Chapter XXVI: Part 26

416. The inflammatory actions are to be subdued by general bleeding, the application of leeches, the administration of diluent drinks in moderate quantity, the exhibition of gentle aperients, such as castor-oil, and by enemata. Opium in all these cases is an important remedy, principally in the shape of morphia. Opium in substance, when introduced into the rectum in the shape of a suppository, or dissolved in half an ounce or an ounce of water as an enema, should be repeated in such quantities, beginning with two grains, as will procure ease.

417. The urine, in most cases of injury below the peritoneum, flows readily through the wound of entrance, if not of exit, in the first instance, and care should be taken, by enlarging the posterior wound, that no obstacle within reach shall prevent it; but after inflammation has been established, the parts swell, and as the sloughs begin to separate, its passage is often obstructed; the elastic catheter, if not used before, will then render important service by allowing the sloughs to be separated without the healthy parts being irritated by the urine being retained. After a time the urine may be only drawn off in small quantities through the catheter, as frequently as circumstances may render advisable. The permanent use of the catheter in these cases will often prevent the urine from forming any devious paths as it proceeds outward, ending in abscesses and fistulous openings, causing much discomfort and even misery. It is not common for blood to be poured into the bladder in such a quantity as to cause much inconvenience; it coagulates with equal proportions of urine, and a silver catheter should be used, by which it may be broken up and rendered more easy of solution by injections of warm water. When the neck of the bladder or the prostatic part of the urethra has been divided so that a catheter cannot be efficiently used, surgery must come with more immediate aid to the assistance of the sufferer, by making a clear and free opening from the perineum for the evacuation of the urine and of the discharge from the wound. If a ball lodge in or near the bladder, or in the prostate, it must be removed by an operation in the perineum.

A soldier of the Light Division was wounded on the heights of Vera, in the Pyrenees. A musket-ball had entered behind near the sacrum and lodged. He was bled twice, in consequence of suffering pain in the part, but was not otherwise much disturbed. There was at first a difficulty in passing urine, but this gradually subsided, although he always suffered pain in micturition, which was frequent and distressing. He remained in this state until December, when he passed, with considerable effort and after much difficulty, a hard piece of his jacket about half an inch in length, larger than the orifice of the urethra, through which it was forced. As it was not incased by calcareous matter, it could not have been long in the bladder, but must have been lodged near it before it ulcerated its way in, giving rise to the constant desire and irritation which he had so long experienced. His symptoms then subsided, although they had not entirely disappeared when he left for England.

A French soldier was wounded by a musket-ball on the back part of the right hip, at Almaraz, on the Tagus, was taken prisoner, and sent to Lisbon in the autumn of 1813. The ball had lodged, but gave him little inconvenience at the time beyond some pain in the course of the sciatic nerve, subsequently followed by defect of motion on the right side. Four months after the injury pain came on about the region of the bladder, with great desire to pass urine, which he could not do when standing, but which dribbled away when lying down. When quiet he suffered little, but great pain followed any attempt at continued motion. A catheter could be introduced, but with great difficulty when it reached the prostate gland, which was exceedingly tender to the touch. After a time the instrument could not be passed, and the man was in great agony until something appeared to give way, and a discharge of matter took place, when the urine followed, and he was relieved. An abscess had formed, in all probability from the proximity of the ball, which still could not be felt. The man recovered, retaining, however, his former state of lameness and defect of power, although relieved from the vexatious irritation of the bladder.

A soldier of the Fourth Division of Infantry was wounded at the battle of Toulouse, while entering a redoubt, by a musket-ball, which entered at the left groin, and, crossing the pelvis, came out on the upper part of the opposite hip behind. The urine flowed from both wounds and from the rectum, indicating that the ball had passed between these parts, and a little feces came from the posterior wound for three weeks. The pain and suffering were not great, and principally arose from retention of urine, requiring the use of the catheter, which was left in, and changed from time to time, until the urine flowed by the side of it, instead of through the wounds, which it did occasionally for some weeks in drops, but not in any quantity; after which the wounds gradually closed, and the man was sent to England cured.

A soldier of the Cavalry of the King’s German Legion was struck, at the battle of Salamanca, by a musket-ball, which entered just above the pubes a little to the right side, and came out below on the opposite nates. The urine flowed readily through both wounds for the first three days, and he suffered afterward from great pain and distress about the region of the bladder, from which he could not expel any urine, neither would it pass by either wound. I immediately introduced a catheter, drew off a moderate quantity of urine, and then fixed it in the bladder, desiring him to draw off his urine every hour when awake. This he did, often leaving the stopper out at night. The urine flowed after a few days through the posterior wound, and then ceased. The catheter was washed from time to time, and was at last withdrawn, as the urine began to flow by the side of it, and the wound had finally closed when he left the San Domingo Hospital.

Captain Martin received a wound from a musket-ball at the siege of Ciudad Rodrigo; it entered just above the pubes, passed through the bladder and rectum, and came out behind, splintering the sacrum, the contents of both viscera being freely discharged through this opening. As he suffered but little inconvenience from the urine, very little of which passed by the urethra, that passage was not interfered with in the first instance. Inflammatory symptoms were kept within due bounds, the rectum was carefully washed out by emollient enemata, and his food rendered as light as possible. Under this treatment he gradually improved; the anterior wound first healed, and subsequently the posterior one, leaving him comparatively well when he left me for Lisbon on his way to England.

