Part 10

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.

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 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.