Chapter XXVII: Part 27

Deputy Inspector-General Taylor, who was present during the operation, adds: “The want of a longer tracheal tube than is commonly supplied for such operations was obvious, and is a good practical hint. For the first time in my life I found my two forefingers transfixing a man’s neck from side to side. The fingers did not cause any cough or irritation, but those symptoms were occasioned by the least attempt to swallow water. The thyroid cartilage was separated into two pieces.”

The following cases, one of wound of the profunda femoris, the other of the popliteal, deserve attention:--

Late in the afternoon of the 14th of August, Private George Irvine, aged twenty-five, was brought from the trenches, having been struck by a Minié-ball of the largest size, which had penetrated the left thigh, about two inches below Poupart’s ligament, just in the course of the femoral artery. The ball passed slightly outward, fracturing the femur, and was cut out at the back of the limb, completely flattened. As there was considerable hemorrhage, both venous and arterial, no examination with the finger was permitted. Dr. Taylor, superintending the Division, having been informed of the case, a consultation was held.

Amputation at the hip-joint was forbidden by the prostration of the man, who had lost much blood before he was brought to camp. Excision of the head of the femur was also inadmissible, from the evident wound of a large artery, with probably that of a large vein. Search for the wounded artery, for the purpose of applying a ligature, was then determined upon, but before the operation had well proceeded, the hemorrhage was so great that it was found impossible to continue it, and pressure by means of graduated compresses was resorted to, with complete success.

On the following morning an operation was still out of the question. Prostration continued, with great irritability of stomach, and a small, quick pulse. No return of hemorrhage, though the pressure of the tourniquet was but very slight.

On the 16th, the pulse was more quick and irritable, with the same irritability of stomach, and urgent thirst. He had passed a better night, however. At the consultation this morning, the circulation through the posterior tibial artery was so evident that the question of the femoral artery being wounded was set at rest. It was decided, as no return of hemorrhage had occurred, that the case should be left to nature.

On the 17th, he suffered from starting pains in the thigh. There was less irritability of stomach, but the pulse was very small and weak. During the night there was slight hemorrhage, owing to his restlessness, but it was easily arrested by a turn or two of the tourniquet.

On the evening of the 20th, this restlessness increased; delirium set in, and early in the morning of the 22d he died.

The limb was examined after death, when the following appearances presented:--

Femoral artery intact. Femoral vein wounded, with more than half its caliber shot away. At about two inches from its origin there was a wound of the profunda artery, on which an aneurism, nearly the size of a pigeon’s egg, had formed, and passed upward through the wound made by the ball. The profunda vein was intact. The injured vessels having been removed for preservation, the bone was then cut down upon, when a fracture, nearly transverse, and not at all comminuted, was observed below the trochanters. No splitting of bone upward; downward its outer plate was slightly cracked, but nothing more. The preparation is in the museum of the Royal College of Surgeons.

Private James Ross, a lad of eighteen, was brought up from the trenches, on the morning of the 3d inst., having had his right leg blown off below the knee by a round shot. He had lost a very large quantity of blood before the tourniquet was applied, and was consequently so much collapsed that an operation was out of the question. He was therefore dressed and the tourniquets (two had been put on) removed. He never rallied, and died on the 12th, nine days after the receipt of the injury. No hemorrhage ever occurred, though all pressure had been removed from the artery.

R. V. DE LISLE,
_Surgeon, 4th King’s Own Regiment_.

Camp before Sebastopol, Sept. 14, 1855.

The following is worthy of publication, as showing the successful effects of strychnia, when carried to the extreme verge of propriety, in injuries of the spinal cord.

Sergeant William Aldridge, 46th Regiment, aged 39 years, during a sortie from Sebastopol, was knocked down in the trenches, and his back formed a bridge over which Russians and English passed. The result was serious injury to the spine, causing paralysis of the lower extremities and bladder. The pain was excruciating, and the patient could not be moved in bed for several weeks.

On the 4th of March, 1855, he was placed under my charge in the military hospital at Portsmouth, when he complained of great pain and tenderness along the spine, and incontinence of urine, together with wandering day dreams and insomnolency at night. Solution of the muriate of morphia ʒj was prescribed without any effect. (ʒj contains 1 gr.) The dose was gradually increased to ʒij of the solution.

15th March.--Fell out of bed during the night, trying to hide himself. Is wandering, and fancies that he has deserted from the Crimea, and will be shot. The narcotic has been omitted for several days. Strychnia was now ordered, one-sixth of a grain three times a day.

20th.--Continues much the same, with slight twitchings of the face.

25th.--Has been unconscious for three days. Now complains of intense pain in the back and violent cold perspiration.

28th.--Returning consciousness; feels easier, having slept uninterruptedly for forty-eight hours. Expressed a desire to make his will, and send to Dublin for his wife; both wishes were complied with.

30th.--Sensation and motion are gone from the lower extremities, and the urine is still passed involuntarily. One-eighth of a grain of strychnia was ordered twice a day.

31st.--Is powerfully under the influence of the remedy, with convulsive movements of the upper and lower extremities; wild stare and fixed jaws. The lower extremities had not moved for several months previously. This paroxysm lasted for one hour under my own observation, after which the muscles became relaxed, the face bedewed with a gentle perspiration, and resumed its ordinary tranquil appearance.

April 2d.--Feels greatly relieved from pain, and is comparatively comfortable; sleeps calmly. His appearance is entirely changed; looks natural; features calm; is cheerful, and reads the papers. Strychnia was omitted for some days after the last paroxysm, and replaced by the tincture of the sesquichloride of iron with quassia, and a generous diet.

6th.--Continues to improve. Has now and then slight twitchings in the legs and arms. The strychnia was resumed and omitted, as the symptoms indicated, to the end of the month.

May 1.--Is greatly improved; goes about the balcony in a chair. Returning sensation in the right leg. Bladder still not under the control of the will.