418. These cases give, however, a brighter view of the nature of these wounds than they frequently justify; extravasation of urine, inflammation, and death are not of infrequent occurrence in cases to which strict attention is not paid; and great misery is often caused from the irritation of the bladder and the discharge which follows, until the constitution is undermined and death ensues.

Captain Sleigh, of the 100th Regiment, was wounded at the battle of Chippewa, on the 5th of July, 1814, by a musket-ball, which entered the left groin immediately over Poupart’s ligament, by the side of the spermatic vessels, injuring in its course the anterior brim of the pelvis. It thence passed through the bladder obliquely across the pelvis, and terminated its course beneath the integuments in the right buttock, whence it was immediately extracted. Blood and urine flowed incessantly from the groin; the quantity of blood lost was considerable. He complained much of pain in the hypogastric region; the abdomen was tense and painful to the touch, and he had an almost continued inclination to micturate; but his attempts, after the most painful efforts, were entirely frustrated. The anxiety was great, the respiration hurried, and the pulse quick and fluttering. He was bled to the extent of thirty ounces; an enema was given; fomentations applied to the belly; and the catheter introduced--all which afforded him some relief. The next day he was removed to the rear, a distance of seventeen miles, in an open wagon, partly during the inclemency of the night, and was quite worn out by so long a journey. He was carried thence on board ship, and landed at York on the morning of the 9th of July, the fourth day after he received his wound.

July 9th.--Abdomen tense and painful to the touch; severe pain in the perineum; great inclination to void urine, but fruitlessly; wound in the groin sloughy, discharges urine and blood mixed with a small quantity of pus; posterior wound healthy, no discharge of urine from it; catheter attempted to be passed without success. Ordered an ounce and a half of castor-oil immediately.

10th.--Passed a restless night; had two copious stools; voided a few drops of urine by the urethra; still great inclination to pass urine. Ordered two grains of extract of opium made into a pill.

11th.--All the painful sensations much relieved; abdomen less tense; a small piece of bone extracted from the urethra about an inch in length, of the thickness of a crow-quill; a little urine followed more freely.

15th.--Complains of severe pain in the spermatic cord; discharge from groin more offensive; wound filled with large maggots; bowels open.

19th.--Wound of groin looks clean; a small piece of bone discharged by the urethra, and a piece of cloth extracted from the groin.

24th.--A small piece of bone extracted from the groin.

August 5th.--Passes a good deal of pus and urine by the urethra.

29th.--Posterior wound much inflamed and very painful upon pressure. A poultice to be frequently applied.

Sept. 1st.--An abscess has burst; a piece of cloth has been extracted; urine and pus are discharged by both wounds.

12th.--Doing well; wounds closing.

16th.--Bladder resuming its power; discharge of matter from groin very trivial.

Oct. 4th.--Posterior wound closed.

30th.--Wound of groin closed; urine, passed by the natural passage, mixed with pus.

At first it was supposed that only the fundus of the bladder was wounded; but when the collection of matter took place in the right buttock, and a piece of cloth was extracted from it, the urine following, it was evident that both sides of the bladder had been transfixed by the ball; and that, probably, the urine from the commencement had been prevented flowing posteriorly by the intervention of this foreign body. An elastic gum catheter could not be passed into the bladder on account of the piece of bone which had forced its way into the urethra, and from its being obstructed afterward by smaller pieces of bone.

When I saw this gentleman some time afterward, it appeared to me that the purulent discharge from the urethra was not from the inner membrane of the bladder, but was probably caused by some dead bone of the pelvis having a communication with the bladder by a fistulous opening.

A soldier, of the King’s German Legion, was struck, at Waterloo, by a musket-ball, which entered a little way above the pubes, and lodged. The symptoms which immediately followed were by no means severe, although he passed a little bloody urine at first; the external wound closed without difficulty. He complained of pain at the neck of the bladder, and had a great desire to pass urine, with other signs of stone in the bladder, which induced me to pass a sound, when I found that the ball was lying loose in that viscus. On his arrival at the York Hospital, at Chelsea, from Brussels, he became, with the French soldier, whose thigh had been amputated at the hip-joint, an object of great attention. I performed the operation for the removal of the ball in the presence of a large concourse of military and medical persons. It was done in less than two minutes; but the calculus, composed of the triple phosphates, which had formed around the ball, yielded, and broke under the forceps. The pieces were removed separately. The ball, being heavy, fell below the neck of the bladder, which, being healthy, yielded to the pressure, and allowed it to sink on the rectum, where it could not be caught by the forceps, until it had been raised by a finger in the bowel. The bladder was then well washed out, so as to remove all the pieces that might remain, and the man was placed in bed. He was bled once in consequence of some apprehension of pain; but he had not a bad symptom, and rapidly recovered.

The symptoms of irritation did not, however, entirely pass away, as could have been wished, and I began to fear that some small pieces of calculus had been overlooked; when, one morning, after considerable effort, he passed a ring of sandy calcareous matter, which had formed around the orifice of the bladder, and which, being dislodged, had fortunately entered the urethra, along which it was forced by the urine. It was evidently formed of the phosphates in minute portions, which had become agglutinated together, around the meatus of the bladder. This he took with him to Hanover, where it, himself, and the cicatrixes of his wound, and of his operation, attracted great notice. The ball, which was flattened on one side, I kept in a small box, together with the pieces of calculus which were extracted, and showed them annually at my lecture on this subject for many years. One evening, however, I unfortunately left my little box on the table after lecture; and when I recollected, and returned for it, I found that some gentleman had borrowed it, and has not yet returned it. At the battle of Chillianwallah a similar wound took place; the ball formed the nucleus of a calculus, and was removed successfully by a gentleman in the service of the East India Company, whose name I have not been able to learn.

