A Treatise on Gunshot Wounds

by Sir T. Longmore

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.”[14] 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.[15] 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.

SECONDARY HEMORRHAGE.

Army surgeons meet in practice with secondary more frequently than primary hemorrhage in gunshot wounds. It may arise in several ways. Sometimes it results from the coagulum being forced out of an artery in which hemorrhage had previously been spontaneously averted by the ordinary natural process, this accident being consequent upon muscular exertion or increased impulse of the circulating system from any cause. This occurrence in the bottom of a deep wound will be often found to be a very troublesome complication. Sometimes an artery which did not appear to be injured in the first instance ulcerates or sloughs; or, without direct injury, a vessel may become involved in unhealthy deterioration of the wound, and give way; or, in a granulating wound, general capillary hemorrhage may be excited by stimulus of any kind, such as venereal excitement or excess in drinking; or the coats of the vessel may ulcerate under pressure from a detached fragment of bone or from some foreign body; or the artery may be accidentally penetrated by the end of a sharp spiculum. Secondary hemorrhage has been said to arise from increased arterial action, from the first to the fifth day; from sloughing, the effects of contusion, from the fifth to the tenth; from ulceration, to any more distant date. M. Baudens has remarked that he has observed secondary hemorrhage to be most frequent about the sixth day after the wound—the traumatic fever having then reached its highest point of intensity, and the sharp, hurried contractions of the heart having most power in forcing out the coagula. If we could compare all the cases of hemorrhage which occur, secondary would, perhaps, statistically appear less dangerous than primary hemorrhage; for the latter, when happening from large vessels, must be very generally fatal, while, when hemorrhage occurs in them secondarily, the collateral branches have become partially adapted to the interruption of the flow of blood through the regular channel. Moreover, the larger arteries, when once filled with coagula and well contracted, fortunately do not frequently yield to the impulse which serves to produce secondary hemorrhage in vessels of smaller caliber.

Secondary hemorrhage is not uncommon after deeply-penetrating gunshot wounds of the face, and sometimes it is difficult to determine the site of the bleeding vessel. It may be so situated that the rule of tying both ends of the bleeding artery in the wound cannot be carried out, and where, if the ordinary styptics fail, resort must be had to the ligature of the common trunk from which the bleeding vessel branches. In the museum at Fort Pitt is a cranium showing the passage of a musket-ball from the inner side of the right orbit to the entrance of the carotid canal in the petrous portion of the temporal bone, where the ball had lodged. Death ensued, ten days after the wound, by hemorrhage from the internal carotid. In another case, a branch of the external carotid artery was wounded by a ball which penetrated at the zygomatic fossa. Secondary hemorrhage ensued, and the usual means failed to arrest it. The external carotid was tied; but blood continued to flow, though less abundantly than before. Compression in the wound, which failed previously, now served to arrest the hemorrhage, and cure followed. Care must be taken, before tying the trunk, that pressure upon it exerts control over the hemorrhage from the wound; for the irregular course of projectiles is not unlikely to lead to mistakes, such as tying the common carotid, which is stated to have been done when the hemorrhage has been from the vertebral artery.

The rule of treatment, however, holds good in secondary as in primary hemorrhage—the bleeding vessel must be secured at the wounded part whenever practicable, and it must be tied both above and below the line of division, taking care to ascertain that the spot where each ligature is applied is sound. Hemorrhage from general oozing, from sloughing, and other causes must be treated on the general principles applicable in all such cases.

WOUNDS OF NERVES.