PERISCOPIC DEPARTMENT. Surgery. HOW SHOULD GUN-SHOT WOUNDS PERFORATING THE KNEE-JOINT BE TREATED? By JULIAN J. CHISHOLM, M.D., Professor of Surgery in the Medical College of South Carolina, U.S.A.; formerly Surgeon in the Confederate Army. As a rule, gun-shot wounds perforating the knee-joint are so fatal under the usual methods of treatment that military surgeons are seriously embarrassed in selecting a course from which they might hope for a successful issue, In European army experience such cases do very badly, whether left to themselves, or whether operated upon by amputation or excision. In by very far the majority of cases the patient dies, proving, as the result of experience, that gun-shot wounds perforating the knee-joint are among the most fatal wounds of the battle-field. In the large experience gathered from five years' war in the United States, it would appear as if the previous reports of European army surgeons had been confirmed, and that amputation of the thigh in recent perforating wounds of the knee-joint offered the best means of saving life. In recent years resection or excision of the heads of bones crushed or injured by a ball has been urged as a substitute for amputation, and unfortunately in both the Federal and Confederate armies resections became too much the fashion, many lives being sacrificed to this modern operation. Every joint, and nearly every long bone of the extremities, was freely excised, often, as in the shoulder and elbow, with the best results; but in the shafts of long bones disastrously, and in the knee and hip-joint with the most fatal consequences : Where amputation was resorted to as the remedy for gun-shot injuries perforating the knee-joint, the results were as follows: (a) This percentage would have been larger had all the fatal cases been reported. Federal Army Reports to July, 1864. No. of cases. Mortality. Per cent. 112 46 (b) Amputation through the lower third of femur.. 243 Confederate Army Reports to February, 1864. No. of cases. Mortality. Per cent. 46 (b) Amputation through the lower third of femur.. 259 These results of amputation in the lower third of the thigh for injuries of the knee-joint are so satisfactory that where the tissues about the articulation are much lacerated, or the bones much crushed, amputation will always be resorted to. But there is a class of cases in which the perforating injury to the joint appears trivial,, or in which the bones are to no great extent injured, and in which the surgeon can with difficulty overcome the patient's abhorrence to an amputation. Under these conditions, the experience of Confederate surgeons in attempting to save the limb gives so satisfactory a result, that it becomes a question whether conservative surgery may not be more extensively used for gun-shot wounds of the knee-joint than it now is. The following table was compiled from Confederate army reports : (c) A very much larger number of cases had been reported by Confederate surgeons, but these reports had not been examined or their contents collated when the above tables were compiled. These only include such as had their termination satisfactorily traced in February, 1864. It may be argued that the successes exhibited by this table must be partially attributed in many cases to the trivial character of the injury, which could not have implicated the cavity of the articulation. An examination into the duration of treatment of the successful cases gives an average of 166 days, the shortest period of successful treatment being in only one case 96 days, which of itself marks in the strongest terms the very serious character of the least dangerous case; clearly proving (b) Only such cases are engrossed in these Reports as had been traced to their termination at the date of the Report; the many cases not discharged from hospital are not incorporated. the suppuration and the too much to be dreaded suppurative synovitis. Simple flesh wounds in the neighbourhood of joints heal usually without difficulty in two or three weeks. It may be presumed that most, if not all, of the cases of knee-joint wounds, retained for conservative treatment, were perforations by balls, without crushing of bones being detected. The surgical statistics of the Confederate army would warrant us in treating all such cases without amputation or resection of the heads of the bones forming the joint. For the successful treatment, the patient should be kept as quiet as possible, in a well ventilated ward or tent, with his nervous system kept at the least stage of irritation by the continued administration of opium. The general condition of the system is to be constantly watched, excretions promoted, and such tonic and supporting remedies administered as will control the circulation, increase the tone of blood-vessels, and moderate inflammatory action. The most conspicuous of these elements of medication are opium and iron. The limb should be kept at absolute rest, which can be best insured by securing it to a posterior splint, extending from the buttock to beyond the heel. To the surface about the joint are continuously applied cold evaporating lotions, of which iced water is the simplest and best. This, however, can be medicated so as to increase the evaporation and the refrigeration of the external articular surfaces. As soon as the swelling, redness, and pain in the superficial structures with systemic irritation indicate synovitis with suppuration, the joint should be freely laid open, the articulating cavity fully explored, and all the fragments of bones or foreign bodies removed, and a free outlet given to the purulent discharge. It is from the apparently bold surgery of opening freely the joint that the best results are obtained. During the entire treatment of the suppurative stage the best antiphlogistic remedies are found to be nutritious food and the free use of alcoholic stimuli. In cases in which there was excessive engorgement of the limb, with a general suppurative disposition