Part 12

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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=Macleod’s Surgery of the Crimean War.= Notes on the Surgery of the War in the Crimea; with Remarks on the Treatment of Gunshot Wounds. By GEORGE H. B. MACLEOD, M.D., F.R.C.S., Surgeon to the General Hospital in Camp before Sebastopol, Lecturer on Military Surgery in Anderson’s University, Glasgow, &c. &c. One vol. 12mo. $1.50.

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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