A. TREATISE ON GUN-SHOT WOUNDS: WRITTEN FOR AND DEDICATED TO THE burgeons of the dfonfdmrfe states %n\% BY M. SCHUPPERT, M. D., Of New (Mlriins. Louisiana. N E W 0 R L E A N S : PRINTED AT THE BULLETIN BOOK AND JOB OFFICE. 18 6 1. Med. riift UJO S s^at c I PREFACE. We are in the midst of a Revolution in which Southern rights and Southern chivalry are arrayed against Northern aggression and Northern fanaticism. Large armies are rush- ing to the contest, and while preparing for the deadly struggle, all the appliances of modern warfare will be brought in requi- sition. We may, therefore, expect to see many a bloody battle, many a hard won field. The soldier is already dreaming of glory and renown, and, therefore, eagerly grasps the theories of war; but military tactics necessarily leave out of the ques- tion the ghastly field, its wounded, and the bed of suffering. There the province of the physician begins, and on the field of battle itself, his knowledge and skill are put to the severest test. He must be prepared and ready for every emergency; he has no time to consult, no time to read up, he must act; for while he hesitates, the current of life may be ebbing away. We have thought that a short manual on the treatment of gun-shot wounds might be serviceable at the present time, and though we admit that many are more competent for the task, none will undertake it with more zeal. INTRODUCTION. In the following pages we propose to present our readers with a brief and practical account of the treatment of gun- shot wounds. While omitting all theoretical discussions, we intend to explain principally the treatment of those gun-shot wounds which arc complicated Avith injuries of the bones. Our views and treatment are based upon the experience of some of the most celebrated military surgeons of the age, and that ex- perience is gained by a treatment of over two thousand shot- wounds, in the late war in Schleswig-Holstein.* Boldly may we assert, says Esmarch, that those three years' experience in the treatment of gun-shot wounds has established a new era in the history of military surgery. It is now settled beyond a doubt, that in future, amputations will not be deemed indispensable, and that, though primary resections of the shaft of bones are generally to be considered a dangerous enterprise, resections in joints are a new and great acquisition. More than three hundred doctors from all parts of Germany, have witnessed the favorable results chiefly obtained from resections of the elbow- joint. The prejudice of old military surgeons, who thought that resection of a joint was inadmissible during war, must now be done away with, for experience has shown that this operation was successful under circumstances where even am- putation proved fatal. * We have derived the greatest information in this respect from the invaluable writings of Stromeyer, Surgeon-in-Chief, and Esmarch, Physician to the Staff, in the army of Schleswig- Holstein. TREATISE ON GUN-SHOT WOUNDS. GENEBAL OBSERVATIONS. -PROVISIONAll BANDAGES.-- TRANSPORTATION OP THE WOTJNDED.--MANAGEMENT OP MILITARY HOSPITALS. Capital operations are seldom executed on or near the battle field; yet it is well known that when amputation of an injured limb is indicated, every hour's delay diminishes the chance of the patient's recovery. In most cases the wounded are con- veyed to the hospitals with a temporary bandage. It is here that we experience the most painful disappointments. Opera- tions however skillfully executed, very seldom result favorably, notwithstanding the most careful after-treatment. The princi- pal cause of this frightful mortality is mismanagement of the wounded on the field of action, together with the miserable conveyances on which the wounded are usually carried, sometimes over a distance of many miles to some hospital. Thus it is that a crushing of any one of the long bones is soon followed by the symptoms of concussion in the whole limb; all the cellular tissues around the wound, including the nerves and vessels, are covered with extravasated blood, sensitiveness is diminished from the shock and compression of the nerves, causing a kind of paralysis. The circulation in the veins is diminished, and this stasis of blood is soon followed by an abundant exudation of serum, infiltrating all the soft parts. The wounded are conveyed from the field of battle on badly constructed wagons, which cause them to suffer excruciating pain; the muscles of the injured limb become spasmodically contracted, so that the fragments of the splintered bone are driven into the flesh. We frequently find, moreover, that ill 6 A TREATISE ON GUN'SHOT WOUNDS. adjusted bandages increase the evil. From fear of hemorrhage the surgeon applies a roller around the injured limb. This bandage being put on tightly, acts as a tourniquet, stops the circulation, but increases the serous exudation; should there happen to be a laceration of one of the larger blood-vessels, the bandage increases the danger, for the blood, though prevented from escaping externally, becomes infiltrated into the cellular tissue; the pressure and swelling which are thereby occasioned, being generally followed by gangrene of the whole extremity. The care, says Esmarch, with which the wounded were properly bandaged and conveyed from the battle field to the hospitals, was probably the means of bringing about the happy results which followed the subsequent treatment of many severe injuries, complicated with lesions of the bone, after the battle of Idstedt. The surgeon who accompanies the army on the field of battle has, therefore, great responsibility; for, upon his preliminary dressing much of the result of the after treatment depends. It ought to be his chief aim to support the wounded limb in such a way that the fragments of the bones cannot be displaced during transportation, and also, that the sufferer be made as comfortable as possible. For this purpose, a well applied bandage, with splints, resting on a pillow stuffed with finely cut straw or oat-chaff, will prove very servicable. In fractures of the humerus, the best bandage that can be used is a small cushion placed between the chest and the frac- tured limb, the latter of course being supported by a mitella (sling) and a roller around the body. A fractured thigh should be placed in an abducted position and rotated outwards, supported on a large pillow filled with chaff, or placed on a double inclined plane. A fractured leg is best attended to by putting it in a fracture box, which consists of four boards—a bottom, two sides, and a foot board, joined by hinges, in such a way that they can close at right angles, and thus receive the wounded limb properly supported on a pillow. A fractured forearm should be placed on a properly padded A TREATISE ON GUN-SHOT WOUNDS. i splint, care being taken not to exercise undue pressure on the internal condyle. The wagons used for transporting the wounded should have good springs. In default of these, moveable springs could easily be provided so as to be adapted to the interior