Copyright
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

. (page 19 of 24)
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 19 of 24)
Font size
QR-code for this ebook


comfortable to the sufferer. The uneasiness and
irritation which the splints and bandages give, do
much to prevent success. It matters little what
length of limb the patient has, provided his life
be saved, and the convalescence be speedy. A
shortened arm does not affect its usefulness, and
a slightly changed direction can be corrected in
the after-stages of the treatment. The most
effectual management is the simplest, and tedious
daily dressings are to be discouraged; straighten-
ing the limb upon the bed, a pillow, or a long,
broad splint, without bandaging, being the best
and most comfortable dressing for au}^ resec-
tion. The patient is kept in bed until the sup-
purative stage is established, when he will be
permitted to get up. His arm is then placed in a
sling, and the water dressings are continued until
a complete cure is effected. When the parts are
nearly cicatrized, it will be time enough to apply
the tumefaction bandage, for removing the oedema
of the limb. Anchylosis rarel}^ follows this oper-
ation in the shoulder-joint. As a proof of the



TREATMENT OF RESECTION. 849

efficacy of resection, Strom jer excised nineteen
shoulder-joints with a loss of seven, chiefly from
pyaemia. Of eight cases in which the operation
was required, but from some mitigating circum-
stances was not performed, five died.

Gunshot wounds in the neio^hhorhood of the
elbow-joint are much more readily recognized by
the escape of the synovia, etc., than injuries
of the shoulder. Inflammatory reaction runs high,
as in all cases in which the joints have been
opened by a ball. Collections soon form, and
the excessive swelling stretches the softened cap-
sule, which, giving way, allows of the burrowing
of pus and final discharge through open abscesses.
After running a tedious, painful, and dangerous
course, if the patient escapes with a shattered
constitution and an anchylosed limb, he is fortu-
nate. A primary resection ofi:ers a diminution of
the risks to life, a rapid convalescence, and a
movable joint. In the Schleswig-Holstein army,
of fifty-four amputations of the arm nineteen
died, whilst of forty resections under similar
circumstances only six died. The results of the
operations were also modified by the period of
performing the resection. Of eleven cases ex-
cised within twenty-four hours before reaction
ensued, but one died ; of twentv cases between



850 RESECTING ELBOW-JOINT.

the second and fourth day, or during the stage
of irritation or excitement, four died; and of nine
cases operated upon between the eighth and
thirty-seventh day, only one died : an exempli-
fication of a general rule laid down in the com-
mencement of this chapter, that the wounded
bear operations before the stage of reaction, or
after the establishment of suppuration, much
better than they do whilst sufiering under high
inflammatory excitement. This shows the neces-
sity of deferring operations.

The elbow-joint, for gunshot wounds, transfix-
ing its capsule and fracturing the bones, is best
resected from the back of the joint, the patient
lying upon his abdomen. An H, L, or T incision,
taking in the breadth of the articulation, when
sufiiciently long, will expose perfectly the heads
of the bones. There are no important vessels on
this posterior portion of the arm, and only one
lierve, the ulna, which must be sought on the
inner side and avoided in the incision, or paralysis
of all the muscles supplied by it will follow its
section. When the posterior ligaments are divid-
ed, and the joint exposed, only remove the frac-
tured head and all foreign bodies, and do not
interfere with that bone which has not been
injured. The lips of the wound are closed by



HAND RARELY REQUIRES AMPUTATION. 351

sutures, and cold water dressings become the
principal treatment. The limb is placed upon
pillows, and not disturbed, if possible, until sup-
puration is established. When the soft parts are
cicatrizing, and healing is nearly completed, pas-
sive motions in the joint will prevent anchylosis,
and a tumefaction bandage will remove the
oedema of the limb. Instances of good results
are recorded for injuries at the wrist-joint, where
the spiculated ends of both radius and ulna have
been satisfactorily removed ; also, instances in
which either of these bones have been removed
entire, for chronic ostitis and necrosis brought
on from gunshot injuries. Similar incisions to
those recommended for the resection of the
elbow-joint will expose the heads of the wrist-
bones, and permit of the read}^ removal of any
injured portion. In this as in all other cases, we
must save all tendons passing over a joint to sup-
ply distant bones; and in the wrist particularly,
many of the muscles which supply the fingers can
be d.rawn out of the way and thus escape injury.
However frightful an injury involves the hand,
it is very seldom that it is so mangled as to be
beyond the pale of surgical skill, and unless it is
literally ground up it should not be amputated.
In certain cases, fingers may have been already



