Part 11

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.”

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 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.