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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 8 of 24)
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he attempted to rise.

It appears as if every gunshot wound was
accompanied by a certain amount of shock, or
a partial paralysis of sensation, which is nature's
preparation, permitting a thorough examination,
with little or no pain. The unusual quiet of
a hospital the night following a^ battle has been
repeatedly noticed, and is accounted for by this
nervous shock. When this condition passes off,
then reaction brings with it much suffering.
In this nervous shock, with the suspension of
activity in the circulatory function, lies the
safety of many a wounded soldier. Its influ-
ence is immediately felt in the injured tissues,
and the infiltration and engorgement of these
are prevented. When nervous depression exists,
but little blood escapes from the injured vessels,
and as there is no force from behind, owing to
the diminished action of the heart, to drive on
and keep in motion this blood, its clotting is
favored. When reaction ensues, the clot is al-



HEMORRHAGE, HOW CHECKED. 139

read}^ so firmly established that it cannot be dis-
placed; the injured vessels remain thoroughly and
permanently plugged up, and the dangers from
immediate hemorrhage are prevented.

As the wounded soldier is always clamorous
of having his injuries attended to as early as pos-
sible, and as experience teaches, that all wounds,
вАҐand above all others gunshot wounds, are benefited
by immediate dressing, they should be attended
to on the field of battle ; then they give less
trouble to the surgeon, less pain to the soldier,
and much better final results in treatment.
Here all hasty, dressings or examinations are to
be deprecated, and a methodical course pursued.
The indications of treatment, in all gunshot
wounds, are, 1st, To control hemorrhage; 2d, To
cleanse the wound b}^ removing all foreign
bodies, and, 3d, To apply such dressings and
pursue such a rational course of treatment as
will establish rapid cicatrization.

Hemorrhage, which produces such terror in the
bystanders and anxiety in the patient, should
never unnerve the surgeon, who requires all of his
self-possession and surgical tact to cope success-
fully with this ebbing away of life. Fortunately,
in gunshot wounds, serious hemorrhage is of rare
occurrence; and when the largest arteries are in-



140 TOURNIQUETS DISCARDED.

jured, they either cease bleeding spontaneously,
or the patient dies so rapidly, that art is of little
avail. If the case is not injuriousl}?- interfered
with, the natural hemostatics soon controls the
bleeding. The ragged character of the wound,
and the nervous shock accompanying the injury,
or brought on by the loss of blood, reacting upon
the circulatory organs, so diminishes the heart's
impulse and drives so little blood to the extremi-
ties, as to favor a stagnation of blood in the
Avound. The formation of a clot plugs up the
orifice in a bleeding vessel, and stops any further
loss of blood.

This siwiitaneoits arrest of hemorrhage is itsually
jjermanent; and if the ordinary prophylactic
course is pursued of absolute rest and quiet,
with the limb elevated and bandaged, no return
shows itself. Should, on the contrary, meddle-
some surgeiy suggest the use of a tourniquet,
which cuts off the circulation and especially the
veinous return, the limb soon swells, tissues
become engorged, excessive extravasation in the
wound follows, and a train is laid for future mis-
chief. The field tourniquet, in former days, was
so much in vogue that it was considered indis-
pensable on the battle field, and was therefore
carried in large numbers, to be applied to' every



HEMORRHAGE, HOW CHECKED. 141

limb from which blood was trickling, or from
which hemorrhage Avas feared. Now, they are
nearly discarded from field service, and recent
experience recommends their abolition from the
field, as doing more harm than- good to the
wounded. Unless very tightly applied, it is of no
service, as it does not control the bleeding, and if
firmly applied it acts as a general ligature around
the extremity, and can be used but for a short
time without injury to the limb.

Recent writers warn surgeons of the too hasty
use of hemostatics, and suggest that it is better
for the wounded to lose a little blood, which will
diminish the heart's propulsive force, than have
the wounded tissues filled with extravasated
blood. If the hemorrhage be free, immediately
after the receipt of injury, the best mode of con-
trolling it would be the application of a ball of
lint, a compress, or sponge over the wound, secured
by a bandage, which, in closing the outer orifice,
favors the formation of a clot. If the hemor-
rhage is at all active, as if from some large artery,
in addition to the compress on the wound, the
entire limb should be carefully enveloped in a
bandage, to some distance above the injury, so
that by compressing the soft parts it could dimin-
ish the timount of circulating fluid in the limb.



