A Manual of Military Surgery (SGO 1861)

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A manual of military surgery, by S.D. Gross, MD,1861

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5-12-2006

A manual of military surgery [full volume]

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Recommended Citation"A manual of military surgery [full volume]" (2006).A manual of military surgery, by S.D. Gross, MD,1861. Paper 1.http://jdc.jefferson.edu/milsurgusa/1
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Entered, according toAct of Congress, in the year 1861, byJ. B.LIPPINCOTT & CO.,

Inthe Clerk's Office of the District Court of the United States for theEastern District of Pennsylvania.


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roSAMUEL WIESSELL GROSS , M.D. ,

UXTURER O N A N A T O M Y AND SURGERY ,Amiuiifof the Editors of theNorthAmerican M edico-Chi rurgica l Rev i ew .

THISLITTLEVOLUME,

OF THE CIVILWARNOW IMPENDING OVEB

("UKONCE HAPPY AND GLORIOUS COUNTRY.IS AFFKCTIOSATKjYINSfUIHIM*

BYTHE AUTHOR.

IiKSIONEI)TO MITIGATE SOME OF THE HORRfIKF


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PREFACE.

The sole object which prompts me to publish thislittle book is an ardent desire to be useful to theyoung physicians who have so hurriedly entered thevolunteer service, perhaps not always with a ful lknowledge of the weighty responsibilities of theirposition. Itreats, very succinctly, of various mat-ters not generally discussed, except in large andponde rous volumes, inaccessible in the camp and onthe batt le-field. Itis essentially a book fo r emergen-cies; portable, easy of reference, always at hand.The substance of itwas original ly intended as anart icle fo r the July number of the North AmericanMedico-Chirurgical Review, and itwas not untilT had made considerable progress in its compositionthat the idea suggested itself to my m ind that itmight, ifpublished separately, be of service to apart ofmy profession at this particular juncture inour public affairs.Iray the young men into whose hands thisManua l may happen to fall, to be careful of the

(v)


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CONTENTS.PAGE

DedicationPreface >

C H A P T E R I.Historical Sketch of MilitarySurgery 9

C H A P T E R 11 .Importance of Military Surgery 1 8C H A P T E R 111 .

Qualifications and Duties of MilitarySurgeons 21C H A P T E R IV.

Medical Equipments , Stores and Hospitals '1 1C H A P T E R V.

Wounds and other Injuries 45C H A P T E R VI.

Amputations and Resections 74C H A P T E R VII.

11 l Consequences of Wounds and Operations 9 0C H A P T E R VIII.

Injuries of the Head, Chest, and Abdomen 98vii


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VIII CONTENTS.CHAPTER IX. PAGE

Diseases Incident to Troops 112CHAPTER X.

MilitaryHygiene , 139CHAPTER XI.

Disqualifying Diseases 151CHAPTER XII.Feigned Diseases 155

CHAPTER XIII.Medical, Surgical, and Dietetic Formulae 165Appendix 183


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AMANUALOF

MILITARY SURGERY.CHAPTER I.

HISTORICAL SKETCH OP MILITARYSURGERY.The duties and requirements of mili tary-

are essentially s im i la r to those of civil sur-gery. It is founded upon th e s a m e knowl-e d g e of ana t omy , medic ine , and th e associatesciences; itdemands th e s a m e qualifications,physical , mo r a l , and in te l lec tual . Th e differ-ence co nsists in th e appl icat ion of our knowl-e d g e r a the r t han in its range or d ep t h . Thec iv i l su rgeon r ema ins at h ome ;h e m i li ta ryfol lows th e a r m y , examines r ec ru i t s for th epuh l i c service, and supe r in tends th e heal thof th e t r o op s . Ifh e f o rme r is wel l educated,h e willhe qu i te a s compe ten t , at any t im e , a sth e la t te r to pe r f o rm these du t i e s ; for th eemergenc i e s of civilare of ten not less tryingthan those of military prac t ice , although t h eym ay not be on s o large a scale.I


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10 A MANUAL OF

The best civilhave often also been the bestmilitary surgeons. In p r o o f of this asser-t ion it is necessary on l y to refer to the namesof Pare", Wiseman , Schmucker , Kern,Larrey,Guthrie , Charles Bell,Alcock , Thomson , Bal -l inga l l , an d Macleod , of Europe ;r to thoseof Rush, Jones, Thacher, Ma n n , an d Home rof our own country.M ilitary surgery occupies, at the presentday, a deservedly high r a nk in the estim atio nboth of the profession an d of the publ ic . Thewar in the Crimea , the mut iny in India,an d the r e cen t convuls ions in Italy, all at-tended with so much waste of b lood an d life,have attracted to it the universal attention ofthe profession ;n d the revolutionary move-men t s now in progress in o ur own coun t ryinvest it with a new an d a fear fu l interest toevery American physician. Its praises havebeen sung by Homer , and , in all ages of theworld , governmen t s have extended to it afoster ing hand. As a distinct branch, how-ever, of the healing art, it dates back n o f u r -ther than the early part of the sixteenth cen-tury, when it was inaugurated by AmbrosePa r e1,by the publication of his treatise o n


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MILITARYSURGERY. 11

"Gunshot Wounds," the fruits of his observa-tions in the French a rmy inItaly. This man ,who w a s surgeon to four successive kings, wasan eye-witness of the numerous French cam-paigns, from 1536 down to the b a ttle ofMoncontour, in 1569, a period of thirty-three years. His populari ty , both a s a civila nd military surgeon, wa s , up to that time,without a parallel. The soldiers w o r s h i p e dhim;nd the s u c c e s s of more than one siege,as wel l of one bat t le , w a s due a lmost exclu-sively to the w onderful influence of his pres-ence. His treatise on "Gunshot Wounds"appeared toward the middle of the sixteenthcentury, and , after having p a s s e d throughvarious editions, w a s ultimately incorporatedin his surgical writings, published nearly aquarter of a century la ter .In England, the earliest work on militarysurgery w a s tha t of Thomas Gale, entitled a"Treatise on Gunshot Wounds," designedchiefly to confute the errors of some of hiscontemporaries, respecting the sup posed p ois-onous nature of these lesions. Gale w a s bornin1507, and after having served in the army

ofKingHenry VIII.,at Montrieul , and also


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12 AMANUAL OFin that of King Philip, at St. Quintin, finallysettled at London, where he acquired greatdistinction in his profession. In 1639 ap-peared the work ofJ.Woodall, "The Surgeon'sMate ;r,Military and Domestic Surgery."He w as surgeon under Q u e e n Elizabeth, bywhom he was sent to France, along with thet roops that were d i s p a t c h e d to the assistanceof Henry IV.and Lord Willoughby. In]676, Richard Wiseman, sergeant-surgeon toKing Charles 11., published his famous "Chi-rurgical Treatises," one of which was ex-pressly devoted to the consideration of gun-shot wounds. Tw o years after this a treatiseon gunshot wounds w as p u b l i s h e d at London,by John Brown , also surgeon to Charles. Hewas aman of eminence, and served wi thmuchcredit in the Dutch war of 1665. The nextEnglish work on military surgery appearedin 1744, f rom the pen of John Itanby, ser-geant-surgeon to George 11., under the title of"The Method of Treating Gunshot Wounds."After Itanby c ame the imperishable work ofJohn Hunter , familiar to every reader ofEng-lish surgical literature. The part relating togunshot wounds w as founded upon his observ-ations made while serving as staff-surgeon at


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13ILITARYSURGERY.

Belleisle and in Portugal, and is one of th emost precious legacies of th e las t century,near th e close of which it a p p e a r e d .

The present century has supplied quite anumber of works on military surgery, as isshown b y th e valuable publications ofLarrey,Hennen, Hecker , Augustin, Guthrie, Thom-s o n , Hutchinson, Bal l ingal l , Baudens, andothers, which have contributed so much to th eelevation of this department of th e healing art.Some of these works have been reissued inthiscountry, and have acquired a wide celebrity.W e mus t not forget, in this rapid enumer-ation of works on military surgery, th e"Manuel de Chirurgien d 'ArmeV' of BaronPercy, published at th e commencemen t of th erevolutionary war inFrance. It is a m o d e lof what such a treatise ought to be .The only work on this department of sci-

ence yet furnished in this country, is that ofth e late Dr. James Mann, published at Ded-ham, Massachusetts, in 1816. It is entitled"Medical Sketches of th e Campaigns of1812, '13, and '14," and forms a closely-printed volume of upwards of three hundredoctavo pages.2*


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14 AMANUAL OPThe latest treatise on this subject in theEnglish language is tha t of Dr. George H.B. Macleod , now Professor of Surgery atGlasgow, entitled "Notes on the Surgery ofth e War in the Crimea; ith Remarks on the

Trea tment of Gunsho t Wounds . " It is aw o rk o f intense interest , wri t ten wi th greatability b y an ac cu r a t e and diligent observer ,and is wor thy of a place in eve ry medica ll ib ra ry . To this wo r k f r equen t reference willb e made in th e fo l l owing pages.T o Dr. Lewi s Stromeyer, Physic ian of theRoya l Hanover ian Army , w e are indebtedfor the mo s t r e c e n t G erm an w o rk o n militarysu rge ry . Itwas issued in 1858, u nder thetitle of "Max imen der Kriegshe i lkunst ," intwo duodec imo volumes , to whi ch a Supple-ment w a s added in the ear ly part of the pre-sent year . A mor e valuable con t r i bu t i onto this depar tment of su rgery co u l d hardly b eimag ined .Besides the above mor e recent work s , thereader should ca re fu l ly study th e "Pr inc ip lesofMili tary Surgery ," by the late Dr. JohnHennen , o ne of the mo s t zealous and distin-gu ished military surgeons tha t Grea t Britain