352 INJURIES TO INFERIOR EXTREMITY.

torn off, or may be hanging by a fragment of
skin, when they should be removed; but for ordi-
nary gunshot lacerations of the hand, amputation
of the entire hand is very rarely required. Dif-
ferent bones of the hand and wrist are to be
removed when irrevocably injured, with or with-
out the metacarpal bones of the fingers or the
thumb. Any fingers which can be saved will be
better than the best artificial limb. In cases of
lacerated hands in military surgery, Avhen attempts
are made to save the limb, under cold water dress-
ings, the inflammation which comes on makes
a shocking limb to those unaccustomed to treat
lacerations of this extremity; but at the end of
eight or ten days, when suppuration has been
well established and granulations are forming, the
swelling subsid,es, the torn portions are drawn
together, cicatrization advances rapidly, and often
but little deformity remains : at least the patient
retains a useful limb. Some surgeons lay down
the rule, that an amputation of the hand is never
imperative, however frightful the injury to it may
appear; and there is much truth in the assertion.

»
In the inferior extremity^ we find the treatment
of gunshot injuries somewhat different from those
of the upper limb, on account of the minor degree



HIP-JOINT INJURIES. B53

of vascularity, and the mucli greater tendency to
mortilication, so that the rule to which we called
attention, of amputations being rarely required
for the superior extremity, is reversed for the leg,
where it is often the only way of escape left to
save the life' of the wounded.

We have elsewhere stated that when halls
embed themselves in the pelvic bones, and their
position can be discovered, provided a serious
operation is not needed, they should be removed,
as their presence will, sooner or later, give rise
to trouble ; and also that all loose spiculse should
be taken away. Sequestra frequently show them-
selves from time to time during the ti^eatment,
and are withdrawn. When the ball strikes
lower down, in the neighborhood of the tro-
chanters, it usually splinters the bone, and
frequently involves the ilio-femoral articulation.
Such injuries are of the most serious char-
acter, and are usually considered fatal. It is a
question of much moment to inquire, how can
' modern surgery, with all of its appliances, im-
provements and experience, assist in saving the
life and limb of such seriously wounded? Within
a few years the rule for all compound fractures
of the femur was amputation of the limb; but the
statistics from military hospitals in time of war
30



354 HIP-JOINT INJURIES.

are bo frightful — but few successes for the num-
bers treated — that it was naturally suggested that
the risks could not be materially increased by
letting the patient take the chances with his limb
on ; when, if his life was saved, it would be with,
and not without his leg. This has settled down
into a conviction for fractures of the upper third
of the femur, which are now treated without
amputation, inasmuch as nearly every amputation
in the neighborhood of the trochanter and all at
the hip-joint are fatal. If we are assured that the
l)all has crushed the head of the bone, then the
operation of resection offers the best prospects
of success for the patient; but it does not always
follow that this diagnosis can be clearly made
out, if the signs of intra-capsular fracture be not
present. Military surgical experience shows, that
a fracture of the upper portion of the shaft of a
bone does not necessarily extend into the head,
and vice versa. Unless the junction of the epiphy-
sis with the shaft is struck, the fracture is more
apt to be confined to a centre of ossiiication, so
that, in the thigh as in the arm, a blow just below
the trochanter will not usually fracture the head
of the femur. When the joint is opened and the
head of the bone fractured, the wound should be
enlai-gcd, or an opening made into the joint



hlP-JOINT INJURIES. 355

from tlie outer side of the hip, by which the frac-
tured liead iui;rrht be removed. If any success is
hoped for, tliose cases alone sliould be selected
in which neither blood-vessels nor nerves are
injured, nor the soft parts extensively torn. If
all or any of such are injured, where experience
teaches us that the chances from successful resec-
tion are more than doubtful, do not have recourse
to amputation which is so certainly fatal, but let
the patient live his few remaining hours or days
without being haunted by the ghost of a useless
operation. Should he i-evive the reactionary
stage, and still retain a good pulse and compar-
atively unshattered constitution, then a secondary
operation might give a chance of success. In
the Criniean service, no amputation in the vicin-
ity of the hip-joint was successful — every indi-
vidual case died. This only corroborates the
experience of other campaigns, and shows the
inutility of such mutilations. When death, from
a crushed thigh-joint is inevitable, it is hardly
humane to amputate under the plea of giving the
patient the benefit of the chances which experi-
ence teaches us are nutratorv.

