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J. Julian Chisolm.

A manual of military surgery, for the use of surgeons in the Confederate Army; with an appendix of the rules and regulations of the Medical Department of the Confederate Army online

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Online LibraryJ. Julian ChisolmA manual of military surgery, for the use of surgeons in the Confederate Army; with an appendix of the rules and regulations of the Medical Department of the Confederate Army → online text (page 13 of 24)
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violence, until the morbid state calling them into
play has exhausted itself.



The not unfrequent sequela of severe gunshot loounds
is long-continued discharge^ producing emaciation and
hectic, with its gradual dissolution of body and soul.
It is not at all surprising that the daily dis-
charge of a wound, wdien at all profuse, should
cause debility, as we have already characterized
pus as the nutritive essence of the circulating
fluid. If the surgeon, who has many suppurating
wounds under his care, overlooks the fact that he
must make allowance for this drain and feed the



HECTIC FEVER.



233



wound as well as the patient, the wound heing
more imperious in its demands than the economy,
deprives the latter of its due supply of nourish-
ment, and progressive starvation must follow. It
is on this account that what is called the antiphlo-
gistic treatment, when full}^ carried out in the
treatment of suppurathig wounds, is injurious,
and that the supporting plan is required. With
diet, wc have a powerful weapon for weal or
woe in surgical practice. Soon after injuries
have been received, when reaction runs high, hy
abstemiousness we can do much to quiet exces-
sive irritability. But as soon as this stage has
passed, and suppuration has become established,
then the course of diet should be modified ; now,
liberal diet is necessary to prevent the febrile
complication, which, in the earl}^ stage of the
wound, abstemiousness controlled.

The use of an abundance of strong nutritious
food, b}^ enriching the blood, will increase the
vital properties of the plasma, improve the tone
of the tissues, stop the excessive demands of the
irritated wounded parts, and diminish the drain.
This treatment, with the li])cral use of the astrin-
gent tonics, and the injection of stimulating
astringents into the wound (as nitrate of silver,
ten grains to one ounce of water, or tincture of
20



264: PERIODIC PAINS.

iodine, or the acid tinctures of iron diluted, one
part to five of water), will gradually diminish a
discharge, which, under less supporting treatment,
would continue for a much longer period. The
economy cannot withstand this constant drain; it
becomes irritable in its weakness. In its efforts
to throw off the yoke, it still further enfeebles
itself. Daily fevers, with their profuse sweats,
reappear Avith fearful regulal•it3^ Finally, the
blood becomes so poor, that it deteriorates rap-
idly, and the useless material which is ejected
from the circulation, irritating the organs through
which it passes, causes diarrhoea, and also copious
deposits in the urine. The quadruple drain from
wound, skin, bowels and kidneys, cannot long
be resisted. Debility gradually increases, the pa-
tient rapidly wastes to a living skeleton, having
literally melted away, and at last dies from sheer
exhaustion — the conjoined result of mal-nutrition
and wasting discharges. Such is hectic fever.



Another sequela of gunshot wounds *is more or
less permanent or periodic jyain in- the injured limb,
connected or not with paralysis of certain mus-
cles, the nervous supply to which has been impair-
ed by the ball in its passage. When a nerve has



PERIODIC PAINS. . 2o5

been completely divided, permanent paralysis,
with atrophy of the muscles, ensues — the limb
gradually dwindling, if the muscles, indirectly de-
stroyed, be important to the common movenients
of the extremity. A bruising of the nerves,
without division, is also followed by a paralysis
more or less persistent, which time, however, and
stimulating embrocations will, to a great extent,
remedy. This is not so much the case in sabre
wounds. Where a nerve is divided by a sharp,
cutting instrument, when the tissues are not dis-
placed and the wound lieals without suppuration,
both experiments upon animals and experience in
man show that a reunion of the ends of the
nerves is effected, and nervous action restored to
its former integrity.

