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 trochanter of 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 the _Memoirs 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
immediate _primary_ amputation 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 the _consecutive_ results of gunshot wounds,
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 be serviceable, 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 of _primary_ as compared
with _secondary_ amputation 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 superadded to 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, when the 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 the objections
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 having then 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 and
power 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 compared with 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 tuberosity of 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 has again 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;
and =Pyemia=, 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.”