20th.--Sensation much improved in both legs, and motion increasing in the right leg.

25th.--Convulsive movements all over the body, resulting from the use of the strychnine. Lower extremities decidedly improved both in motion and sensation.

June 1st.--Maintains his improved condition. Recommenced the strychnine to-day, without any marked effect at the moment.

10th.--Violent tetanic spasms followed the employment of the remedy, producing considerable increase of motion in both extremities. The paroxysms _usually_ continue about fifteen minutes, when the muscular system resumes its ordinary appearance.

20th.--Continues the same. Strychnia not resumed since last entry, as occasional twitchings occur about the head and face, and he is now affected by the smallest dose.

July 1st.--General health excellent.

10th.--Continues to improve daily in regaining the use of his limbs. Is now able to walk on the ramparts with crutches, but is exceedingly sensitive to every change of weather--damp always causing pain in the spine. Continued to improve to the end of the month.

August 1st.--No change worthy of note.

14th.--Discharged to Chatham.

T. H. BURGESS, M.D.,
_Military Hospital, Portsmouth_.

The following case of injury of the abdomen, sent to me by Dr. Rooke, civil surgeon with the army in the field, is very remarkable:--

Robert Cousins, aged 20, 77th Regiment, was admitted into the general hospital, camp, June 8th, with severe injuries caused by a round shot, which struck him when he was on duty in the advanced trenches. When the shot struck him he was standing up, half-face toward the enemy, his right arm extended in front of the right hip; he was in the act of reaching his water-can, which rested against the parapet of the trench.

On admission he was in a state of semi-collapse, the integuments of the right hand and forearm greatly lacerated, the wrist-joint laid open, the bones of the carpus comminuted; the radius and ulna were also fractured at the middle third. There was a lacerated wound in the right iliac region, the size of the palm of the hand; over this space the skin and muscles of the abdominal wall were torn away, the peritoneum lining it was also lacerated, and at the bottom of the wound was seen a coil of intestine in situ; there was no tendency to protrusion, nor were its coats at all injured. The crest and body of the ilium were much comminuted, the fracture extending downward between the anterior superior and anterior inferior spinous processes. The anterior superior spinous process was broken off. There was another wound just below the great trochanter; this apophysis was also shattered. The right limb was two inches shorter than its fellow, the foot everted, but, from the great comminution of the pelvis and the extreme pain produced by examination, it was not satisfactorily made out that the neck of the femur was fractured, but the shortening of the limb and eversion of the foot were in favor of that diagnosis. The injuries which the patient had received were considered mortal; it was thought unnecessary cruelty to amputate the forearm. Such pieces of the ilium as were loose were removed; wet lint applied to the wounds; and brandy and water with opiates were ordered. One of his comrades volunteered to watch over him, and he was left, as all thought, to die. The next day (June 9th) he had partially rallied from the state of collapse; had taken liquid nourishment--beef-tea, arrow-root, etc. There was no pain or tenderness of the abdomen; had passed his water without difficulty. The surface of the abdominal wound was sloughy; intestine still visible; complains of pain in the arm. It was not yet considered advisable to perform any operation. He was ordered opium gr. j every four hours; also a dose of morphia at night, arrow-root, beef-tea, and port wine, which he prefers to brandy.

10th.--Has rallied completely; no pain or tenderness of the abdomen; complains greatly of his arm, and is anxious that something should be done. He slept well after taking the morphia; his face is tranquil, breathing natural, pulse weak; no irritability. Deputy Inspector-General Taylor saw the case in consultation with Dr. Mouat, P. M. O. of the hospital. It was decided to amputate the forearm. This was done at the upper third; chloroform was administered, and produced no ill effects. He was ordered any fluid nourishment he might fancy, with port wine, and an opiate at night.

11th.--No symptoms of peritonitis; suffers no pain; tongue clean and moist; pulse quiet; passes his water regularly; the bowels have not acted. The abdomen is quite soft and fallen, not the slightest tenderness on pressure. To continue on the same plan. He could now give some account of the way in which he was wounded. He stated that he thought it must have been a round shot that struck him. It first struck his arm, then entered the right iliac region, emerging at the lower wound. The surface of the wound in the iliac region is in a sloughy state from the severe bruising of the parts. The coil of intestine is still visible at the bottom of the wound.

12th.--No symptoms of peritonitis; bowels have not acted; tenderness down the outside of the thigh, with redness of the skin, and pitting upon pressure. Stump dressed to-day and looking well.

13th.--No unfavorable constitutional symptoms. The outer part of the thigh is tender and the skin red; free incisions were made; the fascia was sloughy. He takes nourishment; has eight ounces of port wine daily, eggs, arrow-root, and essence of beef. Bowels not acted.

21st.--He had no symptoms worthy of remark since the 13th. The bowels have not been moved; he complained to-day of not being able to pass his motions. Two injections of warm water were administered in the course of the day. He passed a large quantity of hardened feces, which relieved him greatly. The sloughs are separating from the incisions in the thigh; the crest and ala of the ilium are exposed; healthy granulations are springing up from the bottom of the wound. Stump healing favorably.

July 26.--The case has progressed without a bad symptom. At first it was thought that the greater part of the ala of the ilium would exfoliate, but some red points appeared on the surface, and the concavity of the bone became covered with granulations. The exfoliation was limited to the anterior part of the crest of the ilium, which separated on the 17th instant. At various times pieces of bone have been removed as they became detached; there are others still left to come away. The granulations on the upper wound are on a level with the skin of the abdomen. The crest of the ilium is covered with granulations; the wound is contracting, but there is a deficiency of skin to cover the projecting portion of the ilium. The lower wound is also open, and has been enlarged to remove pieces of bone; the incisions in the thigh have healed. The bowels have acted regularly without medicines until to-day, when he required a castor-oil injection. The right thigh is more than two inches shorter than the left; union appears to have taken place; he has no pain on motion. The dead bone that still remains alone prevents the wounds from closing, their surfaces being covered with healthy granulations. His general health is good. He has taken at intervals some oleum jecoris aselli, and, for a mild attack of bronchitis under which he suffered at the end of June, expectorants and diaphoretics. There has not been a single symptom of any abdominal complication. He has an opiate at night. The stump has been healed nearly three weeks.