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MILITARYSURGERY. 15has yet produced ; man of vas t e x p e r i e n c eand of th e mos t enl ightened views u p on e ve ry-thing wh i ch h e has touched wi th h is p e n .Pe r h ap s th e mos t systematic wo r k on th esub jec t in th e English language is t h a t of SirGeorge Bal l inga l l , ent i t l ed "Out l ines of Mil-i t a ry Surge ry ," th e l a s t ed i t i on of wh i c h ,th e f ou r t h , a p p e a r e d only r ecent ly at Edin-bu rgh , whe r e th e author h e l d fo r many yea r sth e cha i r of military s u r g e r y , fo r a l o n gtime, w e be l i eve , th e on ly one in Grea t Bri-ta in. Itis a p r o d u c t i o n of much mer i t , andis d e s t i n e d to maintain a very h i gh r a nk inthis spec ies of l i t e r a tu r e .Th e wo rk s of th e late Mr.George Guthr iealso deserve attentive study;they a r e wr i t t enwi th g r e a t clearness and ab i l i ty , and embodyth e r e su l t s ofan immense e x p e r i e n c e , acqui reddu r ing many yea r s of a r duous and fa i thfu ll abor and observat ion in th e Br i t i sh a rmy .Ih a v e always r e ga rded th e wo rk s of th is g r e a tman as among th e mos t valuable con t r ibu -t ions, not on ly to military s u r g e r y , bu t tosurgery in genera l , in th e English l anguage .With these wo rks befo re h im, th e s tuden tof military s u r g e r y cannot fail to make him-


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16 AMANUAL OF

self in a short t ime perfectly familiar witheverything per ta in ing to the subjects of whichthey treat. He should also prov ide himselfwith a copy of the excellent little volume en-titled "Hints on the Med ic al Exam inatio n ofRecruits fo r the Army," by the late Dr.Thomas Henderson , fo rm e rly Professor ofMedic ine in Columbia College, WashingtonCi ty . A new edit ion of it w a s published afew years ago b y Dr. Richard H. Coolidge,of the Uni ted States a rmy .Although we have long had one of th e mostr e s p e c t a b l e and thoroughly organized a rmyan d n av al medical staffs inthe world,our coun-try has, nevertheless, not p r o d u c e d on e grea tmili tary surgeon ;imply, itm ay be p r e s u m e d ,because no opportunity has occurred since theestablishment of our government , inwhich themen in the public service could distinguishthemselves. Thei r a id has been required inth e duello and in skirmishes rather than ing rea t battles, such as have s o often charac-terized the movemen t s of th e armies of theOld Wor l d . W e make no exception in thisremark in favor even of th e battles tha t werefought during the Revolut ion , and during ourLate War , as ithas usually been designated,


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MILITARY SURGERY . 17

with Great Britain. Those engagementswere, fo r the m o s t part, comparatively blood-less . Happi ly l iving under a f lag which,until recently, commanded alike the respectand the admiration of all nations, belongingto a g o v e r nme n t which w a s at peace with allforeign powers , the medical and surgicalstaffs of the public service had little else todo than to prescribe fo r such diseases as areincident to c iv i lpractice. America has neverwitnessed, and we trust in G od she never m aywitness, such carnage as that which attendedthe footsteps of Napoleon at the Bridge ofLodi , at Leipzig, at Dresden, and at Water-lo o;or which, more recently, characterizedthe exploits of the English, French, andRussian forces in the Crimea; o r of theFrench, Italian,and Austrian armies in Italy;o r of the English soldiers during the late re -bellion in India. Nor has she ever beenengaged in one grea t nava l battle similar tothat of La Hogue, Tou l on , Trafalgar, o rAboukir. A number of highly respectablephysicians a c c o m p a n i e d our a rmy to Mexico,b u t they retu rn ed withou t an y special laurels ,and without an y substantial contributions tomilitary medicine and su rge ry .


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18 A MANUAL OF

CHAPTER 1 1 .IMPORTANCE O F MILITARY SURGERY.Its impossible fo r any civil ized nation toplace too high an estimate upon this branch

of the publ ic service. Without the aid of a pro-perly organized medical staff, no army, howeverwel l disciplined, could successfully carry on anywar, even when it is one , as that which is nowimpending over us, of a civi l character. Nomen of any sober reflection would enlist inthe service of their country, if they were notpositively certain that competent physiciansand surgeons would accompany them in theirmarches and on the f ield of battle, ready toattend to their d i s e a s e s and accidents. Hencemilitary surgery, or, more correctly speaking,military medicine and surgery, has alwaysoccupied a deservedly high rank in publicestimation.Dionis , a surgeon far in advance of hisage, in referring to the value of medical ser-vices to soldiers, exclaims, with a burs t ofeloquence: "We m u s t then allow the neces-


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MILITARYSURGERY. 19sity of chirurgery, which daily raises manypersons from th e brink of the grave . H owm an y men has it cured in th e a rmy!H owm an y grea t commanders would have died oftheir ghastly wounds without its assistance !Chirurgery triumphs in armies and in s i e g e s .'Tis true that its empire is owned :tis theret ha t its effects, and not words, express itseulogium."The confidence reposed by soldiers in theskill and humanity of their surgeon has oftenbeen of signal service in su ppo rting them,w hen exhausted by hunger and fatigue, intheir struggles to repel the advancing foe, o rin s u c c e s s f u l l y maintaining a s i e g e when theprospect of speedy surrender was at hand.W ho that is versed in th e history of our artd o e s not remember with what enthusiasm andresolve A m b r o s e Pare1,the father of Frenchsurgery, inspired th e souls of th e half-starvedand desponding garrison at Metz , in 1552,when b e s i e g e d by 100,000 men under thepersonal command of Charles V.? Sentthi ther by h is sovereign, he was introducedinto the city during the night by an Italiancaptain ;and th e next morning, when he


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20 A MANUAL OFshowed h imse l f upon th e breach, h e wasreceived wi th shouts of welcome. "We sha l lnot die," th e soldiers exclaimed, "even thoughwounded ;a r e " is among us ." Th e defensef rom th is t ime was conducted wi th renewedvigor , and th e French a rmy ultimately c om -pletely triumphed, through th e sole influenceof th is i l lustrious surgeon.Noman in th e French a rmy under Napo-l eon rendered so many and such important ser-

vices to th e F rench na tio n as Larrey, th e il-lustrious surgeon w ho accompanied t h a t mightywar r i o r inh is various campaigns, everywhereanimat ing th e t roops and doing all in h isp ow e r to save them f rom th e destructiveeffects of d i s e a s e and injury. His humanityand tenderness w ere sublim e ;nd so h i g h lywas h is conduct, as an honest , brave , andskillful surgeon, appreciated by Napoleon,t h a t h e b e q u e a t h e d h im a large sum, wi t hth e r emark t ha t "Larrey w a s th e mo s t vir tu-o us man h e h ad ever known . "


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21ILITARYSURGERY.

CHAPTER 111.QUALIFICATIONS AND DUTIES O F MILITARYSURGEONS .Its of paramount importance that nonebut men of the best talent and of the highesteducation should be received into the publicservice. Rigid a s the examinations of thearmy and naval medical boards already are,there is need of increased rigor, in order that

none may be admitted w ho are not thoroughlyprepared for the discharge of their responsi-ble duties. Equal vigilance should be exer-cised in regard to the introduction of physi-cians and surgeons into the volunteer service.Every regiment should be provided wi th anable medical head, a man ready for everyemergency, h o w e v e r trying or unexpected;a man skilled in the d i a g n o s i s and treatmentof d i s e a s e s , and competent to perform anyoperation, whether small or large, on the spurof the moment. To do this, he must be morethan a mere physician;e must be both phy-sician and surgeon, in the true s e n s e of theterms, o t h e r w i s e he will be unfit, totally un-

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22 AMANUAL O Ffit, for his position. He must have beeneducated in the modern schools; b e of un-doubted courage, p r o m p t to act, willing toassume responsibili ty, humane an d sympa-thizing,urbane an d c ou r t e ou s inhis manners ;in shor t , a medical gentleman, as wel l as amedical phi losopher , not hesitating, if needb e, to p e r fo rm the most menial services, an dto d o all he can to preserve the health an dthe l ives of the soldiers committed to his care.T he white-gloved gentry, such as figured ins o m e of the regiments that w e n t to M e x i c o ,have no business in the service; their timecan b e much bet ter s p e n t in the discharge o ftheir domestic duties, in the practice of theirneighborhood, an d in the contemplation, at adistance, of the miseries of war.Itis much tob e feared that , from the rapidmanner inwhich o ur volunteers have been hur-ried t oge ther , m a n y medical m e n , o ld as wellas y o u n g , have a l ready been admit ted into theservice utterly unfi t for the office. Ifhis b ethe c a s e , let o ur authorities, warned b y thep a s t , b e more c i r c u m s p e c t in regard to thefuture. A b o v e all, let them s e e t h a t themedical staffs of the brave volunteers of thec o u n t r y b e not defiled b y charlatans an d un -


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23ILITARYSURGERY.worthy m e n , between whom and the regularpractitioners there c an n o t possibly be an yprofessional, much less social intercourse,either in civilor mili tary pract ice. The m e-dical m en should be on the best p o s s i b l e t e rmswi th each other; all c a u s e s of discord andbickering a m o n g themselves should be stu-diously obviated, and speedily s u p p r e s s e d , if,unfortunately, they should arise. Concert ofaction on the part of the medica l corps is in -d i s p e n s a b l e to th e success of th e medicaloperations of an a r m y .Every regimental surgeon should have atleast two assistants in t ime of peace, orduring the inactivity of the t roops under h ischarge; when on active duty , on the con -trary, the numbe r should at least b e double,especially in th e face of an anticipated bloodye n g a g e m e n t . These assistants should be s e -lected solely wi th reference to their compe-t e ncy ; they should , like the principal, bee m i n e n t l y intelligent, and ready, in case ofe m e r g e n c y , to perform an y operation thatoccasion m ay demand . Every brigade shouldhave its brigade surgeon, who should exercisea supervisory cont ro l over th e regimentals u r g e o n s , principals as wel l a s assistants, as