As regards resections in suitable cases, the re-
port is a little more satisfactory. Of six resec-
tions performed by the English surgeons in the



35(5 IIir-JOINT INJURIES.

Crimea, one was successful, and the condition of
all operated upon was made more comfortable.
Had the conveniences for treatment been greater,
and the general sanitary condition of the troops
better, with less pyaemia, hospital gangrene and
scurvy, much better results might have been ob-
tained. Some of the cases were doing well, with
every prospect of final success, when they were
swept oft" by one of the above diseases. In ampu-
tations at the hip-joint, all the cases died speedily.

In cases of resection, the greatest difliculty lies
in the after-treatment. As it is not expected to
restore a perfect limb, no good result can be ob-
tained by using violent extension. The leg, how^-
ever, must be fixed, to facilitate those movements,
in changing position, which are necessary to the
patient's comfort. A long, straight splint is used
for this purpose by some surgeons, whilst the
incline-plane, which I would much prefer, is de-
pended upon by others. Some have bandaged the
limb to the sound one, and speak of it as a good
mode of support. Water dressings compose the
local treatment.

Baudens succeeded in saving both limb and life
in cases in which compound fractures of the upper
half of the thigh were treated without operation.
Consolidated and useful limbs, with but little



Ilir-JOINT INJURIES. 357

deformity, are reported as having been saved.
By the use of the fracture box. and incline-plane,
lie succeeded in curing a compound fracture on a
level with the trochanter, saving a useful limb,
although he had extracted two inches of the shaft-
of the femur. His experience proves that com-
pound comminuted fractures of the upper half
of the thigh are not so fatal when attempts are
made to save the limb as when the thigh is ampu-
tated.

As the resection of the hip is so much more
successful when performed for disease than for
injury, it has been suggested by surgeons of expe-
rience, that an exception to the rule of immediate
resections be made for the hip-joint, and that
such cases, even the most suitable for the opera-
tion, be deferred until suppuration be well estab-
lished. For hip-joint resections, it is said that
nothing is lost by this delay, whilst, on the con-
trary, there may be a chance of saving the limb
without an operation. Larrey, in 1812, reported
six cases of gunshot fractures of the neck of the
femur, with three cures, sliowing that the pros-
pects are not altogether hopeless. When the pa-
tient is in a measure placed in similar conditions
to those affected with diseases of the bones, his
prospect for a successful resection appears to be



858



HIP-JOINT INJURIES.



improved. Bauclens says, that as the resection of
the hip-joint only succeeds as a secondary opera-
tion, attempts should first he made to save the
limb.

We preface the following table, taken from Ar-
mand's Histoire Medico-Chirurgicale de la Guerre
de Crimee, with the suggestion that any surgeon
who has ever had a successful case of resection at
the hip-joint, has always been eager to publish it;
whilst many -have been disposed to hide their
misfortunes from the public, so that the tables,
showing the relative advantages of primary and
secondary resections, appear in their very best



light.



PRIMARY RESECTIONS AFTER GUNSHOT WOUNDS.



Surgeons :



Operated]



upon.



Cures.



Deaths.



Larrey. (Volume 8, Cliniquej

J. Cooper. (Dictionary)

Leteille. (Relatione du Siege d'Anvers, par

M. H. Larrey) '.

Ilutin. (Memoires do Medicine et de Chi-

rurgie Militaires)

Sedillot. (Anuales de la Chirurgie Francaise

et Etrangere)

Guyon. (Expedition de Churchill, Algerie)

Ruchct. (Journees de Juiu, 1848)

Gubiot. (These de Montpeliier, 1840). ...

French Crimean Service

McLeod. (Crimean War)

Stromyer



1

1 6




! 9

1


"


i 1


"


2


••


1

' 5




1


, ,


1


, .


3


. .


9


. ,


5


1*


1


••


36


1



6
2

1

2

5
1
1
3
9
4
I

35



* This successful case was found, after the articulation had been laid open, not
to be a fracture extending within the joint, but confined without the capsule; and
we are, tlierefore, justified in the bcHef that the case would have done equally
well without the resection.



COMPOUND FRACTURE OF THIGH.