When nerves are pricked, or in any other way
injured without complete division, very severe
neuralgic pains, with spasmodic action of the mus-
cles of the limb, ensue. These pains extend up
and down the injured limb, and, as in cases
reported by Guthrie, have, with irregular inter-
missions, annoyed the patient for years. In one
case, although the severity of the symptoms sub-
sided after six or seven years, annoyance was,
at times, experienced forty years after the injury
had been received. A coldness of the parts sup-



2o6 PERIODIC PAINS.

plied by tlie injured nerve is not an uncommon
effect, and is more or less persistent. Sudden
changes in the temperature, cold weather, or
mental excitement, are among the exciting causes
of such attacks The best means of mitigating the
suffering, independently of the application of warm
flannels, is the free use of stimulating narcotic
embrocations. Any combination from the many
articles of the materia medica, of stimulating and
narcotic, or anaesthetic ingredients, would fulfil
the indications of treatment. The internal use
of quinine, aconite, hyoscyamus, belladonna or
opium, will blunt sensibility.

The en dermic use of morphine in one-fourth
grain doses, or aconitine, one-sixteenth of a
grain dissolved in two or three drops of water,
will give immediate . relief — in some instances
a permanent cure has followed the first injec-
tion. Gi-reat reliance will hereafter be placed
upon this new method of treatment. A complete
division of the nerve at fault has been recom-
mended, and practiced with some good results;
but the divided nerve is liable to become diseased,
or its cut ends swell into a neuroma, which, incor-
porating itself with the cicatricial tissue, would,
from the amount of pressure exercised by the new
formations, allow of only temporary relief.



CHAPTER VII.

Treatinent of wounds of the different parts of (he body,
or topical surgery- Wounds of the head; ConeJ-
sion; its characters and treatment— Compression ;
its symptoms— Variety of wounds of the head;
their prognostic value— Simple wound of the scalp';
treatments-Fracture without depression; course to
be pursued when inflammation of the brain threat-
ens—Fracture, with depression, to be treated with-
out an (yperaiion-Trephhimg very rarely called
for— Compound fracture, with depression and com-
pression; trephining even here of doubtful propri-
ety— Perforating wounds of the cranium complicated
^vith foreign bodies.

Wounds of the head, when received in battle,
requii-e a special treatment, which cannot be en-
grossed in the routine practice for wounds. Owino-
to the proximity of the brain and membranes
and the focility with which shocks or direct injnry
can bo transmitted through the protective envel-
opes, injuries of the head possess a peculiar si<.-
■nficance. All wounds of the head are more or



238 CONCUSSION.

less serious, as the surgeon can never know in
advance whether the brain he injured, and what
amount of irritation or inflammation wdll ensue
upon such an occurrence. Hence the necessity
of caution in prognosis and treatment, which the
experienced surgeon will always exhibit, however
trivial the wound may appear.

Injuries of the head would divide themselves
into those produced from shot, those from the
bayonet or clubbed musket, and those caused by
the blow of a sabre. Wounds are found of every
grade of intensity, from a simple scratch to ex-
tensive destruction of the soft and hard parts,
with or without those phenomena recognized as
concussion and compression. As these terms
will be continuall}^ referred to in speaking ot
the treatment of head injuries, we will, in brief?
define the meaning wdiich the surgeon attaches
to them.

Concussion, or stunning, appears to be a shock
to the brain by which its substance is more or less
shaken, with interference of its circulation, and
often injury to its structure — its functions being
suspended for a certain period. Immediately as
an injury upon the head has been received, if at
all severe, the patient is knocked senseless. He



CONCUSSION. 239

lies perfectly insensible, motionless, and all but
pulseless. His face and surface becomes pale and
cool; the breathing, although feeble, is regular
and easily perceived ; the pupils irregularly con-
tracted or dilated ; sphincters are relaxed, in
common with the entire voluntar}^ muscular sys-
tem, so that the contents of the bladder and
bowels often escape involuntarily. After con-
tinuing in this condition for a few minutes,
hours or days, he gradually recovers conscious-
ness. The heart first regains its accustomed
action, the pulse gradually undergoes develop-
ment, and the skin becomes warmer. At this
period vomiting usually comes on, which arouses
the action of the heart. This organ, under the
excitement of emesis, drives blood to the brain,
and with this free supply of stimulus to the gene-
ral controlling organ, the patient rapidly rallies.
This is the common picture of concussion as
seen in surgical practice, and the combination of
its symptoms will be more familiarly recognized
as those of ordinary fainting or s^'ucope. The
extremes would be those cases in which the pa-
tient staggers, but, after supporting himself for an
instant against some house, fence or tree, recovers
himself and, without further annoyance, continues
his employment; or those in which the patient is