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24 A MANUAL OFevery State should have its surgeon-general,ormedical-director, whose du ty itshould he tosuperintend the w h o l e medical arrangements ,seeing th at th e candidates fo r th e medical de-partment of the service he subjected to a r igidexaminat ion , attending to the purchase ofmedicines an d ins truments , providing suitablenurses, inspecting th e quarters, stores, an d pro-visions, that noth ing of an unwholesome char-acter m ay f ind its w ay in to the ranks , poin t ingout the proper locat ion of camps, an d th e con-struction of hospitals, an d giving general in-structions inregard tomilitary hygiene , or th e

> e s t means of avoiding d i s e a s e an d accident.Irior to every engagement at all l ikely tob e severe or serious, a proper number of menshou ld b e detailed for th e purpose of render-in g p romp t assistance to th e wounded , an dcarrying them o ff th e field of batt le to thehospita ls , o r ten ts , erected fo r their accommo-dat ion an d treatment. Unless this b e doneas a preliminary step, much suffering willin-evitably b e th e consequence, ifnot great con-fus ion , highly prejudicial to the issue of th ecombat . So ful ly aware are th e leaders an dsub-commanders of our armies of this factt ha t they never permit an y man to fall out


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25ILITARYSURGERY.

of the ranks, during an engagement , to per-form this service.While the battle isprogressing itis the dutyof the surgeon and of his assistants to remainin the rear of the combatants, as much as pos-sible out of harm's way , bu t at th e same t imeready and on th e watch to render thepromptest p o s s i b l e aid. They mus t be Argus-eyed, and in th e fullpossession of the i r wits.One of the leading differences between mil i -tary and c iv i l practice is th e instantaneousaction so often demanded by the one and thedelay so frequently admit ted by the other .T he first duty of eve ry surgeon is to theofficers and men of his own corps; bu t o9th e field of battle, or soon after the battle isover , he is often brought in con tac t with th emembers of other regiments, or even with thewounded of th e e n emy ; and under such cir-cumstances th e dictates of humanity, not lessthan the usages ofwar, demand that he shouldrender h is services wherever they m ay bel ikely to be useful. T he medical officers ofthe contending parties sometimes me e t uponsuch occasions, and, when this is the case,their conduct should invariably be character-

8*


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26 AMANUAL OPized by the courtesy of th e gentleman, not theasperity of th e enemy. They should not for-get t h a t they are brethren of th e same nobleprofession, acting in the capacity ofm in ister-in g a n g e l s to th e sick a n d the dying. Coun-trya n d cause al ike should be forgotten ingene-rous deeds.By the usages of w a r inall civilized coun-tries, the surgeons a re a lways r e s p e c t e d byftie enemy if, during a n engagemen t , theyhappen to fall accidentally into their hands .Their lives are regarded as sacred, the moreso , a s they are comparatively defenseless.They are not, however, during the r a g e a n dsmoke of th e battle-field, a lways easily distin-guishable from the other officers, or even thecommon soldiers. The green sash, their dis-tinctive badge of office, d o e s not a lways affordthem immuni ty , because it is not a lways re-cognized ;n d it is wor thy of considerationwhether, a s an additional safeguard, th eword "surgeon" should not be em broideredin legible characters upon a p i e c e of c lo th , tobe t h rown across the chest in t ime of batt le.The significance of such a badge could not bemistaken by friend or foe, a n d would be themeans of sa vin g m a ny valuable lives.


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MILITARY ST JRGEKY . 27

CHAPTER IV.MEDICAL EQU IPMENTS , S TO R E S AND HOS -

PITALS.Every regiment , or body of mil i tary men ,should be amply provided, in t ime of war,wi t h th e means of conveying th e wounded

an d disabled from th e f ield of bat t l e . Forthis purpose suitable carriages an d l i t te rsshould constantly be inreadiness. T he car-riages should be built in th e form of lightwagons, drawn each b y two horses; wi thlow wheels , easy springs, and a large, widebody, furnished wi t h a soft ma t t r e s s and pil-lows, and capable of accommodat ing not lessthan eight or ten persons , while a r r a n g emen t smigh t be made at th e side for seating a num-be r more, as in th e Fr ench voi ture . As ameans of protection against th e sun and ther a in , it should have a l i gh t cover of oil-clothor canvas .A great numbe r of l i t t e rs , or bearers , willbe found described in t reatises on mil i tary


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28 AMANUAL OP

surgery;utIm not acquainted with a n ywhich combine so much simplic i ty a n d c h e a p -ness, with lightness a n d conven ience , as onewhich, after a good de a l of reflect ion,Ia vejust devised, a n d of which the accompany ingsketch aflbrds a good i l lus t ra t ion . Itconsistsof two equa l parts, connectedat the ends by stout hinges,the a r r angemen t being such asto permit of their being foldedfo r more easy transportationon the field of battle. E a chpart ha s a side p i e c e of wood,three feet four inches l o ng , bytwo inches in depth, a n d ani n c h a n d a half in thickness,the free extrem ity terminat ingin a sl ightly curved hand le .The side pieces are united byfour traverses, a n d the entiref r ame is covered with ducking ,

twenty-four inches inwidth. Thus constructed,the appa r a tus is not o n ly v ery l ight, so thata n y on e m ay easily c a r ry it, or, i ndeed , eventhree or four at a t ime, but remarkably c o n -


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29ILITARYSURGERY.

venient both for the transportation of pa-t ients , and for l ifting them in and out of thewagons, which should always be at handduring an engagement . Moreover, by meansof side straps, provided wi th buckles, itwillanswer extremely well for a bed-chair, so ne-c e s s a r y in sickness and during convalescence,the angle of flexion of the two p i e c e s thusadmitting of ready regulation. Incarryingthe wounded off the field, the labor m ayeasily be performed by two men, especiallyif they use s h o u l d e r - s t r a p s to diffuse theweight of the burden. The body, in hotweather, might be protected w i t h an oil-cloth, while the face might be shielded fromthe sun wi th a veil or handkerchief. Apil-low for the head can be made wi th the coatof one of the carriers.B e s i d e s these means, every regiment shouldbe furnished wi th an ambulance, or, as theterm literally implies, amovable hospital, thatis, a place for the temporary accommodationand treatment of the wounded on the field ofbattle. Itshould be arranged in the form ofa tent, and be provided wi th all the meansand a p p l i a n c e s necessary for the prompt suc-


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30 AMANUAL O F

cor of the sufferers. The materials ofwhich itconsists should be as l ight as p o s s i b l e , possessevery facility fo r rap id packing and erection,an d be c o n v e y e d f rom point to p o i n t by awagon s et apa r t fo r this object. The ambu-lance, fo r the invent ion and improvement ofwhich we are indebted to two eminent Frenchmil i tary surgeons, Percy and Larrey, is in-dispensable in every well-regulated a rm y .This temporary hosp i t a l should be placedin an open space, convenient to wate r , andu p o n d ry ground, with arrangements fo r thefree admission of air an d l ight, which, nextto pu r e air, is one of the m o s t powerfu l s t im-u lan t s in all cases of accident attended withexcessive prostration. The direct rays of thes u n , in ho t weather, must of cou r s e be ex-cluded, an d itm ay even be necessary, as ininjuries of the head an d eye, to wrap thepatient in c o m p l e t e darkness . A properly-regulated temperature is also to be m ain -ta ined , a good average being about 68 ofFahrenheit 's thermometer.As engagements are sometimes begun afterda r k , or are continued into the night, an ade-quate s upp ly ofwaxcandles should be provided,


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31ILITARYSURGERY.as they willbe found indispensable both infieldand hospital practice inperforming o p e r a t i o n sand dressing wounds and fractures . Torches,too, will frequently be needed, especially incollecting and t ransporting th e wounded.Bed-pans, feeding-cups, spoons, syringes, andother a p p l i a n c e s usually found in the sickchamber , will form a necessary part of thefurni tu re of such an establishment.T he object of th e ambulance is , as al readystated, to afford p r omp t succor to the wounded.Here their l ighter injuries are speedily dressed,and the more grave subjected to th e o p e r a t i o n sn e c e s s a r y for their cure . In due t ime , thef o r m e r are sent back to th e r anks , whi le therest are conveyed to suitable lodgings or tope rmanen t hospitals.As soon as practicable, af te r th e hu r ry andconfusion at tendant upon a combat are over,the surgeon should classify th e wounded andd i s a b l e d , taking care t h a t those laboring undersimilar lesions are not brought in close c o n -t ac t ; lest , witnessing each other 's s u f f e r i n g s ,they should be seized wi th fatal d e s p o n d e n c y .Lar r ey , in order tomeet th e exigencies ofth e grand a rmy in I ta ly , const ructed af ly ing


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32 AMANUALOPam b u lan ce;n i m m e n s e , a n d , at first sight, avery cumbersome establ ishment . Itconsistedof twelve l i g h t w a g o n s , o n easy springs, fo rth e transportation of th e wounded;o m e withtwo, others w i th f o u r wheels . T he frame ofth e former , w h i c h were designed fo r flat, l eve lcountr ies , resembled an elongated cube , curvedo n th e top;ith a d tw o s m a l l windows on eachside, w i th a folding-door in f ron t a n d b e h i n d .T h e f l oor of th e body, separable an d movableo n ro l lers , w as covered with a mat t r e s s a n dbols ter . Handles were secured to itlaterally,t h r o u g h w h i c h th e s a s h e s of th e soldiers werep a s s e d in lifting th e sick in a n d out of th ecarriage, w h e n , o n a c c o u n t of th e weather ,their w a n t s c o u l d not b e relieved on th eground. E a c h vehicle w as thirty-two incheswide, a n d w a s drawn b y two horses ;t cou ldconveniently accommodate two pat ients at fulllength , an d was furnished w i t h several side-pockets fo r such articles a s mi g h t b e neededfo r th e sufferers.T h e large carriage, drawn b y four h o r s e s ,a n d designed for rough an d hi l ly roads, w a sconstructed u p o n th e same pr in c ip l e as th es m a l l ; it h a d f o u r wheels , a n d cou ld accom-