September 14th.--Since the last report no unfavorable symptoms have occurred. The stump of the forearm has been healed some weeks; his health is good; indeed, from first to last, he has not had a single symptom denoting constitutional disturbance. All the dead bone from the crest of the ilium has separated; the wound of the abdomen is skinned over, with the exception of a small spot about the size of a sixpence. This is healthy, and is gradually healing. The bowels act regularly. There are still two sinuses on the outer side of the thigh--one above, the other below, the great trochanter. On probing these, dead bone is felt, which has not yet separated. The right limb is about three inches shorter than the left, is freely movable in any direction without pain. He can raise the knee from the pillow, but cannot lift the heel from the bed; he can, however, turn himself over on to the left side without assistance. The prominence of the crest of the ilium is greatly diminished from loss of bone. The trochanter major is unusually projecting; the natural appearance of the hip-joint is entirely gone. The injuries to the bones have been so severe, it is difficult to say what changes have occurred. The ilium and pubis have been greatly comminuted, the fracture most probably extending through the acetabulum. Immediately below Poupart’s ligament, to the outside of the femoral artery, a hard substance is felt beneath the skin. This, when he was admitted, was at first supposed to have been a piece of a shell, but it is now thought to be a portion of the pubis driven downward upon the thigh.

He may now be said to be convalescent.

* * * * *

John Shehan, aged nineteen, 57th Regiment, was wounded in the left thigh before the Redan, on the 18th of June. He was brought to the general hospital, and placed under the charge of a gentleman of considerable skill and experience. The wound presented two openings, an anterior and a posterior; the latter offered greater facilities for examination than the former; the finger, passed from behind, detected several fragments, which were removed, and as a tolerably uniform surface of bone (_vide_ specimen) was then felt, it was determined, after consultation, to make an attempt to save the limb. The injured extremity was accordingly bound up with a long splint in the most careful manner, and matters promised favorably for a time. He, however, complained of a good deal of suffering in the limb from time to time, gradually wasted, suffered from diarrhœa, and finally sank on the 6th of August. On examination post-mortem, I found the chief organs in a normal condition. There was some congestion of the ilium, and the colon presented a few points of ulceration. The condition of the parts in the left lower extremity was very remarkable. Beneath the integuments, all the muscular and other textures, from the seat of injury to the groin, were converted into a soft, broken-down, black, rotten mass; and I may here observe that this low but intense disorganizing process, extending through the greater part of the limb, has presented itself in several of my examinations of somewhat similar injuries, and appears to me to be connected with _a peculiar pathological state in which all the vital organs remain sound, but the vis vitæ is remarkably reduced below par_. The fractured bone it is unnecessary to describe. The vertical and cross infraction of the fragments and its almost “arborescent” appearance are most remarkable. I look upon it as a specimen of no ordinary value, conveying more than one most useful lesson. The bones are in the museum of the Royal College of Surgeons.

R. D. LYONS,
_Pathologist to the Army in the East_.

Camp before Sebastopol, August 30, 1855.

Private William Leah, 30th Regiment, aged twenty-one, was brought to me on the 27th of June, while I was on duty in the trenches, with fracture of the external condyle of the humerus of left arm, by a musket-ball, which had entered the joint between it and head of radius, and had made its exit over olecranon process of ulna. Artery uninjured. On being sent to camp, the joint was excised by Mr. Dowse, surgeon of the regiment. The patient progressed favorably, and the wound has been healed for nearly a month. He can use all the muscles of the forearm, except the flexor of the little finger, and is regaining the motion possessed by the elbow-joint.

DAVID MILROY, M.D.,
_Assistant-Surgeon, 30th Regiment_.

Camp, Second Division, Heights of Sebastopol, Sept. 5, 1855.

J. Maguire, 31st Regiment, aged twenty, wounded in the advanced trenches.

July 12, five A.M.--Carried into hospital, wounded by a splinter of shell in left elbow and on left hip. The splinter struck him in an oblique direction, from behind, fracturing olecranon process and internal condyle of humerus, lacerating and otherwise injuring the joint, the ulnar nerve being also injured. The splinter continuing its onward course, inflicted a lacerated wound on the hip, with comminuted fracture of about the anterior fifth of the crest of the ilium, several small pieces of bone being driven in on the peritoneum, causing pain on the slightest motion. All the loose portions of bone were removed, and several others separated from the muscles. Abdomen painful, and swollen at that side. Abdomen continued painful during the day; bowels acted; he also passed water freely.

13th.--Pain in abdomen much less; little, if any, constitutional disturbance; elbow extremely painful; the pain accompanied with partial paralysis of the little and ring fingers. Staff-Surgeon Dr. Gordon having seen him, and not apprehending any danger from the wound in the side, the operation for excision of the elbow-joint was determined on, and performed under chloroform, by a single straight incision passing through the original wound, including the upper and lower fourths of the forearm and arm. There was very little hemorrhage. The arm was then put up in an angular splint. It continued to progress favorably, the greater part healing by the first intention. There was some suppuration, but a free exit being given to the matter, it did not retard recovery.

August 19th.--This patient was discharged from the regimental hospital, to general hospital, Balaklava. The wound nearly healed; sensation partially restored to the fingers; slight motion at the bend of the elbow; but he has not power to raise the hand.

THOMAS J. ATKINSON,
_Assistant-Surgeon, 31st Reg. in Med. Charge_.

Camp before Sebastopol, Sept. 1, 1855.

