Part 9

When, in addition to the cavity being opened, viscera are penetrated, and death does not directly ensue from rupture of some of the larger arteries, the shock is not only very severe, but the collapse attending it is seldom recovered from up to the time of the fatal termination of the case. This is sometimes the only symptom which will enable the surgeon to diagnose that viscera are perforated. The mind remains clear; but the prostration, oppressive anxiety, and restlessness are intense; and, as peritonitis supervenes, pain, dyspnœa, diffused tenderness, irritability of the stomach, distention, and the other signs of this inflammation are superadded. In ordinary wounds from musket–shot, scarcely any matter will escape from the opening of the parietes, the margin of which becomes quickly tumefied; but if any escape, it will probably indicate what viscus has been wounded. If the stomach has been penetrated, there will probably be vomiting of blood from the first. If the spleen or liver be wounded, death from hemorrhage is likely to follow quickly. In some instances patients, however, recover after gunshot wounds involving these viscera, and examples in illustration may be found in various works on military surgery. Two particularly manifest instances, where officers were shot through the liver by musket–balls, occurred lately in India, one at Lucknow, the other at the siege of Delhi: both recovered. The cases are described in the Indian Annals of Medical Science for January, 1859. If the small intestines have been perforated, and death follows soon after from peritonitis, the bowels usually remain unmoved, so that no evidence is offered of the nature of the wound from evacuations; but in any case of penetrating wound of the abdomen, when the opportunity is offered, steps should be taken—a matter not unlikely to be omitted under the circumstances of camp hospitals full of patients—to isolate and examine all evacuations which may follow. By attending to this direction, the writer had the satisfaction of ascertaining the passage of a ball and piece of cloth, after a wound in the loin, in a case already alluded to. If the kidneys or bladder are penetrated, the escape of urine into the abdomen is almost a certain cause of fatal result. The latter viscus may, however, be penetrated without the peritoneal cavity being opened; and, as experience proves, the wound is then by no means of a fatal character. Musket–balls sometimes lodge in the bladder. This was ascertained to have happened in a soldier of the 20th Regiment, in the Crimea; but the patient died from other injuries, so that the information could not be turned to account. Mr. Guthrie performed the usual operation of lithotomy, with success, to remove a musket–ball which had struck a soldier just above the pubes, at Waterloo, and lodged. He also records a similarly successful case in a man wounded at the battle of Chillianwallah: this ball formed the nucleus of a calculus. Baron Percy removed a ball and a portion of shirt from the bladder. In all such cases, it is probable that the bladder has been penetrated at some part uncovered by peritoneum, so that the cavity of the abdomen has not been opened; or, if otherwise, the foreign body has found its way in by ulceration, after adhesions had been established, and thus circumscribed the openings of communication. Small foreign bodies may also pass into the bladder by the ureter. A case in which the kidney was wounded came under the care of the writer, after the 8th of September, 1855. The patient survived twelve days, and then died from pyemia. He had been taken prisoner, but was found in Sebastopol, and brought to his regimental hospital on the second day after the assault. There was only one wound in the right loin, and the ball had lodged. Extensive abscesses formed among the gluteal muscles on the left side, and down the left thigh; and though free incisions were made, great constitutional irritation supervened, and he sank. The substance of the right kidney had been perforated, but the ureter had escaped. The ball had passed across the abdomen, and lodged in the left buttock. Mr. Guthrie mentions some wounds of the kidney where recovery took place; in one, seven months after the wound, after an attack of retention of urine, a piece of cloth was forced out by the urethra, which must have come down from the pelvis of the kidney. When the abdominal parietes have been opened by shell or passage of large shot, protrusion of omentum and intestines will probably be one of the results. This does not always happen. In Dr. Macleod’s Notes, p. 237, is detailed a remarkable case of recovery, which was witnessed by the writer, after the wall of the abdomen, including the peritoneum, had been destroyed to the extent of five inches long by three broad; and a coil of intestine laid bare without protrusion, in the right iliac region. This patient had also a fracture of the ileum, another of the great trochanter on the same side, and his right forearm smashed. This case was treated in the general hospital before Sebastopol, by Mr. Hooke. Sometimes a wound caused by a large projectile, which was at first not penetrating, will indirectly become so, from the severe contusion and consequent sloughing to such an extent as to denude the viscera; and if, as is not unlikely, adhesion has taken place in the mean time between a portion of the viscera and peritoneal lining of the abdominal paries, the sloughing action may extend more deeply and the bowel itself become opened.