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moda te four persons. The left side of thebody had two long sliding-doors, extendingalmost its whole length , s o as to pe rm i t thewounded to be laid in a horizontal pos i t ion .These carriages were used for conveying the w o u n d e d from the field of bat t le to the hospi-tals of the l ines, and comb ined , it is said ,solidity wi th lightness and elegance.The number of m en a t tached to the flyingam bulance w as 113, embracing a soldier 'sguard wi th twelve m en on horseback, aquartermaster-general, a surgeon-major , wi thhis two assistants and twelve ma t e s , a policeofficer, and a number of se rvan t s . The flyingambulance was, in fac t , a costly and imposingestablishment, devised b y the humanity andingenuity of the grea t and good Larrey , whocould never do too much fo r the wounded sol-dier , and whose presence, like tha t of his illus-tr ious coun t ryman , Pare", always served toanimate the French t roops . At one t imethree divis ions of the flying ambulance,e q u i p p e d upon this grand scale, were uponthe field in different par t s of I ta ly .Itis not deemed necessary , in a work likethis, to give an a c c oun t of the c onstruc tio n o f

4


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34 AMANUAL OFhospitals, properly so termed; for, with therailroad and steamboat facilities which we nowpossess, there can b e little difficulty in obtain-in g comfortable accommodations for the sickand wounded soldiers. Lodgings can almostalways b e procured, in nearly every portionof the count ry where a battle is likely to b efought, in houses, churches, and b arns. T e m -porary sheds might easily b e erected in a fewhours, with such arrangements as would servefor the more pressing wants of the wounded.T he chief points to b e attended to, in theirconstruction, are sufficient elevation of theground floor for the free circulation of air,windows for light and ventilation, and such aposition of the fire-place as not to annoy theinmates.T he medical stores of the military hospital,whether temporary or permanent , includemedicines, instruments, an d various kinds ofapparatus, as bandages, oiled silk, and splints.Itwould far transcend my l imits wereIoenter fully into all the details connected withthese different topics. A few br ief remarksunder each head m u s t suffice for m y purpose.Ist. Inregard to medicines, a few articles


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MILITARY SURGERY . 35only, well selected and arranged for readyuse, willbe necessary. Itis bad enough, inall conscience, for a man to be severely shotor stabbed, wi thou t physicking h im to death .Let h im by all means have a chance for h islife, especially when h e h as already beenpros t ra ted by shock and hemorrhage. Foodand d r ink , wi th opium and fresh air, willthen do h im more good t han anything else.Ihall enumera te th e medicines upon wh i c h ,inmy judgment , mos t reliance is to be placedin t h i s kind of practice, according to t he i rknown effects upon th e sys tem.1. Anodynes: opium, morph ia , and blac kdrop, or acetated t inc ture of opium.2. Purgat ives:

blue mass , calomel, r h u -barb, jalap, c o m p o u n d extract of colocynth,and sulphate of magnesia. Some of thesearticles should be variously combined, and

put up inpill form for ready use.3. Depressants :

tartrate of antimony andpotassa, ipecacuanha, and t inc tu re of vera-

trum vi r i de .4. Diaphore t i c s : ant imony, i p e c a c u a n h a ,nitrate of potassa, morphia, and Dover 's

powder .


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36 A MANUAL OF5. Diuretics: nitrate and carbonate ofpotassa, and colchicum.6 . Antiperiodics: quinine and arsenic.7. Anaesthetics : chloroform and ether.8. Stimulants: brandy, gin, wine, andaromatic spirits of ammonia.9. Astringents : acetate of lead, perchlo-ride of iron and alum, tannin, gallic acid, andnitrate of silver.10. Escharotics: nitric acid, acid nitrate

of mercury, (Bennett's formula,) and V iennapaste.2d . The surgical armamentarium should alsobe as simple a s possible. Itshould embracea small pocket c a s e , with a screw catheter; afull amputating c a s e , with at least threetourniquets, two s a w s of different sizes, andseveral large bone-nippers; and, lastly, atrephining case. Several silver catheters ofdifferent sizes, a stomach pump, small andlarge syringes, feeding-cups and b e d - p a n sshould also be put up.3d . Under the head of apparatus m ay beincluded bandages, lint, linen, adhesive plas-ter, splints, cushions, wadding, and oiled silk.

The bandages, composed of tolerably stout


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37ILITARYSURGERY.muslin, should be free f rom starch and selvage,wel l ro l l ed , and, on an average , f rom twoinches and a quarter to two inches and a ha l fin width by eight yards in length. Thebandage of Scultetus, ve ry serviceable inc o m p o u n d factures, can easily b e made, asoccasion may require, out of p i e c e s of th ecommon roller.Of lint,th e patent , or apothecary's, as itiste rmed, is th e best, as it is sof t and easilya d a p t e d to th e parts to which it is intended

to b e applied. Old linen or muslin also an-swers sufficiently well . Charpie is now sel-dom used.An abundance of adhesive plaster , put upin small cases, should b e prov ided . Collo-dion willnot b e necessary.Splints, of binders or t runk-makers ' board,and of light wood, should find a place inev e r ymedical store, as f r equen t occasions occur fo rtheir use. In fractures of th e lower ex-t remity special apparatus may b e r equ i r ed ,which, however , as itis cumbrous and incon-venient to ca r ry , may general ly b e preparedas itis needed.Cushions are made of muslin, s e w e d in th e

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38 AMANUALOFform of bags, of variable size and s h a p e , andfilled with cotton, tow, saw-dust or sand. Theyare d e s i g n e d to equalize and ward off pres-sure inthe treatment of fractures of the lowerextremities.

Wadding is a most valuable article in sur-gical practice, both for lining splints and mak-ing pads, as well as in the treatment of burnsand scalds, and cannot be d i s p e n s e d with.Oiled silk is a prominent article in thedressings of the present day; it preservesthe heat and moisture of poultices and ofwarm water-dressings, at the same time thatitprotects the bed- and body-clothes of thepatient.Oil-cloth, soft and smooth, is required inall cases of severe wounds and fractures, at-tended with much discharge.Air-cushions should be put up in consid-

erable numbers, as their use will be indis-p e n s a b l e in all cases of d i s e a s e and injuryinvolving protracted confinement.Bran and saw-dust willbe found of greatvalue inthe treatment of c o m p o u n d fractures,ulcers, gangrene, and suppurating wounds, as


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MILITARYSURGERY . 39an easy support for the injured l imb and ameans of excluding flies.Medica l case-iooks should be put up alongwith the other articles, for th e accu r a t e regis-tration of th e n ame s of th e sick and wounded,th e nature of their lesions, and th e results oftreatment. The medical offic ers should alsokeep a fai thful record of th e s ta te of th eweather, th e temperature of th e air, the na-ture of the climate, th e products of the soil,and the botany of the country through whichthey pass or in which they sojourn, togetherwith such other mat te r s as m ay be of profes-sional or scientific in te re s t. T h e knowledgethus acquired should be disseminated aftertheir return for the benefit of their profes-s iona l bre th ren .Finally, inorder to complete hospital equip-ments , well-trained nurses should be provided;for good nursing is i n d i s p e n s a b l e in eve rycase of serious disease, whatever may be itscharac te r. The importance of this subject ,however, is now s o well appreciated a s not tore q u ire a ny special comment s here .

The question as towhether this duty shouldbe performed bymen or women is of no ma-


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40 A MANUAL OPterial consequence, provided it be welldone. The eligibility of women fo r thistask was thoroughly tested in the Crimea,through the agency of that noble-heartedfemale, Florence Nightingale; and hundredsof the daughters of our land have alreadytendered their services to the government fo rthis object. No large and well-regulatedhospital can get on without s o m e male nurses ,and they are i n d i s p e n s a b l e in camp and fieldpractice.It is not m y purpose here to poin t out thequalities which constitute a good female nurse.