Private Anthony Murray, aged twenty-eight, 41st Regiment, a healthy man, was struck, while on duty in the trenches before Sebastopol, on the night of the 23d of July, 1855, by a portion of a shell, which penetrated the left elbow-joint; the head of the radius and the outer half of the articulating surface of the humerus were comminuted, fragments being impacted in the cancelous structure of the humerus, and driven in between that bone and the ulna. Excision of the joint having been determined on, it was performed in the following manner: a straight incision was made along the posterior surface of the joint, the olecranon cut through, and the extremities of the several bones removed in succession; the parts were then brought together by suture, and the limb placed in a flexed position; about a third of the wound healed by the first intention; no inflammation supervened. On the 3d of August the wound was granulating in a healthy manner; on the 22d, it had almost healed, and the limb was put up permanently, the forearm at right angles to the arm; on the 31st, some union had taken place between the bones; the man can move the thumb and three fingers; he is free from pain; his health is very good, and he appears to be progressing favorably in every respect.

J. E. SCOTT, M.D., _Surgeon, 41st Regiment_.

August 31st, 1855.

Private Jesse Lockhurst, 31st Regiment, aged twenty-six, was wounded in the advanced trenches, 17th of August, 1855.

August 17th.--Six o’clock A.M., carried into regimental hospital, having received an extensive lacerated wound of right cheek: very little apparent hemorrhage, but the power of deglutition was completely lost, and respiration impeded. On making an examination of the wound, it was ascertained that the right superior maxillary bone was fractured, and a portion of the hard palate with the molar teeth driven in on the tongue; there was a large piece of shell or shot lodged at the bottom of the wound, lying on left palate, and, as far as could be ascertained, on the back of pharynx. Staff-Surgeon Dr. Gordon being present, the ball, after much labor, was extracted, and found to be a grape-shot of seventeen and a half ounces weight. During the operation it was found necessary to dilate the wound by dividing the lip near its external angle--the portions of bone that were removed were the alveolar process, with all the molar teeth, including part of the palate and a portion of the orbital plate and nasal process of the superior maxillary bone, and all the malar bone. There was no serious hemorrhage during the operation, nor immediately after the extraction of the shot. The cheek was then plugged with lint and the wound brought into apposition by sutures. The man experienced immediate relief after the operation, sat up in bed, washed out his mouth, and drank some water; he seemed extremely thankful, and blessed the doctors. During the night and part of the next day there was some oozing from the mouth. No bad symptom occurred until the 20th, when an active hemorrhage came on from the back of the palate. The exact source could not be ascertained. He became very weak and almost pulseless; but the hemorrhage was eventually restrained by means of ice and plugging the wound with lint moistened in tincture of matico. Iced drinks occasionally.

31st.--The man is now doing extremely well, can talk, and takes a pint of jelly daily; the external wound is not yet quite healed, in consequence of the saliva flowing through it. The right eye is uninjured, and sight unaffected.

September 1st.--He has just been discharged to general hospital, Balaklava, from the regimental hospital.

THOS. J. ATKINSON, _Assistant-Surgeon_,
_31st Regiment, in Med. Charge_.

Camp before Sebastopol, September 1, 1855.

On the morning of July 24th, Private Francis O’Brien, a lad of eighteen, was brought from the trenches, with a wound from a musket-ball in the right temple. It entered about two inches above the orbit, passed downward, and drove out a large portion of the supra-orbital ridge, which appeared to be imbedded in the upper eyelid, and was cut down upon by the medical officer in the trenches, in mistake for the ball, which it certainly very much resembled. As no ball could be found, it was supposed to have passed out at the opening of entrance.

The finger when passed into the wound could feel the pulsation of the brain, yet from that day to the present no symptom of cerebral disturbance has appeared, unless it be that since his convalescence the muscles of the face work convulsively when he feels faint and weak from remaining too long in the erect posture. About a month after admission, the detached portion of the bone above the orbit was removed from the eyelid, though with considerable difficulty, and on the following morning the ball fell from the wound, much to the poor lad’s horror, who thought his eye had dropped out.

Both wounds have now healed, but he is unable to raise the right eyelid; the eye is perfect, but apparently without power of vision, though sensible to the stimulus of light, for on turning the wounded side to the light, the left pupil contracts. His general health is good.

R. V. DE LISLE,
_Surgeon, 14th King’s Own Regiment_.

Camp, Sept. 10.

Private Joseph Bourke, 17th Regiment, admitted on 9th of September, 1855, with fracture of anterior superior angle of right parietal bone, with depression of about one-third of an inch, for the size of a florin. No attempt was made to elevate the depressed portion. Has not had a bad symptom. Wound of scalp nearly healed.

W. P. WARD,
_Surgeon, 17th Regiment_.

Private Michael Caffrey, 88th Regiment, wounded at the attack upon the Redan on the 8th of September, was brought to the hospital of the 38th Regiment on the morning of the 9th. A round rifle-ball struck him at the anterior part of the left parietal bone, and passed through the brain in a line which brought it out at the vertex, fracturing the parietal bone of the opposite side; the ball at its entrance split, and one-half pushing before it a small piece of bone, both lodged at the entrance; the other half of the ball was found lodged in the brain at the upper and back part, having detached a circular portion of the skull.

A director was passed along the track of the wound, and the scalp laid open; the brain was found to protrude through the fracture. In this condition the patient lived for eleven days, utterly unconscious of everything passing around him, the urine and feces coming away involuntarily. There was paralysis of the opposite side.

A post-mortem examination showed the brain to have been reduced to a pultaceous mass only in the direction of the passage of the missile; the remaining portion of the wounded hemisphere and that of the opposite side were healthy.

The absence of the usual train of head symptoms, and the length of time which so extensive an injury permitted life to remain, render this case worthy of some remark.

FREDERIC WALL,
_Surgeon, 38th Regiment_.

Camp before Sebastopol, Sept. 20, 1855.

