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 1854-55, 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.

by G. J. Guthrie

152. After the first incisions have been made, and the larger splinters, which can be felt, have been removed, a secondary danger occurs from those which are smaller, and may have been overlooked, or not been discovered. This arises from the enveloping of these splinters in the new ossific matter described as being formed by the inflamed periosteum. This evil must be prevented by a careful examination of the wound when suppuration has been fully established, and the sensibility of the parts is in some degree diminished; when, if loose splinters of bone can be felt, they ought to be removed by incisions carefully and gently made to the extent which may be required. If this be not done early, the ossific deposit will take place around, and shut them in, even if the wound should close, which it usually will not. Their retention is accompanied by a firm thickening of the part, and in due course of time a spot of inflammation implies the formation of an abscess, and an ulcerated opening through the new bony deposit. When this abscess breaks externally, the probe will pass through the hole in the new bone, and rest on the rough, dead, and now perhaps movable splinter, the extraction of which can alone afford permanent relief. The earlier this is done the softer the ossific matter will be; at an early period, it will cut like Parmesan cheese intermixed with lime. If deferred until the bony matter is quite hard, it must be cut through with the chisel, or bone scissors or forceps, the application of which sometimes requires great force.

153. The successful treatment of a gunshot fracture of the thigh cannot be effected while the patient is lying on a little straw or a mat on the ground, and proper bedsteads should always form a part of the hospital stores of an army in the field. There is one in use at the Westminster Hospital, and another at the Royal Westminster Ophthalmic Hospital, which may be taken as models. Each, when complete, with mattress, etc., costs ten pounds, and, with a second inclined plane and mattress, might answer for two fractures; six may be easily carried in any common or spring cart wherever they are wanted. They would alleviate the sufferings, the horrible torments, many suffer unnecessarily. There is a very good and even cheaper one in use in the London Hospital, well worthy attention. An instrument or iron machine, movable from bed to bed, has been invented by Dr. Thomson, of Stratford-on-Avon, which lifts a man readily from his bed, and, after he has been dressed, lays him down again with ease in a similar manner to the bedstead alluded to. It has, however, the advantage of being movable, while the apparatus in the bedstead is fixed. Lord Strafford has sent one to his regiment, the Coldstream Guards, and Dr. Thomson has sent another. Young backs and young knees only can bend for consecutive hours over men lying on the ground. Doctors of fifty years of age cannot do it; they are physically unequal to the labor. A staff-surgeon half a century old on a field of battle is almost an absurdity in the art, if not in the science of surgery: he ought to be promoted to the rank of inspector. The custom of the present day is to promote men more on account of the length of their services than because of their value: whereas, to make good physicians and surgeons, it should be from their value, combined with a due regard to a moderate yet sufficient length of service, which certainly should never exceed, even if it amounted to, twenty years; ten or twelve, in time of war, would be better,—a matter of expense against life and human misery.

154. The position of the patient in a gunshot fracture of the thigh or leg is of the utmost importance. He should lie on his back, and the limb should be straight. It is almost impossible to keep a man’s thigh in the bent position, or on its side, without his turning on his back, and the union of the bone, if it take place at all, must then be at an angle. The bent position forward, or on an inclined plane, is defective, inasmuch as the matter, which must necessarily be secreted in great quantity, will gravitate backward in spite of every care to prevent it. When a proper bedstead is used, a slightly inclined plane will sometimes be advantageous at a later period, when the body may also be raised, even to the erect position, the principal object being to take off the action of the two muscles inserted into the smaller trochanter, which, with the rotators behind, raise and evert the upper end of the broken bone. This direction outward should be met by a similar direction of the lower part of the bone, and by the application, from time to time, of a proper splint, compress, and bandage on the elevated bone, if they can be borne with perfect ease.

155. Splints are of various kinds, and made of different substances. The discovery of gutta-percha has enabled some to be made of that substance, which, when moulded into sheets, of from one to two or three eighths of an inch in thickness, can be rendered soft and pliable by the application of hot water, regaining its firmness as it dries. Splints can thus be made of any size or length, and of any form, with apertures, if necessary, for the passage of the discharge from the wounds. Leather tanned without oil, and called splint-leather, is equally useful; if, when dried, the splints thus made become too hard, and press unequally, they can be softened by hot water, and removed and replaced with little comparative inconvenience.

One wooden splint of more than the length of the limb, somewhat similar to that called Desault’s, is absolutely necessary for the thigh, if it can be borne, which it rarely can, as a means of extension, or rather of preserving length. A shorter one on the inside, and one behind, will sometimes be required to complete the set A short one may be wanting for occasional use in front.

156. The bones of the leg being more exposed, admit of greater liberties being taken with them, and of larger portions, or even parts, being taken away successfully, than ought to be attempted in the thigh. A leg should, therefore, be seldom amputated for a fracture from a musket-ball. The splinters should be removed to almost any extent and number, and irregular portions sawn off from both ends, if they should be thus implicated. If one bone of the leg remain uninjured, the case becomes comparatively simple. The position should be straight on the heel, as a general rule, admitting of few exceptions.

157. The best apparatus for a compound fracture of the leg in either civil or military surgery, particularly in the latter, is that contrived by Mr. Luke, which may be seen in use at the London Hospital, and is supplied by Mr. M’Lellan, 3 Turner Street, Whitechapel Road. It is a simple iron cradle of small size, such as is used to guard a limb from the weight of the bedclothes, composed of three bars or large segments of a circle, united at their middles and ends or sides, as all cradles are, by a bar of iron of equal thickness. This is placed on a board a little wider than itself, with a ledge or bar at each side to prevent the cradle from moving, aided by two buttons or little pieces of wood on each side, which, being movable, turn over the iron bars, and thus render the board and cradle one firm piece. In this the leg is to be slung, to the center bar above, by ordinary tapes. A splint made of copper, to prevent rust or injury, hollowed to receive the leg, extending beyond the foot with a footboard, and beyond the condyles of the femur above, enables the tapes to be passed under the limb for slinging it; while from the extension of the splint beyond the condyles, it causes the leg and thigh to move together, in a manner which will often prevent the pain which follows a sudden motion of the patient. Solid wooden side splints are still wanting, and these should have holes cut in them to allow a vent for the discharge and for the application of dressings; or if a portion of the splint, say the middle, should require removal altogether for this purpose, the upper and lower parts may be united by a semicircular bar of iron, at the pleasure of the surgeon; within this the dressings may be applied, and by it the splint will be rendered firm.[3] When the leg is thus slung, the knee will be somewhat bent, the thigh raised, the muscles of the leg behind relaxed, and the patient can be moved with much greater facility than with any other apparatus; one great advantage of this apparatus is, that it can be used with effect even if the patient be obliged to lie on the ground. It admits of being slung as a whole in a spring-cart, by additional but strong, elastic straps fastened to or applied on the under part of the board, and thus a double slinging motion may be obtained when the sufferer is obliged to be moved.

[3] This apparatus has, I think, been improved upon at the Bristol Hospital by the addition of a bar on each side of the center one.