of any wagon. On these springs a light frame work can rest, to receive a mattrass upon which the wounded can lie. As soon as the wounded arrive at the hospital, it is the duty of the surgeon in attendance, to make at once a careful exam- ination of the wounds. This examination is of the utmost importance, for it has to decide whether an operation is necessary or not. If the injury is found to be of such a nature that an attempt to save the limb would hazard the life of the patient, amputation must be performed at once. The advan- tage of immediate action is acknowledged by all military surgeons. On the other hand, in attempting to save the in- jured limb, great care should be taken to maintain a perfect adaptation of the fragments of bone together. The simplest apparatus are always the best. We have already mentioned cushions filled with oat-chaff as very advantageous in this respect. The surgeon should not leave the bed of his patient until he has placed him in such a position as to relieve him from all pain. Laborious and tiresome as this may be, the good results which the surgeon obtains, are, besides the thanks of the sufferer, sufficient compensation for the trouble. Another important point in the treatment qf the wounded, is the selection of proper places for the establishment of hospitals. Buildings should be well ventilated in order to prevent the development of miasma. Such localities, there- fore, ought to be selected, which admit of a plentiful supply of fresh air. Unfortunately, it often happens after a battle, that the wounded must be placed in localities which are unfit for hospital purposes : still the surgeon can do much in such cases towards improving the condition of his patients by attention to ventilation. He should not fear a draft of air as much as a deficiency in this respect. The war of Schleswig-Holstein has proved that the best results were obtained in those localities where a permanent ventilation was instituted day and night. 8 A TREATISE ON GUN-SHOT WOUNDS. As the surgeon will meet with prejudice from the wounded and the nurses; it may become necessary to have the window- shutters permanently removed, so that the regulations may be certainly carried out. Cleanliness is of the utmost importance in a hospital. In dressing the wounded, also, too much cleanli- ness cannot be used. The dressings soaked with pus and blood should be taken out of the room immediately after being removed from the patient. Sponges should not be used at all, as it is impossible to keep a separate sponge for each patient. The wounds should be first washed with warm water poured out from a spout and afterward wiped with dry char pie. INJURIES TO THE SHAFT OP BONES. THE NATURE OF THOSE INJURIES. In a critical examination of gun-shot wounds of the long bones, we must make a distinction between those which injure the continuity or shaft of the bone, from those which implicate the joints or the extremity of the bones. For injuries of the joints involve more dangerous consequences than injuries in the length of a bone. Before taking up this subject, however, we shall say a word in regard to the injuries caused by cannon-shot or bombshells. Wounds from such projectiles are generally accompanied with extensive laceration of the soft parts, or loss of the ontire limb. Such wounds generally prove fatal, on account of the shock to the nervous system; death commonly taking place in the first twenty-four hours, or mortification may ensue from which the patient dies usually by the fourth day. The loss of an arm does not necessarily prove fatal, but the danger increases with the proximity of the injury to the trunk. For we often find simultaneous injuries of internal organs, as for instance, rupture of the liver and spleen. Not less dangerous are those injuries where extensive fractures of the bones have taken place, though the soft parts are uninjured. We diagnose the frightful extent of such inju- ries by the singular sensation derived from the crepitation of A TREATISE ON GUN-SHOT WOUNDS. 9 the fragments of bone when we press upon the limb. Mortifica- tion here commonly ensues. The only chance of recovery in such cases is to amputate at once so as to save the wounded the pain of transportation, for this is certain death. When a ball strikes the shaft of a bone at right angles, going through a limb, the bone is generally shivered into many fragments. The size and number of these splinters vary considerably, many of them being still connected with the soft parts. It is now well settled by a great number of ob- servations, that these fragments retain their vitality, as long as the periosteum is not detached from the surrounding parts, and that they can be united by callus to their fragments. Baudens, in his "Clinique des plaics d'armes a feu," adopts Dupuytren's classification of splinters into primary, secondary and tertiary, and recommends the extraction of all splinters, whether loose or still connected with the integuments; and he further advances the principle, that all bones should be resected as far as a fissure exists; but experience has proved that this precept is dangerous. Fissures, like splinters, may heal by the formation of callus. The older surgeons regarded fissures as very dangerous, an opinion which has some foundation, if inflammation and putrefaction should happen to supervene; for then necrosis will follow, unless the patient should succumb from phlebitis, a complication which is very frequent in wounds associated with fractured bones. The danger increases when the fissure extends into the joint. But, as in fractures of the bones of the skull, at least in young individuals, a fissure seldom extends beyond one bone, on account of the sutures, the same thing takes place in the long- bones. There fissures of the shaft seldom reach the joint, neither will a ball passing through the epiphysis cause a fissure of the shaft. It is only when a ball happens to strike the exact point of union between these two parts, that a fissure may extend in both directions. The explanation of this fact is easily found, if we bear in mind that the shaft and extremi- ties of bones arc formed by separate points of ossification, and 2 10 A TREATISE ON GUN-SHOT WOUNDS. do not unite until a mature age, being, however, connected by cartilaginous tissue. In the war of Schleswig-Holstein, frac- tures combined with splinters and extensive fissures were frequently seen in the tibia. If the fibula be not implicated, the full extent of the injury may escape detection. The surgeon in such a case removes the loose splinters, and endea- vors to save the limb; but generally, however appropriate the treatment otherwise may be, extensive inflammation and sup- puration will set in. Some cases recover after the removal of large splinters which were either loose in the first place,' or became so by necrosis. In other instances, secondary bleeding takes place during the suppurative process to such an extent as to require amputation, though the life of the patient will seldom be saved by it. If