Private William Doyle, 19th Regiment, aged nineteen years, was wounded in the head by a rifle-ball, in the advanced trench of the right attack, on August the 30th. The scalp and pericranium were cut about two inches, and a portion of the cranium, a little in advance of the posterior and superior angle of the right parietal bone, close to the sagittal suture, about an inch in length and half an inch in breadth, was depressed. According to statement the man was rendered perfectly senseless and motionless, from the instant of being struck by the bullet. On reaching camp he presented all the usual symptoms indicating compression; pupils dilated and fixed, warm surface, total unconsciousness, complete paralysis, etc. On examination of the depressed portion of bone, no opening whatever could be felt; the edges of the sunk bone and the bone adjoining were in contact, and it was presumed to be an ordinary case of fracture with depression simply. Some very minute portions of cerebral substance were observed to be mixed with the clot of blood about the wound, such as might be squeezed through a fissure. Trephining being determined on, it was performed at once, and the depressed bone raised without difficulty. No relief of symptoms followed. The dura mater bulged slightly upward into the opening. On passing the finger over its surface, a little beyond the space exposed by the trephine, a defined cut edge was felt about an inch in advance of the depressed piece of bone, being the boundary of an opening into the cerebral substance.

Three hours after arrival in camp the patient died. On examination post-mortem, a wedge-like section of the ball was found to have entered and penetrated the cerebral substance; it was discovered in the anterior lobe on the right side, just above the orbitar plate. It had not completely penetrated, but was lying just above the membrane covering the lobe. The ball--a conical rifle-ball with three cannelures--was cut smoothly from apex to base, as if by a sharp knife. This must have been done by the edge of broken bone above the opening made in the parietal bone, one-half of the ball flying off, the other entering the skull. On close examination, several very small points of lead were found to be imbedded along the margin of the bone alluded to. The depressed portion of bone, directly after the piece of ball entered, must have sprung up again by its own resiliency, or been forced up by sudden pressure from within, so that no evidence of an aperture, but merely a fissure and depression remained. The inner table was separated, and nearly detached, for a space rather more extensive than that of the depressed part of the outer table. The superior longitudinal sinus was wounded by the sharp edge of the broken inner table, and a very considerable quantity of blood extravasated upon the surface of the brain.

The portion of bone implicated in this injury has been preserved.

THOMAS LONGMORE,
_Surgeon, 19th Regiment_.

Camp before Sebastopol.

REMARKS.

Six amputations at the hip-joint (if not more) have been performed in the Crimea, and all the sufferers have died, a loss which has not been experienced in civil life under any circumstances, many persons having survived the operation for years. It has been fairly attributed to the depressing causes from which the army suffered, and for which the government has been blamed; although the great functionaries appear to me to have less to account for than their subordinates, as far as regards deficiencies in the treatment of the sick and wounded.

The operation for removing the head of the femur from its connection with the hip, leaving the limb for future use, was first recommended by me as a substitute for amputation at the hip-joint, and has been done in at least six instances, one only surviving. I limited the operation to injuries of the head and neck of the bone, or with little extension beyond these two parts, being cases which hitherto invariably died unless amputation at the hip-joint were performed, and which it was and is hoped the operation of excision might render unnecessary; but it must be done under happier circumstances, and perhaps with greater restriction. The success which has followed the removal of the head of the humerus from the shoulder-joint even with as much as one-third of the shaft, as low as the insertion of the deltoid muscle, has led to the belief that as much may be done in the thigh; and in the hope that it might be so, a considerable portion of the shaft of the femur has been removed with the head and neck in the cases alluded to, so that an approximation of the remainder of the shaft to the cavity of the joint has not been possible. If the operation performed by Surgeon O’Leary, 68th Regiment, (page 564,) which at the end of seven weeks is reported as doing well, although the pulse remained between 80 and 100, should succeed, it is doubtful whether the limb will be of any use or better than an artificial leg, from the extent of the bone removed, which will prevent the formation of a firm joint or union. The sling used in this case has been considered very advantageous by all who have seen the man, and proves how much may be done in all cases of compound fractures by similar appliances, but which has not yet been done. A correct judgment cannot, however, be formed as to the value of this operation until it has been performed on one of those cases in which a ball shall simply lodge in the head or neck of the femur without injuring the shaft of the bone--an accident which has been so frequently observed in the head of the humerus, and of which I have sent two preparations to the museum of the College of Surgeons. (See page 127.)

It has been already stated that the loss of life after amputations performed for gunshot fractures of the upper part of the thigh has been so great, both in the French and English armies, that such operations have been nearly abandoned.

The Russians, at the commencement of the siege of Sebastopol, made use of a conical rifle bullet, flat at the base, weighing nearly one ounce and three-quarters. Latterly they have used a larger conical one, with three grooves around the circumference of the base of the cone, which is hollowed out to receive a cup, and shows a projection on the inside of the hollow. This ball is near two inches long, and weighs somewhat more than one ounce and three-quarters.

The balls formerly used by the French army were twenty to the pound, and by the English, sixteen. The balls alluded to are nine to the pound. When this Russian ball strikes soft parts only, such as the thigh, it merely makes a larger hole than the common bullet, into which the finger passes easily, and the wound heals as readily. Whenever it strikes a bone, it would appear to break it more extensively, and to require more certainly the amputation of the limb; although the smaller French ball used in former days, when it struck a bone, disabled the sufferer as effectually for all future service, yet it might not as certainly lead to his death.

Dr. Lyons not only transmitted to me the case, related page 579, of John Shehan, but has since sent me the broken bones, which confirm everything I have said on this subject, page 321. The sound bone above the fracture has become more solid; the splinters not having been removed are lying across, and prevent the approximation or union of the ends of the old bone, while the effort made by nature to effect this object by the deposition of new ossific matter, adds to the evil by fixing these splinters in so solid a manner that they cannot escape or be removed by any other means than that of forcible abstraction, after painful and perhaps dangerous operations, each splinter possibly requiring a separate one. Shehan’s case was one for amputation from the first, if he had been in a state to undergo it with a prospect of success.

