projecting fragments upward; but they are generally mixed with lesions
of viscera of the pelvis, or fracture of its structure, or injuries
about the upper parts of the thighs or buttocks. In one such case, a
portion of the scrotum, the whole of one testicle, and the greater
part of the other were carried away. This wound healed without fungous
growth from the remaining portion of the testis. Separate wounds of
the external organs of generation are usually caused by bullets. In
two cases in the Crimea, a bullet entered between the glans penis
and prepuce, and traversed upward without penetrating the erectile
tissue. M. Appia records a case where the ball entered the summit of
the glans, traversed the whole length of the corpus cavernosum, passed
under the pubic arch, and went out by the right buttock. The urethra
was not opened. Double orchitis and scrotal abscesses followed; but
favorable cure took place. In another case, a ball carried away the
inferior part of the glans but did not wound the urethra. A soldier of
the Rifle Brigade was wounded in the Crimea by a musket–ball, which
entered the right buttock and came out by the body of the penis, just
below the glans, having ruptured the urethra about four inches from
the meatus. The wound of the penis closed favorably. Mr. C. Hutchinson
has recorded the case of a soldier of the 42d Regiment, treated at the
Deal Naval Hospital, who was wounded in the upper part of the thigh by
a musket–ball, which lodged. Three weeks afterward, the ball was found
imbedded in the pubes, the urethra being stretched around the convex
surface; and this explained the cause of a distressing distention of
the penis and dribbling of urine which had existed without intermission
from the time of the injury, but ceased at once on the removal of the
bullet.
GUNSHOT WOUNDS OF THE EXTREMITIES.
These injuries, always very numerous in warfare, offer many subjects
of consideration for the military surgeon. No class of wounds includes
so many cases that fall under his prolonged care as this. A large
proportion of wounds of the head and trunk are immediately fatal, or
from the commencement contain the elements of fatal results; while
wounds of the extremities, if those of the thigh be excepted, are free
from this extremely serious character. The treatment to be pursued,
including questions of conservation, resection, amputation, and the
proper time for the adoption of these latter if determined upon, often
demands the closest attention of the surgeon. These subjects will
be considered in their general bearing in other parts of this work,
and only those points especially connected with the circumstances of
warfare will be here referred to.
Gunshot wounds of the extremities divide themselves into flesh wounds
and contusions, and those complicated with fracture of one or more
bones. Flesh wounds may be simple, and these offer few peculiarities,
whatever their site; or they may be accompanied with lesion to nerves,
or blood–vessels, or both, and these usually increase in gravity in
proportion as they approach the trunk.
When complicated with fracture, the lesion is usually rendered compound
by the direct contact of the projectile with the bone injured; but the
fracture is sometimes simple, when caused by indirect projectiles,
such as stones or splinters, or by spent balls. These injuries are
liable to become further aggravated by the fracture extending into or
being complicated with an opening of one of the joints. Joints may
be contused or opened by projectiles, without apparent lesion of any
portion of the bones entering into their composition; but these are
exceptions to the usual order of such cases from gunshot.
Simple flesh wounds have already been referred to both in respect to
their nature and treatment in the commencement of this essay. It is
in connection with fractures of bones and their proper treatment that
the interest of surgeons is chiefly attracted in gunshot wounds of the
extremities. From the nature of the injuries, already described, to
which bones are subjected by the modern weapons of war, together with
the irreparable nature of the wound in the softer structures, except
after a long process of suppuration and granulation, as well as from
the usual circumstances of military life, it might be anticipated that
difficulty would often arise in determining which of the double set of
risks and evils—those attending amputation, and those connected with
attempts to preserve the limb with a profitable result—would be least
likely to prove disadvantageous to the patient. Experience in such
injuries has established certain rules which are now generally acted
upon; some still remain _sub judice_.
Although the subject of pyemia is considered in its general bearings
elsewhere, it is right to mention here that this serious complication,
as met with in gunshot wounds, appears to be especially induced
by injuries of bones, particularly those of long bones in which
the medullary canal has been laid open and extensively splintered.