Itwill suffice to say that she should b e keenlyalive to her duties, and perform them, how-ever menial or distasteful, with promptnessand alacrity. She mu s t be tidy in her ap-pearance, with a cheerful countenance, lightin her step, noiseless, tender and thoughtfulin her manners, perfect m istress of her feel-ings , healthy, able to bear fatigue, and atleast twenty-two years of age. Neither thecrinoline nor the silk dress must enter intoher wardrobe; the former is too cumbrous,while the latter by its rustling is sure to fretth e patient and distu rb h is s l e e p . W hisper-


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MILITARYSURGERY . 41ing and walking on tiptoe, a s has been trulyobserved by Florence Nightingale, are anabomination in th e sick chamber . Finally,a good nurse never fails to anticipate all, ornearly all, the m ore important wants of th esufferer.Among th e things to b e specially attendedto innursing is ventilation. Persons visitingth e sick mus t at once b e struck w i t h th e dif-ference of pure air in those chambers wherea proper ventilation exists and those whereth e reverse is th e case . To insure this th efresh air should always b e admitted from awindow not open directly on th e bed, orcausing th e patient to b e in a draught. Evenin winter it is highly proper that fresh a irshould b e admitted s om e time during th e daywhen there is a g o o d fire and th e patient wellprotected b y covering.Th e pillows, bedding, and bedclothes shouldb e well aired and often changed, as also th eflannel, under-garments, and night-dress. Tofacilitate this , it is well, when th e patient isvery illand unab le to help himself, to haveth e shir t open all the way down in front, andbuttoned up. The patient often escapes great


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42 AMANUAL OFsuffer ing an d annoyance by this s imple me thod .Where there is adischarge f rom s o r e s orwhenwater-dressings are appl ied to a l im b, itis ad-visable to p l ace the latter u p o n a fo lded sheetwi th a th in , so f t oi l -c loth unde rnea th . Gr ea ttenderness an d cleanl iness should be u s ed ind r e s s i ng wounds or sores . Old l i n e n , mu s l i n ,an d lint should a lways be had in readiness fo rthis p u r po s e . 'Ag r e a t p r e j ud i c e exists aga i n s tthe u s e of mu s l i n , the p r e f e r e n c e be i ng g e n e r -ally g i v e n to l i n e n , bu t the f o rme r is reallyqui te as good as the other, ifit is so f t an d o ld .Inr egard to the cleanl iness of a s i ck - room,

itis advisable to u se a m op occasionally fo rthe r emova l of f lue f rom u n d e r the bed;hen,however , the p a t i e n t is in too cr i t ica l a s itua-t ion fo r d a m p n e s s , a few tea- leaves scatteredover the a p a r tm e n t willabsorb the dus t , an dcan be quiet ly taken u p wi th a hand-brush .A f requent c h a n g e of bed l i n e n is v e r y bene-f ic ia l when practicable, an d the clothes m u s talways be fo lded smoothly u n d e r the p a t i e n t .Grea t cleanl iness should be observed in allthe sur roundings of the s ick - room, an d par-t icular attent ion m u s t be pa id to the g l a s s e sin wh ich m edicin e is given, in orde r to r ende r


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43ILITARYSURGERY.the d o s e s as palatable as possible . The pat ientshould be washed whenever able , and histeeth and hair we l l attended to. The bodyseems infused wi th new v igor after such ablu-t ions.A f requent change of po s t u r e is immenselyconducive to the comfo r t and well-being of asick person, ifpe rfo rm ed wi th a careful eye

to his particular condition. Severe pa in , lossof sleep, excessive constitutional i r r i ta t ion,and dreadful bed-sores are sure to fo l l ow, inall low states of the system , ifthis precautionb e not duly heeded. No pa t ient mu s t havehis head suddenly raised, or be p e rm itted tolie high, when he is exhausted f rom s h o c k ,hemorrhage, or sickness. Many l ives havebeen l o s t by this indiscretion.The apa r tm ent must b e free f rom noise,the l ight should neither b e too freely adm ittednor too much excluded, excep t in head andeye affections, and the tem p e ra tu re mu s t beregulated b y the thermometer , f rom 65 to68 of Fahrenheit being a p r o pe r average.As the patient a c q u i r e s strength, he m aygradually sit up in bed, propped up at firstb y pil lows, and afterward b y a bed-chair.


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44 AMANUAL OFHis food and drink, and also, at t imes, hismedicine, must be given from a feeding-cupduring th e height of h is disease, and a g o o dgeneral ru le is to administer them with g r e a tregularity, provided th is does not interfere

too m u c h with h is repose . Ife is v ery weak,and sleeps v ery long, itwill be necessary towake h im in order to g i v e him nourishment;but, in general , sleep ism o r e refreshing thanfood, and more beneficial t han medicine. T h ebed-pan and ur ina l of course find th e ir appro-priate sphere under such c i r c u m s t a n c e s .A s the appe t i t e and s t rength increase, th epatient is perm i t t ed to resume, though v erygradually, h is accustomed diet and to exerciseabout th e room, ifnot in the o p e n air. Aftersevere accidents and pro t rac ted sickness, awise m an will not best ir h imse l f too soon o rtoo m u c h , b u t court th e f ickle g o d d e s s ofheal th with becoming caut ion.Dying patients should be carefully screenedfrom the ir neighbors, placed in th e easiestp o s t u r e , ha v e free access of air, and be notdisturbed b y noise, l o u d ta lking, or th e pres-ence of persons not needed fo r the ir comfort .A s s o o n as the morta l struggle is over, thebody must be removed.


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MILITARYSURGERY. 45

The excretions should be removed as s p e e d -ily as possible from the apartment, and thevessels in which they are received imme-diately wel l scalded, the air being at the s a m et ime perfect ly pur i f ied by vent i la t ion , or ven-t i la t ion and disinfectants .Finally, the nu rse m u s t take care of her-

self. She must have rest, or she will s o o nbreak down . Ifhe is obliged to be up allnight , she should be spared in the day.

CHAPTER V.WO U N D S AND OTHER INJURIES.

The injuries inflicted in w ar are, in everyrespec t , s imilar to those received in civillife.The m o s t common and impo r t a n t are frac-tures, dis locat ions , bruises, spra ins , burns ,an d the different k inds of wounds, as the in -cised, punctured, lacerated, and gunshot.With the nature, diagnosis, an d mode oft reatment of these lesions every a rmy sur-geon must, of course, be s u p p o s e d to befami l iar ;andIhall therefore limitmyself,5


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46 A MANUAL OFin the remarks whichIm about to offerupon these subjects, to a few pract ical hintsrespecting their manag emen t on the field ofbatt le and in the ambulance.Mos t of the c a s e s of fractures occurring onthe f ield of battle are the result of gunshotinjury, and are f requently, ifnot generally,attended b y such an amo u n t of injury to theso f t parts and also to the bone as to demandamputat ion. The bone is often dreadfullycomminuted, and consequently utterly unfi tfor preservation. The more simple fractures,on the cont rary, readily admi t of the reten-t ion of the l imb , without r isk to life.In transporting persons affected with f rac-

tures, whether simple or complicated, theutmost care should be used to render themas comfortable as p o s s i b l e , by placing the in-jured l imb in an easy position, and applying,ifneed be, on accoun t of the distance towhich they have to be carried, or the modeof conveyance, shor t side splints of binders'board , thin wood, as a shingle, or j unks ofstraw, gently confined b y a rol ler . For wan tof due precaution the danger to l imb andlife m ay be materially augmented. Perma-


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47ILITARYSURGERY .nent d r e s s i n g s should be applied at th e ear-l ies t moment after th e patient reaches thehospital . Ifhe fracture be attended withsplintering of the bone, all loose or detachedpieces should at once be extracted; a pro-ceeding which always wonderfully s implif iesth e case , inasmuch as it prevents , in grea tmeasure , the fr ightful i r r i ta t ion a nd s uppu r a -t ion which are su re to follow the ir re tention.When this point has been p rope r l y attendedto, the parts should be neatly brought to-gether by su tu re , and covered with a c om-press wet with blood . As s o on as inflamma-t ion arises not before water-dressings areemployed. A suitable opening, or bracket ,shou ld be made in the a pp a r a t u s to faci l i tatedra inage a nd dressing.Dis loca t ions , accidents by no means com-mon in military operat ions , are treated a c -cording to th e general rules of practice ;heyshou ld be speedily reduced, without th e a idof chloroform, if the patient is faint or ex-haus ted ; with chloroform, ifhe is strong' orreact ion has been ful ly established. Theoperation may generally be successfully per -formed by simple manipulation; if,however,


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48 A MANUAL OFthe case is obstinate, pulleys may be n e c e s -s a ry , or extension and counter-extensionmade by judic ious ass is tants .Bruises , or contusions, unless attended withpulpification, disorganization, or destructionof the tissues, are bes t treated, at f irs t , untilthe pain subsides, with t ep id wat e r impreg-nated with laudanum and suga r of lead , ors ome tepid spir i tuous l o t ion , and afterward,especia l ly ifth e pa t i en t be s t rong and robust ,w ith c o ld water, or cold a s t r ingen t f luids .Ifthe injury be deep seated, extensive, andat tended with lesion of very impor t an t s t ruc -tures, th e c a s e will be a serious o n e , l iable tobe fol lowed by the wors t consequences , re-qu i r i ng , perhaps , amputation.Sprains are often accompan ied with exces-sive pain and even severe const i tu t iona l s ymp-t oms . They should be treated with the freeuse of anodynes and with warm water-dress-ings m e d i c a t e d with l audanum, or l audanuma nd l e ad . T he jo in t mus t be elevated a ndk e p * t at rest in an easy position. Leechesmay be applied, if they can be obta ined;otherwise, if plethora exi s t , blood may betaken from the arm. By-and-by sorbefacient


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49ILITARY SURGERY .

liniments and friction come in play. Passivemotion should not be instituted too soon.Among the accidents of war are burns, and,occasionally, a lso sca lds. The former may beproduced by ordinary fire or by th e explosionof gunpowder, either casual or from th e blow-ing u p ofredoubts, bridges, houses, or arsenals,and vary from the most t r ivia l to the mos tserious lesions, involving a great extent ofsurface or of tissue, and liable to be followedby the worst consequences. Such injuriesa lways require prompt attention; for, apar tfrom the excessive pain and c o l l a p s e which sooften accompany them, the longer they re-main uncared for the more likely will theybe to end badly.Various remedies have been p r o p o s e d forthese injuries.Iav e myself always foundwhite-lead paint , such as tha t employed inth e arts, mixed with linseed oil to th e consist-ence of very thick c r e a m , and applied s o asto form a complete coating, the mos t soothingand efficient means . The dressing is finishedby enveloping the parts in wadding, confinedby a moderately tight roller, It should notbe removed, unless there is much discharge or

5*


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50 AMANUAL OFswelling, for several days. Ifvesicles exist,they should previously be opened with aneedle or the point of a bis toury. A lini-ment or ointment of glycerin, lard or simplecerate, and subnitrate of bismuth, as sug-gested by m y fr iend, Professor T. G. Rich-ardson, of New Orleans, is also an excellentr emedy , and may be used in the same man-ner as the white-lead paint. In the mildercases, carded cotton, cold water , water andalcohol, water and laudanum, or solutions oflead and laudanum, generally afford p r omp trelief. Amputation will be necessary whenthere is extensive destruction of the muscles,bones, or joints. Reaction mus t be promotedby the cautious use of stimulants ;while painis allayed by morphia or laudanum given withmore than ordinary circumspection, lest itinduce fatal oppression of the brain.Inburns from the explosion of gunpowder,

particles of this substance are often buried inthe skin, where, ifit be not removed, theyleave disfiguring marks. The best way to getrid of them is to pick out grain after grainwith the po in t of a narrow-bladed bistoury orcataract needle.