The following case, from Baron Percy, is in point: A young man was wounded by a pistol-shot, which entered just above the os pubis, through the linea alba, wounded the bladder, and lodged. The belly swelled; a tumor formed in the perineum; no urine passed; the bowels were confined, and fever ran high, with a tendency to delirium. Believing that the tumor in the perineum, and the fluctuation he thought he perceived, might be caused by extravasated urine, he punctured it with a trocar, and evacuated a large quantity of bloody urine. This induced him to enlarge the opening, and carry it on to the bladder, through which he brought out the ball, some shirt, and several clots of blood. The man was bled nine times in all; the urine after a time passed in the ordinary way, and the patient slowly recovered.

An officer was wounded near Bayonne, by a musket-ball, on the left side; it passed through the ilium across the pubes, and made its exit through the gluteus maximus of the opposite side, but lower down. Urine flowed through both wounds at first very readily, but none of any moment came by the urethra, from which some blood occasionally oozed. The attempt to pass a catheter failed, although the desire to make water was urgent and painful. After a few days the passage of urine by the external wounds became obstructed, apparently by the sloughs; great pain and misery were experienced; fever ran high; rigors and delirium followed extravasation of urine, and death closed the scene. The mischief here arose from the catheter not having been passed into the bladder, which could not be effected, from the prostatic part of the urethra or the neck of the bladder having been injured.

419. Surgery in such, or in nearly similar cases, requires a catheter or staff to be passed down the urethra as far as it will go; an incision should then be made upon it, from the center or across the perineum, and the urethra divided on the staff until the finger rests upon the wounded parts, when, in all probability, a straight catheter, with the aid of the forefinger in the rectum, can be carried through them into the bladder. The urine will then have a direct passage outward, instead of coming indirectly from the bladder by the wounds. If the straight catheter cannot be passed, which can scarcely occur, the central incision is to be continued from the point of obstruction into the bladder, guided by the finger in the rectum. A free opening from the bladder offers the only hope of safety.

420. The _rectum_ may be wounded without any other organ being injured within the pelvis; of this I have seen several instances. Captain Gordon, of the navy, was struck by a rifle-ball toward the lower part of one side of the sacrum, after being knocked down by one he had received on the head, and by another in the neck and back. The ball, which passed into the rectum, made its exit on the opposite side of the sacrum, and stercoraceous matters were evacuated by both wounds. The pain was severe; the limbs were deprived of much of their power of motion, and the next day the bladder was incapable of expelling its contents. This was relieved by the catheter, and the rectum was kept clear by warm, mild enemata, while the inflammatory symptoms were subdued by bleeding, opium, starvation, and rest. At the end of three months he was able to walk, but with some difficulty, on account of defective power in one leg. Some small pieces of bone came away and the wounds closed, although he was subject to an occasional slight opening of the orifice of entrance, from which a little matter was discharged, when it again closed. He remained more or less lame until his death, which took place with the loss of the ship he commanded, in a hurricane, on the coast of North America.

A French soldier was wounded at the battle of Salamanca by a ball, which entered by the side of the sacrum, and lodged. Having been rode over and bruised, he was taken prisoner, and brought to me on the field of battle. From this wound he suffered comparatively little, except from a difficulty of passing urine. On the third day after his arrival at the San Carlos Hospital, or the sixth from the receipt of the injury, he passed the ball per anum. The wound quickly closed, and he aided his comrades as an orderly in the hospital afterward.

CONCLUSIONS.

421.--1. Severe blows on the abdomen give rise to the absorption of the muscular structures, and the formation of ventral hernia, in many instances; this may, in some measure, be prevented during the treatment, by quietude, by the local abstraction of blood, and by the early use of retaining bandages.

2. Abscesses in the muscular wall of the abdomen, from whatever cause they arise, should be opened early; for although the peritoneum is essentially strong by its outer surface, it is but a thin membrane, and should be aided surgically as much as possible.

3. Severe blows, attended by general concussion, frequently give rise to rupture of the solid viscera, such as the liver and the spleen, causing death by hemorrhage. When the hollow viscera are ruptured, such as the intestines or the bladder, death ensues from inflammation.

4. Incised wounds of the wall of the abdomen to any extent rarely unite so perfectly (except, perhaps, in the linea alba) as not to give rise to ventral protrusions of a greater or less extent.

5. As the muscular parts rarely unite in the first instance after being divided, sutures should never be introduced into these structures.

6. Muscular parts are to be brought into apposition, and so retained principally by position, aided by a continuous suture through the integuments only, together with long strips of adhesive plaster, moderate compression, and sometimes a retaining bandage.

7. Sutures should never be inserted through the whole wall of the abdomen, and their use in muscular parts under any circumstances is forbidden; unless the wound, from its very great extent, cannot be otherwise sufficiently approximated to restrain the protrusion of the contents of the cavity. The occurrence of such a case is very rare.

8. Purgatives should be eschewed in the early part of the treatment of penetrating wounds of the abdomen. Enemata are to be preferred.

