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 chloroform to 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 second casualty, 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 the _Medico–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 wounds than 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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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 cloth 101,779 kilogrammes = 100 2 1 23
Rolled bandages 46,446 ” = 45 13 2 14
Charpie 47,776 ” = 46 19 3 4
And estimates the following as the proportion consumed by each of the
wounded:—
English weight avoirdupois.
lb. oz. dr. gr.
Linen cloth 2 kil. 482 grammes = 5 7 0 10
Rolled bandages 0 ” 891 ” = 1 15 7 13
Charpie 1 ” 181 ” = 2 9 11 0
—————————— ——————————————
Total 4 ” 554 ” = 10 0 2 23
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.
End of Project Gutenberg's A Treatise on Gunshot Wounds, by Thomas Longmore