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51ILITARYSURGERY.The subject of wounds is amost important

one in regard to field practice, as these lesionsare not only of frequent occurrence, but pre-sent themselves in every variety of form andextent. Their gravity is influenced by numer-o us circumstances which our space d o e s notpermit us to specify, bu t which the intell igentreader can readily appreciate. Inmany casesdeath is instantaneous, owing to shock, orshock an d hemorrhage ;n others it occursgradually with or without reaction, at a periodof several hours, o r, itmay be, not under sev-eral days. Sometimes men are destroyed byshock, by, apparently, the mos t insignificantwound or in jury, owing, not to want of cour-age, bu t to s ome idiosyncrasy.The indications presented in all wounds, ofwhatever nature, are Ist, to relieve shock;2dly, to arrest hemorrhage ;3dly, to removeforeign matter;4thly, to approximate andretain the parts; and , sthly, to limit theresulting inflammation.1. Itis not necessary to describe minutelythe symptoms of shock, as the nature of the

case is sufficiently obvious at first sight, fromthe excessive pallor of the countenance, the


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52 AMANUAL OPweakened or absen t pulse , the confused s t a t eof the mind , th e nausea, or nausea a n d vomit-ing, a n d the excessive bodi ly pros t r a t ion . Thec a s e mus t be t rea ted prompt ly ;y free a c -c e s s of fresh air an d the use of the f a n , byloosening the dress or the removal of allsourcesof cons t r ic t ion , b y dashing co ld water in toth e face an d upon the ches t , b y r e cumbencyof the head , a n d b y a draught of cold wa t e r ,orwater a n d spirits, wine or har t shorn , ifthepatient can swal low ;ided , ifthe c a s e b e ur-gent, b y sinapisms to the region of the heart,the in s id e of th e thighs an d th e sp ine , a n dstimulating inject ions, a s brandy , turpen t ine ,mustard, or ammonia , in a few oun c e s ofwater. No fluid mus t be put into the mouths o l o n g a s th e p ow e r of deg lu t i t ion is g on e ,l e s t s ome ofit should enter th e windp ip e , a n ds o occasion suffocat ion. Wha teve r the cause ofthe shock m ay have been , let th e medica la t t e ndan t not fail to encourage the sufferer bya kind an d soo th ing express ion , which is of tenofmore value in reca l l ing an imat ion than th ebes t cordials .During an ac tua l e ng a g emen t , the medica lofficers, a s we l l a s the i r s e r v an t s , should carry


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MILITARYSURGERY. 53in their pockets such articles as the woundedwillbe mos t likely to need on the field of bat-tle, as brandy, aromatic spirits of hartshorn,an d morphia , put u p in suitable doses.2. The hemorrhage may be arterial or ve-nous, or both arterial an d venous , slight orprofuse , pr imary or secondary, external orin terna l . The scarlet color and saltatory jetwillinform us when it is arterial; the purp lehue an d steady f low, when it is venous."When the wound is severe, or involving alarge artery or vein, or even middle-sizedvessels, the bleeding may prove fata l in a fewminutes , unless immediate assistance is ren-dered. Hundreds of persons d ie on the fieldof battle from this cause . They allow theirlife-current to run out, as water pours froma hydrant, without an a t tempt to stop it bythrusting the finger in the wound , or c om-pressing the main artery of the injured l imb .They perish simply from their ignorance,because the regimental surgeon has failed togive the proper instruction. Itis not n e c e s -sary tha t the common soldier should carry aPetit's tourniquet, bu t every one may putinto his pocket a stick of wood , s ix inches


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54 A MANUAL OPlong, and a handkerchief or p i e c e of roller,with a thick compress, and be advised how,where, and when they are to be used. Bycasting the handkerchief round the l imb, andplacing the compress over its main artery,he can, by mean s of the st ick, p r o d u c e suchan amoun t of c o m p r e s s i o n as to put at oncean effectual stop to the hemorrhage. Thissimple contrivance, which has been instru-mental in saving thousands of lives, consti-tutes what is called the field tourniquet . Afife, drum-st ick, knife, or ramrod m ay beused, ifno special piece of wood is at hand.The mos t reliable mean s for arresting hem-orrhage permanently is the l igature , ofstrong,delicate, well-waxed silk, well applied, withone end cut off close to the knot. Acupres-sure is hardly a proper expedient upon thebattle-field, or in the ambulance, especiallywhen the number of wounded is considerable.The rule invariably is to tie a wounded arteryboth above and below th e seat of injury, lestrecurrent bleeding should arise. A notherequally obligatory precept is to ligature thevessel, ifpracticable, at th e place whence theblood issues, by enlarging, if need be, the


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55ILITARY SURGERY .original wound . The main t runk of the ar-tery should he secured only when it c a nno t betaken u p at th e point jus t mentioned. Lastly,itis hardly requisite to add tha t th e operationshould be performed, wi th th e a id of th e tour-niquet, as early as possible, before th e super-vention of inflammation and swe l l ing , whichmu s t necessarily obscure th e parts and in -crease th e surgeon's embarrassment, as wella s th e patient's pain and risk.

Venous hemorrhage usually stops sponta-neous ly , o r readily yields to compression,even when a large vein is implicated. Theligature should b e employed only in th e eventof absolute necessity, fo r fear of inducing un-due inflammation.Tors ion is unworthy of confidence in f ieldpractice, and the same is true of styptics, exceptwhen th e hemorrhage is capillary, or th e bloodoozes f rom numerous points. The mo s tapproved articles of this kind are Monsel 'ssalt , or the persulphate of iron and th e per-chloride of iron; the latter deserving th epreference, on a c c o un t of th e superiority ofits hemostatic properties. Alum and lead areinfer ior styptics.


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56 A MANUAL O PTempora ry compression m ay be made withthe tourniquet, or a compress and aroller. Itm ay be di rect , as w h e n the compress is ap -plied to the orifice of the bleeding vessel, orindirect , as when itis applied to the trunk of

the vessel, at some distance f rom the wound.Constitutional treatment in hemorrhage isof p a r amoun t impor tance . It compr isesperfect tranquillity of mind and b o d y , cool-ing dr inks, a mi l d , concentrated, nourish-ing diet , especially when there has been ex-cessive loss of blood, anodynes to a l l ay pa in ,induce s l eep , and allay the heart 's inordinateaction, fresh air, and a p r o p e r l y r egula tedlight.

Internal hemorrhage is more d a n g e r o u sthan external , because it is generally inac-cessible. T he chief remedies are c o p i o u svenesection, elevated position, opium andace ta te of l e ad , cool air, and coo l dr inks .

Exhaustion from hemorrhage should bet reated according to the principles whichguide the practitioner in c a s e s o f severeshock. Opium should be given freely as soonas react ion begins to quiet the tremulousmov em en t s of the hear t and tranquilize the


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MILITARY SURGERY . 5 7mind. When the bleeding is internal, thereaction should b e brought about gradually,not hurriedly, les t w e thus become instrumentalinpromoting or re-exciting the hemorrhage.Secondary hemorrhage c ome s on at avariable period, from a few hours to a num-b er of days; it may d e p e n d upon imperfectligation of the arteries, ulceration, softeningor gangrene of th e coats of these vessels, orupon undue constriction of the tissues b y t igh tbandages. In s ome cases it is venous , andmay th en b e owing to i n a d e q u a t e suppor t of theparts. Whatever the cause may b e , it shouldb e promptly searched out, and removed.

3. The third indication is to remove allforeign matter. This should b e done at onceand effectual ly; wi t h sponge and water ,p r e s s e d upon the parts, wi th f inger , or fingerand forceps. Not a particle of matter, not ahair, or the smallest clot of b lood mus t beleft behind, otherwise itwillb e sure to pro-voke and k e e p u p irritation.4. As soon as the bleeding has been checkedand the ex t raneous matter cleared away, thee d g e s of the wound are gently and evenly

G


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58 A MANUAL OFapproximated and permanently retained bysuture and adhesive p laste r, aided, ifneces-sary, by th e bandage. Th e best suture,because th e least irritating, is tha t madeof silver wire; but if this material is notat hand, strong, t h in , well-waxed silk isused. The adhesive strips are applied insuch a manner a s to admit of free drainage.The bandage is required chiefly in injuriesextending deeply among th e muscles; whenthis is th e case, its use should be aided bycompresses arranged so as to force togetherth e deep parts of th e wound.5. When th e wound is dressed, th e nextduty of th e surgeon is to moderate th e re-sulting i n f l a m m a t i o n . For this purpose th eordinary antiphlogistic means are employed.In general , very little medicine will be re-quired, except a full anodyne, as ha l f a grainof morph ia , immediately after th e pat ienthas sufficiently recovered from th e effects -ofh is shock, and p e r h a p s a mild aperient th eensuing morning, especially if there be con-stipation with a tendency to excessive reac-t ion. Th e drinks must be cooling, and th ediet l i gh t and nutritious, or o t h e r w i s e , accord-


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6 0 AMANUAL O Pwet; two c i rcumstances highly favorable toi n cuba t ion .