The treatment of gunshot fractures of the leg ought to have been more successful than it has been, even when both bones were broken; the want of success may be in part attributed to the remissness which has taken place in supplying the necessary, nay, the essential appliances, by means of which much suffering might have been alleviated, perhaps prevented, even if cures could not have been effected.

In performing the operation for the excision of portions of the extremities of bones, a chain saw is a most desirable aid on many occasions. There was not one with the British army in the Crimea, and when wanted, they were borrowed from the French ambulances. It was only on the 30th of September last some were ordered to be sent out, and they cannot yet have arrived. In a lecture I delivered on the 14th of April last in the Theater of the College of Surgeons, as its President, by permission of the Council, the proceeding being unusual, I drew attention, for the express purpose, to the necessity which existed for the Crimean army being supplied with a machine capable of being moved from bed to bed, by means of which the unfortunate soldier could be raised in the extended state, and after being washed, his wounds dressed, and his bedclothes changed, he might be again laid down with comparatively little uneasiness. Fifty of them would not cost £300, but there are none in the Crimea, except two, one sent to the Coldstream Guards, by Lord Strafford at his own expense, and one which the makers placed at my disposal. I hear that _three_ have been ordered lately, like the chain saw, when too late, for many are now no more who stood in the greatest need of them, and without which machine they had little chance of being saved.

On the 14th of April, 1855, I published a lecture, in which I gave a sketch of an apparatus for slinging a broken leg, which instrument I declared to be a _sine qua non_ in the successful treatment of a gunshot fracture of the leg. By permission of the Duke of Newcastle, I sent out forty-six sets complete for every part of the body, the year preceding. They were, I am told, left at Varna; and four medical officers, of character and knowledge, who have lately returned from the East, assure me within the last week that no such, or any similarly useful, apparatus was ever seen in the hospitals in front of Sebastopol. Other instances of remissness of equal importance might be adduced, if it were not useless to advert to them; for we delight, I believe, in being admitted by foreigners to be a wonderful people in the mismanagement of our affairs in the first instance, however important or trivial. It is, I believe, an admitted maxim, that the right men should be in the right place--the square ones in the square holes, the round ones in the round holes; but there is another one of equal importance, viz., that the right thing should be in the right place at the right time, without which teaching or practicing surgery becomes of little value.

Amputation at the knee-joint has been done, I hear, in six cases since the taking of Sebastopol; four are dead; one is doing well under Mr. Blenkins, of the Guards, and the other yet survives. Excision of the knee-joint has been performed since the taking of Sebastopol in one case by Staff-Surgeon Lakin, and is doing well.

The excisions performed on the head of the humerus, and on the bones composing the elbow-joint, have been very successful. There is, however, a circumstance to which I am desirous of drawing attention, viz., that the head of the humerus should never be removed in amputations, when it is uninjured, however close the destruction below may have approached it. The round head of bone left in the socket preserves the squareness of the shoulder, and renders the loss of the arm less unseemly. It tends to prevent the inclination the body generally has to the opposite side, and its being left adds nothing to the difficulties of the operation. The excisions of the ankle-joint have been numerous and more successful than might have been expected under the depressing causes alluded to.

For the preparations of the head of the humerus and of the astragalus, referred to at pages 110 and 128, I have since learned I am indebted to Deputy Inspector-General Macgregor; and I am particularly so to Assistant-Surgeon Gregg, of the 17th Regiment, for the great care he has bestowed on several of the specimens of injury sent to me.

Wounds penetrating the cavities of the chest and abdomen have been no less fatal than those of the lower extremities. The same want of power has been exhibited in them; the same inability to bear the means of cure which, under happier circumstances, have proved successful.

I hope to receive reports on wounds of arteries, on secondary hemorrhage, and on injuries of the head, so as to enable me to remove any doubts which may exist on these points; and I beg to assure those officers who will favor me with their opinions and facts, that they shall be duly reported in another “Addenda.”

I cannot conclude these remarks without expressing my sense of the great practical ability displayed by very many of the medical officers in the Crimea, of their devotion, of their self-denial--qualities which ought to obtain for them the special approbation of the nation.

_October 18, 1855._

INDEX.

Abdomen, wounds of, 488, 649.
causing abscesses in parietes of, 489.
penetrating wounds of, 497.
protrusion of viscera in, 498.
of omentum, 498.
of intestine, 501, 509.
effusion of blood into, 505, 510.
treatment of hemorrhage in penetrating wounds of, 510.
suppuration in cavity of, 511.
and pelvis, conclusions respecting wounds of, 555.
right arm and thigh, extensive injury to, by a round shot, 576.

Abdominal parietes, gunshot wounds of, 489.
lodgment of balls in, 489.
incised wounds of, 490.
followed by ventral rupture, 493.
on continuous suture of, 493.
severe contusions of, followed by rupture of the hollow or solid
viscera, 491.

Abernathy’s mode of tying the external iliac, 257.

Abscess of liver, consequent to injuries of the head, 356.
in abdominal parietes, caused by neglected injuries, 489.

Acids, mineral, use of, in sloughing wounds, 70, 168.
in hospital gangrene, 70, 168.

_Addenda_, commentaries on the cases in, 586.

Alexander, Deputy Inspector-General, on amputations, while under the
influence of chloroform, 563.

Amaurosis from balls passing behind the eyes, 478.