Curious instances are recorded in which balls have passed directly through the abdomen without perforating any important viscus, as proved by examination after death. As an example, on the other hand, of the number of wounds which may thus be inflicted, a soldier of the 19th Regiment, on duty in the trenches before Sebastopol, who was shot through the abdomen in the act of defecation, was found by the writer, on post–mortem examination, to have had as many as sixteen openings made in the small intestine. He survived the wound nineteen hours.

Gunshot wounds of the colon, especially of the sigmoid flexure, appear to be less fatal, probably from structural causes as well as circumstances of position, than wounds of the small intestine. In the Museum of Fort Pitt, however, is a preparation of jejunum exhibiting three constrictions, and supposed to have been perforated in three places, from a private of the 80th Regiment, who was shot through the abdomen at Ferozeshah, in 1845, and who died from cholera in 1851. Inspector–General Taylor, C.B., then surgeon of the regiment, who made the examination post mortem, thus described the injured part of the intestine: “The intestines neither there nor elsewhere were morbidly adherent; but the fold of intestines immediately opposed to the cicatrix presented a line of contraction as if a ligature had been tied round the gut. The same appearance existed in two other places.” It seems more likely that the gut was contused than perforated, and that contraction gradually supervened, especially as no adhesions were found; and, when wounded, the symptoms were so slight as to have led to the supposition that the ball had gone round the abdominal wall.

A gunshot wound of the intestine, more especially the colon, may lead to fecal fistula, and life be thus saved for a time. One such case only occurred in the Crimea, in the 19th Regiment, of which the writer was then the surgeon; this case, which has been before casually mentioned, subsequently passed under the care of his friend Mr. Birkett, of Guy’s Hospital, in which institution the patient died, from the effects of albuminuria, four years after the receipt of the wound referred to. The surgical history of this case has been already published at some length in the Lancet; the medical history, together with the results of the post–mortem inspection, have been detailed by Dr. Habershon, in vol. v., Ser. III., of the Guy’s Hospital Reports. The fistula became closed at intervals, and occasionally, before other disease supervened, hopes were entertained that recovery might result. The direction and depth of the wound precluded any of the usual operations for attempting to effect a radical cure. Two cases of abnormal anus by gunshot perforation are recorded by Dr. Williamson among the wounded who have recently returned from India; in both instances the descending colon was the part of the bowel implicated. A similar result is recorded in a private of the 13th Regiment wounded at Cabul in 1840.

=Wounds of the diaphragm.=—Musket–balls occasionally pass through the diaphragm; and Mr. Guthrie has remarked that these wounds, in instances where the patients survive, only become closed under rare and particular circumstances. Hence the danger of portions of some of the viscera of the abdomen, as the stomach or colon, passing into the chest, and thus forming diaphragmatic herniæ, and of these, eventually, from some cause becoming strangulated. Two very interesting preparations of these accidents from gunshot exist in the museum at Fort Pitt. In both instances, the stomach, colon, and omentum form the hernial protrusions. In one, death occurred, a year after the wound, from strangulation induced suddenly after a full meal; in the other, the soldier continued at duty twenty–two years after, and died from other causes. All the cases which occurred in the Crimea in which openings had thus been established between the cavities of the chest and abdomen proved fatal. A case is detailed in the Surgical History of the War where the patient survived a double perforation of the diaphragm, together with a wound of the liver, six days; in another instance, where the lung, diaphragm, liver, and spleen were wounded, the soldier lived sixteen hours. The direction of the ball, hiccough, dyspnœa accompanied with spasmodic inspiration, and inflammatory signs more particularly connected with the chest will be the usual indications of such a wound; and in case of recovery, the risk of hernial protrusion and strangulation must be explained to the patient. Should strangulation occur, it can hardly be expected that division of the stricture could be performed without the operation itself leading to equally certain fatal results.

