139. It has been proposed to use ligatures made of cat-gut or other animal substances, which may be cut short, and left in the wound to be absorbed. This has taken place in some instances, while in others little abscesses have followed, allowing their discharge, and not expediting the cure, so that the practice has not prevailed; it is said that greater success has attended in America ligatures used in this way made of very fine shreds of the strong tendons of the large deer of that country. Ligatures should not be applied on large veins when they continue to bleed, if it can be avoided, although it has frequently been done without subsequent inconvenience. A little delay and moderate pressure will generally suffice to arrest the bleeding.
140. If the surgeon find, after completing the operation, that the bone cannot be sufficiently covered to make a good stump, a piece should be sawn off at once, and the error remedied, with little comparative inconvenience to what would occur afterward, if the bone be too long. No false shame should prevent its being done. If, however, the error have occurred, and the end of bone should become uncovered during the process of healing, it may be allowed to separate of itself, as it cannot be sawn off at this period without difficulty and much suffering; for an exposed surface will then remain, from which an exfoliation will take place before the stump can heal. In cases of great protrusion, an incision should be made down to the bone, which should be firmly held by strong forceps, or by a tube in which it will fit, when it is to be sawn off by the chain saw at a sound part, above that which has been exposed. The wound, in all cases, should be well supported by compress and bandage, to secure a good stump; whence the necessity for the bone being shorter than in those secondary amputations which are done at the period of election, and which will, on the contrary, often unite without difficulty. In primary operations, cold water is most applicable in the first instance; in secondary amputations, warmth by fomentations, rather than by even the lightest of poultices.
ON COMPOUND FRACTURES.
141. A fracture of a bone, however simple it may be in its nature, is said to be compound when accompanied by an external opening in, or a wound of, the soft parts, communicating with the broken bone—a complication which usually gives rise to ulcerative inflammation and suppuration throughout the whole extent of the injury, preventing thereby those milder processes being effected which, under the more favorable circumstances of the skin being unbroken, lead to a speedy union of the broken parts; whence the desire manifested by the surgeon, in ordinary cases of compound fracture, to close the external wound, if possible, but which, from the nature of a gunshot wound, it is useless to attempt. A fracture is said to be comminuted when the bone is crushed, as by a heavy wheel passing over it. It may still, however, be a simple fracture, that is, without an external wound; and in that state it is much less dangerous than a similar injury accompanied by an external opening, however small, the edges of which cannot be immediately and permanently reunited.
142. An arm or a leg, as a general rule, is not to be amputated in the first instance for a compound fracture caused by a musket-ball, unless the ball be of large size, and the bone much shattered. An effort should always be made to save it; and, under reasonable circumstances with regard to the extent of injury, the comfort, climate, and ordinary good health of the sufferer, the object will frequently be obtained under good surgical treatment.
143. It is not so with the thigh. After the battle of Toulouse, forty-three of the best of the fractures of the thigh were attempted to be saved under my direction, and even selection. Of this number thirteen died; twelve were amputated at the secondary period, of whom seven died; and eighteen retained their limbs. Of these eighteen, the state three months after the battle was: five only could be considered well, or as using their limbs; two more thought their limbs more valuable, although not very serviceable, than a wooden leg; and the remaining eleven wished they had suffered amputation at first. Of the officers with fracture of the femur, one (having been taken prisoner during the action) died under the care of the French surgeons, by whom he was skillfully treated; the other has preserved a limb, which he rather wishes had been exchanged for a wooden leg.
In the five successful cases, the injury was in all at or below the middle of the thigh. In the thirteen others who retained their limbs, the injury was not above the middle third; and of those who died unamputated, several were near or in the upper third, and either died before the proper period for secondary amputation, or were not ultimately in a state to undergo that operation. Of the seven amputations which died, two were at the little trochanter, by the flap operation; and the others were for the most part unfavorable cases. In one case only was the head or neck of the bone fractured. The man lived for two months, and, from the dreadful sufferings he endured, it was much regretted that he had not lost his limb at the hip-joint at first. The operation ought, however, to have been the removal of the head and neck of the bone; but he was not seen in time by those who could or would have done this operation, which was then, however, only contemplated for the first time.
Nearly all the wounded, after this battle, had every possible assistance and comfort, from the second day after the action. The hospitals were well supplied with bedsteads—no inconsiderable point in the treatment of fractures—and several of the surgeons had been in almost every battle from the commencement of the war. The medicines and materials for their treatment were in profusion. The sick and wounded (1359 in number, including 117 officers) were in charge of two deputy inspectors-general, ten staff-surgeons, six apothecaries, and fifty-one assistant-surgeons; and the whole worked from morning until evening with the greatest assiduity. The surgery of the British army was then at the highest point of perfection it attained during the war; and this enumeration is given to show the number of medical men required under the most favorable circumstances for 1500 wounded men, if they are to have all the aid surgery can give them. Doctors are not the most ornamental part of an army perhaps, but there are days in a campaign when many poor fellows find them to be the most useful.
Every broken thigh or leg was in the straight position, and the success was greater than on any previous occasion. Nevertheless, with all these advantages, there can be little doubt that if amputation had been performed in the first instance, on the thirty-six out of the forty-three who died or only partially recovered, some twenty would have survived, able, for the most part, to support themselves with a moderate pension, instead of there being perhaps five, or at most ten, nearly unable to do anything for themselves. Baron Larrey, with the élite of the military surgeons of France, as well as of those of Germany, have maintained this opinion; and the result of the practice as yet observed in the Crimea essentially confirms it, partly from the greater extent of mischief done to the bone by the large needle two-ounce rifle bullets of the Russians, and partly perhaps from the want of the accommodation and appliances which the circumstances of the siege of Sebastopol did not admit of. In the present state of our knowledge, it is perhaps the safest practice, particularly under doubtful circumstances, in which it cannot be ascertained whether rest, the best surgical care, and comfort may not be wanting; without all which a favorable result cannot be expected.
144. War is an agreeable occupation, trade, or professional employment for the few only, not for the many; and particularly not for the poor, when they have the misfortune to have their limbs broken by musket-shot. There are very few men in England who know what are the first principles of a medico-military movement with an army in the field; and it will not materially signify whether there should be even one so instructed, until the nation at large shall be impressed with the idea that no expense, no trouble, ought to be spared to obtain for their soldiers so unhappily injured the utmost comfort and accommodation that can be procured for them, as well as the best surgical assistance. The first was little attended to in England during three-fourths of the Peninsular war; and the latter was supposed to be obtained, when the demand was urgent, by giving a warrant to kill or cure to persons as dressers who were unable to undergo an examination with any prospect of success, and prove themselves worthy a commission. Many a gallant soldier lost his life from the want of that proper attendance and care alluded to; many a desolate and unhappy mother mourned the loss of a son she need not have mourned for under happier circumstances, and who might have been the support, the happiness, of her declining years. Yet England calls herself the most humane, as well as the greatest, nation upon earth; she claims to be the most civilized, and she may be so; but certainly, in the case of those who have hitherto fallen in her defense, she could not on many occasions have been more careless or less compassionate. I have endeavored to impress on the directors of the East India Company in particular the injustice, the carelessness, of their treatment of the wounded soldiers of the royal army of Great Britain. My remonstrances have hitherto been in great part useless. It is to be hoped, however, that the present War Minister will cause an official public inquiry to be made into this matter, for that alone can cause this grievance to be redressed. Old habits are not to be overcome but by public opinion.