Amputation, primary, not required in gunshot wounds of the upper
extremity, 120.
aphorisms on, 73.
at the ankle-joint, Mr. Syme’s operation for, 105.
of the arm below the tuberosities, 126.
by the circular incision, 134.
by Mr. Luke’s operation by two flaps, 135.
primary, of the arm, 120.
at the elbow-joint, 137.
place of election for, in local mortification of a limb, 46.
of the fingers, 139.
of the foot, 114.
by Roux’s plan, 108.
of the forearm, 137.
by the flap operation, 137.
by the circular incision, 138.
for gunshot wounds of the femur, 145.
at the hip-joint, 77, 92, 562, 563, 586.
Mr. Guthrie’s mode of operating in, 79, 83.
Professor Langenbeck’s, 80.
Mr. Brownrigg’s, 82.
under chloroform, 564.
immediate, question as to, 51.
cases for, 150.
of the leg, 99.
by the circular incision, 99.
by Mr. Luke’s flap operation, 101.
immediately below the tuberosity of the tibia, 102.
of the metacarpal bones, 139.
of a metatarsal bone, 118.
in cases of mortification from wounded arteries, 228.
necessity for, 51.
of the phalanges, 140.
primary and secondary, 59.
secondary, 59, 141.
at the shoulder-joint, 122.
by two flaps, 124.
by one flap, 125.
by Lisfranc’s operation, 125.
at the tarsus, 112.
of the thigh, by the circular incision, 83.
by Mr. Luke’s flap operation, 86.
at the wrist, 138.
under the influence of chloroform, in the Crimea, 561.
case of death from, 561.
Deputy Inspector-General Taylor on, 562.
Deputy Inspector-General Alexander on, 563.

Ankle-joint, excision of, 103.
Mr. Syme’s amputation at, 105.

Aneurism of the arch of the aorta, 276.
formation of, after wound of artery, 212.
Hunterian theory respecting, 188.
popliteal, operation for, 263.
traumatic, formation of, 214.

Aneurismal swelling after deep wound of an artery, 212.

Anus, artificial, 525.
operation for the formation of, in the loins, 558.
Desault’s operation for, 527.
Dupuytren’s forceps for, 527.
Mr. Trant’s forceps for, 528.

Aorta, ligature of, 250, 252, 256.
aneurism of the arch of, 276.

Arachnoid and dura mater, wounds of, 345.

Arm, amputation of, below the tuberosities, 126.
primary, 120.
by the circular incision, 134.
by Mr. Luke’s double flap operation, 135.
gunshot fracture of, 121, 156.
wounds of the arteries of, 238.
thigh and abdomen, extensive injury to, 576.

Arsenic, local use of, in hospital gangrene, 169.

Arteries, wounded, the Hunterian theory inapplicable in the treatment
of, 189.
Mr. Guthrie’s theory respecting, 189.
principles of surgery relative to, 191.
punctured wounds of, 210.
formation of aneurism after, 211.
transverse wound of, 212.
complete division of, 212.
large, mode of arresting hemorrhage from, 234.
of arm and forearm, wounds of, 238.

Artery, structure of, 176.
deep wound of, forming aneurismal swelling, 213.
effects of a ligature on, 203.
wounded, not to be operated on, unless it bleed, 215, 241.
to be tied at the seat of injury, 191, 219.
main, of the lower extremity, mortification caused by a wound of,
45, 226.

Artificial anus, 525.
formation of, in the loins, 558.
Desault’s operation for, 527.
Dupuytren’s forceps for, 527.
Mr. Trant’s forceps for, 528.
foot, M. de Beaufoy’s, 119.

Astragalus and calcis, Mr. T. Wakley’s operation for the removal of,
115.
ball lodged in the, 109, 590.
removal of, 109.

Auscultation, value of, in injuries of the chest, 367.

Axillary artery, gunshot wounds of, rarely cause mortification of the
hand or fingers, 46, 235.
ligature of, 278.
wounds of, 235.

Ball, lodging in the abdominal parietes, 489.
in the astragalus, 109, 590.
in the bladder, 553.
calculus formed on, 553.
operation for removal of, 554.
in bone, 36, 149.
in the brain, 283.
behind the eye, 478.
or other foreign bodies loose in the cavity of the pleura, 448.
inclosed in a cyst, 451.
lodged in the head of the humerus, 128.
in the liver, 532.
orifices of entrance and exit, 27, 489.
passing behind the eyes, causing amaurosis, 478.
lodging in the pelvis, 545.
penetrating the brain, 347.
rolling on the diaphragm, 451.
operation for extraction of, 455.
separating the sutures of the skull, 349.

Balls, relative size of those used by the Allies and by the Russians,
588.
on cysts inclosing foreign bodies, in gunshot wounds of the chest, 451.
operation for empyema, 452.
operation for gunshot fracture of the lower jaw, 480.

Baudens, M., on excision of the head of the humerus, 133.

Bayonet, wounds by, 37.
wounds, delusion as to, 38.

Bearers for the wounded, 156.

Beaufoy’s, M. de, artificial foot, 119.

Bedsteads for gunshot fractures of the femur, 152.

Bell, Mr. J., on emphysema in gunshot wounds of the chest, 412.

Bennet, Dr. Hughes, on phlebitis, 71.

Blackadder, Mr., on hospital gangrene, 164, 169.

Bladder, wounds of, 546.
ball in the, 553.
calculus formed on, 553.
operation for extraction of, 554.

Blood, effusion of, into the abdomen, 505, 510.

Boggie, Dr., on hospital gangrene, 168, 169.

Bone, lodgment of a ball in, 36, 149.
protrusion of, after amputation, 89.
exfoliation of, after amputation, 89.

Bones of the face, penetrating wounds of, 479.

Brachial artery, ligature of, 279.

Brain, balls lodging in, 283.
balls penetrating into, 347.
M. Burdach’s statistics of lesions of, 306.
compression of, 302.
paralysis caused by, 305.
injuries of the head affecting the, 283.
concussion of, 287.
causing mania, 299.
laceration of, by contre-coup, 340.
motions of, 303.
suppuration of the surface of, 342.
wounds of, 347.
causing abscess of the liver, 356.

Bronchophony, 372, 376.

Brow and eyelids, wounds of, 477.

Brownrigg’s mode of amputating at the hip-joint, 82.

Brunner, glands of, 486.