the ball have lost some of its projectile power, it may cause a simple fracture, and the ball itself be found between the fractured ends or near them in the soft parts. It may happen that the clothes be not perforated, and the place where the ball struck be driven into the wound, and then some movement of the patient or pulling on the clothes might have brought out the ball, though the patient be not aware of it. It is therefore important to examine attentively the wearino- apparel of the patient. A simple fracture may again be caused though the ball retain its full force, if it happen to hit the bone obliquely instead of a right angle. In such cases the ball, after touching the bone, glances in another direction, so that a straight line from the place by which the ball entered to that of its exit would seem to leave the bone untouched. On probing the wound with the fingers, the fracture will be,at once detected. In such cases a proper treatment, under favorable circumstan- ces, will generally preserve the limb. We have seen, says Esmarch, a great number of such injuries of the thigh-bone recover perfectly; the prognosis being unfavorable only in such cases where the fracture was near the upper third of the femur or in the trochanter itself. It frequently happens that a portion of the shaft of a bone A TREATISE ON GUN-SHOT WOUNDS. 11 may be shot off without fracturing the bone itself. These cases generally have a favorable result. On the other hand, a ball may penetrate the bone, remain in it or pass through it without the bone being fractured or splintered. Such cases, which occur mostly in the upper portion of the tibia, allow a favorable prognosis. Finally, a ball may strike a bone and become flattened against it, without causing a fracture. But those portions of the bone which are struck, generally mortify, for the periosteum is necessarily destroyed. Such cases, where one of the long bones has been so injured, when brought into over-crowded hospitals, are apt to cause suppuration of the medulla, and death commonly follows by purulent absorp- tion. EXAMINATION OP THE WOUNDS. No task appears easier than to recognize an injury of a bone if accompanied by an external wound. For such injuries, it seems, could be more closely examined than simple un- complicated fractures; experience proves, nevertheless, that error occurs more often than the correct diagnosis. This can be explained by the abuse which the surgeons generally make of their probes,, for they commonly use this instrument in their examination, though in reality nothing can be learned from it, whereas the finger is the best and most reliable probe. It would be well, says Stromeyer, if all the probes could be confiscated at the beginning of a war, for then surgeons would have to use their fingers instead. Another difficulty in the examination of gun-shot wounds arises from their very nature. Whereas in ordinary fractures the periosteum is generally separated with the bone, in gun-shot wounds the periosteum may remain entire, though the bone itself is fractured, so that the form and position of the bone remain apparently intact. This deception will occur even after a digital examination, if the limb be not examined in the same position in which it was when the injury occurred. The deeper the wound, the more difficult the diagnosis becomes. In this condition, if a doubt arises as to sacrificing or preserving the limb, and a digital 12 A TREATISE ON GUN-SHOT WOUNDS. examination cannot settle the question, the surgeon should not hesitate to make a free incision so as to increase the original wound, in order to examine its exact condition. PROGNOSIS. There is no doubt that a gun-shot wound complicated with an injury of the bone, is more dangerous than without it. The gravity of the injury is proportioned to the size of the bone, and the prognosis rendered more doubtful the nearer the wound approaches the trunk. The condition of the soft parts, which are generally lacerated by the fractured bone, exercise a great influence upon the extent and gravity of the subsequent inflammation. That the fracture itself does not aggravate the case, is easily demonstrated by comparing the result of those cases where only one bone was broken, with those in which both were fractured. The former generally progress favorably and the inflammation is circumscribed; but when the fragments of the bone have been displaced by the action of the muscles, keeping up a constant irritation, as occurs when both bones are broken, then the most extensive inflammation will be found. Another serious consideration in the prognosis of these injuries is their tendency to pyoemia, a circumstance which might be explained by the anatomical fact, that the veins of bones are always open, having no power of contractility, and therefore greatly favor the absorption of pus. It is of the utmost importance to find means by which the medulla of a long bone could be protected against purulent absorption. Certain constitutions are not susceptible of pyemic intoxica- tion; nevertheless, many of these sink from the exhaustion which accompanies an extensive suppurating wound. TREATMENT. A fresh wound is not aggravated by introducing the finger, to ascertain the extent of the injury, or to remove foreign substances, such as the ball or pieces of cloth together with the fragments of bone which are detached. When it is re- A TREATISE ON CUN-SHOT WOUNDS. 13 quired to enlarge a wound it should be done in the line of the long axis of the bone. When the ball can be easily felt by the finger, a strong forceps should be introduced, guided by the index finger of the left hand, and as soon as the forceps touches the ball, the finger is withdrawn, the ball seized with the forceps and extracted. We must carefully abstain from too long a search for a ball, and if it cannot be easily reached, or cut out on the opposite side, it should be left untouched. Of all foreign substances, a bullet is the most harmless, as proved by numerous instances in which it has remained in the bones. What is true of the ball, is also applicable to splinters. Those which are entirely separated from the bone, should alone be removed. It is remarkable, how frequetly fractures heal after a small exfoliation of bone, when no attempt was made to extract any splinter. This generally occurs, where the ball having passed entirely through the limb, and where there was no necessity to search for the projectile. Those splinters which are still connected with the periosteum should be the last removed ; even if the periosteum be separated from the bone during the subsequent inflammatory process it will assist in the formation of a new bone, whereas, in the beginning a splinter could not be removed without carrying with it the periosteum. On the principle above stated, remarks Stromeyer, I consider extensive resections in the continuity of bones inadmissible in recent wounds, because they cannot be executed without simultaneous removal of the periosteum, for then the ends of the bone are less apt to