9. The omentum, when protruded, is to be returned by enlarging the wound through its aponeurotic parts if necessary, but not through the peritoneum, in preference to allowing it to remain protruded, or to be cut off.

10. A punctured intestine requires no immediate treatment. An intestine, when incised to an extent exceeding the third part of an inch, should be sewn up by the continuous suture in the manner recommended, _Aph._ 391.

11. The position of the patient should be inclined toward the wounded side, to allow the omentum or intestine being closely applied to the cut edges of the peritoneum. Absolute rest, without the slightest motion, should be observed. Food and drink should be restricted, when not entirely forbidden.

12. If the belly swell, and the propriety of allowing extravasated or effused matters to be evacuated seem to be manifest, the continuous suture or stitches should be cut across to a certain extent, for the purpose of giving this relief.

13. If the punctured or incised wound be small, and the extravasation or effusion within the cavity seem to be great, the wound should be carefully enlarged, and the offending matter evacuated.

14. A wound should not be closed until it has ceased to bleed, or until the bleeding vessel has been secured, if it be possible to do so. When it is not possible so to do, the wound should be closed, and the result awaited.

15. A gunshot wound penetrating the cavity can never unite, and must suppurate. If a wounded intestine can be seen or felt, its torn edges may be cut off, and the clean surfaces united by suture. If the wound can neither be seen nor felt, it will be sufficient for the moment to provide for the free discharge of any extravasated or effused matters which may require removal.

16. A dilatation or enlargement of a wound in the abdomen should never take place, unless in connection with something within the cavity rendering it necessary.

17. If the epigastric, circumflexa ilii, or other artery in the wall of the abdomen, be injured and bleed, the wound should be enlarged, and the bleeding vessel secured by ligature. If the main trunk or the external iliac artery be sought for and tied, the patient will in all probability die.

18. When balls lodge in the bones of the pelvis, they should be carefully sought for and removed, if it can be done with propriety and safety.

19. In a wound of the bladder, an elastic gum catheter should be kept in the urethra, frequently without a stopper, until the wound is presumed to be healed--unless its presence should prove injurious, from excess of irritation, not removed by allowing the urine to pass through it by drops as it is brought into the bladder.

20. In all cases in which a catheter cannot be introduced, in consequence of the back part of the urethra or the neck of the bladder being injured, an opening for the discharge of the urine should be made from the perineum into the bladder. It is essential to the preservation of life.

21. The treatment of all these injuries must be eminently antiphlogistic, principally depending on general and local blood-letting, absolute rest, abstinence from food, and in some cases almost even from drink, the frequent administration of enemata, and the early exhibition of mercury, and especially of opium, in the different ways usually recommended, with reference to the part injured.

422. As the operation for opening into the colon may be necessary, after an injury of that part, as well as from disease below it, the following method, recommended by Mr. Hilton, is briefly transcribed from the Reports of Guy’s Hospital. A line drawn parallel to the spinous processes directly downward from the angle of the seventh, eighth, or ninth rib across the costo-iliac space to the crest of the ilium, will correspond with the outer edge of the erector spinæ muscle and the apices of the transverse processes. A measured inch outwardly corresponds with the outer edge of the quadratus lumborum muscle. A vertical incision, two inches long, made at the extremity of the measured inch, should divide the skin, cellular tissue, and the tendon of the internal oblique muscle, and expose the outer edge of the quadratus lumborum muscle. Any bleeding vessels to be secured. The last dorsal nerve, if seen lying across the upper part of the incision, should be divided, to prevent the occurrence of pain from its being engaged in the cicatrix. The transversalis abdominis muscle is then to be divided vertically to nearly the same extent of two inches, parallel to the edge of the quadratus, when a quantity of loose lobulated fat will be seen, which should be partly removed and partly displaced by the blunt end of a director, in the vertical direction of the original incision, when the intestine will be brought into view. Any bleeding vessels should be secured, and pressure made on the abdomen, which will cause the intestine to become more prominent at the bottom of the incision. A silk ligature is now to be passed into the bowel and through the integuments at the upper part, so as to fix the intestine above, when a second ligature is to be applied in a similar manner below. The intestine is then to be opened between them, care being taken to apply another ligature above and below it, if the intestine should not appear to be firmly held in its place. If a vessel in its wall should bleed, it must be tied. Inflammation, pain, and restlessness should be obviated as far as possible by fomentations, opiates, and diaphoretics, and strict attention paid to cleanliness and the comfort of the patient, until the first symptoms have passed away, and he is able to assume the erect position.

423. These commentaries are restricted to those points which constitute, in a great degree, what the French call _la haute chirurgie_. They are published that every soldier should have the opportunity of knowing how he ought to be treated, when suffering for a country not too grateful for the services rendered by her bravest sons; and I have labored with the hope that some few of them, when they find that their limbs, perhaps their lives, have been saved under the precepts I have laid down, may acknowledge, when I am beyond that bourn whence no traveler returns, that they owe them, under the will of God, to those efforts I, more than any one else, have made, and continue to make, for the adoption of that practice which led to their preservation.

ADDENDA.