142 HExMORRHAGE, HOW CHECKED.

and prevent the ingress of blood into the tissues.
The hemostatic properties of this dressing can
be increased by soaking the sponge or compress
covering the v^onnd w^ith the per chloride or per
sulphate of iro'n, which, as a powerful astringent,
w^hen coming in contact with fresh blood, will
immediately form a clot. A lump of ice placed
upon the compress will act with equal efficiency.
A sponge or compress, with or without the iron
styptic, tied on the bleeding wound, is all that
the surgeon superintending the transportation of
the w^ounded is expected to do. Unless the hem-
orrhage is very violent, threatening immediate
destruction of life, the tourniquet is rarely re-
quired. All recent writers on military surgery
recommend that field tourniquets be dispensed
with, as they are generally a useless, and often
when carelessly used, a dangerous instrument.
The finger pressure of an intelligent assistant is
better than any tourniquet ever made, and is a far
preferable means of controlling excessive hemor-
rhage, which the compress and bandage may fail to
check. The femoral arter}^, for any injury to its
trunk or large branches, should be compressed in
the groin where it runs over the pubic bone ; the
brachial, where it pulsates against the head of the
humerus, as here its course is nearly subcutaneous.



PROBING WOUNDS. 143

"When the position of these main trunks are
shown to any intelligent assistant, and he is made
to recognize the throbbing of the artery, he will
have no difficulty in keeping the vessel com-
pressed during the transportation.

As soon as the wounded arrives at the tempo-
rary resting place where the surgeons are assem-
bled, all bandages are removed, and the wound
carefully examined. A glance at the wound
when the clothing has been previously examined,
will often tell when there are two orifices differ-
ing in appearance and in a direct line with each
other, whether foreign bodies have lodged or not.
As the patient is now faint from loss of blood
and from nervous depression, the w^ound not yet
being painful or swollen, the surgeon using his fin-
ger, ivhich is the only achnissihle probe on such occa-
sions that the military surgeon of experience recognizes,
examines the entire extent of the wound, search-
ing for foreign bodies.

This examination is made without fear of repro-
ducing hemorrhage, as the finger cannot displace
the clots which hold firmly to the openings in the
vessels. Every surgeon has noticed how rudely
a stump might be sponged, and what force it
requires to wipe away clots which have formed
over the face of a smooth, incised, open wound.



144 PROBING WOUNDS.

The adhesions are increased a hundred-fold by
the irresrularities of a concealed bullet track.
The finsrer finds no difficulty in entering: a hole

o I/O

through which a bullet has passed, if examined,
as every wound should be, before swelling has
taken place.

A silver probe will travel in the direction
given to it by the surgeon, in examining fresh
wounds, and as most persons guide the i^robe in-
stead of alloiving the probe to guide them, the true
course of a ball can only be determined by it
with great difficulty. It is but recently that
I saw a physician of experience, in seeking the
course of a ball which had lodged in the thigh,
apparently without effort, pass the probe among
the muscles quite across the limb; so that, the
bullet wound being on the outer side of the thigh,
the end of the probe could be felt under the skin
on its inner side. When the finger was intro-
duced it followed the track of the ball at a very
oblique course from the one which the probe had
taken. This example is sufficient to show wh}^
military surgeons denounce the silver probe, and
distinguish by its use the tyro in surgical practice.

The wound is examined from both sides, with
the double object of finding foreign bodies which
may have lodged, and seeing the proximity of the



REMOVK FOREIGN BOD IKS. 1-45

courso of the ball to tlie main arteries of tlie
liml). It is a matter of great importance to deter-
mine the condition of large vessels, whether thej
be injured or not, by examining the degree of
pulsation which they possess ; as an injury wx)uld
necessitate a very careful after-treatment to avoid
secondary hemorrhage.

Should but one opening exist, and all the
clothes of the soldier covering the wound be
torn, the probability is, that foreign bodies com-
plicate the wound. It must be remembered that
the ball as a hard body can usually be^ readily
recognized, but that portions of wadding or
clothing may be readily mistaken for a clot of
blood or the ragged lining of the w^ound. This is
particularly the case when they become satura-
ted with the secretions. Forewarned being fore-
armed, the surgeon, remembering these difficul-
ties, will examine with special care for these soft,
foreign complications. When found they should
be extracted, as their presence is certain to estab-
lish a high degree of inflammatory excitement,
with profuse subsequent suppuration.

