Part 1

COMMENTARIES ON THE SURGERY OF THE WAR

IN PORTUGAL, SPAIN, FRANCE, AND THE NETHERLANDS,

FROM THE BATTLE OF ROLIÇA, IN 1808, TO THAT OF WATERLOO, IN 1815;

WITH ADDITIONS RELATING TO THOSE IN THE CRIMEA IN 1854-1855.

SHOWING

THE IMPROVEMENTS MADE DURING AND SINCE THAT PERIOD IN THE GREAT ART AND SCIENCE OF SURGERY ON ALL THE SUBJECTS TO WHICH THEY RELATE.

REVISED TO OCTOBER, 1855.

BY G. J. GUTHRIE, F.R.S.

SIXTH EDITION.

PHILADELPHIA: J. B. LIPPINCOTT & CO. 1862.

TO The Right Honorable The Lord Panmure, SECRETARY OF STATE FOR THE WAR DEPARTMENT, ETC. ETC. ETC.,

THESE COMMENTARIES ARE, BY PERMISSION, INSCRIBED, BY HIS LORDSHIP’S VERY OBEDIENT AND FAITHFUL SERVANT,

G. J. GUTHRIE.

PREFACE TO THE FIFTH EDITION.

Twenty months have elapsed since the Introductory Lecture was published in THE LANCET; fifteen others succeeded at intervals, and fifteen have been printed separately to complete the number of which the present work is composed. Divested of the historical and argumentative, as well as of much of the illustrative part, contained in the records whence it is derived, it nevertheless occupies 585 pages--the essential points therein being numbered from 1 to 423.

Sir De Lacy Evans, in some observations lately made in the House of Commons on the subject of a Professorship of Military Surgery in London, alluded to these Lectures in the most gratifying manner; he could not, however, state their origin, scope, or object, being unacquainted with them.

On the termination of the war in 1814, I expressed in print my regret that we had not had another battle in the south of France, to enable me to decide two or three points in surgery which were doubtful. I was called an enthusiast, and laughed at accordingly. The battle of Waterloo afforded the desired opportunity. Sir James M’Grigor, then first appointed Director-General, offered to place me on full pay for six months. This would have been destructive to my prospects in London; I therefore offered to serve for three, which he was afraid would be called a job, although the difference between half-pay and full was under sixty pounds; and our amicable discussion ended by my going to Brussels and Antwerp for five weeks as an amateur. The officers in both places received me in a manner to which I cannot do justice. They placed themselves and their patients at my entire disposal, and carried into effect every suggestion. The doubts on the points alluded to were dissipated, and the principles wanting were established. Three of the most important cases, which had never before been seen in London nor in Paris, were sent to the York Military Hospital, then at Chelsea. The rank I held as a Deputy Inspector-General precluded my being employed. It was again a matter of money. I offered to do the duty of a staff-surgeon without pay, provided two wards were assigned to me in which the worst cases from Brussels and Antwerp might be collected. The offer was accepted; and for two years I did this duty, until the hospital was broken up, and the men transferred to Chatham. In the first year a Course of Lectures on Military Surgery was given. The inefficiency of such a Course alone was soon seen, for Surgery admits of no such distinctions. Injuries of the head, for instance, in warfare, usually take place on the sides and vertex; in civil life, more frequently at the base. They implicate each other so inseparably, although all the symptoms are not alike or always present, that they cannot be disconnected with propriety. This equally obtains in other parts; and my second and extended Course was recognized by the Council of the Royal College of Surgeons as one of General Surgery.

When the Court of Examiners of the Royal College of Surgeons of England--of which body I have been for more than twenty years a humble member--confer their diploma after examination on a student, they do not consider him to have done more than laid the foundation for that knowledge which is to be afterward acquired by long and patient observation. When a student in law is called to the bar, he is not supposed to be therefore qualified to be a Queen’s counsel, much less a judge or a chancellor. The young theologian, admitted into deacon’s orders, is not supposed to be fitted for a bishopric. When the young surgeon is sent, in the execution of his duties, to distant climes, where he has few and sometimes no opportunities of adding to the knowledge he had previously acquired, it is apt to be impaired; and he may return to England, after an absence of several years, less qualified, perhaps, than when he left it. To such persons a course of instruction is invaluable. It should be open to them as public servants gratuitously, and should be conveyed by a person appointed and paid by the Crown. He should be styled, in my opinion, the Military Professor of Surgery, and be capable, from his previous experience and his civil opportunities, of teaching all things in the principles and practice of surgery connected with his office, although he may and should annually select his subjects. Leave of absence for three months might be advantageously granted to officers in turn for the purpose of attending these lectures, and the Professor should certify as to their time having been well employed. For thirty years I endeavored to render this service to the Army, the Navy, and the East India Company, from the knowledge I had acquired of its importance. To the Officers of these services my two hospitals, together with Lectures and Demonstrations, were always open gratuitously, as a mark of the estimation in which I held them. By the end of that period the enthusiasm of the enthusiast who wished for another battle in 1814 had oozed out, like the courage of Bob Acres in “The Rivals,” at the ends of his fingers. The course of instruction was discontinued, but not until such parts were printed, under the title of “Records of the Surgery of the War,” as were not before the public, in order that teachers of civil or systematic surgery should be acquainted with them.