240 CONCUSSiON.

picked up apparentl}^ dead, witli relaxed muscles,
pale surface, glassy eye, scarcely perceptible pulse
and very feeble and irregular respiration. Tbe
death-like appearance becomes more and more
confirmed, the breathing gradually ceases, and the
pulse imperceptibly flitters away, without any
sign of consciousness from the moment of injury.
In fatal cases, where concussion had been
present, the brain has been found more or less
injured, and so highly congested as to exhibit a
dusky hue. Fissures have been found in its sub-
stance, or extravasations of blood in numerous or
concentrated spots. In certain instances the brain
has apparently shrunk from the excessive shaking
or vibrations to which it has been subjected, so
that it no longer fills the cavity of the skull. In
some fatal cases where the brain had been fissured,
the commotion among its particles had at once
annihilated its functions, so that the heart's action
had instantly ceased and no blood had been driven
to the mano:led brain to be extra vasated into its
substance. In cases of nearly instantaneous
death from concussion or stunning, the brain, on
examination, appeared in every respect healthy.
On the other hand, in cases of perfect recovery
after concussion, where the patient had lived
some time (weeks or months) in the full enjoy-



TREATMENT OF CONCUSSION. 241

ment of all of his faculties, and had died from
some disease totally foreign to the former head
injury, extensive lesions have been found in the
brain, and traces of large and extended extravasa-
tions of blood covering the hemispheres as well
as in the cerebral substance. The irritable con-
dition of the brain in which the patient is often
left, after concussion of limited duration, with the
impairment of memorj^ or of some one of the
special senses or even partial paralysis, would be
physiological proof of cerebral injury. Although
its symptoms are usuallj' transient, we may, doubt-
less, consider it a contusion or interstitial lacera-
tion of brain substance.

As this is an alarming cqndition, to those not
familiar with the march of such lesions, those
interested in the injured man are always clamor-
ous for active interference, and it is with difhculty
that the surgeon can free himself from the urgent
solicitations of friends who believe that, unless
prompt means are used, the accident must ter-
minate fatally. The surgeon, under such circum-
stances, requires all of his presence of mind, and
with firmness pursues strictly the non-interference
plan of treatment. The course which rational
surgery now recommends is to lay the patient
horizontally, with his head perhaps a little lower

• 21



242 TREATMENT OF CONCUSSION.

than his body, so that the brain may have the
benefit of gravitation to assist in its supply of
blood. He is wrapped in warm blankets, hot
bottles are placed around his body, and dry fric-
tions may be used to excite the re-establishment
of the circulation in the extremities ; but beyond
this the surgeon should not interfere. The safest
practice co7isists in doing as little as -possible. The use
of stimuli on the one hand or bleeding on the other
are to he especially and studiously avoided.

Only a few years since bleeding was the prac-
tice in stunning, and the amount of mischief done
by this universal mania for bloodletting was often
irreparable. We might as well bleed in a faint-
ing fi^t and expect good results. We find, as in
syncope, that the heart scarcely pulsates ; so little
blood is driven to the surface that it is pale and
cold. The same for the brain where so little
blood circulates that, from want of its proper
stimulus, its functions are temporarily suspended.
Were it possible to cb^aw away much blood, the
cessation of the nervous functions would become
permanent. Modern surgery, in studying the
natural history of disease and injuries, sees now,
what it should long since have recognized, that
nature, in her desire to harbor the circulating
fluid, tries to put a safeguard against the rash-



TREATMENT OF CONCUSSION. "24o

ness of surgeons, by shutting up the bulk of this
living fluid in the inner recesses of the body,
where it cannot he easily despoiled. On account of
this change in practice, we now seldom hear of
deaths from concussion, which was com[)aratively
of common occurrence a few years back.

As regards stimulation, we must also desist as
long as it is possible, and, when its administration
is compulsory, give it with a most cautious, spar-
ing hand. Remember that the degree and dura-
tion of shock depends upon the extent of injury
which the brain has received, and that nature,
always the most skilful physician, adopts this
concussion as a safeguard to prevent further
lesion. How are we to know that the In-ain has
not sustained severe injury, extensive bruising or
laceration, and that this extreme depression of
the brain, with consecutive control of the heart's
action, is not especially indicated to prevent hem-
orrhage within the brain substance and rapid
death from compression by extravasated blood.
We know this, that after severe injury to the
brain, when, through oflicious meddling and the
free use of brandy, the symptoms of concussion
early disappear, violent reaction is induced, and
internal hemorrhage or violent iniianinuition soon
shows itself; and that, for the doubtful gratifica-



244 TREATMENT OF CONCUSSION.

tion of seeing the patient rapidly revive, we
have the mortification of seeing him as rapidly
destroyed.