This efi:ect was well shown in the case of a pri-
vate of the 2d Regiment of South Carolina Yol-
unteers, who, during the attack on Fort Sumter,
was shot by the accidental discharge of a musket.
13



146 HISTORY OF CASE IMPORTAxNT.

The ball entered the chest at the anterior fold of the
armpit, fractured the clavicle, and after a course of
nearly six inches, was stopped by the tough skin
over the posterior portion of the shoulder. The
ball was readily detected by the regimental sur-
geon, and, by an incision through the skin, w^as
easily removed. Inflammation of a high grade
followed. He was sent up to a city hospital one
week after the accident, when he was losing from
three to four ounces of pus daily from the wound.
On the day after his admission, in examining the
wound, I detected in the shoulder wound some
substance resembling a slough, and upon extract-
ing it, found a mass of wadding over two inches
long and as thick as the finger, which tent-like
mass had been driven into the tissues by the ball.
Examination of his clothing now^, for the first
time, showed the deficiency in the lining of his
coat from which this mass had been torn. The re-
moval of this irritant diminished the discharge
immediately, so that, in the succeeding twenty-four
hours, the discharge diminished to one-sixth its
former quantity, and in four days was hardly suffi-
cient to soil the dressing.

The history of the case is of much import-
ance in examining wounds. Often, the course of
the ball cannot be discovered without it. What



HISTORY or CASE IMPORTANT. 147

surgeon, however great bis experience, seeing
ii wound made in the arm by a l)all, would
think of looking in the opposite thigh for its
place of lodgment, did he not learn that the
injury was received from above, whilst mount-
ins: a scalin 0^-1 adder, with arms raised above the

O CD '

patient's liead ? The ball entering the back of
tlie arm near the elbow, passed down the arm
under the shoulder-blade, across the loin and,
traversing the buttock, lodged under the skin
of the outer part of the opposite thigh, where
it was found, and removed. Knowing the direc-
tion from whence the ball came, and the position
in which the soldier Avas placed, you know at
once the course which the ball most probabl}^
took ; and your examinations in that direction
will not only save much time, but save the pa-
tient much suiiering and annoyance. Often, the
play of a muscle will shut oft* the track of the
ball. The relations of the soft parts var}^ with
every positi(ui of the limb, and a passage made
when a limb was flexed, could not be followed
when the same limb is extended. Hence the
necessity of placing the limb in the same posi-
tion in which it was when the injury was re-
ceived.

The wound havino- been carefullv examined



1-4:8 REMOVAL OF i^ORElGN BOBIES.

by the linger within and careful manipulations
without, and the foreign body detected, it should
be at once removed. This rule may nearly be
considered absolute, as all military surgeons place
great weight upon its accomplishment. The ques-
tion is not so much whether balls can remain
innocuous in the flesh, hut do they ? Those who
have had experience in gunshot wounds in the
fleld, know how excessive is the irritability caused
by the presence of a ball in a wound; how restless
and irritable the patient is until it is removed;
how profuse the suppuration and prolonged the
period of treatment in those cases in which it
has been left; and how frequently the after-conse-
quences are so distressing, the pain so perma-
nent, and discharge sD constant, as to demand
future interference or make life a burden. If
such be the case with ball, how much the more
urgent the extraction of the foreign bodies is
indicated, especially fragments of shell, portions
of clothing, etc.

Balls may, in time, become encysted, but
these are exceptional cases ; and even when
such occur, their presence in after j-ears may
set up inflammation, which will mat together and
bind down important parts, whose usefulness
depends upon freedom of motion. Repeated



REMOVAL OF FOREIGN BODIES. 149

abscesses may form, pressure upon bones may
give rise to ulceration and a tedious exfoliation,
blood-vessels may ulcerate, nerves be painfully
compressed, and life rendered miserable, if not
jeopardized.

In McLeod's Surgery of the Crimea, the report
of M. Hutin, chief surgeon of the Hotel des
Invalides, is given, which is a striking commen-
tary in favor of the removal of all foreign bodies.
He reports that of 4,000 cases examined by him,
in which balls had remained unremoved, only
twelve men suffered no inconvenience ; and the
Avounds of two hundred continued to open and
close continually till the foreign body was re-
moved.