unite, than when this membrane is intact. Besides this, a resection of bone increases the liability of inflammation or suppuration. I do not wish, however, to be understood as arguing against sawing off the sharp and pointed fragments of bone, if it can be done without enlarging the wound. All the cases in which extensive resections were performed during the cam- paign invariably proved fatal. The precautions which are necessary even for the extraction of foreign substances in wounds of recent date, are still more necessary when the 14 A TREATISE ON GUN-SHOT W.OUNDS. opening made by the ball is so swollen, that the finger can hardly enter without causing the patient great pain. In such cases an examination ought only to be made when an operation is dependent upon the diagnosis. If there be any hope of preserving the limb, the wound should not be touched, either with the finger or probe. In fresh wounds an incision may be sometimes indicated, to get rid of a quantity of ex- travasated blood collected near the fracture, but after an interval of twenty-four hours, such an incision is entirely inadmissible, for it would allow the entrance of air to the col- lected blood, would cause it to decompose, and thereby prevent its absorption; it also increases inflammation and suppuration, and therefore the tendency to necrosis in the frac- tured ends of the bone. On the contrary, when inflamma- tion can be subdued, we find that the splinters which are already loose will alone be separated, and only the ends of the fractured bones exfoliated. Knowing the obnoxious influence of a necrosed bone in retarding the healing process of a wound, it should be our greatest care to remove this source of irrita- tion. But this is not always in the power of the surgeon. The great means of preventing inflammation and necrosis, are, rest, antiphlogistic treatment, and free discharge of pus. If the prognosis be favorable, and hope of preserving the injured limb be entertained, the attending surgeon should place the wounded extremity in such a manner that the fragments of bone cannot be displaced and irritate the surrounding muscles. Large cushions filled with chaff' or chopped straw will be of the greatest advantage. If the extremity be shortened by a dis- placement of the ends of the fractured bone, no attempt should be made to overcome the deformity by any method of traction, for some time after the patient has been admitted into the hospital. The consequence of such an attempt would only pro- duce fresh irritation of the soft parts without the end being accomplished. On the other hand, a few days' rest, under, a proper treatment, will result in a relaxation of the muscles, and then the bones can be easily brought in a better position and retained there by splints. The treatment of wounds should be A TREATISE ON GUN-SHOT WOUNDS. 15 as simple as possible. The leading principle for the surgeon is to watch closely the condition of the wound, and remove all influences which interfere with the healing process. When wounded men were brought to the hospitals, says Esmarch, with the shafts of the long bones crushed by balls, if the limbs were already well bandaged and supported by splints on the field of battle, and the external appearance did not indicate infiltration or some other dangerous complication, we let them remain as they were. After placing the limb properly, cold applications were used, and no attempt made to remove splinters, or interfere with the wound in any other way. Under such a treatment we have seen cases recover in a short time, with very little suppuration, even where the thigh-bone itself was fractured. The wounded limb should be brought, if possible, into such a position, that it can be dressed without being moved. The greatest injury that can be done to a wounded limb in the beginning of the treatment, is to move it too often. The importance of keeping a wounded limb com- pletely at rest, is unfortunately not so generally understood as it ought to be. This will spare the patient much pain, and avoid slight and repeated bleeding,—together with irritation which keeps up inflammation. Another element in the proper management, of gun-shot wounds, consists in an antiphlogistic treatment. That great man, John Hunter, says in his treatise on gun-shot wounds, that the injuries of the extremities did not bear blood- letting as well as injuries of the trunk. This doctrine is ap- proved by most surgeons says Stromeyer, but, as I have already stated in relation to the treatment of simple fractures, I consider it erroneous, and have always seen the best results follow venesection in the treatment of complicated gun-shot wounds. But, alas ! the value of blood-letting, is like so many other valuable remedies, now discredited, and expectant homoeopathy seems to rule the day, so that young physicians are afraid to practice venesection. As they treat pneumonia, without blood-letting they think it just as reasonable to avoid venesection in traumatic injuries of the body. The small 16 A TREATISE ON GUN-SHOT WOUNDS. and contracted pulse, which is so commonly met with in recent gun-shot wounds, seems to forbid venesection, but in most cases such a pulse will be found to rise soon after blood- letting. The appropriate time for bleeding is within the first three days after the patient recovers from the first shock. If suppuration has taken place, venesection is no longer indicated, though leeches may still be sometimes used with advantage, when applied in the neighborhood of the fracture to diminish the inflammatory swelling ; they will dispense with incisions, which otherwise may be required. When suppuration sets in sloivly, venesection may be performed even after the third day, with benefit to the patient. Many surgeons are averse to blood-letting, in compli- cated fractures, because they fear to weaken the patient in anticipation of the suppurative process which commonly follows these injuries ; but these surgeons do not consider that suppuration will be diminished in proportion as the in- flammatory process is shortened. I have seen several patients die delirious within four days, from injuries of the upper ex. tremities, from too much inflammation, and I am convinced that blood-letting would have prevented it. Younger surgeons therefore, should not be afraid of drawing blood ; and this was the practice of the English surgeons during the French war, a practice which we entirely approve. Although the type of disease of our times appears to be less inflammatory than thirty years ago, and although practical surgery is bound to profit by the lessons of internal pathology, we think, never- theless, that a mechanical lesion, such as a gun-shot wound, must be treated on different principles than a case of pneu- monia, pleurisy, or typhoid fever. Next to blood letting, cold applications, the use of ice, cold irrigations are the most efficacious remedies. The principal action of these cold water applications is to keep down inflam- mation and prevent early suppuration. These means will also facilitate the absorption of much of the extravasated blood, between and near the fractured parts of bone. If no care be taken to diminish inflammation and suppuration, the extra- A TREATISE ON GUN-SHOT WOUNDS. 