T he bes t loca l applications are the water-dressings, e i ther t e p i d , cool, or cold , accord-ing to the t e m p e r a m e n t of the p a t i e n t , theto lerance of the p a r t s , a n d the season of they ea r . U n i o n b y the first i n t en t ion i s , in allthe m ore s imp l e cases , the th i ng a imed atan d steadily kept in view, an d hence the lessthe p a r t s are encumbered , moved or f re t t ed ,the m o r e l ikely shall we be to a t t a in theobjec t .

T he m e d i c a l a t t endan t should have a con-stant eye to the cond i t ion of the b l adde r af te rall severe in jur ies , of whatever charac ter , asre t en t ion of ur ine is an ext remely commono c c u r r e n c e , an d should always be p romp t lyr emed i ed . Atten t ion to th is p o i n t is themore necessa ry , because the p o o r pat ien t , inhis c o m a t o s e or insens ible cond i t i on , is f re -qu e n t l y unable to mak e k n o w n his w a n t s .Such , in a few words , are the gene r a l p r i n -c i p l e s of treatment to be followed in allw o und s ; b u t there are some wounds whichare charac te r ized b y pecu l i a r i t i e s , an d thesepeculiarities a re of such prac t ica l importance


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as to require separate consideration. Of thisnature are punctured, lacerated, and gunshotwounds.Punctured wounds are inflicted by variouskinds of weapons, as the lance, sabre, sword,orbayonet. Incivil practice they are mostgeneral ly met with as the result of injuriesinflicted bynails, needles, splinters, and frag-ments of bone. They often exten d in to thevisceral cavities, joints, vessels, and nerves;and are liable to be followed by excessivepain, erysipelas, and te tanus ;eldom heal byadhesive act ion; and often cause death byshock or hemorrhage. When the vulneratingbody is broken off and buried, itmay be diffi-cult to find and extract it,especially whensmal l and d e e p seated. When this is thecase, the wound mus t be freely dilated, an eyebeing had to the situation of the more im -por tan t v e s s e l s and nerves. Inother respects,the general principles of treatment are similarto those of incised wounds. Opium shouldbe administered largely;nd , ifmuch ten-sion supervene, or matter form, free incisionswillbe necessary.In lacerated wounds the edges should beG *


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62 A MANUAL OPtacked together very gently, and large in -terspaces left fo r drainage. A smal l po r -tion will probably unite b y th e firs t inten-tion;h e remainder, b y th e granulating pro-cess. Such wounds nearly always suppura temore or less profusely, and s om e of th e tornand bruised tissues not unfrequently perish.The s am e b ad consequences are ap t to fol lowthem as inpunctured wounds . Warm waterconstitutes th e best dressing, either alone o rwi th th e addition of a little spirits of cam-phor . Opium should be used f ree ly internally,and th e diet mus t be supporting.Gunshot wounds , in their general character ,partake of th e nature of lacerated and con-tused wounds. They are, of course, th e mostcommon and dangerous lesions met wi th inmilitary practice ;ften killing instantly, o r ,at all events , so mutilating th e pat ien t as todestroy h im with in a few hours or days aftertheir receipt. The mo s t formidable woundsof th e kind are made b y th e conical rifle andmusket balls and by cannon bal ls , th e latteroften carrying away th e grea te r portion of al imb , or mashing and pulpifying th e musclesand viscera in th e mo s t frightful and destruc-


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63ILITARYSUR GE R Y .tive manner; while th e fo rm er commit terribleravages among th e bones, breaking them. intonumerous fragments, each of which may , inits turn, tear up th e soft tissues, in a w ayp e r h a p s not less mischievous than th e ballitself. The o ld round ball is a much lessfatal weapon than th e conical , which seldombecomes flattened, and which has been knownto pass through th e bodies of two men andlodge in that of a third some distance off.

When a ball lodges itmakes generally onlyone orifice;ut it should be remembered thatit m ay make two , three, and even four, andat last bury itself more or less deeply. Suchc a s e s are, however, uncommon. Should themissile escape, there willnecessarily be twoopenings ;r, if itmee t a sharp bone and bethereby divided or cut in p i e c e s , as sometimesh a p p e n s , there m ay be even three. T he orificeofent rance and the orifice ofexit differ in theirappearances. The first is small , round, andoften a little discolored from the e x p l o s i o n ofthe powder ;he other, on the cont ra ry , iscomparatively large, slit-like, everted, andfree f rom color . These differences, however,are frequently very trifling, particularly ifth e


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64 A MANUAL OFball be projected with great velocity and itdo not encounter any bone. The openingof entrance made by the round ball is oftena little d e p r e s s e d or inverted, but such an ap-pearance is extremely uncommon in woundsmade by the conical bal l .Itis often amatter of great importance todetermine, when two openings exis t ina l imb ,whether they have been made by on e bal l ,which has passed out, or by two balls, whichare retained. The question is of grave im -portance, both inapractical and in a medico-legal point of view;ut its solution is , unfor-tunately, not always p o s s i b l e . Sometimesthe openings of entrance and exit are materi-ally modified by the introduction but non-escape of a foreign body, as apiece of breast-plate, belt, or buckle, along with the ball,which alone passes out, or by the flatteningof a ball against a bone, or its division by abone into several fragments, each of whichm ay afterward produce a separate orifice.Generally speaking, the missile, at the placeof entrance , carries away a piece of skin ,and rends the skin where it escapes, the for-m er being often found in the wound.


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65ILITARYSURGERY.Bullets sometimes glance, bruis ing the skin,but not penetrating it;t other t imes they

effect an entrance, but, instead of passing onin a stra ight l ine , are deflected, coursing, per-haps, partially ro und the head, chest, or ab-domen , o r round a lim b. Such results arem o s t c ommon l y caused by a partially spentbullet coming in con t a c t with bones, aponeu-roses, and tendons; and the round is morefrequently served in this way than the conical.

Gunshot wounds bleed profusely only whena tolerably large artery has been injured,and in this event they m ay speedily provefatal. During the Crimean war, however,ma n y c a s e s occurred in which there w a s noimmed ia te hem o rrhage, im peri li ng life, not-withstanding th e lim bs, lower a s well as upper,were left hanging merely by th e integum ents.Under such circumstances, i n te rm ed i a ry hem-orrhage, as itis termed, is apt to show i tself a ssoon as react ion takes place; generally withina few hours after th e accident.The pain is of a dull , burning, smarting,o r aching character, and the patient is p a l e ,weak, trem ulo us, nauseated, and d e s p o n d e n t ,of ten in a degree far beyond what migh t be


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66 AMANUAL OFe x p e c t e d from the apparent violence of theinjury, and that , too, perhaps, when th e indi-vidual is of th e mos t undaunted courage ands e l f - p o s s e s s i o n in the heat of batt le. Atothertimes aman may have a l imb torn off, or beinjured in some vital organ, and ye t hardlyexperience any shock whatever ; nay, p e r h a p sbe scarcely conscious tha t he is seriously hurt.The pain and prostrat ion are always greater,other th ings being equal, when a bone hasbeen crushed or a large joint laid open, thanwhen there is amere flesh wound.The gravity of gunshot wounds of the jointshas been recognized by allpractitioners, bothmilitary and civil,from t ime immemorial. Theprincipal circumstances of the prognosis areth e s ize and complexity of th e articulation,the extent of the injury, and th e s ta te of thesys tem. A gunshot wound of a ginglymoidjointis , ingeneral, amore dangerous affair thana s imilar one of a ball-and-socket joint. Thes t ructures around the articulation often sufferseverely, thus adding greatly to the r i sk ofl imb and life. O f 65 c a s e s of gunshot woundsof different jo in t s , related by Alcock , 33 re -covered; but of these 21 l o s t th e l imb. O f


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MILITARY SURGERY. 67the 32 that died no operation w a s per fo rmedu p o n 18.Gunsho t wounds of the smal le r jo in ts ,even those of th e ankle , o f t en do ve rywe l l , although they always require l o ng an dcareful treatment. Lesions of this kind , in -volving the shoulder , are f requently amenableto o rd i na ry means . If the ball lodges in th ehead of th e humerus, it mus t b e extractedwi thou t delay, its re ten t ion be ing sure toexci te violent in f lammat ion in th e so f t pa r t s ,an d caries or necrosis in th e b o n e , ultimatelynecessitating amputation, ifnot causing death.

G u n s h o t wounds of the knee- j o i n t are amongth e mo s t dangerous of accidents, an d noa t t emp t should b e made to save th e l imb whenthe in jury is at all extensive, especially ifitinvolves f racture of the head of the t ibia o rcondyles of the f emur . Even extensive lacer-ation of the l igament of the patella should,It h i nk , as a general rule , b e regarded as a suf-f ic ien t cause ofamputation. In1854, M a c l e o dsaw upwards of f o r ty cases of gunshot woundsof the knee in th e French hospitals in theCrimea, an d all, excep t o n e , in which an at-t em p t w a s made to save th e l imb , proved


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68 AMANUAL OFfatal. Ofnine c a s e s which occurred in Indianot one w a s saved. Guthrie never saw apatient recover f rom a gunshot wound of theknee-joint; and Esmarch, who serv ed in theSchleswig-Holstein wars, expressly declaresthat all lesions of this kind demand immediateamputation of the thigh.When, in bad cases of these articular inju-ries, an attempt i s , made to save th e l imb, thepatient often p e r i s h e s within the first three o rfour days, from th e conjoined e f f e c t s of shock,hemorrhage, and traumatic fever. Ifhe sur-vives fo r any length of time, large a b s c e s s e sare ap t to form in and around the joint, thematter burrowing extensively among th e mus-cles, and causing detachment of th e perios-teum with caries and necrosis of the bones.Muscles , badly injured bybullets, generallysuppu ra te , and are very ap t to become perma-nently useless. Special pains should thereforebe taken to counte ract this tendency duringthe cure. Large shot and other foreign bodiessometimes lodge among these structures, wheretheir presence may remain fo r a long timeu n s u s p e c t e d .