Several reports and cases having reached me from various medical officers in the Crimea, too late for publication in their proper places, I have thought it best to notice some generally as to results, others particularly. Chloroform has been freely administered in all the Divisions of the army save the Second, and has been generally approved; one death only, as far as is known, having occurred directly from its administration, of which Staff-Surgeon Gordon, P.M.O. of the Second Division, has favored me with the following report:--

Martin Kennedy, 62d Regiment, aged 32 years, a healthy soldier, having accidentally wounded one of his fingers by his musket going off, and the medical officer in charge considering it necessary to remove it, was brought under the influence of chloroform, but, according to his (the surgeon’s) statement, only about ʒij could have been inhaled. He had commenced the operation, when the patient suddenly expired. On the post-mortem examination, beyond a little fatty deposit on the external surface of the left ventricle, together with a degree of hypertrophy of the same, no morbid appearance existed. The usual restoratives were resorted to, but ineffectually.

The following case, furnished by Assistant-Surgeon Hannan, 49th Regiment, is given as an illustration of the success of amputation without chloroform in the Second Division:--

Patrick Kenny, 49th Regiment, aged 22. This soldier, while on duty in the trenches on the 21st of July, received a compound comminuted fracture of the right humerus, extending from its middle third to the head of the bone. The integuments of the outer and upper part of the shoulder were carried away. There was also a contused and lacerated wound of the left knee, opening into the joint, with comminuted fracture of the patella, these injuries being caused by pieces of shell. He was seen a quarter of an hour after admission by Dr. Gordon, P.M.O., who removed the arm at the shoulder-joint, making a sufficient flap from the integuments of the axilla. The thigh was then amputated in its lower third. These operations were performed in immediate succession without the administration of chloroform. The thigh healed nearly by the first intention--all the ligatures having come away by the fourteenth day. The shoulder healed by granulation--the ligature of the axillary artery coming away on the twenty-first day. During the progress of treatment he had not any constitutional disturbance further than three slight attacks of diarrhœa. He is now up and about, and goes to England by the next opportunity.

In the worst cases of amputation at the hip-joint, or at the upper third of the thigh, chloroform has appeared to cause insensibility to pain without diminishing the powers of the sufferer, when given with due caution or not carried so far as to affect the pulse or respiration. (See _Aphor._ 51.) The evidence on this point is sufficient to authorize surgeons to administer it in all such cases, with the expectation that it will always prove advantageous, an accidental death, such as has been observed from its use, being independent of the nature of the injury. The amputations performed at the hip-joint, at least six in number, have not been successful as to the result, although the sufferers bore them well in the first instance, offering every prospect of recovery for days and even for weeks.

Deputy Inspector-General Taylor informs me, and his opinion is corroborated by all the medical officers, that the labors the troops had to perform, the privations they suffered, the frequent insufficiency of their food, the want of proper clothing, with other depressing causes, had so deprived them of that power British soldiers generally possess, that all the operations of importance performed on the lower extremities were more or less unsuccessful, while those on the upper were as remarkable for their success. This deprivation of power, it is said, was even more observable in the French army; and he informs me that most of their surgeons had declined performing any of the great operations usually done on the upper third of the thigh, in consequence of their almost certain failure, preferring to let the injuries take their course, even unto the death of the sufferers, rather than hasten their dissolution by any operation usually considered and often found to be conservative; a lamentable state of things from which governments may draw an inference of the utmost importance, viz., that to guard against the effects of disease as well as of injuries, the utmost pains should be taken to preserve the health and maintain the vigor of their soldiers. A matter of expense as well as of arrangement.

This statement is corroborated by Deputy Inspector-General Alexander, who informed me, on the 3d of August, 1855, that “during the whole of this campaign, where we have had ample opportunities of testing the use of chloroform, both after the battles of the Alma and Inkerman, as well as throughout the whole siege operations before Sebastopol, up to the present period, no operations whatever of any consequence (save with one or two exceptions, and then at the patients’ own request,) have been performed in the Light Division, without first placing the patient under the influence of chloroform, and in no single instance have either the medical officers of the Division, or myself, seen any bad results follow, or had to reject its use, but quite the contrary. Of course, in such a campaign, many operations of the most serious character, both on the upper and lower extremities, have been performed in the Division by the different medical officers as well as by myself. At the Alma, I operated upon three patients at the hip-joint, two being our own men and the third a Russian. All the three patients were first placed under chloroform, with the results above stated. In the case of a soldier of the 90th Regiment, whose right arm I removed at the shoulder-joint on the 10th of July, for great destruction of the soft parts and extensive injury to the humerus, the patient was so low when placed on the table that brandy and water was given to him, and he was then immediately afterward placed under chloroform. When I had finished, it was found that his pulse was stronger than before commencing the operation. In Sir T. Trowbridge’s case, in which I had to remove both feet, one at the ankle-joint and the other above it, he was placed under chloroform for both operations, a few minutes having been allowed to elapse before giving it to him again for the second operation, and with the best results. Both feet were much injured by round shot, the bones of both being completely smashed with great destruction of the soft parts, so much so, that in the case at the ankle-joint I had to form the flap from the cushion of the heel. I, however, did not remove the articular surface of the lower end of the tibia, as recommended by Mr. Syme, and the wound healed well. Of the three cases mentioned at the hip-joint, two were performed on the 21st, and the Russian on the 22d of September. At one of the former I was assisted by the late Dr. Mackenzie, from Edinburgh. All three were carried down on the 22d, to be placed on board ships for conveyance to Scutari. It has been reported to me that one of the two operated on, on the 21st, Peter Sullivan, 33d Regiment, died at Scutari General Hospital on the 11th of October, three weeks from the date of the operation, ‘from excessive debility.’ Nothing could be ascertained about Peter Cleary, 23d Fusiliers; it is therefore most likely that he died on the passage.