17 vasated blood is turned into pus; which, added to the swollen and inflamed parts will exercise an undue pressure upon the veins, and by interfering with the circulation of the blood, will cause a stagnation and serous infiltration of the whole limb. This condition is often a precursory symptom of phlebitis and death. It seldom occurs in hospitals where iced applica- tions have been made early. In using cold applications, it is necessary to make them directly on the wound. Charpie and sticking plasters should be avoided, as they prevent a free discharge from the wound. Another mistake is to cover the cold applications with oiled silk, for, by preventing evapora- tion, it causes the dressings to get warm sooner, requiring fresh applications of cold, and these too frequent alternations of heat and cold irritate the parts and increase congestion. The antiphlogistic treatment described above, accompanied by a low diet and mild saline purgatives, will be found the best. Cold applications should be continued as long as they prove agreeable to the patient. In wounds of the joints, we have seen ice applied during six or eight weeks with the best result. If these cold applications should not be tolerated any further by the patient, they ought to ba replaced by poultices, or perhaps by warm water dressings. The latter, while they fulfil all the effects of a poultice, are preferable : they are easier removed, they are cleaner, and the patient can apply them himself, thus dispensing with the constant ser- vices of a nurse, an object of some importance in crowded wards. In wounds situated near the extremities of the forearm and legs, if the bones are much injured and many small splinters exist, then warm poultices or better still, warm water baths, will be found exceedingly beneficial. They relax the tension of the parts, promote the discharge of pus, and act favorably on the capillary vessels on the surface of the limb. For this purpose, tin boxes eight inches high, of the same width, and two feet long, having a lid, and an open- ing at the end for the reception of the limb, will answer very well. They are to be filled with warm water, which might be kept warm for a longer period by means of blankets. 3 18 A TREATISE ON GUN'SHOT WOUNDS. Finally, an important point in the management of the wounds is a free discharge of pus, besides the protection of the limb from serous infiltration. For serous exudation, if allowed to collect, will soon be replaced by pus; whereas this will not be the case when a proper opening is made to facilitate the discharge of all fluids. The best proof hereof, is found in the treatment of the parts situated beneath the deep facia. If incisions be made early, when exudations are simply serous, the suppuration will be found to diminish ; but if incisions are not made early, extensive suppuration will follow, impeding the treat- ment, and endangering the life of the patient. This is especially tyue of gun-shot wounds. Sometimes a ball after striking a bone glances in a different direction, lacerating the muscles, and burrowing beneath the fascia, so that the finger cannot ascertain the direction of the ball. In such cases pus accumu- lates in these sinuses, as it cannot escape by the narrow and tortious opening made by the ball; this opening in fact becomes nearly closed by the swelling. In such cases, free incisions should be made at the entry and exit of the ball. By intro- ducing the finger into the opening it can be used as a guide for the incisions, which should follow the long axis of the bone. Many modern surgeons are opposed to these dilatations of fresh wounds, except for the purpose of extracting foreign substances, or for ligating an artery. Many therapeutical methods which have undergone dis- credit, though really efficacious, are slow in recovering their former position. Thus it is admitted that the dilatation of all gun-shot wounds is not necessary, but it would be a great mistake to assert that they are never necessary. Of course the surgeon has to decide whether an incision should be made or not. My experience, says Stromeyer, is undoubtedly such, that in cases where a ball has pur- sued a long and devious track, lacerating muscles and fascia before it, a dilatation is absolutely necessary to pre- vent the most frightful results. For extensive suppuration will soon take place, and in order to discharge the collection of pus, many incisions will be found necessary afterwards, A TREATISE ON GUN-SHOT WOUNDS. 19 when they might have been prevented by an early dilatation of the original opening. This principle is also applicable to gun-shot wounds in the thigh itself. When the laceration is in the neighborhood of the larger blood vessels, then the danger increases, because the inflammation might spread to the femoral vein, and thereby cause pyaemia; for this was observed in cases where the bone itself was not injured. Besides the dilatation of the wound, there are many important precepts which should be taken into consideration to prevent the secretion of wounds from accumulating. The wounded limb should be placed in such a manner that the discharge can leave the wound by the •simple laws of gravity. An opening which is too small should be dilated; also, a fistulous track should be treated in the same manner, or a counter-opening made. Isolated abscesses should bo opened as soon as fluctuation is felt. Sometimes it will be found necessary to apply leeches, or cut through the fascia, to avoid a fresh swelling. Young surgeons are generally very hold in making such incisions, but they forget that their object is the discharge of pus. Instead of putting the limb in an appropriate position, in order that pus may exude from the opening, they dress the wound with charpie and sticking plaster, besides a compress and a roller, and therefore no fluid can possibly escape. When such a bandage is removed after twenty-four hours, the pus escapes in great quantity. On discovering this, these surgeons are most anxious to get rid at once of all the pus and squeeze the limb most unmercifully, to the great distress of the patient. Heedless that the pus is formed as fast as it is removed, they reapply their bandages, and of course the pus becomes more acrid and more fetid. As usual, this fault brings on another. They apply what is called an expulsive bandage, to prevent the accumulation of pus, Jbut really it does nothing of the kind. When this fails they resort to solutions of nitrate of silver and chloride of soda, but still the pus continues to accumulate. Let our surgeons beware of such practice as this. One good incision in the right place, will diminish the quantity of the pus, change its quality, and improve the general health of the 20 A TREATISE ON GUN-SHOT WOUNDS. patient. By attention to these principles we shall avoid all deposits of pus, which