Cases of concussion^ absolutely requiring stimulants,
are hut very, very seldom met until in practice. Even
when of a very severe form, all that is necessary,
in the vast majority of cases, is to apply warmth
to the surface, and carefully to watch the case.

Should it so happen — but this occurs very
rarely — that the patient is manifestly in danger of
sinking from depression of the circulation, then
stimulants must be resorted to. As long as the
pulse does not lose its strength under concussion
of the brain, desist from active interference, should
the insensibility last for hours or even days.
After-trouble will be avoided by allowing nature
to take its own course unmolested. When from
the great and long-continued depression stimuli
are called for to prevent threatening dissolu-
tion, their efiects should be carefully watched,
and as soon as reaction is apparent, with an im-
improving pulse, at once desist from further inter-
ference. As is the state of depression, so will be
the state of reaction. When the depression is
extreme, the reaction will be correspondingly
excessive, and, especially so, if stimuli have been
freely administered.



COMPRESSION. 245

When the patient has recovered from the state
of insensibility, he should be kept perfectly quiet,
excitement of every kind should be carefully
avoided, the diet should be abstemious, the head
kept cool, and tendency to constipation cor-
rected; but, beyond this, no treatment is re-
quired until expressly called for by excessive
reaction, with symptoms of congestion or in-
flammation of the brain. The precautionary
bleeding, with repeated doses of calomel, to
keep off symptoms, which, in the majority of
cases, would not have occurred, was the routine ^
practice of the old school, and cannot be too
severely criticised. The complications which
might arise in injuries of the head, after more
or less serious concussion, will be hereafter con-
sidered.



Concussion is always simultaneous with the
blow, and gradually decreases, if death does not
carry off the patient early. Compression^ the con-
dition with which it is often allied, usuall}^ comes
on some little time after the reception of in-
jury, although it may appear either at the mo-
ment, or may not show itself for da3^s or even
weeks after the injury. The name explains the
lesion. Compression is pressure made upon the



24(j OOMPRESSrON.

brain, either by a portion of the skull or some
foreign body driven into or upon the cerebral mass ;
or by an escape of blood from some torn vessel,
which, by forcing itself into the unyielding skull,
compresses its contents, or by effusion of lymph
or pus, which inflammation causes to be deposited
within the cavity of the skull. The symptoms by
which this condition would be recognized, are as
follows: — The patient lies in a state of coma,
stupor, or lethargy, being paralyzed more or less
completely, both as regards motion and sensa-
tion. He is heavy, insensible, and drowsy, at
times answers mutteringly when rudely shaken
or loudly spoken to, but immediately afterward
is again breathing slowly, heavily and laboriously,
as if in deep sleep. Should his face be examined,
the lips and cheek on one side will be found to
flap, during expiration, with a blowing sound, as if
smoke was being blown from the mouth as in
smoking. There is paralysis of that side of the
bod}^ opposite to the seat of injury, and as a neces-
sary consequence, both in expiration or in attempts
at speaking, the corner of the mouth is drawn
over to the sound side. The countenance is
usually pale, cold, and ghastly, although it may
be flushed with a hot and perspiring skin, the
eyelids are partlj^ or completely opened, with the
pupils dilated and insensible to light; the pulse



COMPRESSION. 247

is slow, the heart acting under great oppression ;
there is constipation from torpidity of the bowels,
with involuntary discharge of the fl^ces. From
want of action in the bladder the urine is re-
tained, and unless drawn oiF will decompose
within the orgau, when, from accumulation, either
the bladder will rupture with poisonous infiltra-
tion, or the blood becomes poisoned from absorp-
tion. These symptoms are not always equally
marked— the degree depending upon the cause.
Unless the causes of compression be removed,
the case usually terminates fatally, although cases
are not rare, in which, after weeks of uncon-^
sciousness, reason has gradually been restored —
the accompanying paralysis slowly disappearing.
Having now explained the two conditions of
concussion and compression, which so commonly
accompany severe wounds of the head, we are
better prepared to study this special class of in-
juries.