4 Berkeley Street, Berkeley Square, June 21, 1853.

PREFACE TO THE SIXTH EDITION.

The rapid sale of the fifth, and the demand for a sixth edition of this work, enable me to say that the precepts inculcated in it have been fully borne out and confirmed by the practice of the Surgeons of the Army now in the Crimea in almost every particular. To several of these gentlemen I desire to offer my warmest thanks for the assistance they have afforded. Their names are given with the cases and observations they have been so good as to send me, and a fuller “Addenda” shall be made from time to time, as I receive further information from them, and others who will, I hope, follow the example they have thus set. More, however, has been done; they have performed operations of the gravest importance at my suggestion, that had not been done before, with a judgment and ability beyond all praise; and they have modified others to the great advantage of those who may hereafter suffer from similar injuries. They have thus proved that if the Administrative duties of the Medical Department of the Army have not been free from public animadversion, that its practical and scientific duties have merited public approbation; which I am satisfied, from what they have already done, they will continue to deserve.

The precepts laid down are the result of the experience acquired in the war in the Peninsula, from the first battle of Roliça in 1808, to the last in Belgium, of Waterloo in 1815, which altered, nay overturned, nearly all those which existed previously to that period, on all points to which they relate. Points as essential in the Surgery of domestic as in military life. They have been the means of saving the lives, and of relieving, if not even of preventing, the miseries of thousands of our fellow-creatures throughout the civilized world.

I would willingly imitate the example lately indulged in, by many of the best Parisian surgeons, of detailing circumstantially the improvements they have made in practical and scientific surgery; the manner in which they were at first contested, and the universal adoption of them which has succeeded, were it not that I might run the risk of being accused of gratifying some personal vanity, while only desirous of drawing the attention of the public to the merits of the men who so ably served them in the last war, nearly all of whom are no more; and who have passed away, as I trust their successors will not, with scarcely a single acknowledgment of their services, except the humble tribute now offered by their companion and friend.

4 Berkeley Street, Berkeley Square, October 7, 1855.

CONTENTS.

LECTURE I.

A wound made by a musket-ball is essentially a contused wound; sometimes bleeds; attended by shock and alarm, particularly when from cannon-shot, or when vital parts are injured; secondary hemorrhage rare. Entrance and exit of balls. Course of balls. Position. Treatment: cold or iced water; no bandage to be applied; wax candles. Progress of inflammation. Extraction of balls in flesh wounds; manner of doing it. Dilatation; when proper. Bayonet wounds; delusion respecting them. pp. 25-39

LECTURE II.

Peculiar phlegmonous inflammation. Erysipelatous inflammation; internal treatment. Erysipelas phlegmonodes, or diffused inflammation of the areolar tissue; treatment by incision; first case treated in England by incision; caution with respect to the scrotum. Mortification--distinction into idiopathic or constitutional and that which is local; humid and dry; traumatic. Local mortification from intense heat or cold; wind of a ball; electricity; search for these cases after the battle of Waterloo; case of recovery after amputation; appearances on dissection. Mortification from injury of the great vessels; appearance of the skin. Patient dies when the mortification passes the knee. Points of practice; amputation to be performed below the knee. Wound being on the thigh, amputation not to be done above the knee when the line of separation has formed below it. Wounds of the axillary not so dangerous as wounds of the femoral. Wounds of nerves; complete division of, followed by the loss of sensation, motion, and the power of resisting cold and heat. Cases of Sir James Kempt, of Sir Philip Broke, and Brigade-Major Bissett. Treatment; external and internal remedies. pp. 39-51

LECTURE III.