Buck, Dr. Gurdon, operation for excision of the knee-joint, 97.

Burdach’s statistics of lesion of the brain, 306.

Calcis and astragalus, operation for the removal of, 115.
removal of, 104.

Calculus formed on a ball in the bladder, 553.
operation for extraction of, 554.

Cannon-shot, hemorrhage after the carrying away a limb by, 25.
wind of, 43.
causes mortification of a limb, by destroying its internal textures,
43.

Carotid, common, ligature of, 270.
statistics of ligature of, 241.
external, ligature of, 272.
the common carotid not to be tied for wounds of, 242.
internal, ligature of, 272.
wounds of, through the mouth, 245.
operation for securing, 245, 248, 272.
the primitive carotid not to be tied for wounds of, 246.
primitive, not to be tied for wounds of external carotid, 541.
nor for wounds of the internal carotid, 246.

Cartilages, costal, fracture of, in gunshot wounds of the chest, 429.

Cerebrum, fungus of, (hernia cerebri,) 352.

Chain saw, utility of, 588.

Chelius on suture of incised wounds of abdominal parietes, 493.

Chest, wounds of, 364, 590.
effusion into, 371, 378, 420.
purulent effusion, etc. into, 378, 390, 420, 435.
operation for, 394.
non-penetrating wounds of, 364.
value of auscultation in wounds of, 367.
incised wounds of, 364, 414.
wounds of both sides of, 417.
large penetrating wounds of, the lung injured, 418.
with hemorrhage into the cavity, 421.
ecchymosis a sign of internal hemorrhage in penetrating wounds of, 424.
conclusions respecting wounds of, 424.
gunshot wounds of, 426.
statistics of, 426.
enlargement of, 427.
fracture of the ribs in, 428.
of the costal cartilages in, 429.
involving the lungs, 429.
removal of splinters, etc., 445.
the ball loose in the cavity of the pleura, 448.
rolling on the diaphragm, 451.
inclosed in a cyst, 451.
involving the lungs, effusion caused by, 435.
formation of a dependent opening, 452.
operation for the evacuation of the fluid, 455.
anatomy of the parts concerned, 453.

Chloroform, use of, 55.
Dr. Snow on, 55.
Mr. Syme on the treatment of approaching death from, 58.
amputation under the influence of, in the Crimea, 561.
case of death from, 561.
Deputy Inspector-General Taylor on, 54, 562.
Deputy Inspector-General Alexander on, 563.

Circulation, collateral, 184.

Colon, Hilton’s operation for opening into, 558.

Commentaries on the cases in the _Addenda_, 586.

Compound fractures, 145.
splints for, 153.

Compression of the brain, 302.
convulsions caused by, 307.
paralysis caused by, 305.
in hemorrhage from wounds of the hand, 238.

Conclusions respecting wounds of the chest, 424.
abdomen and pelvis, 555.
hospital gangrene, 173.

Concussion of the brain, 287.
causing mania, 299.

Contre-coup, fracture of the skull by, 316.
laceration of the brain by, 340.

Contusions, severe, of abdomen, followed by rupture of the hollow or
solid viscera, 490.

Convulsions caused by compression of the brain, 307.

Cooper, Sir A., mode of tying the external iliac, 258.

Cranium, fracture of the base of, 317.

Crepitating râle, or rhonchus, 375.

Delpech on hospital gangrene, 165, 166, 167.

Deposits, purulent, 61, 68.

Depression of the skull, 329.
of the back of the skull, with fracture, 338.

Desault’s operation for artificial anus, 527.

Diaphragm, ball rolling on the, 451.
operation for the extraction of, 455.
wounds of, 458.
may cause internal hernia, 463.

Dupuytren’s forceps for artificial anus, 527.

Dura mater, incision of, 343.
removal of blood from the surface of, 360.
suppuration on the surface of, 342.
wounds of, 345.

Ecchymosis, a sign of hemorrhage into the chest, 424.

Effusion, purulent, in penetrating wounds of the chest, 420, 435.

Elbow-joint, amputation at, 137.
excision of, 135, 580.

Emphysema, 410.
Mr. J. Bell on, in gunshot wounds of the chest, 412.

Empyema, 390, 436.
operation for, 394, 455.
M. Baudens on, 452.
necessity for depending opening in, 452.
Mr. Quekett’s experiments on the anatomy of the parts engaged in,
452.
operation for, by incision, 455.

Endocardial sound of the heart, 466.

Epigastric artery, ligature of, 510.

Erysipelas phlegmonodes, 40.
improvement in the treatment of, 41.
of the scrotum, 42.
of the scalp, 359, 363.

Excision of the ankle-joint, 103.
calcis, 104.
calcis and astragalus, 115.
elbow-joint, 135, 580.
with injury to left hip, 581.
head of the femur, 90, 150, 564, 587.
in gunshot wounds of, 150.
of the head, neck, and great trochanter of the femur, 564.
of the head of the humerus, 126, 571, 590.
Langenbeck’s operation for, 130.
M. Baudens on, 133.
of the knee-joint, 97.
Mr. Jones’s mode of operating, 97, 98.
Dr. Gurdon Buck’s operation for, 97.
metacarpal bone of thumb, 140.
phalangeal joints, Langenbeck’s operation for, 140.

Excito-motory system of Dr. Marshall Hall, 286.

Exfoliation of bone after amputation, 89.

Exocardial sound of the heart, 466.

Expiration, 369.

Extraction of the ball in gunshot wounds, 32.

Extremities, upper, gunshot wounds of, 20.

Eye, ball lodged behind, 478.
wounds of, 477.

Eyelids and brow, wounds of, 477.

Face, wounds of, 476.
penetrating wounds of the bones of, 479.

Femoral artery, gunshot wound of, a cause of local mortification,
45, 226.
laceration of, 208.
ligature of, 260.
superficial ligature of, 262.
and vein, injuries of, may cause gangrene, 45.