are otherwise inevitable. It is important for us to notice in this place that there are two different ways in which pus may accumulate near a gun-shot wound. The most common origin of pus deposits is when it fuses beneath the cellular tissue and reaches a spot different from its origin, this percolation taking place according to the laws of gravity. In the second instance, inflammation, swelling and fluctuation, show a local tendency to the formation of pus. Here, if early incisions are made, we shall find that nothing but serum, or a gelatinous fluid will be discharged, and yet these deposits of serum are connected with larger deposits which do contain pus. This can be proved sometimes by passing the finger through the smaller cavity into the larger one. It would appear that in such cases, the fluid portions of the pus becomes infiltrated in the tissues, and by their acrid nature cause a new inflammatory process, from which, in course of time, pus originates. After a few days, when poultices are applied, pus will appear in the new incisions, which become outlets of pus from the deeper cavities. In practice, it is important to discriminate between these two different sources of pus collections. The first kind should be opened as soon as they are discovered, the last kind may require the application of leeches to prevent the formation of abscesses. After the expulsion of all foreign substances, and the sepa- ration of fragments of bone, the inflammatory symptoms de- crease, and together with it the discharge of pus. At this period of the treatment, the limb should be rolled in flannel; flannel bandages should be used in preference to cotton. Pressure is necessary to diminish the oedematous swelling of the limb; but bandages should not be applied before a fracture has been consolidated, for otherwise the moving of the limb would counterbalance any benefit derived from the bandao-e. When wounds, which have ceased to secrete pus, become filled with granulations, in order to accelerate the healing process, they should be dressed with pieces of soft linen or c°otton cor- responding with the size of the wound, dipped in a solution of A TREATISE ON GUN-SHOT WOUNDS. 21 nitrate of silver, of one to five grains to the ounce of water, and the whole covered with a piece of oiled silk to prevent them from drying too quickly. All cerates and salves should be dispensed with. The only dressing used after the patient leaves the bed should consist of oiled charpie. And now, while closing these general remarks on the treat- ment of gun-shot wounds affecting the shaft of bones, we would again particularly call the attention of our confreres to the necessity of keeping the patients on a low diet during the inflammatory state of the wound. The diet should corres- pond to the antiphlogistic treatment, and consist of light soups, a few vegetables, a small quantity of bread, and a cooling beverage, which treatment sometimes has to be continued for weeks. GUN-SHOT WOUNDS AFFECTING THE ARTICU- LATIONS. Wounds affecting the larger joints are generally so danger- ous as to require an early operation. Their gravity and fre- quency, together with their manifold varieties make them peculiarly important for the consideration of the surgeon. DIFFERENT KINDS OF INJURIES AFFECTING THE JOINTS. A shot by simply grazing a joint may wound only the liga- ments, without causing, however, any injury to the bone itself. On the other hand, if a ball strikes the end of a bone, it may, according to its force, either go through the bone or remain in it; or it may break off a portion of it, or, finally, if it has lost its power, it may strike the epiphysis and rebound, after caus- ing more or less damage. In such cases, where the joint is 22 A TREATISE ON GUN-SHOT WOUNDS. injured, the synovial capsule is not necessarily affected, but generally fissures occur, which extend through the head of the bone. The inflammation following this will sooner or late im- plicate the whole joint. Those wounds are the most dangerous in which the extremity of the bone, together with the synovial membrane have been torn and lacerated. The gravity of such injuries is readily understood when we remember the liability to inflammation of serous membranes in the first place, and secondly, the extent of these membranes in the joints, together with the various ligaments and tendons surrounding it, all of which will become included in the process of inflammation; be- sides this, the danger is increased by the destruction of the cartilaginous coverings of the bones, whereby the joint is des- troyed. Moreover, the joints consisting of irregular cavities will facilitate the accumulation of the secretions of the wound, a condition which is much aggravated by the presence of splinters and other foreign substances. The extremities of bones are more spongy and vascular than other portions, con- sequently, wheu inflammation sets in, they offer a large surface for suppuration. On examining such wounds soon after the accident, the joint will be found to contain a large quantity of blood together with lymph, immediately around the spot injured by the passage of the ball. The medullary cavity itself show- ing the extent of the injury. As soon as suppuration begins in the wound, the extravasated blood will be decomposed, and thereby rendered offensive. This condition will extend as far as the fissures and embrace all the injured portion of bone. PROGNOSIS OF INJURIES OF THE JOINTS. In injuries of the larger joints, it commonly happens that serous infiltration takes place around it. Inflammation sets in, the limb begins to swell on both sides, the skin takes on a bright red color, becomes hot and tense, and the epidermis vesicated. The distal extremity of the limb becomes oedema- tous from obstruction of the venous circulation. Accom- panying this condition, we find the following general symp- toms: a frequent pulse, a dry tongue, constant thirst, and A TREATISE ON GUN-SHOT WOUNDS. 23 from continued suffering, the patient frequently becomes deliri- ous. The pain is increased by the slightest motion of the limb. Suppuration soon follows, generally preceded by a chill, and pysemia, with all its sequela closes the scene. In these cases the pus is soon decomposed and fetid; gas forms in the cavity of the joint, and the patient becomes either comatose or delirious with an icteric hue, and death rapidly follows. Such are commonly the consequences of gun-shot wounds in the knee-joint. When these symptoms appear, amputation is l no longer of any avail. An early operation only, would save the life of the patient. Should a smaller joint be injured, the symptoms which we have just enumerated are usually milder in proportion, and make their appearance more slowly. For instance, if the capsule of the joint should be slightly injured and no blood penetrate into the joint, the pus may still be normal; but if the pus so formed be retained within the capsule, it will cause extensive inflammation, and finally escape by a rupture of the capsule at its weakest point. The pus will then fuse into the cellular tissue between the muscles, cause phlegmonous inflammation and the formation of abscesses. It frequently happens in such cases that pus burrows the whole extent of the limb, so that if death does not take place from pyaemia, the profuse suppuration will so endanger the life of the patient, that amputation will be the last resort. The symptoms which set in when the synovial capsule has not been injured, are very slowr and gradual, though the joint may become implicated at last from the suppuration around it. When the extremity of a bone has been struck, so as to cause fissures through the epiphysis without injury to the cartilage, the cavity of the joint in such a case may not communicate with the wound; but in the process of suppuration, the car- tilages become eroded, and pus will enter the cavity of the joint, causing intense inflammation at a late day, and the patient who had been previously considered in a favorable condition, will at once present all the dangerous symptoms above enumerated. 