Necessity for immediate amputation when an extremity is so wounded as to preclude all hope of saving it; degree of danger attending amputations of the upper and lower extremities; the question us to immediate amputation--of the arm, or leg below the knee; in the upper half of the thigh. Constitutional alarm of shock from the injury. Illustrative cases by Dr. Beith, Dr. Dane, etc. Advantages of primary over secondary amputations; consequences of secondary amputations. Purulent deposits; cases by Dr. Irwin, Mr. Rose, and Mr. Boutflower; case of purulent deposit in the thyroid gland; Daniel Lynch’s case. Inflammation of the veins; cases; two varieties of phlebitis--the adhesive and irritative, or unhealthy; symptoms and treatment of the unhealthy inflammation. The case of Private A. Clarke; of Jane Strangemore; cases of endemic fever after secondary amputation ending in sub acute inflammation of the lungs and effusion into the chest. Employment of the sulphuric acid lotion in sloughing stumps. Writers on purulent deposits: the author’s claims; opinions of Mr. Henry Lee and Dr. Hughes Bennett. Hemorrhage in sloughing stumps, and its treatment; ligature of the principal artery of the limb in such cases, and its failure; hemorrhage after amputation at the shoulder-joint; sloughing of the stump caused by the bad air of the hospital; hemorrhages from irritable stumps not unfrequent in crowded hospitals; symptoms and treatment. pp. 51-73

LECTURE IV.

Aphorisms for amputations; necessity for the operation; compression of the femoral artery as it passes over the edge of the pubes; no necessity for the tourniquet in great amputations; the hemorrhage greater when a tourniquet is applied; use of the instrument after amputation; old mode of performing circular amputations; nicking the periosteum injurious; ligature of wounded vessels; bringing together the integuments; dressing the stump; subsequent treatment. AMPUTATION AT THE HIP-JOINT; injuries justifying the operation; case of Captain Flack; wound of the principal artery, with fracture of the femur, necessitates the operation; in malignant diseases of the femur, the operation affords the only chance of success; amputation at the hip-joint not to be done when the bone can be sawn through immediately below the trochanter major, and there be sufficient flaps; mode of operating; prior ligature of the femoral artery, by Baron Larrey; not practiced in the British army; directions for operating; Professor Langenbeck’s mode; Mr. Brownrigg’s; illustrative engravings; amputation by the circular incision; secondary amputation; number of vessels to be tied in primary and secondary operations; Mr. Luke’s amputation of the thigh by the flap operation; protrusion of bone after the operation; exfoliation from badly sawing or splitting the bone, or unduly separating the periosteum. Bulbous enlargement of the divided nerve. pp. 73-89

LECTURE V.

Removal of the head of the femur, dislocated in consequence of strumous disease, or for fracture of the head or neck of the bone, caused by an external wound; cases most favorable for the operation; anatomical description of the operation; the operation on the dead body; commencing for the removal of the head of the bone: completing, by amputation of the thigh at the hip-joint, the injuries being such as to require that operation; ligature of a great artery, close to a large branch, successful; completing the operation for the removal of the head of the femur; case of removal of the head of the femur; wounds of the knee-joint from musket-balls, with fracture of the bones, require immediate amputation; secondary amputation does not offer such a chance of success; compound fractures of the patella without injury to other bones; the joint involved; lodgment of the ball in the joint; the ball penetrating the condyles of the femur; wound of the popliteal artery; cases for amputation; clean incised wounds of the knee-joint; case of Colonel Donnellan; excision of the knee-joint; formerly rarely successful; Mr. Jones, of Jersey, mode of operating; Dr. Gurdon Buck’s case of excision of the knee-joint, for anchylosis, following a gunshot wound; Mr. Jones’s improvement of the operation; amputation of the leg; by the circular incision; the flap operation, as performed by Mr. Luke; amputation at the tuberosity of the tibia: removal of the head of the fibula; excision of the ankle-joint; removal of the os calcis; Mr. Syme’s amputation at the ankle-joint; sloughing of the under flap, and its causes; gunshot wounds of the foot; wounds of the fore part of the foot by cannon-shot, grape-shot, or musket-balls; amputation at the tarsus of the foot, leaving the astragalus and os calcis; operation for the removal of the astragalus and os calcis by Mr. Wakley, jun.; necessary not to wound the anterior tibial artery; amputation of a single metatarsal bone; M. de Beaufort’s artificial foot. pp. 90-120

LECTURE VI.

