fractures des Membres par armes à feu, par M. H. Baron Larrey, Paris, 1860.[11]Dupuytren made a division of the splinters of bone broken by gunshot into three classes, viz.: primary sequestra, those directly and completely separated by the force of the projectile; secondary sequestra, those retaining partial connections by periosteal, muscular, or other attachments, but afterward thrown off during the suppurative process; and tertiary sequestra, or necrosed portions, produced by the effects of the contusion and prolonged inflammatory action in parts adjoining the seat of fracture. In accordance with this arrangement, the removal by the surgeon of the primary and secondary splinters has been regarded as simply anticipating nature in her work; but Dr. Esmarch states, as one result of the experience of the surgeons of the Sleswick-Holstein army, that, in the majority of comminuted fractures, the removal of splinters retaining any connection with periosteum is unnecessary and often injurious, as is also the practice of sawing off the broken ends of the bone projecting from the comminuted part. By proper treatment and under favorable circumstances, he asserts, such splinters become impacted in callus, and in time unite with the other fragments of the bone, and in this manner a cure is completed without operative interference. It is a matter, however, of frequent observation that splinters which have thus become impacted in callus lead to mischief in various ways, or are subsequently discharged as if they were so many foreign bodies, while the removal of the jagged ends of the broken bone seems to be a valuable means of preventing irritation, and thus of favoring union between them; and English surgeons, therefore, generally pursue the practice above recommended.[12]The officer referred to must have greatly improved in condition since Dr. Macleod wrote, as he has been of late on active service in India.[13]Notes on the Surgery of the Crimean War, p. 264.[14]In the surgical history of this war, this statement, which was quoted by the late Mr. Guthrie, in the Addenda to his Commentaries, is said to be a mistake, on account of the absence (not to be wondered at, amid the confusion of that period) of official records on the subject. Special reports on these cases were obtained at the time from Scutari, and were shown to the writer by the late Director-General shortly before his decease.[15]A committee was appointed by the Surgical Society of Paris to examine and report upon this essay of Dr. Legouest on Coxo-femoral Disarticulation for Gunshot Wounds. Baron Larrey drew up the report, which will be found in the 5th vol. of the Mémoires de la Société de Chirurgie, 1860. It confirms the principle laid down by Dr. Legouest, excepting only those cases of fracture where the mutilation of the limb from a heavy projectile has been so great as to partly separate it from the pelvis, and those in which there has been simultaneous lesion of the crural vessels and femur near the pelvis, with extensive laceration of the surrounding tissues.
[1]Notes on the Surgery of the Crimean War, p. 104, J. B. Lippincott & Co.’s edition.
[2]See Guy’s Hospital Reports, 3d series, vol. v., 1859—case of Gunshot Wound in the Loins, by S. O. Habershon, M.D.
[3]The portion of cranium referred to, with the piece of ball weighing half an ounce, which lodged in the cerebrum, are in the museum at Fort Pitt.
[4]In the Medical and Surgical History of the War against Russia in the Years 1854-55-56, published by authority, vol. ii. p. 265, the physical effects of concussion in producing “shock” are strongly dwelt upon. It is remarked: “The shock of the accidents frequently witnessed by the military surgeon differs, often in a very material degree, and possibly in kind also, from that witnessed in civil life. When a cannon-shot strikes a limb and carries it away, the immense velocity and momentum of the impinging force can scarcely be supposed to have no physical effect upon the neighboring or even distant parts independent of, and in addition to, the ‘shock,’ in the ordinary acceptation of the term, which would result from the removal of the same part by the knife of the surgeon, or the crushing of it by a heavy stone or the wheel of a railway wagon. * * In the great majority of cases, the whole frame is likewise violently shaken and contused, and, probably, independent of these physical effects, a further vital influence is exerted, which exists in a very minor degree, if at all, in the last-named injuries, and may possibly depend upon the ganglionic nervous system.”
[5]M. Scrive gives the following as the weight of the linen dressings consumed by the wounded of the French army in the campaign in the Crimea:—
And estimates the following as the proportion consumed by each of the wounded:—
In an Army Medical Department Circular, dated 27th May, 1855, it was announced that the Secretary of State for War had decided the following “Field Dressing” should form part of every British soldier’s kit on active service, so as to be available at all times and in all places as a first dressing for wounds:—
Bandage of fine calico, 4 yds. long, 3 in. wide.Fine lint, 3 in. wide, 12 in. long.
Folded flat and fastened by 4 pins.
[6]Perchlorure de fer, 30 drops, two or three times daily as a tonic, and diluted with six parts of water as an injection.
[7]Dict. des Sciences Méd., Paris, 1813, p. 217.
[8]See Edin. Med. and Surg. Journal, vol. xiv.—Case of gunshot wound of the heart, by J. Fuge, Esq.
[9]For 1855, vol. i. p. 606, and vol. ii. p. 437.
[10]Bulletin de l’Académie Impériale de Médecine, 24th April, 1860. See also Des Amputations consécutives à l’Ostéomyélite dans les Fractures des Membres par armes à feu, par M. H. Baron Larrey, Paris, 1860.
[11]Dupuytren made a division of the splinters of bone broken by gunshot into three classes, viz.: primary sequestra, those directly and completely separated by the force of the projectile; secondary sequestra, those retaining partial connections by periosteal, muscular, or other attachments, but afterward thrown off during the suppurative process; and tertiary sequestra, or necrosed portions, produced by the effects of the contusion and prolonged inflammatory action in parts adjoining the seat of fracture. In accordance with this arrangement, the removal by the surgeon of the primary and secondary splinters has been regarded as simply anticipating nature in her work; but Dr. Esmarch states, as one result of the experience of the surgeons of the Sleswick-Holstein army, that, in the majority of comminuted fractures, the removal of splinters retaining any connection with periosteum is unnecessary and often injurious, as is also the practice of sawing off the broken ends of the bone projecting from the comminuted part. By proper treatment and under favorable circumstances, he asserts, such splinters become impacted in callus, and in time unite with the other fragments of the bone, and in this manner a cure is completed without operative interference. It is a matter, however, of frequent observation that splinters which have thus become impacted in callus lead to mischief in various ways, or are subsequently discharged as if they were so many foreign bodies, while the removal of the jagged ends of the broken bone seems to be a valuable means of preventing irritation, and thus of favoring union between them; and English surgeons, therefore, generally pursue the practice above recommended.
[12]The officer referred to must have greatly improved in condition since Dr. Macleod wrote, as he has been of late on active service in India.
[13]Notes on the Surgery of the Crimean War, p. 264.
[14]In the surgical history of this war, this statement, which was quoted by the late Mr. Guthrie, in the Addenda to his Commentaries, is said to be a mistake, on account of the absence (not to be wondered at, amid the confusion of that period) of official records on the subject. Special reports on these cases were obtained at the time from Scutari, and were shown to the writer by the late Director-General shortly before his decease.
[15]A committee was appointed by the Surgical Society of Paris to examine and report upon this essay of Dr. Legouest on Coxo-femoral Disarticulation for Gunshot Wounds. Baron Larrey drew up the report, which will be found in the 5th vol. of the Mémoires de la Société de Chirurgie, 1860. It confirms the principle laid down by Dr. Legouest, excepting only those cases of fracture where the mutilation of the limb from a heavy projectile has been so great as to partly separate it from the pelvis, and those in which there has been simultaneous lesion of the crural vessels and femur near the pelvis, with extensive laceration of the surrounding tissues.