=Treatment.=—In the general treatment of penetrating wounds of the abdomen by gunshot, the surgeon can do little more than to soothe and relieve the patient by the administration of opiates, and to treat symptoms of inflammation when they arise on the same principles as in all other cases. The usual directions to attempt agglutination of the opposite portions of peritoneum by favorable posture cannot generally be carried out, the attempts being defeated by the restlessness of the patient. The collapse which attends such injuries may be useful in checking hemorrhage; and the exhibition of stimulants is further contra–indicated by the risk of exciting too much reaction, should the wound not prove directly fatal. If the wound be caused by grape–shot or a piece of shell, and intestine protrudes, it must be returned; if the intestine be wounded, sutures are inapplicable, as in an incised wound, without previously removing the contused edges. When the bladder is penetrated, care must be taken to provide for the removal of the urine, either by an elastic catheter, or, if this cannot be retained, by perineal incision. A freely communicating external wound prevents the employment of the catheter from being essential. A soldier of the 57th Regiment was wounded, on the 18th June, 1855, by a musket–ball, which entered the left buttock, fractured the pelvis, and came out about three inches above the os pubis and one inch to the right of the median line. The bladder was perforated; urine escaped by both openings, chiefly by the one in front. Here the catheter caused so much irritation that it was withdrawn; but the posterior wound soon ceased to discharge urine, and in eighteen days the anterior wound was free from discharge also. Seven weeks after the date of injury symptoms resembling those of stone in the bladder came on; these were relieved on three spiculæ of bone making their escape by the urethra. About the same time the anterior wound became again open, and some pieces of bone were discharged. After ninety–seven days’ treatment in the Crimea, the man was sent home—the anterior wound being still so far open that distention of the bladder, as from accumulation at night–time, led to a little oozing from it. This subsequently healed; and he was sent to duty on the 22d of November, nearly six months after the date of injury.

GUNSHOT WOUNDS OF THE PERINEUM AND GENITOURINARY ORGANS.

From the position of these parts of the body, uncomplicated gunshot wounds of them are comparatively rare. Throughout the whole of the Crimean war, the number of cases treated amounted, among the men, to 70; among the officers, only to 4. The number of deaths which resulted were 21 among the men, chiefly cases of extensive laceration involving the urinary apparatus; among the officers, none. Three men only, out of 603 who returned from the late mutiny in India to Chatham, are recorded under this class. In one, the injury was from a spent shot, which caused a bruise without laceration over the symphysis pubis, and produced persistent incontinence of urine; in each of the other two, a musket–ball wounded the left testicle, injured the urethra, and led to urinary fistula, which was, however, afterward healed. In one, the testicle was so much injured that it was removed on the day the wound was received; in the other, it sloughed away shortly after. A corporal of the 19th Regiment, wounded in this region on the 8th September, 1855, was under the care of the writer. A portion of the ascending ramus of the ischium on the right side was driven into the perineum, the soft parts were much injured, and the right testicle was destroyed. The viscera of the pelvis escaped. He was doing well until nearly a fortnight after the injury, when nervous irritation and trismus set in, and he sank.

Perineal wounds are not unfrequently caused by shells bursting and projecting fragments upward; but they are generally mixed with lesions of viscera of the pelvis, or fracture of its structure, or injuries about the upper parts of the thighs or buttocks. In one such case, a portion of the scrotum, the whole of one testicle, and the greater part of the other were carried away. This wound healed without fungous growth from the remaining portion of the testis. Separate wounds of the external organs of generation are usually caused by bullets. In two cases in the Crimea, a bullet entered between the glans penis and prepuce, and traversed upward without penetrating the erectile tissue. M. Appia records a case where the ball entered the summit of the glans, traversed the whole length of the corpus cavernosum, passed under the pubic arch, and went out by the right buttock. The urethra was not opened. Double orchitis and scrotal abscesses followed; but favorable cure took place. In another case, a ball carried away the inferior part of the glans but did not wound the urethra. A soldier of the Rifle Brigade was wounded in the Crimea by a musket–ball, which entered the right buttock and came out by the body of the penis, just below the glans, having ruptured the urethra about four inches from the meatus. The wound of the penis closed favorably. Mr. C. Hutchinson has recorded the case of a soldier of the 42d Regiment, treated at the Deal Naval Hospital, who was wounded in the upper part of the thigh by a musket–ball, which lodged. Three weeks afterward, the ball was found imbedded in the pubes, the urethra being stretched around the convex surface; and this explained the cause of a distressing distention of the penis and dribbling of urine which had existed without intermission from the time of the injury, but ceased at once on the removal of the bullet.

GUNSHOT WOUNDS OF THE EXTREMITIES.

These injuries, always very numerous in warfare, offer many subjects of consideration for the military surgeon. No class of wounds includes so many cases that fall under his prolonged care as this. A large proportion of wounds of the head and trunk are immediately fatal, or from the commencement contain the elements of fatal results; while wounds of the extremities, if those of the thigh be excepted, are free from this extremely serious character. The treatment to be pursued, including questions of conservation, resection, amputation, and the proper time for the adoption of these latter if determined upon, often demands the closest attention of the surgeon. These subjects will be considered in their general bearing in other parts of this work, and only those points especially connected with the circumstances of warfare will be here referred to.

Gunshot wounds of the extremities divide themselves into flesh wounds and contusions, and those complicated with fracture of one or more bones. Flesh wounds may be simple, and these offer few peculiarities, whatever their site; or they may be accompanied with lesion to nerves, or blood–vessels, or both, and these usually increase in gravity in proportion as they approach the trunk.