“The Russian died on the 22d of October, ‘from great debility and extensive sloughing.’

“A shoulder-joint case in the 90th Regiment never had a bad symptom, and the wound is all but healed. The flap in this case was made from the axillary portion of the arm, the deltoid having been all but destroyed.

“The flap operation has been invariably performed in the Light Division, with but two exceptions, viz., one of the arm and the other of the thigh.”

Excision of the head, neck, and trochanter of the femur, with portions of the shaft, has been performed at least six times before Sebastopol. The result has been unfavorable in five, although in all there were well-grounded expectations of success for weeks. In one case by Mr. Blenkins, of the Grenadier Guards, he informs me, it was for the first three or four weeks very favorable. The man, however, sank at the end of the fifth week from deposition of matter in the knee-joint. (See p. 42 et seq.) Of the second case, which occurred in the general hospital in the camp and ended fatally, I have no further notice. The third, in the 68th Regiment, in charge of Mr. O’Leary, the operation performed on the 19th of August, was going on most favorably on the 5th of October.

Private Thomas M’Kenena, aged twenty-five, was struck by a fragment of shell, on the 19th of August, over the great trochanter of the left femur. The wound, nearly an inch in length, extended down to the bone, which was distinctly fractured. Some loose scales could be felt at the bottom of the wound. On examination, the injury appeared to be a transverse fracture of the neck of the thigh-bone, apparently involving the joint.

After a consultation with superior medical officers, it was decided that excision should be performed, which was done without difficulty. No vessels required ligature, although the man lost a considerable quantity of blood.

The excised parts, which are herewith forwarded, show that the nature of the injury was different from what it was supposed to be, and that the head of the bone was intact.

After the wound, about five inches long, had been sewn up, the limb was placed in a sling made of strong canvas, and was swung from a beam over the man’s cot, the bed being raised.

This method of treatment was adopted with a view to encourage approximation of the upper end of the bone to the pelvis, and by pressure on the sides of the limb to prevent the accumulation of matter among the tissues. The man progresses favorably.

Diet was very generous.

J. C. O’LEARY,

_Surgeon, 68th Light Infantry_.

Camp, 4th Division, Crimea, Sept. 14, 1855.

The bones removed are in the museum of the Royal College of Surgeons.

The fourth case is given at length by Staff-Surgeon Crerar, as follows:--

Private William Smith, First Battalion First Royals, was brought to hospital from the Greenhill trenches, in front of Sebastopol, about twelve P.M., on the 6th of August. On questioning him, I ascertained that an hour or so before he was struck by a fragment of an exploded grenade, which first broke into small pieces a water canteen which was suspended over the left hip, and then made an opening or wound about the size of a shilling nearly a quarter of an inch posterior to the great trochanter. Crepitus was quite distinct on moving the limb; and I easily ascertained, on exploring the wound with my finger, that a fracture through the trochanter had taken place, but was quite unable to ascertain to what extent upward and downward the fracture extended. I accordingly solicited a consultation with Deputy Inspector-General Taylor and Staff-Surgeon Paynter. After a careful examination, (the patient being under the influence of chloroform,) the femur was discovered to be comminuted. Excision at the hip-joint being recommended by these officers, in which opinion I concurred, I proceeded to perform the operation by commencing an incision, nine inches in length, in a line with and two inches posterior to the anterior superior spinous process of the ilium, and carrying it down in a straight line directly over the trochanter major; a second incision about two and a half inches in length was made, commencing immediately below the trochanter backward through the gluteus maximus; by a little easy dissection the seat of fracture was exposed, the trochanter was found broken into several portions, detached and imbedded in the contused muscles around, from which they were at once removed. The fracture was found to extend obliquely inward about an inch and a half along the shaft of the bone. The femur was now protruded through the wound, and I sawed off the whole of the fractured bone, leaving a smooth, clean surface; I then proceeded to disarticulate the head of the femur, which was effected without difficulty. Scarcely three ounces of blood were lost, and little or no shock was induced; only one small bleeding point was secured near the tail of the wound, and the divided parts were brought together by two sutures and bands of adhesive plaster.

At twelve A.M., two hours after the operation on the 7th instant, his pulse being rather feeble, he was ordered some wine and water.

7th, vespere.--Countenance cheerful, voice strong; says he intends keeping up his pluck, and is sure he will get well; has no inclination to take the beef-tea ordered for him, but has had some arrow-root and wine. To have a morphia draught at bedtime.

8th.--Passed a good night; limb in a good position; retracted about two inches; wound looks healthy; pulse 100, soft; has made urine freely; skin moist; bowels were opened freely in the night.

9th.--Slept well at night; says that he feels very comfortable; skin moist; pulse 120; sutures were removed, and the wound allowed to gape; it has a remarkably healthy appearance. To go on with the simple water dressing, chicken-broth, arrow-root, and wine.

Vespere.--Has been very cheerful all day; limb has retracted about another half inch; pulse 112.

10th.--Passed a more restless night, in consequence of not having the morphia draught as early as the previous night; has had several hours’ sleep this morning, and is more refreshed; pulse, on waking, from 114 to 120, skin comfortable; no sign of distress in his aspect; wound suppurating healthily; bowels were opened again once last night.

10th, vespere.--Has been very easy all day; skin cool; tongue normal; pulse 120, soft and regular; has had to-day two eggs, one ounce of arrow-root, two gills of wine, and two pints of chicken-broth, all of which he relished much. To have a grain of acetate of morphia in solution at bedtime.

