Part 59

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.

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.