When complicated with fracture, the lesion is usually rendered compound by the direct contact of the projectile with the bone injured; but the fracture is sometimes simple, when caused by indirect projectiles, such as stones or splinters, or by spent balls. These injuries are liable to become further aggravated by the fracture extending into or being complicated with an opening of one of the joints. Joints may be contused or opened by projectiles, without apparent lesion of any portion of the bones entering into their composition; but these are exceptions to the usual order of such cases from gunshot.

Simple flesh wounds have already been referred to both in respect to their nature and treatment in the commencement of this essay. It is in connection with fractures of bones and their proper treatment that the interest of surgeons is chiefly attracted in gunshot wounds of the extremities. From the nature of the injuries, already described, to which bones are subjected by the modern weapons of war, together with the irreparable nature of the wound in the softer structures, except after a long process of suppuration and granulation, as well as from the usual circumstances of military life, it might be anticipated that difficulty would often arise in determining which of the double set of risks and evils—those attending amputation, and those connected with attempts to preserve the limb with a profitable result—would be least likely to prove disadvantageous to the patient. Experience in such injuries has established certain rules which are now generally acted upon; some still remain sub judice.

Although the subject of pyemia is considered in its general bearings elsewhere, it is right to mention here that this serious complication, as met with in gunshot wounds, appears to be especially induced by injuries of bones, particularly those of long bones in which the medullary canal has been laid open and extensively splintered. Several circumstances probably conduce to this result: the prolonged suppurative action during the removal of sequestra, the irritation caused by sharp points and edges, sometimes increased by transport from primary to secondary hospitals, the patulous condition of veins in bones leading to thrombosis, being its chief local sources; while depressed vital power from any cause, and continued exposure to an impure atmosphere from the congregation of numerous patients with suppurating wounds, are the principal agents in producing the state of constitution favorable to its development and progress. Unless the hospital miasmata engendered in this way are constantly removed as they arise, or very greatly diluted by proper ventilation, it is almost impossible that patients laboring under severe wounds of the extremities with comminuted bony fractures can be long saved from septicemia and pyemia; and these, when they supervene, rarely lead to any but a fatal termination. The different conditions of hospital air, which in one set of cases lead to the appearance of hospital gangrene, in another set of pyemia, are not properly understood; but from the frequency with which the latter complication follows wounds of bones, it would seem that an especial influence is exerted by the local peculiarities of these injuries already mentioned. However, observation would also lead to the belief that certain individuals are much more predisposed to pyemic action than others placed under similar circumstances. Occasionally, in gunshot injuries of bones, where no splintering has occurred, but only a small portion of the periosteum has been torn off and the shaft contused by the stroke of a bullet, severe inflammation will follow, the medullary canal become filled with pus, and death ensue from pyemia. The attention of surgeons has been particularly called to the various circumstances producing inflammation and suppuration of the medullary tissues—osteo–myelitis—in long bones after gunshot injuries by M. Jules Roux of Toulon.

=Upper Extremity.=—Fractures of the bones of the arm are well known to be very much less dangerous than like injuries in the corresponding bones of the lower extremity. Unless extremely injured by a massive projectile, or longitudinal comminution exist to a great extent, especially if also involving a joint, or the state of the patient’s health be very unfavorable, attempts should always be made to preserve the upper extremity after a gunshot wound. In the Director–General’s History of the Crimean Campaign, the recoveries without amputation are shown to be, in the humerus, 26·6; radius and ulna, 35·0; radius only, 70·0; ulna only, 70·0 per cent. of cases treated. The proportion of deaths in these cases was only 2·3 per cent. Although not the result of gunshot, a remarkable case, published by Staff–Surgeon Dr. Williamson, by whom the operation was performed, serves to illustrate how extensively bone may be removed from the upper arm, and a useful member be still retained. The details will be found in his Notes on the Wounded from the Mutiny in India. The whole of the ulna, (not merely sequestra, but also the new bone which had formed around them, the object of which proceeding is not stated,) two inches of the humerus, and the head and neck of the radius were removed; and, four months after the operation, the man could “bend his forearm, raise his hand behind his head, lift a 28–lb. weight from the ground, pronate and supinate the hand, and use his fingers well.” Of 194 wounds and injuries of the upper extremity among men returned from the late mutiny in India, 100 are recorded by Dr. Williamson to have been sent to duty regular or modified, 67 invalided from the service, 1 died, and 26 were still under treatment.

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; 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;” 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. 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.” 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. 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.

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.