359



SECONDARY OPERATIONS FROM GUNSHOT WOUNDS.



l-arrcy. (Clinique, volume 5)

Guthrie. (Clinic, volume 5)

Baudens. (Traite des Plaies d'Armes a feu)
Fernssac. (Bulletin des Science Medicales,

volume li)

Robert. (Journee de Juin, 1848)

Guersant. (Journees de Juin, 1848)

Vidal. (Traite de Cliirur<::;ie)

Mounier. (Constantinople, 1854)

Le,2:ouest. (Constantinople, 1854)

McLeod. (Crimean War)





1




1




1


























12


3



It has been suggested, that if the patient who
has been operated upon could have facilities for
slinging the whole body, it would aiFord many
advantages in the management of excisions of
the hip-joint.

A compound fracture in the upper third of the
thigh should be treated in every respect as if in
the arm. Unless the les; is so mane^led that an
amputation' is an act of necessity, it should not be
thought of. We have already said that, in field
military surgery, amputation near the trunk is
synon^-mous with death. The treatment must
commence on the battle field by proper transpor-
tation; as the judicious removal of fractured limbs
is as important as an operation, and any neglect in
this department wdll deprive the wounded man of
all hope of retaining his limb, or often of having
his life saved. We will carefully remove all loose



360 COMPOUND FRACTURE OF THIGH.

and movable spiculse, dilating the wounds if neces-
sary, to facilitate the thorough cleansing of all
foreign bodies. Until suppuration is well estab-
lished, the limb is kept in an easy position and sur-
rounded with cold applications. All tight, reten-
tive bandages are to be rejected, as they interfere
with topical antiphlogistic applications. Dispense
with bandages. On the eighth or tenth day, when
the reactionary stage has passed, the wound is
again to be examined for foreign bodies, and all
portions of bone which may have become separ-
ated by the inflammatory process must be re-
inoved ; or as sequestra, they will become incor-
porated in the new osseous formations, and be
the cause of much trouble and suffering.

In all compound fractures, with much loss of
bone, it is always injurious to attempt to obtain
a limb of equal length with the sound one. It
cannot be done, and the chafing and annoyance of
splints and tight bandaging may react very seri-
ously, if not fatally upon the constitution. The
first things to be attended to is the facilities for
treating such a fracture. If we are striving for
successful results, we must not expect to obtain
them if a patient, with a compound fracture of the
thigh, is being treated upon the ground or is lying
upon a little straw. He must have a proper bed



COMPOUND FRACTURE OF THIGH. 361

and a good firm mattress, prepared with a bed-pan
hole, for facilitating nature's dail}^ wants without
the necessity of moving him. Upon this the
patient is placed, lying on his back, with the leg
extended. Two long straps of diachylon plaster
are attached to the sides of his leg from the knee
to the ankle ; they form a loop under the foot, and
a weight is swung from this over the foot of the
bed. . This will be sufficient to tire the muscles
and make the necessary degree of extension ; or
the limb might be loosely attached to a long thigh
splint. The tumefaction roller is inadmissible,
and strips of adhesive plaster, or strips of bandage,
will secure the limb to the splint, and at the same
time leave the wound open for inspection and
dressing. For the first week or ten days this will
be all the apparatus needed. As the case ad-
vances, splints ma}^ be more methodically applied
by using long inner and outer splints of light
board, well padded with loose cotton, and secured
in position by bands of adhesive plaster or with
tapes. The counter-extending bands are made by
adhesive strips attached to the sides of the leg
and carried under the foot, where they are secured
to the end of the splint. Allow the ends of the
bones to fill up the void made by the extraction
31



362 COMPOUND FRACTURE OF THIGH.

of the spiculeej as this hastens consolidation.
"With the exception of the mechanical appliances
for the broken bone, the case is treated as for a
long-continuous suppurating wound, by avoiding,
in all cases, depletion and by giving liberal diet.
Many of these cases will die ; but if we have
facilities in a well-ventilated and well-organized
hospital, we will have the satisfaction of saving
some of the patients submitted to our care. •

In fractures of the middle and lower third
of the thigh, not implicating the knee-joint, the
question will again occur — what course is to be
pursued with them ? These are still very serious
cases, and are classed with those of the upper
third. Where attempts are made to save them,
as recommended by Guthrie, the fatality will not
be very dissimilar to fractures nearer the trunk,
and the moderate success which, under the very
best circumstances, we will obtain, will depend
upon the state of health of the sufferer and the
conveniences for treatment.