11th.--Slept soundly all night; when I visited him, at six A.M., he had just awoke; pulse 115, soft; appears contented and comfortable.

Vespere.--Doing well; wound continues to look healthy; position of limb good; has consumed a fair quantity of chicken-broth, beef-tea, arrow-root, and three gills of sherry to-day; pulse 113 at eight P.M.

12th.--Bowels were opened in the night; the introduction of the bed-pan gave him a good deal of annoyance; the air of the hut was rather stagnant last night, and he did not sleep as well as usual; pulse 120, soft; tongue continues clean and moist; there is more discharge from the wound to-day.

Vespere.--The progress of the case is most satisfactory; had a fresh egg, tea, and toast for breakfast, his own selection, which he appeared to relish greatly; at twelve he had two mutton-chops and a glass of wine, and at five P.M., a pint of chicken-broth, with bread, and a second glass of wine. The morphia draught as usual.

13th.--Continues to look happy and contented. Healthy-looking granulations are evident over two-thirds of the wound; swelling of limb subsiding; discharge from wound healthy; pulse 114, regular and soft; all the symptoms are so very favorable that I have every reason to expect a successful issue.

14th.--A small slough at the lower part of the wound, remainder healthy and clean; tongue a little too dry this morning, and he has more thirst than usual; pulse 118. To have effervescing draughts of bicarbonate of potassa and citric acid three times a day; to continue simple water dressing.

Vespere.--Thirst not so urgent; tongue cleaner and moister; has a feeling of fullness in the abdomen. To have his usual morphia draught and an ounce of castor-oil at bedtime.

15th.--Passed three large stools in the night, with great relief; aspect resigned, and his spirits continue good; slough has come away; pulse 118, soft and regular; skin tolerably cool.

Vespere.--Felt a good deal exhausted to-day from the heat, which was very great--ninety-two degrees.

16th.--Looks heavy and out of spirits this morning; discharge has increased, but is of a better quality since the slough separated; tongue dry, inclined to brown; pulse the same, skin rather hot; continue effervescing draughts every third hour.

Vespere.--Tongue more moist, less thirst. When asked how he felt, he replied, with a great deal of life in his countenance, “I am very well, and I feel very comfortable;” asked for a mutton-chop early in the day, which he got, and appeared to like; he had at different times in the day arrow-root, chicken-broth, and wine.

17th.--Wound looks very healthy, and the general symptoms very favorable to-day; tongue clean and moist; less thirst; skin cooler; had him removed to a fresh bed without a great deal of pain or trouble; limb retracted less than three inches; position now good since he was shifted.

18th.--Very much worse this morning; had a rigor about ten A.M. yesterday; features now sharpened and pinched; tongue dry and brown; pulse thready, about 125.

Vespere.--Continues in a very low state; wound has a very healthy appearance; discharge healthy, but not as abundant as it was; has had besides wine, a pint and a half of porter, mutton-broth, and a chop to-day; zinc lotion to the wound.

19th.--When I visited him at six A.M. to-day, I was much pleased to find him looking quite cheerful; pulse soft, 112; skin cool and moist, paler than usual; wound doing well. Continue zinc lotion to the sore, and to have his choice to-day of mutton-broth, beef-tea, or chicken-broth; arrow-root to be given twice, four gills of sherry or port as usual.

Vespere.--No change to report.

20th.--Looking rather pale, and features pinched; pulse better, about 100, soft; skin cool; tongue more coated than usual, inclined to be dry. I fear this case is a bad one, not likely to terminate as we so much desire.

Vespere.--Has been very uneasy all day; skin hot; tongue dry.

21st, six A.M.--Has just awoke, having been asleep since nine last night; says that he feels stronger; aspect certainly improved since the last visit; coating on the tongue thicker, brown; the pulse has more strength than it had yesterday; no feeling of uneasiness; wound looking remarkably well, and discharging laudable pus; asks for cold drinks; to have his choice of iced soda, tamarind, toast or rice water; diet the same as yesterday.--Eleven A.M.: has fallen off very much since the morning, features pinched and blue; pulse irregular, small, and wiry.--Twelve nocte: continues to sink; died at half-past twelve P.M.

Examination of the limb six hours after death.--Cut surfaces of femur perfectly smooth; bone easily denuded of its periosteum; acetabulum smooth; muscles infiltrated with pus; nature had not made the slightest attempt to repair the loss.

What would the result have been if amputation at the hip-joint had been performed? The same. The vis medicatrix naturæ is not sufficient to carry our sick through such formidable operations; it is no fault of the surgeons. A better and a more liberal allowance of animal and vegetable food during health is required, if England expects her soldiers to survive severe operations, disease and wounds. An attempt to save the limb, for the very same reason, would, most undoubtedly, have been a failure. Our Minié rifle-ball fractures of the femur all sink under conservative surgery. Our amputations above the middle of the thigh have a like issue; it is truly disheartening.

J. CRERAR, _Surgeon_, _68th Regiment_.

Camp before Sebastopol, 24th August.

Dr. Crerar was greatly distressed by the loss of this man, and the manner in which he expresses his grief is declaratory of his feelings. The excised bones are in the museum of the Royal College of Surgeons.

The fifth, by Dr. Hyde, ended fatally on the sixth day.

