C.C. Richards
1866 The Lancet  
261 almost unchanged, after doing great execution in the long bones; but I have never seen a Prussian bullet, which had struck a bone, remaining unaltered in shape. There were many large lacerated flesh wounds produced by splinters of shells, &c. but these, as a rule, presented but little of interest. Dr. Knorr successfully removed a portion of grenade shell, measuring one inch and a half in two directions, and a quarter of inch in thickness, from the superior maxilla of a Prussian soldier ;
more » ... ussian soldier ; but this was, I believe, the only case of the kind in the hospital during my visit. The search after bullets and their extraction was a source of the greatest interest both to surgeons and patients. It often proved a matter of the greatest difficulty to determine whether a bullet was lodged in the body or not; frequently the men would positively assert that the ball had been extracted on the field, when it subsequently proved not to have been the case. The excitement produced in some men by the sight of the bullet was most astonishing. An Italian seized his bullet, bit it violently, and cursed it so furiously that it had to be taken from him to prevent him injuring himself. A Prussian soldier, apparently by no means an excitable fellow, on seeing the ball which had been removed from his thigh, burst into tears, and -shaking hands with us all round, divided his attention between blessing us and cursing his bullet. The men always kept them as valuable relics, and would not have parted with them at any price. T1?e "Garibaldi sonde," as it is called after the illustrious hero for whose case M. Nelaton invented it, proved of the greatest service. I have known a bullet, buried at a depth of four inches in the fleshy part of the thigh, recognised by the faint streak of lead left on the unglazed porcelain at the end of the probe. By its aid it was easy to determine between a piece of fractured bone and a bullet. Of the instruments used for extraction, the ordinary bullet-screw and long forceps were perhaps the two most commonly employed ; but the new American bullet-forceps was very highly spoken of. Its peculiarity consists in the sharply serrated blades crossing one another, and not simply meeting. Fragments of all shapes were <easily removed by this instrument. FiG. 5. The above figure represents somewhat imperfectly the form of the original. The anterior part of the lower blade is intended to lie in a plane nearer the spectator than the similar part of the upper blade ; whilst in the posterior half the upper blade is the more superficial of the two; so that the two blades cross one another. With regard to the apertures of entry and exit, there was, -as a rule, very little difference to be observed between them ; they were often of the same size, and presented very much the -same characters. I frequently observed that the supposed ,aperture of exit healed more rapidly than the other. The account of the patient could rarely be trusted ; and I found the holes in the clothing to be the best guides, as here the aperture -of exit was invariably the larger and more irregular of the two. In one case, in which a bullet had penetrated both thighs, it was only by examining the trousers that we could determine the direction it had taken, the patient's account proving incorrect. Judging from the number of cases of hopelessly bad fractures that were sent to Dresden from the field hospitals, there must 'either have been a great want of operative assistance on the spot, or the most unbounded faith in the reparative powers of nature. I have had the opportunity of dissecting very many cases of extensive comminution of the bones of the elbow, knee, &c., in which one would have thought that no surgeon could have entertained the faintest hope of saving the limb. Primary operations are so universally recognised by military surgeons as superior to secondary operations, that their non-performance was probably solely due to the enormous strain thrown upon the exertions of the surgical staff on the field. The circular method was almost universally adopted in preference to the flap, in consequence of a belief that the latter exposes the patient to a greater risk of pysemic infection from the magnitude of the wound. In cases where, from the nature of the injury, the flap operation became necessary, the single long flap was generally preferred. Resections were seldom performed; in fact, I only saw one of the elbow-joint. For although several cases must have afforded excellent opportunities for primary resection, yet at a later period the extensive suppuration, and disorganization of the soft parts, precluded all hope of a satisfactory result. Of the other operations of conservative surgery we had but few examples. The only case of Pirogoff's amputation of the foot ended fatally from profuse traumatic gangrene. In several cases, I think, Syme's amputation might have succeeded, but there was generally in these cases too much infiltration of the tissue of the heel to promise a favourable result, and amputation in the lower third of the leg was preferred. Considering the number and variety of the wounds received, secondary haemorrhage was of unfrequent occurrence. Dr. Kohnhorn ligatured the axillary and the femoral arteries for repeated hsemorrhage from wounds of the respective limbs; both cases were successful as far as the operation was concerned, but one of them (the femoral) became pysemic when the wound was nearly closed. A case of ligature of the brachial resulted in amputation at the shoulder-joint, in consequence of severe secondary hsemorrhage at the seat of ligature; on examination, there was found to be a very small and incomplete clot in the artery. In no case of hemorrhage from the lung resulting from gunshot injury was it found necessary to employ venesection. In most cases digitalis was employed in connexion with the ordinary astringents. One very interesting case occurred under the care of Dr. Maennel, in which the patient, after spitting blood for fourteen days, recovered with the bullet remaining in his body; when he left the hospital he had only a very slight cough, and no pain. (To be continued.) ON
doi:10.1016/s0140-6736(02)68105-x fatcat:mtgh22jdvvei7nrjiyc7qshqnu