There are cases which often appear so trivial —
only a small bullet hole leading to the crushed
bone — that it seems barbarous surgery to con-
demn the limb without an attempt at saving it.
The young military surgeon expects much from
conservative surgery in such cases. We are in-



COMPOUND FRACTURE OF THIGH. 363

formed by the experienced, that this striving
after conservatism is the main cause of the heavy
mortality. Surgeons generally are not prepared
to believe how hopeless compound fractures of
the thigh are, until the unwelcomed truth is
forced upon them by an ever-recurring expe-
rience, that many lives are sacrificed to attempts
at saving these broken limbs. In civil surgery,
or with every facility in military hospitals, we
should attempt to save the limb— it is the propei^
course to pursue ; but on the battle field, with
the deteriorated material upon wliich we are
operating, and the poisoned atmosphere of the
wards into which the patient is to be carried, it
is a fatal error. Military surgeons must abandon
their conservative intentions to expediency. It
18 for such cases that primary amputation of-
fers the best chances for life. In rejecting am-
putations we lose more lives tlian we save limbs.
As a rule, amputations are less hazardous the
greater distance we operate from the trunk, and
the reason why amputations are urged for com-
pound fractures of the lower and not upper por-
tions of the femur is, that the chances being
similar without it, amputations are much less fatal
in the lower than in the upper half of the
thigh.



864 PERFORATIONS OF THE KNEE-JOINT.

Resection of the shaft of the femur for a
crushhig of the bone has been often recom-
mended and as often practiced, but the expe-
rience of latter years discourages its performance,
as the operation is more serious than the con-
dition for which tlie remedy is used. When
the splinters of bone are removed, there is con-
siderable space for the play of the rough edges
remaining, and which, therefore, give but little
W'oubre.

Should we attempt to save a fractured thigh
in its lower third, we may use either the straight
splint or the double incline-plane. The latter
is much the more comfortable position for the
patient, but has the disadvantage of promoting
the burrowing of pus, which, in working its way
down the limb, may dissect passages for itself
as far as the buttock, and, by its multiplied
openings, cause much annoyance as well as much
destruction to bones and muscles. Surgeons in
the Crimea often had cause to regret attempts
at saving fractured thighs, but never regretted
an early amputation.

When the knee-joint is implicated in a shot
wound, or cut open by a shell, with injury to
the head of the tibia or femur, experience has
shown that, however trivial the wound may ap-



PERFORATIONS OF THE KNEE-JOINT. 365

pear, if the synovial sac be entered, and air be
admitted, or a foreign body lie within the joint,
violent synovitis, with great pain, swelling and
heat, and with excessive inflammatory fever, will
come on after twenty-four or thirty-six hours.
Should the patient survive the inflammatory stage,
erysipelas, pyaemia or hectic will ultimately de-
stroy life ; and although on the other hand, the
eflusions may be absorbed, and a good anchylosed
limb saved, it is a very rare occurrence. Tf the
soft parts are not much lacerated, or the blood-
vessels and nerves behind the joint injured, such
•cases are well adapted for resection, and ex:cel-
lent results are obtained in practice.

A straight or elliptical incision over the an-
terior portion of the joint, across its entire
diameter, will expose the interior, and enable
the surgeon to remove the foreign bodies, what-
ever they may be, and with them the head of the
injured bones. The section of the bones should
be made in such a way that the surfaces will
adapt themselves to each other. "When the ex-
ternal wound is closed by sutures, union by the
first intention may, to a certain extent, be
obtained. In the successful cases, the bones
eventually become firmly united, and, with all
anchylosed joint, the patient retains a useful



oG6 TREATMENT OF INJURED JOINTS.

limb. After the resection, a long splint upon
the back of the leg, reaching from the buttock
to the heel, is all the apparatus required, whilst
cold water dressings are alone applied around
the joint. In cases of resection, the surgeon
must not expect quick union in the wound, as
that does not often occur in military surgery.
A tedious suppuration, the formation of nume-
rous abscesses, and often the exfoliation of por-
tions of bone is the rule, requiring care and
judicious management to obtain a final success ;
many of those operated upon being lost by the
action of those deleterious causes which act in-
juriously upon all wounds in military hospitals.


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 19 21 22 23 24

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 19 of 24)