24 A TREATISE ON GUN-SHOT WOUNDS. DIAGNOSIS OP INJURIES OF THE JOINTS. . From what we have already said, it will be found diffi- cult to ascertain, in some cases, the true extent of the injury. Doubtless, in many cases, the external appearance of the wound will be a sufficient guide in diagnosis. A wound which is considerably swollen, accompanied with much pain and high fever, with fragments of bones, and an exposed cartilage, while a bloody synovia oozes from the opening, can scarcely allow us to doubt the nature of the injury. But there are many cases, where it is very difficult to ascertain the extent of the lesion. It is well known, that a ball striking a body in an oblique manner, may glance off in a different direction, and passing beneath the skin, may come out in a distant place without penetrating the parts situated between the two open- ings. This has been observed in the shoulder-, elbow-, and knee-joint. But it is necessary to be cautious in concluding from a superficial examination of such a wound. For it may happen that the ball has entered the joint, while the limb was in a different position from that in which it is examined. By a change of position some muscle or tendon may obstruct the entrance of the finger, and the discharge of synovia. It is, therefore, very important to ascertain the exact position of the limb when it received the shot, and to examine it in vari- ous positions. A swelling of the capsule of the joint, though occurring imcdiately after the injury, is not a certain sign of the joint being affected. For this may follow any lesion in the neighborhood of the joint, and the capsule itself may be in- flamed and distended without being touched by a ball, TREATMENT OF INJURIES OF THE JOINTS. It is well known that injuries of the joints when left alone or neglected, speedily become dangerous, they therefore, require more than all other wounds, the intervention of the surgeon. In spite of the best and most energetic treatment, the life of the patient is in jeopardy, and it therefore becomes the imperative duty of the surgeon, either to amputate the limb, or to resect the extremities of the bones, so as to A TREATISE ON GUN-SHOT WOUNDS. 25 simplify the wound. In some cases it may be sufficient to make a free incision into the capsule of the joint, in order to give issue to the fluids which are there abundantly secreted. But the latter treatment is accompanied with long suffering, and followed by complete ankylosis of the joint. On the other hand, the process of healing is much more rapid after a resec- tion, and frequently some mobility may be Obtained in the limb. Wounds of the wrist and ankle will heal under favorable conditions and a proper treatment, though they entail long- suffering and a stiff joint. Amputation is necessary when the bones are badly crushed. Under these circumstances a resec- tion is not advisable; the tendons being generally implicated at the same time that it is extremely difficult to avoid the numerous vessels and nerves which surround those joints: instead of resection, it is even preferable in such cases, to make a large opening into the articulation itself. Wounds of the larger joints call for an immediate operation, unless the. capsule alone be injured, and the bones not affected. In such a case, the wound may heal by a proper antiphlogistic treatment, though it will be followed by ankylosis of the joint. As an exception, and under very favorable circumstances, it may happen that wounds in which the bones have also been implicated, heal without an operation, but the life of the patient runs a great risk, and the responsibility of the surgeon is therefore very great, Taking all things into consideration, we should say that in cases of injuries of the larger joints, complicated with the more or less damage of the bone, it is better to amputate, although under very favorable circumstances, resection may be tried. In the olden time, when a joint was lacerated, by a ball, amputation was invariably performed. Larrey was the first to introduce resection into military surgery. But during the revolution in Paris, of 1848, we find that the most celebrated French surgeons performed no re- sections. In the late war of Schleswig-Holstien, out of forty cases of complicated gun-shot wounds in the elbow-joint, in which the whole joint was resected, thirty-two were discharged 4 '2(> A TREATISE ON GUN-SHOT WOUNDS. cured, with preservation of the limb, and only six died. It can be proved that the resection of the elbow-joint at the least, is a less dangerous operation than amputation, or disarticula- tion, b}' comparing the lists of mortality of both operations. It must be considered also, that most of these resections were made under such circumstances, that the third part of the amputated cases died. This was certainly a great triumph for conservative surgery. When we consider how helpless a man becomes after losing an arm, we can realize the advan- tage of preserving such a limb, although a portion of its utility be lost. Wounds of the joints of the inferior extremities must be viewed in a different light. Thus, an artificial limb, or a wooden stump may be more servicable than a crooked or stiff leg which cannot perform its natural functions. There is still another question connected with this subject, viz : the relative gravity of the two operations, a point still undecided. Resec- tions of the hip and knee-joint did not give good results during the war of Schleswig-Holstein ; they should, however, still be tried, and perhaps would now give better results. 4 TREATISE ON GUN-SHOT WOUNDS. 