Several circumstances probably conduce to this result: the prolonged
suppurative action during the removal of sequestra, the irritation
caused by sharp points and edges, sometimes increased by transport
from primary to secondary hospitals, the patulous condition of veins
in bones leading to thrombosis, being its chief local sources; while
depressed vital power from any cause, and continued exposure to an
impure atmosphere from the congregation of numerous patients with
suppurating wounds, are the principal agents in producing the state
of constitution favorable to its development and progress. Unless
the hospital miasmata engendered in this way are constantly removed
as they arise, or very greatly diluted by proper ventilation, it is
almost impossible that patients laboring under severe wounds of the
extremities with comminuted bony fractures can be long saved from
septicemia and pyemia; and these, when they supervene, rarely lead
to any but a fatal termination. The different conditions of hospital
air, which in one set of cases lead to the appearance of hospital
gangrene, in another set of pyemia, are not properly understood; but
from the frequency with which the latter complication follows wounds
of bones, it would seem that an especial influence is exerted by the
local peculiarities of these injuries already mentioned. However,
observation would also lead to the belief that certain individuals are
much more predisposed to pyemic action than others placed under similar
circumstances. Occasionally, in gunshot injuries of bones, where no
splintering has occurred, but only a small portion of the periosteum
has been torn off and the shaft contused by the stroke of a bullet,
severe inflammation will follow, the medullary canal become filled with
pus, and death ensue from pyemia. The attention of surgeons has been
particularly called to the various circumstances producing inflammation
and suppuration of the medullary tissues—osteo–myelitis—in long bones
after gunshot injuries by M. Jules Roux of Toulon.[10]
=Upper Extremity.=—Fractures of the bones of the arm are well known to
be very much less dangerous than like injuries in the corresponding
bones of the lower extremity. Unless extremely injured by a massive
projectile, or longitudinal comminution exist to a great extent,
especially if also involving a joint, or the state of the patient’s
health be very unfavorable, attempts should always be made to preserve
the upper extremity after a gunshot wound. In the Director–General’s
History of the Crimean Campaign, the recoveries without amputation
are shown to be, in the humerus, 26·6; radius and ulna, 35·0; radius
only, 70·0; ulna only, 70·0 per cent. of cases treated. The proportion
of deaths in these cases was only 2·3 per cent. Although not the
result of gunshot, a remarkable case, published by Staff–Surgeon Dr.
Williamson, by whom the operation was performed, serves to illustrate
how extensively bone may be removed from the upper arm, and a useful
member be still retained. The details will be found in his Notes on
the Wounded from the Mutiny in India. The whole of the ulna, (not
merely sequestra, but also the new bone which had formed around them,
the object of which proceeding is not stated,) two inches of the
humerus, and the head and neck of the radius were removed; and, four
months after the operation, the man could “bend his forearm, raise his
hand behind his head, lift a 28–lb. weight from the ground, pronate
and supinate the hand, and use his fingers well.” Of 194 wounds and
injuries of the upper extremity among men returned from the late mutiny
in India, 100 are recorded by Dr. Williamson to have been sent to duty
regular or modified, 67 invalided from the service, 1 died, and 26 were
still under treatment.
In the latter part of the Crimean campaign, when the health of the
troops and means of treatment were favorable, it was often remarkable
what extensive injuries of the upper extremity, even where the joints
were involved, were repaired without amputation. The following cases
are examples: Sergeant Bacon, 7th Fusileers, aged thirty–six, at the
attack on the Redan on the 8th of September, 1855, was wounded by a
rifle–ball, which entered the head of the left humerus, shattered
the bone very much, and was extracted from below the left scapula.
Dr. Moorhead determined to try to preserve the limb. The head of the
humerus required to be removed in small, broken fragments; and the
shaft, being found to be split down between three and four inches, was
to that distance removed by the saw. The case progressed favorably,
and in 1857 this man was in London with a most useful arm. A young
soldier of the 23d Regiment was wounded, on the 15th August, 1855, by a
large grape–shot, which passed through the right arm near the shoulder,
comminuting the bone for three inches and extensively destroying the
soft parts. Staff–Surgeon Williams, in medical charge, despairing of
saving the limb, proposed to amputate, but, at the suggestion of the
late Director–General Alexander, then principal medical officer of
the Light Division, arranged to allow some days to elapse to watch
symptoms. The case progressed so well that the idea of amputation
was abandoned, and the man recovered with a very serviceable arm. In
another regiment of the Light Division, the 77th, a healthy young
soldier, under the care of Surgeon Franklin, was wounded at the last
assault of the Redan, and sustained a comminuted fracture of the
humerus, had the elbow–joint opened, both bones of the forearm broken
about two inches below the joint, and the soft parts widely opened, by
a piece of shell. Here no excision was practiced, but fragments removed
as they became loose; the arm, with its dressings, was supported on a
zinc–wire cradle, hollowed out and bent at the elbow to the desired
angle; and nourishment, with malt liquor, were freely given from the
first day. Anchylosis was established, and he left for England with
a useful limb. The fractures above and below the joint prevented the
application of passive motion.