Primary amputation of the upper extremity rarely to be practiced for musket-shot wounds, or for injuries of the soft parts; treatment of slight gunshot wounds of the head of the humerus; a depending opening for the exit of matter to be made, if not previously existing; the principal points to attend to in such cases; simple incised wounds of the joint; splintering of the head of the bone, or the passage of a ball through it, requires its being sawn off; cases for amputation of the arm; site of the operation, the head of the bone being uninjured; complete shattering of the arm; complicated with more or less severe injury of the chest or abdomen; if the latter not likely to cause a speedy dissolution, then amputation of the arm is to be performed; moderate hemorrhage or expectoration of blood, under such circumstances, not absolutely fatal; destructive injuries from rebounding or nearly spent round shot, or flat pieces of shell, without external signs of a wound; necessity for an immediate operation in such cases; amputation at the shoulder-joint; the fear of hemorrhage passed away; compression of the subclavian; amputation at the shoulder-joint for malignant disease of the bone and periosteum; the acromion and coracoid processes should not be exposed, nor is it necessary to deprive the glenoid cavity of its cartilage; the nerves to be cut short, after the operation has been completed, else they may cause distressing pain for life; primary amputation at the shoulder-joint a very simple operation; secondary amputation much less so; general directions prior to the operation; the operation by two flaps, external and internal; by one, or nearly one, upper flap; Lisfranc’s operation; modification of it by M. Baudens; difficulties of the secondary amputation; amputation of the arm immediately below the tuberosities of the humerus; excision of the head of the humerus; Langenbeck’s operation; this excision not easy of execution when the head and neck of the bone are broken from the shaft, nor in secondary operations: not to be practiced in every instance of compound fracture of the part; cases; injury of the head of the humerus, with much loss of the soft parts; giving way of the axillary artery during the treatment not a cause for amputation; the vessel to be tied above and below the opening, and the subclavian not to be ligatured till all other means have failed; amputation of the arm by the circular incision; cases requiring this operation; Mr. Luke’s operation by two flaps; excision of the elbow-joint; injuries of the joint not requiring this operation; cases in which it is admissible; mode of operating; amputation at the elbow-joint recommended, but not often performed; mode of operating; supposed advantage attending the retention of the olecranon; amputation of the forearm; seldom requisite; the flap operation preferable, particularly near the wrist; mode of operating; the circular operation in the middle of the forearm; amputation at the wrist; in all injuries of the hand, requiring an operation, the thumb and one or more fingers to be preserved, if possible; treatment of metacarpal bones fractured by a musket-ball; of injured metacarpal bones, the fingers being destroyed; removal of the heads of the metacarpal bones when necessary; amputation of the phalanges; Langenbeck’s operation for excision of the phalangeal joints; excision of the metacarpal bone of the thumb by Langenbeck, the periosteum being separated from the bone, and left behind in the wound. pp. 120-141.

LECTURE VII.

Secondary amputations not so successful after injuries as after incurable disease; circumstances under which the operation is performed in military surgery, and the consequences; secondary hemorrhage; non-union of the stump; phlebitis and sloughing of the stump; depositions of matter in the viscera; in secondary amputations larger flaps required, or the bone to be cut shorter; directions for sawing the bone; larger number of arteries to be tied; torsion of arteries; bleeding from a small branch, cut short, above the ligature; mode of avoiding this; use of the tourniquet; and its inconveniences; in oozing of blood, the wound not to be finally closed for some hours; treatment in cases of non-union; cat-gut or other animal ligatures; hemorrhage from large veins to be controlled by pressure, not by ligatures; if the bone be too long, a piece to be sawn off; consequences of not doing so. COMPOUND FRACTURES: definition of; comminuted; compound fracture of the arm or leg does not necessitate amputation; of the thigh, amputation is requisite; difficulty of treating a gunshot fracture, with extensive splintering of the bone; consequences of the splintering; necrosis of the bone, and formation of sequestra; case of Lieut. Timbrell, fracture of both femurs; recovery without amputation: lodgment of a ball in, or its passage through, a bone, without splintering; consequences; its removal requisite when lodged in a bone; mere grazing a bone by a ball; simple transverse fracture of a bone by a ball; flattening of a ball; its lodgment between the broken portions of a bone; extensive shattering of the femur, a case for immediate amputation; gunshot fractures of head and neck of the femur; excision of the injured portions of bone-if the upper third, or middle of the bone, amputation necessary; in fractures of the lower third, not communicating with the knee-joint, an attempt is to be made to save the limb; when the femur is splintered, if the limb is to be saved, the principal splinters to be removed; the necessary incisions often neglected; if the splinters cannot be got at, amputation is requisite; secondary danger from the smaller splinters; a careful examination to be made for them when suppuration is established, and incisions made if requisite for their removal; consequences of their retention; proper bedsteads for the wounded should form a part of military stores; position of the patient in gunshot fractures of the leg or thigh; splints, and their application; gunshot wounds of the leg; limb rarely to be amputated; removal of splinters; position of the limb; Mr. Luke’s the best apparatus for a compound fracture of the leg; illustrated by wood-engraving; bearers for wounded men; gunshot wounds of the arm; more probability of saving the limb; if an artery ulcerate, it should be tied at each end; primary amputation in such cases rare; secondary, only for mortification, or when the strength gives way; in incisions at a late period, the nerves and arteries to be avoided; splints for the arm. Hospital returns. pp. 141-162

LECTURE VIII.