If the ball be felt loose in the soft parts, a bul-
let forceps can be made to seize it; and it can be
extracted \A4thout difficulty, provided the disengaged
hand of the surgeon supimH the limb on the oppo-
site side to thai at which the forceps is introduced.
Otherwise the ball glides in front of the forceps
and cannot be seized. The ordinary bullet forceps,
as simulating the dressing forceps of the pocket
case, was the instrument preferred by Larrey,
and is still, deservedly, in general use. Many
changes have l)een made in these, without ad-
vancing to any extent the merits of the instru-



150 REMOVAL OF FOREIGN BODIES.

ment. A very good bullet forceps is one ter-
minating with a sharp prong on either blade, at
riofht ano:les to the blade, so that when closed
the points are protected by the blades. These
act as an axis upon which the ball may be
rolled out of the wound, instead of being drawn
out as with the dressing forceps.

When a ball is firmly imbedded in bone, it is
removed by boring into it with a gimlet, which
holds it securely and permits sufficient force
being used for dislodging it, or it may be cut out
by using a trephine. Should a ball have trav-
ersed a limb, as it often does, and its escape be
resisted b}^ the tough, elastic skin which very
often successfully impedes the further progress of
the ball, it should be removed by making an in-
cision over its position, and not be sought and
drawn throuHi the entire leno^th of track which
it had traversed.

Baudens, in noting the difficulty of extracting
these subcutaneous balls, ascribes it to a layer
of cellular tissue, which firmly and completely
caps the ball. It is thin enough to be diaphinous,
and yet tough enough to clasp and hold firmly the
bullet. Gruthrie speaks of the difficulties of ex-
traction depending upon the surgeon being too
fearful of increasing the incision. Balls can be ex-



REMOVAL OF FOREIGN BODIES. 151

tracted with the least pain and with great rapidity
by making a bohi incision. This course marks
the difference ])etween civil and military surgery;
half an inch added to the incision does not in-
crease its dangers, and expedites the extraction.
Be quite sure, liowever, that you are cutting upon
a ball and not upon some bony prominence,
which comparison with the opposite limb should
warn you from. It is sufficient to mention that
such mistakes have happened to military sur-
geons.

By foreign bodies we mean balls, pieces of
clothing, spiculse of bone,. which have been bro-
ken off and are loose in the wound, and any
articles about the person which may have been
driven before the ball. These should all be re-
moved immediately after the injurj^ has been re-
ceived, and before swelling or infiltration renders
the task difficult. When .done early, the wound
will be found sufficiently large to allow of the
easy extraction without dilating. It is only when
this early attention is neglected, and the wound
has closed by inflammatory effusions, that tlie
removal is painful and difficult, requiring, in
some instances, the use of the knife to enlarge
the passage.

The dilatation of gunshot wounds, which was



152 REMOVAL OF FOREIGN BODIES.

formerly the constant ruje of practice, is now
altogether rejected from military surgery, unless
it be for the special purpose of ligating a bleed-
ing artery, or extracting a foreign body which,
from changes in the wound, cannot be readily ex-
tracted without injury to the soft parts. This
old medical dogma was based neither upon ex-
perience nor observation, and is now very prop-
erly considered useless, injurious and barbarous.
When a ball alone complicates a wound, if it be
not readily found, after a careful and intelligent
search, rather than continue the examination from
day to day, which can only be prejudicial to the
case, from the irritation and inflammation which
will be excited, it would save the surgeon much
anxiety and the patient much annoyance, if the
ball or other foreign body be left until suppuration
be well established. Then it will gradually ex-
pose its situation, and can be much more readily
removed than during the height of reaction
wlien the parts are very much swollen and very
painful. The surgeon will assist nature in the
expulsion as soon as the swelling has subsided
to such an extent that the linger or instrument
can again be introduced into the wound.

The above rules apply chiefly to gunshot
wouiids of the extremities; those of the trunk and



I'lmiARY HEMORRHAGE.



158



head offer so many exceptions to the above, and
require, in a measure, such special treatment,
that the course to he pursued in these wounds,
complicated with foreign bodies, will .be speci-
ally dealt with in discussing special injuries.