Corporal Benjamin Shehan, 41st Regiment, advanced with his corps, about twelve o’clock, on the 8th of September, to storm the Redan. Having succeeded in getting into the work, the regiment was afterward obliged to retire; in the retreat to our trenches he was wounded, and lay on the field till the following day, when he was brought to the hospital of the Royal Sappers and Miners. On examining the wound, it was found that a grape-shot had entered at the great trochanter, and, passing inward and a little forward, had passed out at the groin of the same side, about an inch below Poupart’s ligament, externally to, and a little in front of, the femoral vessels. The lower fragment of the fracture protruded through the external wound, and the introduction of the finger discovered a comminuted state of the neck of the bone.

Excision of the joint having been decided on, the operation was performed in the presence of Deputy Inspector-General Taylor, Staff-Surgeon Dr. Paynter, and Surgeon Elliot, Ordnance Department.

Operation performed about one P.M. 9th of September.--An incision, about four inches in length, commencing a little above the trochanter, was carried downward along the outer side of the femur. The lower fragment, for about an inch of its extent, was cleared of its attachments. An assistant holding the thigh below, and pushing the bone upward and outward, so as to bring the fragment through the incision, about an inch of the bone was then sawed off. The head of the bone was next dissected from the socket; this part of the operation was considerably facilitated by an assistant catching a firm hold of the neck by means of a pair of tooth forceps, then rotating the head, and using slight force to dislodge it from the cavity, the operator dividing the capsular and round ligaments, the latter of which is more easily and safely divided at the lower and outer side of the articulation. The upper part of the trochanter was next dissected out, and several small spiculæ of bone removed. The edges of the incision were then brought together by sutures, and a bandage applied. It was not found necessary to tie any vessel, and there was very little hemorrhage. The man bore the operation well, and was returned to his bed in good spirits, and with a good pulse.

10th.--Passed a good night; slept pretty well; pulse 106, soft; skin cool; in good spirits.

11th.--Slept some hours; pulse 106, soft; bowels open; tongue furred, but moist. Wound dressed and looking well; some healthy discharge.

13th.--Going on apparently very well; pulse still 106; countenance good. Vespere: Complains of an increase of pain in the hip, but otherwise says he feels much as usual; pulse small and rapid. Ordered wine and arrow-root.

14th.--Died at six this morning.

The autopsy showed a considerable cavity filled with sanies in the situation of the operation, but no other fractured bone was discovered. The articulating surface of the acetabulum was coated by a fetid, pasty substance.

GEO. HYDE, M.D., _Staff-Surgeon_.

The sixth, by Staff-Surgeon Coombe, also ended fatally.

Private James Nadauld, aged twenty-one, First Battalion Rifle Brigade, was admitted into the Castle Hospital, Balaklava, upon the 16th of July, 1855, five days after the receipt of a gunshot injury of the right shoulder. Upon the 19th of July the head of the humerus was excised, and the ball was found impacted in it. The healing process went on most favorably, and the man was discharged upon the 26th of August, quite well, for the purpose of proceeding to England. The excised bone is in the museum of the Royal College of Surgeons.

W. H. McANDREW, M.D.,
_Surgeon, 57th Regiment_.

Camp, Sebastopol, Sept. 14th, 1855.

Private John Purcell, 57th Regiment, aged twenty-one, was wounded upon the 18th of June, in the unsuccessful assault upon the Redan, by a Minié rifle-ball, which passed directly through the head of the humerus, but did not touch the glenoid cavity. Upon the 22d of June, the head of the bone was excised; and upon the 26th of August, the man was discharged from hospital, quite well, for the purpose of proceeding to England. The excised bone is in the museum of the Royal College of Surgeons.

W. H. McANDREW, M. D.,
Surgeon, 57th Regiment.

Camp, Sebastopol, Sept. 14th, 1855.

The following case of wound of the larynx is instructive:--

Lieutenant Charles H. Evans, 55th Regiment, aged nineteen years, was wounded on the evening of the 5th of August, 1855, about eleven o’clock P.M., while on duty in the trenches. The ball entered the right side of the neck, close to the angle of the jaw, and passed apparently between the hyoid bone and the arytenoid cartilages, and then downward, having its exit below the cricoid cartilage on the left side. The pharynx and larynx were wounded, and the trachea was contused and displaced. Respiration somewhat hurried; a quantity of mucus collects in the trachea, and is expectorated in fits.

About seven o’clock P.M. of the 6th, the respiration becoming more difficult, with a degree of lividity of the lips, indicative of the non-oxygenation of the blood, it was deemed advisable to have recourse to tracheotomy, which, in consequence of the displacement of the parts and the swelling, was effected with considerable difficulty. The usual tubes were found too short for the purpose, and a large silver catheter was inserted, through which the air passed freely. Whenever he attempted to drink, the liquid passed into the trachea through the openings caused by the ball. From the operation no benefit arose, and he continued very restless until within an hour of his decease, which took place about twenty-six hours after the receipt of the wound. The voice was never heard above a whisper.

Post-mortem examination, twelve hours after death. The ball would appear to have passed through the hyo-thyroid membrane, fracturing and shattering the thyroid cartilage. The membrane lining the glottis was torn and destroyed. The vessels escaped without injury, the ball having passed anteriorly.

ARCHD. GORDON. M.D.,
_Staff-Surgeon, 1st Class, in Med. Charge, 2d Division_.

Camp before Sebastopol, September 3, 1855.