Part 58
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.