which, when it occurred constantly, foreboded evil, the most satisfactory results were obtained in a few cases in which the excessive circulation in the limb was suddenly checked by the ligation of the femoral artery. Surgeon Campbell, who introduced this practice into the Confederate military hospitals, considers it a safe and powerful antiphlogistic remedy. The previous development of vessels under inflammatory progress insures the limb against mortification; whilst the control of the circulation from the ligature will in thirty-six hours so reduce the size of the limb and arrest profuse suppuration as to change completely the aspect of the member. Should the ball in the passage through the knee have crushed the heads of the bones, and the case be deemed too serious to warrant treatment without an operation, the experience of both Confederate and Federal army surgeons unanimously condemns primary resection of the knee-joint. In every such instance the life of the patient can best be preserved by amputating through the lower third of the thigh, an operation which army experience proves to be preferable to disarticulating through the knee-joint. Primary resection of the knee-joint is so disastrous as a field operation, that it should be discarded from field practice by army surgeons.—Lon don Medical Times and Gazette. WHEN ONE EYE ONLY IS BLIND, IS IT PRUDENT TO ATTEMPT TO RE- THIS is a question that is put to me many times in the course of a year. I gather from my intercourse with Professional men that there exists an impression against interfering, although I could never discover among them any sufficient grounds for the opinion, nor indeed collect any data. The idea seems to have come down traditionally from an age when ophthalmic subjects were but little understood. I have sought in vain for any definite rules among the treatises on the eye by our countrymen. What is the opinion of the Surgeons of the present, who are fitted by their connexion with Ophthalmic Surgery to speak authoritatively, and who have no doubt examined the question, I do not know. I could wish to have the opinions of each of them all as they exist at this moment, and to hear such in its genuineness, without the influence, bias, or effort inseparable from a discussion. There is a necessity for me to have some definite rules to act on. The exercise of my calling demands them. My patients, too, seek for them. In discussing the subject, there are facts to be recognised, conditions and circumstances to be considered. There must be reviewed the physical causes that render the eye useless, the operations that are needed, and the probability of the result, and the quality of the sight that may be restored. It may be stated in general terms that a person who has lost an eye, besides being blind on one side, has but a very limited field of vision for near objects beyond the centre of the face, and which angle is regulated by the degree of prominence of the nose; that the definition of sight which depends on binocular vision is totally lost; that the power of accurately estimating distance is lost, and in consequence of this mistakes 361 are made in certain mechanical acts, as the pouring of a liquid from one vessel to another, although the vision is quickly rectified by touch. This defect may remain in degrees. Whether it is always entirely overcome by those who have lost an eye in infancy I do not know, for it has never occurred to me to ascertain. That with labour requiring minute sight there are more readily developed the many effects of impaired vision than when two are used, because the one organ cannot do the the work of the two. These are points that some one-eyed people are loth to confess, and they cannot be blamed for their caution. It is, therefore, apparent that an individual is the better for two sound eyes, and that that measure is admissible which, while it restores sight, does no harm elsewhere. And here it is necessary to observe that nothing of value can be gathered from mere spontaneous expression of patients as regards the question, for they cannot understand the subject. Even more than this, when the data from which conclusions can be formed are set before them, they are as likely as not to act wrongly. The accepting or rejecting, then, of a proposal put to them, must be recognised only as a matter of will, which they have the power to exercise or not, and not as a valid opinion. I know of several persons who are now blind in both eyes because they Every Surgeon cannot make up their minds to have anything done. must have seen patients die rather than submit to any operation that After I would save life. As the physical defects of the eyeball proper that need operation for the restoration of the function of sight are cataract, and the loss of the pupillary aperture, it is impossible for perfection to be restored. the removal of cataract, peculiar glasses are needed. In the formation of an artificial pupil, the aperture must be either at the margin of the iris when the quality of the sight is lessened, or in the centre when the lens is absent, and minute use of the eye must depend on cataract glasses. Unfortunately, an eye cannot be fitted with a cataract glass, and brought up to a healthy state so as to match the other eye. The adjusting power is gone, and, for seeing at different distances, glasses of different foci are needed. Therefore arises this important consideration on which the whole matter hinges. Will this kind of sight, which must be inferior to that of the other eye, and at times in marked degrees, be really of material service? It may be premised that, if a Surgeon is to answer from his own knowledge and experience, a long time is required to gather facts and dates; and, to avoid errors, the patients should be watched for years. I speak then from what I have seen, and say yes. I should be deterred from operating only by the probability of the eye being too much damaged to give that amount of sight which is known as useful |