We have already stated that fatal hemor-
rhage, from the larp-e vessels of the extremities,
rarely occurs on the battle field, and that when
the large arteries are wounded, the hemorrhage
is either so immediately fatal that no assistance
can be rendered, or it ceases spontaneously.
The nervous depression so common to shot wounds
Avith its tendency to syncope, and its control
over the circulatory organs, checks the impulse
and supply of blood through the injured vessel,
and promotes the formation of clots. Openings
in arteries may be closed by foreign bodies, and
in such cases hemorrhage would recur when
these are extracted. The largest arteries may
however, be wounded, and may cease bleeding
spontaneously.

The only means of detecting this injury would
be in examining carefully the strength of pulsation
in the vessel, beyond the course of injury. A
diminution of its force, when compared to that
of the corresponding vessel in the opposite limb,
shows conclusivelv some hindrance to the circu-



154 LIGATION OF ARTERIES.

lation. When no external hemorrhage exists, an
absence of pulsation in the course of the artery
below the wound is the only means of detecting
serious injury to the vessel, and it often decides
whether the limb should be at once amputated.
The presence of the pulse is, of course, no indica-
tion that no injury has been received. Although,
from the course of the ball and the flow of blood,
we know that the main vessel of the limb has
been injured, if the bleeding has ceased sponta-
neously, or by the pressure of the sponge, or
compress, which was tied over the wound, the
artery should not be interfered with. In by far
the majority of cases, if proper precautions be
taken, there will be no recurrence of the hemor-
rhage. The patient should bo kept perfectly
quiet, free from all causes of excitement, at per-
fect rest ; and to ensure that the limb shall not
be moved, a bandage should be carefully applied
from the extremity of the limb upward, and a
long splint secured. The flannel bandage being
the most elastic, is the best material for such
methodical pressure and support. Elevation of
the limb will add much to the efiicacy of the
preventive treatment.

The ligation, of art artery, Vvdiich is the only
sure precaution against the return of hemorrhage,



LIGATION OF ARTERIES. 155

is not only a difficult operation, requiring much
sl^ill for its successful performance, but when
necessary to control the bleeding from a recent
wound, becomes a very dangerous one to the
safety of the limb or life of the individual. In
cases of disease, nature, always on the alert, has
enlarged contiguous blood-vessels, which are ready
to assume all the functions of the one requir-
ing obliteration. In a wound in a healthy person
no such preparation has been made ; and in cut-
ting oiF the main supply of blood through a limb
it becomes a very serious question, often answered
by the loss of the limb and even life, whether the
circulation will be re-established in time to save
the member from mortifying. When a ligature
is placed upon the main artery of a limb for
disease, previous developments in the collateral
circulation have been made to such an extent, that
the extremity may not even lose temperature
after the ligation, and as there is no diminution
of the nutrient supply there is no fear of mortifi-
cation. If placed on a healthy vessel for an in-
jury, the limb at once becomes pale and cold,
requiring the application of artificial warmth and
enveloping in flannels to support life in it until
the circulation be re-established, when the limb
becomes actually warmer than its collea2:ue. The



15G LIGATION OF ARTERIES.

arterial supply is now disseminated in vessels
much nearer to the surface than before, where its
chief channel was deeply embedded in the tissues.
The rapidity of this collateral development in the
limb is well exhibited in primary and secondary
amputations. When a thigh is amputated in a
healthy portion, very seldom are there more than
three or four ligatures required to stop all oozing
and render the stump quite dry. If the amputa-
tion be necessary at the same point three or four
days after an injuiy to the main vessel has been
received, the number is greatly increased : as
many as twenty-eight arteries have been ligated
by Langenbeck after amputating a thigh under
similar circumstances.

Shouid active hemorrhage continue and show
no disposition to cease, the wound should l)e
dilated, the bleeding mouths of the artery found,
and a ligatiLve applied both ahorc and heloiD the mprnj.
This has become the fixed practice and the only
safe one, taking its place among the aphorisms of
surg^iy. The universal adoption of this practice
is not only based upon experience and observa-
tion, but could be determined cl priori from the
physiology and anatomical distribution of arteries.

All surgeons are familiar with the anastomosis
or collateral circulation in blood-vessels. When



LIGATION OF ARTERIES. 157



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 8 of 24)