Cannon balls often do immense mischief


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MILITARYSURGERY. 69by striking th e surface of th e body obliquely,pulpifying th e soft structures, crushing thebones, lacerating th e large vessels and nerves,and tearing open the joints, without, perhaps,material ly injuring the skin.A very terrible form of contusion is ofteninflicted upon the upper extremity of artil-lerymen by th e premature explosion of th e

gu n while in the a c t of loading; causing ex-cessive commotion of the entire limb, lacera-tion of the soft parts, and most extensiveinfiltration of blood, a c c o m p a n i e d , in manycases, by comminuted fracture, and penetra-tion of th e wrist and elbow joints. The con-stitutional shock is frequently great. Ifanat tempt be made to save th e parts, diffusivesuppuration, and more or less gangrene, willbesure to fol low, bringing life into imminentjeopardy. An attempt in such a case tosave th e l imb w o u l d be worse than useless, if,indeed, not criminal; amputation must bepromptly performed, and that at a consid-erable distance above th e apparent seat ofth e injury, otherwise mortification might seizeupon the stump.In the treatment of this class of injuries,7


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the first thing to be done, after arresting thehemorrhage and relieving shock, is to extractthe ball and any other foreign substance thatm ay have entered along with it,the next beingto guard against inflam m atio n and other badconsequences.Inorder to ascertain where th e ball is, thelim b should be placed as nearly as possible inthe posi t ion itwas s u p p o s e d to have been at the

m o m e n t of th e ac cid ent. A long, s t o u t , flex-ible, blunt-pointed p r o b e , like that sketchedin th e annexed cut, or a straight silver cathe-ter, is then p a s s e d along th e track and gentlym o ved abou t until it strikes th e ball. Inm a n y c a s e s th e best probe is th e surgeon'sfinger. Valuable info rm atio n m ay often beobtained by th e process of pinching, o r digitalc o m p r e s s i o n , the ends of th e fingers beingfirm ly and regularly p r e s s e d against thewounded structures , bones as well as m u s -cles, tendons, and aponeuroses. Occasionally,again, as when a ball is lodged in an extrem-ity, its presence is easily detected b y thepatient, who m ay m a k e such an examinationas h e lies inb e d .T he situation of th e foreign body having


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71ILITARYSURGERY.been ascer ta ined, the bullet- forceps , seen intheaccompany engrav ing , takethe place of the probe, theblades , which should b e longand s lender , be ing closed un-til they c om e in co n t a c t w i t hthe ball, when they a re ex-panded so a s to grasp it, carebe ing t aken not to include a n yof the soft tissues. Ifthereb e a n y loose or detached splin-t e r s of bone , wadding, or otherforeign mater ia l , itshould nowalso b e removed ;tbe ing c o n -s tant ly borne in mind that ,while a ball m ay occasionallybecome encysted, an d is atall t imes, if smooth, a com-paratively harmless tenant,such substances always k e e pup irritation, and should,therefore , if p o s s i b l e , b e go trid of without delay.Although preference is commonly given tothe bulle t-forceps, properly s o called, as anextractor, the polypus an d dressing-forceps,


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72 A MANUAL OPrepresen ted in the ann ex ed f igures , gene ra l lyanswer quite as well , e s p e -cially the fo rme r , the latterbeing adap t e d only to ca s e swhere the fore ign body is

si tuated a sho r t dis tancebelow the surface, or wherethe wound is of unusuald imens ions , admit t ing of thefree p l ay of the i n s t rumen t .Dur ing the ex t r ac t ion ,the parts should be p r o -pe r ly s u ppo r t e d , an d if thewound is not large enough

fo r the expan s i on of the in -s t r um e n t , itmust be suitablyen l a rged . W hen the ball isl odged a sho r t dis tance f romthe sk i n , it m ay often b er e a d i l y reached by a coun-t e r -open i ng .When a bulle t is embed -ded ina bon e , as inthe he adof the t ib ia , or in the con-dy l e s of the femur , an d the parts are not s o

much i n ju r e d as to demand ampu ta t ion , e x -


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MILITARYSURGERY. 73traction may be effected with the aid of thetrephine and elevator. Sometimes a bullet-worm, as it is termed, an ins trument s im ilarto that used in drawing a ball from a gun ,willbe very convenient for its removal.

The operation being c o m p l e t e d , the partsare placed in an easy, elevated position, and'enveloped in tepid, cool or cold water-dress-ings , as may be mos t agreeable to them andto the system. The best plan, almost always, isto leave the opening or openings, made by theball, free, to favor drainage and prevent painand tension. Ifhe track be very narrow, itmay heal by the f i rs t intention, but ingeneralitwill suppurate, and portions of tissue mayeven mortify. Erysipelas, pyemia, and se-condary hemorrhage are some of the badconsequences after gunshot injuries, the latterusually coming on between the fifthand ninthday, the period of the separation of thesloughs. T*


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74 AMANUAL OF

CHAPTER VI.AMPUTATIONS AND RESECTIONS.

In endeavor ing to dec ide so impo r t an t aques t ion a s the loss of a l imb , V a r i o u s c i r cum-s t anc es a re to be cons idered , a s the a g e , habitsa n d p r e v i o u s hea l th of the pa t i en t , the kin d sof i n ju ry , a n d the numbe r , nature, a n d im -po r t a n c e of the tissues i n v o l v e d . Inmi l i t a rypract ice amputat ion must of t en be pe r fo rmedin ca s e s where in civil pract ice itmigh t bea vo i d e d .It m ay be assumed, a s a r u l e , t h a t youngadu l t s bea r up und e r severe acc iden ts a n dopera t ions, o the r things b e i n g equal, muchbe tte r tha n chi ld r en a n d e l de r ly subjects ;hes t r o ng than the feeble ; the t emp e r a t e than

the in tempera te ;he re sid e n ts of the c ou n t r ythan the i nhab i t an ts of the c r owd e d city.The fo l l ow ingc i rcumstances m ay be enumer-a t ed as just i fying, ifnot impera t ive ly d emand -i n g , amputat ion in c a s e s of wounds , wha t ev e rm ay be the i r nature:


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75ILITARYSURGERY .Ist. When a limb has been struck by acannon ball or run over by a railroad car,frac turing the bones, and tear ing open the

soft par t s , amputat ion should, as a. genera lrule, be performed, even when the injurydone to the skin and vessels is apparen t lyvery slight, experience having shown t h a tsuch accidents seldom do well, if an a t t emptis made to save the limb, the pa t i en t soondying of gangrene, pyemia, or typhoid irrita-tion. The danger of anunfavorable termina-t ion in such a c a s e is a lways greater when thelesion affects th e lower extremity than whenitinvolves the superior .

2d. No at tempt should be made to save alimb wh e n , in addition to serious injury doneto the integuments, muscles, o r bones, itsprincipal artery, vein, or nerve has been ex-tensively lacerated, or violently contused, asth e res ult will be likely to be gangrene, fol-lowed by death.3d. A lacerated or gunshot wound pene-trating a large joint , as tha t of the knee orankle , and accompanied by comminuted frac-ture, or extensive laceration of th e ligamentsof the articulation, will,ifleft to itself, be


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76 AMANUAL OF

very prone to terminate inmortification, andis therefore a proper case for early amputa-t ion.4th. Gunshot wounds attended wi t h severecomminution of the bones, the fragmentsbeing sent widely around among the softparts, lacerating and bruising them severely,generally require amputation, especially innaval and military practice.sth. Extensive laceration, contusion, and

s tr ipping off of the integuments, conjoinedwi th fracture, dislocation, or compression andpurification of the muscles, will,in general ,be a proper cause for the removal of a limb.*Amputation is not to be performed, in anyc a s e , until sufficient reaction has taken placeto enable the patient to bear the additionalshock and loss of blood. A s long as he is dead-lypale, the pulse smal l and thready, the sur-face cold, and the thirs t , restlessness, and jacti-tation excessive, it is obvious that recourse tothe knife mus t be whol ly out of the question.The proper treatment is recumbency, w i t hmild st imulants, sinapisms to the extremities,and other mean s calculated to re-excite the

* Gross ' s Surgery , vol. i. p. 395.


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77ILITARYSURGERY.action of the heart and brain. Power beingrestored, the operation, if deemed necessary,is proceeded with , due regard being had tothe prevent ion of shock and hemorrhage,the two things now main ly to be dreaded.

O ne of the great obstacles about immedia teamputat ion is the difficulty which the surgeonso often e x p e r i e n c e s in respec t to the casesdemanding the operation, and the uncertaintythat none of the internal organs have s u s -tained f a t a l in jury ; a circumstance whichwould , of course , contra-indicate the p ro -priety of such interference.

C a s e s occu r , a l though rarely, where, not-withstanding the m o s t violent injury, or per -haps , even the loss of a l im b, there is hardlyan y appreciable shock, and , in such an event,the opera t ion should be per fo rmed on the spot.The results of the m ili tary surgery in theCr imea show that the s u c c e s s of ampu ta t i onswas very fa i r when p erfo rm ed ear ly , bu t m o s tunfor tuna te when they were put off fo r an ylength of tim e. This was the case, it wou lds e e m , both in the English and French armies .

Should ampu t a t i on ever be p erfo rm ed inspreading gangrene? T he answer to this


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78 AMANUAL OFquestion must depend upon circumstances.W e may give our sanction when the disease,although rapid, is still l imited, and when thepatient, comparatively stout and robust, hasa good pulse, with no serious lesion of a vitalo rgan and no d e s p a i r of h is recovery , but acheerful , buoyant mind, hopeful of a favora-b le issue. No operation is to be done whenthe reverse is th e c a s e ;fit be, the patientwill either perish on the table, from shockand hemorrhage, or from a recurrence ofmortiflcation in

Documents

A Manual of Military Surgery (SGO 1861)