27 GUN-SHOT WOUNDS IN DIFFERENT BONES. UPPER EXTREMITY. INJURIES TO THE SHAFT OF THE HUMERUS. The liability to splinter, which is characteristic of the humerus make its injuries very dangerous. If the soft parts are much lacerated, at the same time that the shaft of the bone has been splintered, amputatiou is at once necessary. But when the ball has only penetrated the muscles, without injur- ing the vessels and nerves, an attempt should be made to preserve the arm, though the bone be considerably crushed. The chief danger of these wounds, consists in the violent inflammation which generally sets in at the inner side of the biceps. This must be combated b}T venesection, leeches and iced applications. If much swelling takes place, incision will be found useful. There is great difficulty in maintain- ing the arm in a proper position. The best way to secure it is to bandage the fore-arm across the thorax, while the wounded part of the humerus is separated from the chest by a cushion filled with oat-chaff, and covered with oiled silk ; the fractured ends of the bone are then kept together by means of Scultet's bandage. The limb is to be supported on the outside by a pasteboard splint, the whole apparatus being secured by a roller bandage passed around it and the chest. Out of twenty-five cases of complicated wounds of the shaft of the humerus, which occurred during the above men- tioned war, only four died, the others recovered perfectly ; though there were several instances in which the humerus had been broken into several fragments by grape-shot. In those cases no operation whatsoever was performed, nature alone accom plishing the cure. Consolidation took place sooner or later, and a useful limb was restored to the patient. Injuries of the bone, in the neighborhood of the elbow, may 28 A TREATISE ON GUN-SHOT WOUNDS. progress favorably if the fracture be a simple one. If the humerus should be struck near its head, fissures when produced will assume a downward direction, for the head being more spongy and cellular, is not liable to such fissures. If the ball should strike the bone lower down, such fissures may go upwards and downwards. Stromeyer recommends, when these fissures are very extensive, either to amputate at once, or if amputation be not indicated, to trust to nature, and leave the wound untouched. He thinks further, that when the removal of the limb is absolutely necessary, amputation is preferable to disarticulation. INJURIES TO THE SHOULDER-JOINT. Gun-shot wounds of the shoulder-joint are quite frequent, and the injury may be done in every possible direction. The diag- nosis of these injuries is sometimes difficult; at least to ascertain the^precise extent of the injury, for the joint being covered by the whole thickness of the deltoid muscle, a thorough examina- tion becomes almost impracticable when the deltoid is largely developed. The ball may pass through a portion of this muscle without touching the bone, or may even open the capsule of the joint, without this fact being recognized until the inflammation of the joint sets in. Fortunately, an exact diagnosis between a mere flesh wound and an injury of* the capsule is not indispensable, the same antiphlogistic treatment being applicable to both injuries. They generally heal with stiffness of the joint. When suppuration is so extensive as to endanger the life of the patient, resection of the head of the humerus is evidently indicated. Not that resection is absolutely necessary in frac- tures of the head of the humerus, for such wounds may heal after the splinters have been extracted, though this occurs at the expense of a stiff joint. In these cases, if resection is performed, a better result will be obtained, because some mobility generally follows. This operation may be performed at once or after suppuration has taken place. The resection of this joint, says Esmarch, has given us such A TREATISE ON GUN-SHOT WOUNDS. 29 good results and so rapidly, that if we add to this the benefit of an artificial joint instead of an ankylosed limb, we can not hesitate to declare that reaction should be performed at once in all injuries of the shoulder-joint, in which the head of the humerus is fractured from gun-shot ivounds. The rule which we have just given is based upon the follow- ing statistics: eight cases were left to the curative efforts of nature; of these five died, and in one it was yet undecided after six months' treatment whether an operation would not still be required. Out of nineteen cases, where resection of the head of the humerus was performed, only seven died, and twelve recovered perfectly, with a more or less useful limb. In none of these cases did ankylosis take place. Some were healed in less than three months. Among those cases which proved fatal, some had been operated during the inflammatory stage, others were treated in unhealthy places, where the simplest wounds gave rise to pyamiia. Larrey and Guthrie have established the rule, that resection should only be performed in those cases where only the head of the humerus is injured; but if the injury extends as far as the medulla, the limb should be taken off at the joint. The statements of Stromeyer and Esmarch are opposed to this. During the Schleswig-Holstcin campaign, most of the resections included a portion of the shaft of the bone, some- times as much as four and five inches. If the ball, after fracturing the head of the humerus, should have entered the chest, it may still be advisable to operate, provided there is a chance of saving the patient's life; the resulting loss of blood would be more serviceable than otherwise. We shall now give those methods of resection which we think the best. Method of Langenbeck.—A longitudinal incision is made in front of the joint, beginning at the anterior edge of the acromion, extending from two to four inches in the direction of the tendon of the long head of the biceps, which is reached after the skin and deltoid muscle have been divided. The sheath of the tendon should now be opened on its outside, the 30 A TREATISE ON GUN-SHOT WOUNDS. knife being passed closely to the inner edge of the greater tuber- osity of the humerus; after the tendon has been exposed, it can be recognized by its silvery hue; the knife should then be introduced into the joint, the point being carried forward and the back resting against the bone. The capsule being opened, the cartilage of the head will be seen beneath the anterior edge of the acromion. The tendon of the biceps should now be taken out of the bicipital groove by means of a blunt hook, drawn inwards and held by an assistant (the edges of the wound during this time being separated by hooks). The assistant who holds the arm should now rotate the limb inwards, by which the larger tuberosity comes into view. A circular incision should then be directed around this tuberosity, beginning at the opening of the capsule, and ending at the external edge of the bicipital groove, the convexity of the cut being outwards. By this incision, the tendon of the supraspinatus, infraspinatus and teres major will be divided. The arm is now rotated outwards, in order to bring the lesser tuberosity in front, and the tendon of the biceps should be replaced in the groove. A semi-lunar incision will then be carried around the lesser tuberosity, by which the tendon of the subscapulars muscle is divided. By means of these incisions, which have the form of the Greek letter