In these injuries, where the bone is much splintered, the detached
portions, and any fragments which are only retained by very partial
periosteal connections, should be removed; projecting spiculæ sawn or
cut off;[11] the wound being extended at the most dependent opening
where two exist, or fresh incisions being made for this purpose, if
necessary; light water–dressing applied; the limb properly supported;
and the case proceeded with as in cases of compound fracture from other
causes. (See FRACTURE.) The same general rules also apply in preserving
as much of the hand as possible, in gunshot injuries. If the shoulder
or elbow joint be much injured, but the principal vessels have escaped,
the articulating surfaces and broken portions should be excised. Care
should be taken to see that the projectile has wholly passed out, or
been removed. In a case of comminuted fracture of the humerus, in the
88th Regiment, no union having taken place a month after the injury,
and some dead bone requiring removal, an incision was made for this
purpose, when half the bullet was found between the fractured ends.
Good union, with free motion of the arm, resulted, after this foreign
body and the necrosed bone were taken away. The results of excision
practiced in the shoulder and elbow joints, especially the former,
after gunshot wounds, have been exceedingly satisfactory. Especial
attention was directed to the practice of resections of joints after
gunshot injuries in the Sleswick–Holstein campaigns between 1848 and
1851; and Dr. Friedrich Esmarch has published the results in a valuable
essay on the subject. Of nineteen patients in whom the shoulder–joint
was resected, in twelve a more or less useful arm was preserved; and
seven died. Complete anchylosis did not occur in any one instance; and
in several the power of motion became so great as to enable the men
to perform heavy work. Of forty patients for whom resection of the
elbow–joint was performed six died, thirty–two recovered with a more or
less useful arm, one remained unhealed at the time Dr. Esmarch wrote,
(1851,) and in one mortification ensued and amputation was performed.
These operations present no peculiarities in the mode of performance
or their after–treatment, as compared with similar resections in civil
practice.
=Lower extremity.=—Gunshot wounds of the lower extremity vary much
more greatly in the gravity of their results, as well as in the
treatment to be adopted, according to the part of the limb injured,
than happens in those of the upper extremity. As a general rule,
ordinary fractures below the knee, from rifle–balls, should never
cause primary amputation; while, excepting in certain special cases,
in fractures above the knee, from rifle–balls, amputation is held by
most military surgeons to be a necessary measure. The special cases are
gunshot fractures of the upper third of the femur, especially where the
hip–joint is implicated; for in these the danger attending amputation
itself is so great that the question is still open, whether the safety
of the patient is best consulted by excision of the injured portion
of the femur, by simple removal of detached fragments and trusting to
natural efforts for union, or by resorting to amputation. The decision
of the surgeon must generally rest upon the extent of injury to the
surrounding structures, the condition of the patient, and other
circumstances of each particular case. If the femoral artery and vein
have been lacerated, any attempt to preserve the limb will certainly
prove fatal.
