Part 60
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.