The divisions which experience has proved of
practical utility, are :

1. Injury to the. soft parts alone, uncomplicated with
injirn/ to skull or brain.

2. Wound of soft parts^ loith simple fracture of the
skull.

3. Wound with depressed fracture of the skull, but
without symptoms of compression.



248 COMPRESSION.

4. Comjyoujul depressed fracture of the skull, with
symptoms of compression of the brain.

5. Perforating wounds of the skidl, complicated
with foreign bodies.

From tlie peculiar formation of the skull and
the resistance which it offers to blows, unless a
shot strikes it fairly at right angles, it does not
perforate; but whether it be a grape, musket, or
pistol ball, it flies off at a tangent, or, running
beneath the skin upward, downward, or laterally,
escapes. The head may even be struck with a
round shot without serious injury. The patient
may, or may not be knocked down by the blow;
severe pain is felt, and a puffing up of the part
instantly follows. When the hair is removed,
although there may be no discoloration of the
skin, there is abundant evidence of subcutaneous
lesion, which, unless counteracted, will soon de-
velop inflammation and extensive suppuration.
The severity of the blow upon the head may
have knocked the patient senseless: and in this
condition, he is found by the litter carriers.

The transportation of head injuries requires great
care, and the best transports should be devoted to
this service. When the patient arrives at the field
infirmary, he is laid down, with head low, until he



rOMPRESSTON. 249

recovers himself. The restoration is left to na-
ture; cold water may be dashed into the face,
but all stimulation should be avoided unless the
pulse is found to flag, when a little brandy may
be cautiously given. The surgeon takes advan-
tage of the insensibility of the patient, shaves
the head at the point of injury, and gives the
wound a thorough examination. When reaction
has taken place, and the patient is restored to
consciousness, should the wound have been a
simple one of the soft parts, the cold water
dressings is all that will be required, and should
be applied according to general principles. The
thin, wet compress, with oiled or waxed cloth
should cover the wound and head for some dis-
tance around the injury, and instead of tying
these in place by the roll of bandage, the better
plan is to adopt the head net of the Prussian
medical service. It is a round piece of coarse
netting made of cotton yarn : a string ties under
the chin to keep the dressing on, and a drawing
string, running around the net, like a purse string,
attaches it securely to the head around the tem-
ples. This is an admirable dressing for all head
injuries, which require light, cool, and efficient
applications.

Should the soft parts have been much bruised,



25(1 TREATMENT OF FRACTURE OF SKULL.

the ice bladder will be required to keep down
excessive suppuration. To prevent mischief, all
injuries of the head demand rest and quiet, avoid-
ance of stimulants, and abstemious diet. By
adopting this course in uncomplicated wounds,
whether gunshot or sabre, a speedy cure is usually
obtained. Effusions of blood under the skin
should not be interfered w^itli; incisions are not
required. If the effusions are allowed to remain
excluded from air, the cold water dressings with
arnica will cause their rapid absorption; if the
skin is punctured and air admitted, suppuration
will surely ensue. Should suppuration occur, as
soon as pus can be clearh^ detected, let it out by
a small incision. If this be neglected at the
proper time, the pent-up pus w^ill separate the
periosteum from the skull, and cause, perhaps, a
necrosis of the bones. When suppuration has
been well established, an oiled cloth is substi-
tuted for water dressings by man}^ surgeons,
although the growing disposition is to continue
the water dressings until cicatrization is com-
pleted.

When the skull has been fractured hj a ball, sabre
blow, or fragment of shell, the treatment should
in no material respect differ from the course pur-
sued in a simple scalp wound. A simple or com-



TREATMENT OF FRACTURE OF SKULL. 251

pound fracture of the skull, uncomplicated with
injury to the brain or its meninges, should be
managed according to the ordinary principles of
surgery, remembering always, however, that the
brain is in near proximity, and may have been
injured, although no s^aiiptoms are present for de-
tecting such a lesion. If the patient is insensible,
we adopt the means already recommended for re-
moving shock, viz : place the body in a horizontal
posture, and leave the case pretty much to na-
ture — avoiding everything tending to internal
stimulation. Whilst insensible, we examine the
wound thoroughly, using the finger as a probe;
and if any loose specul?e of hone he felt quite
free in the wound unconnected with the soft
j)arts, they should he removed. If attached, they


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Online LibraryJ. Julian ChisolmA manual of military surgery, for the use of surgeons in the Confederate Army; with an appendix of the rules and regulations of the Medical Department of the Confederate Army → online text (page 13 of 24)