The femur—the earliest formed, the longest, most powerful, and most
compact in structure of all the long bones of the body—can only be
shattered by a ball striking it with immense force. Attention was
specially directed in the late Crimean campaign to the question of the
proper treatment of these injuries, and expectations were generally
held that the advanced experience in conservative surgery would lead to
many such cases terminating favorably with preservation of the limb,
which previously would have been subjected to amputation. Toward the
latter part of the war, all the circumstances of the patients were as
favorable for testing this practice as they have been in the various
_émeutes_ in Paris, with the advantages of immediate attention and
all the appliances of the best hospitals close at hand. Yet, in the
Surgical History of the Campaign, it is stated that only fourteen out
of 174 cases of compound fracture of the femur among the men, and five
out of twenty among the officers recovered without amputation being
performed; that those selected for the experiment of preserving the
limb were patients where the amount of injury done to the bone and
soft parts was comparatively small; that where recovery ensued, it
always proved tedious, and the risks during a long course of treatment
numerous and grave; and that the proportion of recoveries would not
appear even so large as the above, if the deaths of those who after
long treatment were subjected to amputation as a last resource were
included. Amputations of the thigh, however, were very fatal in their
results also, the recoveries being stated to be, among the men,
in the upper third 12–9/10, in the middle third 40, in the lower
third 43–3/10, per cent. of cases treated. Among the officers the
proportion was rather more favorable. But this percentage includes
those cases in which attempts had been made to preserve the limb,
and failure resulting, amputation was resorted to as a last chance
of saving the patient, so that they ought to have been excluded from
the lists of amputations, both primary and secondary, as commonly
interpreted. On account of this comparatively indifferent success
of amputation, resection of portions of the shaft of the femur was
sometimes practiced; but the records state that no success attended the
experiment, every case, without exception, having proved fatal.
In considering the results of gunshot fractures of the femur, the
situation of the injury is a matter of great importance, whether as
regards chances of recovery without or with amputation. In the Surgical
History of the Crimean Campaign this fact is shown in the results of
amputation; but the distinction is not made in regard to the recoveries
without amputation. Dr. Macleod, in his Notes, remarks that he has only
been able to discover three cases in which recovery followed a compound
fracture in the upper third of the femur without amputation: one, that
of an officer of the 17th Regiment; the second, of a soldier of the
62d; and a third, whose regiment is not named. A case, however, was
under the care of the writer, not included in the above, nor appearing
in the official history of the war; and one, judging from the results
described in Dr. Macleod’s Notes, more fortunate in its issue than at
least two of the number he mentions. With regard to the first patient,
Dr. Macleod states he has been informed “that although his limb was
in a very good condition when he left for England, the trouble it
has since given him, and the deformed condition in which it remains,
makes it by no means an agreeable appendage;”[12] in the second, the
fracture was in the lower part of the upper third, and the injury was
comparatively slight; in the third, a mass of callus was thrown out
which connected the bone, but he died of purulent poisoning, and never
left the Crimea. In the case which was under the writer, the fracture
was within the upper third; there is no distortion, and shortening
only of 1–1/2 inches; the officer is able to walk or ride without any
inconvenience, and competent for all duty. All the circumstances were
most favorable for recovery in this instance; and a consideration of
these on the one hand, and the experience of the unfavorable results
of amputation in this region on the other, led to the effort to save
the limb. A short history of this case will be useful. Lieutenant D.
M., 19th Regiment, aged seventeen, of sanguine temperament, healthy
frame, was brought up to camp about 4 A.M. Sept. 9th, 1855. He had
been wounded in the assault upon the Redan in the upper part of the
left thigh, and had been lying by the side of the ditch where he
fell thirteen hours. When discovered, he was carried carefully in a
soldier’s greatcoat as far as the opening of the trenches, and thence
on a stretcher to camp. He was very cold and prostrate on his arrival.
The wound in his left thigh had been caused by a ball, which had passed
out. It entered posteriorly at the fold between the left nates and
thigh, three inches from the tuberosity of the ischium; passed forward,
downward, and outward, and made its exit seven inches below the
trochanter major. The femur was broken in the line of passage of the
ball, which, from entrance to exit, appeared to be about six inches.
From the trochanter major to the seat of fracture was four inches; to
the external condyle on the same side was 15–1/2 inches. The amount of
comminution appeared slight, but, from its vicinity to the joint, the
great swelling about the limb, and desire to avoid aggravating pain,
the precise condition of fracture was not further ascertained. The
upper fragment projected forward, but any attempts at reduction caused
great suffering; and some restoratives being given, wet compresses
applied to the thigh, and the limb secured against additional
movement, the patient was left to rest. At a consultation the following
morning, from the patient’s age, so favorable for reparative action,
very healthy constitution, and the fact that, the siege being over,
full attention could be paid to the case, conservation of the limb
was settled to be attempted, and the patient was therefore treated
with this view. In addition to the wound just named, he had received
an extensive contusion of the right thigh by the fall of some heavy
substance from the explosion which occurred at one A.M., after the
Russians left the Redan.
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, under Mr.
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.